Click on the cover image above to read some pages of this book! Lacy Jones is hired at Dr. Eve Lyons' urology practice, instantly welcomed into a sisterhood of nurses. However, she discovers her expectations require more than the average employment. At a work social gathering, Lacy is forced to admit her husband's short comings. Armed with the information, Eve exploits the opportunity, preying upon a new victim.
Forcing Mr. Jones onto the examination table, he will face pleasurably humiliating treatments for premature ejaculation. Though, the moment Dr. Lyons sees him, she is haunted by a familiar face. What was intended to be a fetish fix, turns into a mission of revenge. Working with standardised or simulated patients SPs is now commonplace in Simulated Learning Environments. Embracing the fact that they are not a homogenous group, some literature suggests expansion of learning with SPs in health professional education by foregrounding their personal experiences.
Intimate examination teaching, whether with or without the help of SPs, is protected by a particular degree of ceremony given the degree of potential vulnerability. However, other examinations may be equally intrusive for example the close proximity of an eye examination or a chest examination in a female patient. We wished to problematise power relations that construct and subject SPs as clinical tools within simulation-based education. We collected data from 22 SPs, through five focus groups. Analysis was an iterative process, using thematic analysis.
Data collection and reflexive analysis continued iteratively until concepts were fully developed and all theoretical directions explored. Students and SPs construct simulated teaching consultations by negotiating the unequal distribution of power between them. The SPs themselves discussed how they, perhaps unknowingly, acted in accordance with the discourse of the clinical gaze.
However, SPs became disempowered when students deviated from the negotiated terms of consent and they used their agency to resist this. The SPs used strong sexual metaphors to express the subjugation they experienced, as discourses of sexuality and gender played out in the Simulated Learning Environment. We demonstrate that power dynamics and the clinical gaze can have important consequences within the Simulated Learning Environment.
In partnership with SPs, simulation-based education should create a teaching space that no longer fosters the discourse of the clinical gaze but facilitates students to learn to reflectively navigate, in the moment, the fine line between touching patients versus touching loved ones, and the blurred boundaries that exist in the gulf between sexual contact and benevolent touch. The Association of Standardised Patient Educators ASPE recently published Standards of Best Practice for those working with human role players in simulation-based education, perhaps more commonly known as standardised or simulated patients hereafter collectively referred to as SPs [ 1 ].
The role of SPs in medical education commenced in the late s [ 2 ], and they now form an integral part of teaching and assessment [ 3 ]. Wallace et al. It has previously been discussed how SPs working within a typical UK institution may sometimes feel dehumanised because some do not see their role as simulated at all, experiencing some or all of the physical and much of the emotional responses that would be expected in a genuine consultation [ 5 ].
The same study found that these SP participants held as a cornerstone their sense of vocational identity — of giving something of themselves in order to help medical students and their future patients. For some of the SPs, this is what assuaged the associated discomfort [ 5 ]. Other literature shows different motivating factors for SPs; for example, they may feel they benefit from the health knowledge that they gain and from insights that they acquire into the practice of medicine [ 6 ], seeing themselves very much as unreal patients [ 7 ], prioritising the learning needs of the student.
Through tracing the sociocultural history of SPs, we can understand the evolution of their roles through the years in medical education, and more recently in the education of many other health professions. A more modern variation is the involvement of Teaching Associates, at present used in a minority of medical schools [ 10 ]. Previous work done on the experience of patients using their bodies to teach pelvic examination found that taking part had benefits in terms of a strong sense of self [ 12 ]. In an interview carried out by Brian Hodges, Danny Klass, then Associate Dean of the University of Manitoba, acknowledged the sensitivities surrounding teaching such examinations.
Indeed, the particularities for SPs involved in this simulated teaching are highlighted by the fact that this is one of a few specific areas that the ASPE intends to publish further specific standards in [ 1 ].
Because of the nature of these examinations, which have increased potential to be open to misinterpretation, they are often taught with particular emphasis on protecting both patient and doctor. Such an examination performed without appropriate consent can be misconstrued and even cross into the realms of sexual assault.
Furthermore, terminology is thus kept very technical and references to sexuality are minimal. To avoid SP embarrassment, hybrid simulation, typically involving a plastic mannequin for example of a rectum, is often used in conjunction with an SP [ 15 ].
Students are taught a specific, semi-formal ritual around intimate examinations, including the role of chaperones, alongside the technical skill itself [ 16 ]. Furthermore, it is likely that such examinations may be especially poignant for patients who have experience of trauma; clinical assessment by well-intended health care providers risk re-traumatising such individuals.
Whilst there has been much coverage of these alleged sexual assault cases through the popular media, this has not been significantly reflected in research or the academic medical literature. This describes the modern work of medical practice as a discourse where the doctor is powerful as a result of their scientific knowledge and training. In the discourse of the clinical gaze, patients may be dehumanised, with their stories and embodied experiences disregarded in favour of objectivity and technical expertise [ 20 ].
The SPs enter into a contract with the University and are paid for their time. GK is a General Practitioner and clinical teacher and was a postgraduate student at the time. The research team came together due to a common interest in teaching with SPs. Some of the team have particular expertise in simulation including SP methodology and have published in this area previously. The team maintained high levels of reflexivity checks during data analysis by conducting regular critical discussions and reflecting on their own subject positions relative to the research.
The topic guide was discussed and agreed within the research team prior to the focus groups, it then developed iteratively throughout the process.
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The potential for discussions to involve sensitive topics was recognised; however, SPs were well briefed about the nature of the research in advance including an emailed participant information leaflet and at the start of the focus group and appeared comfortable within a small group of their peers. It was also felt that the supportive co-construction of the group seems to encourage SP narratives and contributed to their engagement. SPs discussed examinations that they had taken part in as part of their teaching roles they are generally not involved in intimate examinations in this institution with the exception of some female SPs who chose to be involved in breast examination teaching.
Throughout the focus groups, the SPs chose particularly to refer to their teaching experiences in chest examinations in female patients , breast examinations, abdominal examinations and examinations of the femoral pulse. They also chose to draw at times on their experiences as patients being examined in intimate examinations and otherwise, as had been the case in previous research carried out with SPs [ 5 ]. Contemporaneous field notes were made. Interviews were audio-recorded, anonymised, transcribed verbatim and checked for accuracy by GK.
We undertook a thematic analysis [ 23 ], conducting analysis concurrently with data collection. Analysis involved coding and memo-writing, with data collection and inductive analysis continuing until saturation. GK carried out initial coding. The research team met regularly to advance the analysis until all concepts were well developed, and all relevant theoretical directions had been explored. Theoretical links were only explored after the bulk of inductive analytic work was complete as suggested by the data and are recounted below. Analysis yielded three main themes: boundary negotiation, boundary violations and protecting boundaries.
We observed that the SPs attempted to interrupt the subjectification that was occurring through the clinical gaze, by asserting their individuality and identity. This language subjects the patient as a clinical object or collection of body parts rather than as a whole person, and neglects the extreme embarrassment felt by exposing more than is necessary. When challenged in the way, SPs reasserted their agency by any means available to them. In this study, SPs construct boundary negotiation in teaching examinations as a crucial process in simulation based education.
SPs are at risk of objectification, even at their own hands, and they described examples in this study of how they actively chose to subordinate themselves in order to facilitate learning. Evidence has shown that many SPs strive to be considered active teachers, rather than passive technology, [ 7 , 8 ] so why do SPs at times still appear to subject themselves, under the clinical gaze, to subordination? What are the unspoken power dynamics promoted in simulation based education which enables this to happen?
The medical community often accepts that examinations of breasts, prostates and genitalia, constitute an invasion of personal space [ 16 ]. SPs of both sexes though predominately the female SPs described instances of boundary violation in simulated examinations, where boundary negotiation had not been successful within the clinical encounter. Such dysfunctional encounters with students were on occasions narrated using evocative sexual metaphors.
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These are more commonly used within Western culture to describe a subordinate female position within a sexual relationship [ 25 ]. Drawing on a discourse of female sexuality, [ 26 , 27 ], SPs of both sexes, in using this language appeared to position themselves in an inferior position as a way of expressing their loss of power and their subjugation. Are faculty deliberately avoiding these sensitive discussions with teachers, students and SPs?
Whilst discourses of sexuality, gender and subjectification are not likely to be unique to Simulated Learning Environments, could these important areas be considered during session planning and opportunities to help address them created in an attempt to highlight issues that may be present throughout teaching and learning? Navigating unspoken sexual undertones became a central task for SPs in their experiences of examinations through their narratives. This often played out in a power tussle between student and SP surrounding the degree of necessary exposure for a particular examination.
When the boundaries of the SPs were challenged, they displayed their discomfort by asserting their individuality and agency as human beings through deliberate non-compliance with the instructions dictated by the student. In addition, clothing became an important representation of their agency, and asserting control over disrobing and its extent became a symbol of power struggle between the parties.
They described how they resisted the classic medical formulation of bodies as separate entities from their occupants, and illness as purely mechanical dysfunction [ 18 , 28 ], through their personal narratives expression and desire to be at the centre of their care. Furthermore, the overall quality scores of the evaluation were obtained using the sum of points assigned to each item of the clinical assessment analyzed 1. This sum was divided by 1.
Thus, each student had a minimum global score of zero points and a maximum of ten points, which score is therefore considered as a continuous variable. The global scores were compared before and after the training. The Kolmogorov-Smirnov test was initially applied to verify the normality of the variable. When the distribution found was normal, the paired t-test was then applied; when it was a nonnormal distribution, the Wilcoxon test was applied. Additionally, the possible association between the course year of undergraduate medical training and the global score obtained after the training was evaluated.
This analysis was performed by the Pearson correlation test. In all, 31 students were evaluated, of which 19 examined female patients and 12 examined male patients. Ophthalmoscopy, otoscopy, examination of the testicles and assessment of ABI were ignored by all students Graph 1. The percentage of students who performed a complete assessment of vital signs increased significantly, from P values obtained by means of the McNemar statistical test. RR: Relative risk. Desired and statistically significant results were observed in relation to analysis of the complete clinical assessments, of the cardiovascular system 3.
The only exception to the complete assessment comparisons was observed in the testicular exams, with a total absence of complete assessment prior to student training and a discrete increase to 8. P values obtained by the Wilcoxon statistical test. P value obtained by the Pearson statistical test. The failure among physicians to perform clinical assessments or adequate physical examinations has become a generalized phenomenon, observed worldwide over recent decades 13 , This problem is so common and well reported in medical education services around the world, that one author who researches this area, Chad Cook, a specialist in musculoskeletal disorders, refers to clinical examination as "the lost art" The present study demonstrates the low level of appreciation for the physical examination prior to the training Tables 1 and 2.
The scenario encountered before the training could be compared to findings of other studies. A multicenter study by Barrios et al. Ten years later, the same authors analyzed the physical examinations performed by doctoral students and residents of the Internal Medicine Service of a university hospital and observed that examinations of the cardiovascular system, pulmonary system and abdomen were prioritized in relation to the others, and recorded in the following percentages of cases, respectively: However, despite these records, a complete examination had rarely been performed.
In addition, of the total patient sample, in only Furthermore, the neurological assessment was performed in In another study, the authors used a clinical score based on physical examination data at the time of medical care and according to the patient's information. This clinical score was constructed based on questions addressed to the patient regarding the following medical procedures: 1 blood pressure measurement; 2 heart auscultation; 3 pulmonary auscultation; 4 palpation of the abdomen; 5 after being shown a stethoscope and a tensiometer, whether such devices had been used during the physical examination.
Hence the clinical score could vary from 0 to 5 points, where a score of zero was attributed to medical consultation without apparent clinical investigation, and 5 to that in which the physical examination was supposedly more adequate. The clinical score registered a mean of 3. Of the patients included in this study, 50 Neurological examination may have had a low percentage of complete assessments The complexity of the clinical examination is one of the main reasons why many students find neurology difficult Studies show that medical students generally perform poorer in neurological examinations than in other fields of clinical assessment It is likely that the simplified study guide, which lists the ganglion chains to be evaluated by students in each body segment, helped significantly in achieving this improvement because it enabled students to remember which chains should be examined, in a simple and sequential manner.
There was also significant improvement in the rate of ophthalmological examinations performed after the intervention. However, still only This demonstrates the great challenge involved in teaching direct ophthalmoscopy at undergraduate level.
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The medical literature has already found that most clinicians and students lack the confidence and ability to perform ophthalmoscopy One study showed that the students had an average confidence level of below 2, on a scale of 1 to 5 1 being the least confident 23 to perform an ophthalmologic examination. Change is therefore required in this context, because it is necessary for the clinician to know how to perform direct ophthalmoscopy and how to interpret it.
Thus, there is a need for students to have more exposure to ophthalmology clinics One study created a teaching ophthalmoscope in which a third person could observe the student's vision of the fundus of the eye during the examination Another lower cost option would be to have more specific skills training sessions for the ophthalmological exam, using less expensive materials Significant improvement was also observed in relation to the performance of otoscopy after the intervention, with the rate of complete assessments reaching Prior to the training with the guide, none of the students performed otoscopy, which demonstrates that the teaching of otoscopy is also very poor during graduation.
Another study showed that only Clinical assessment of this gland is poorly performed in medical practice, so much so that Wu et al 27 , in , found a self-confidence level of 2. However, with simple interventions, this scenario is likely to change, as seen in the present study and in the work of Haring et al 28 , in Regarding breast examination, it was reported that only 5. After the training, this rate increased to This is probably due to cultural barriers, as it is an intimate part the woman's body. Wang et al 29 , in , demonstrated in a questionnaire survey that the acceptability of breast examination by male physicians is low among medical students and physicians themselves, with Haring et al 28 presented more worrying data regarding breast examination: in their study, one hundred medical students underwent eight weeks of systematic training in clinical skills, followed by an additional eight weeks of training with actual patients.
In the end, it was observed that only nine students performed breast palpation. To overcome this barrier aginst the clinical assessment of the genitals, more far-reaching measures may be needed, such as an integrated teaching program on female and male genital examination using trained teachers and simulated patients in a supervised clinical teaching setting , since during undergraduate training, there are few opportunities to practice this type of examination The oral cavity examination was performed in In the present study, This discrepancy may be due to differences in the criteria adopted for determining whether the examination was adequate.
The deficiency in knowledge about ABI among physicians has already been shown in other studies. Therefore, a simple intervention, like the simplified guide, can greatly improve the performance of ABI measurement. The rate of anthropometric measurements also improved after the training. However, a complete assessment was still only achieved by This may have occurred because there was only one course year difference between most the students fifth year and sixth year of medicine degree ; therefore, this time difference may not be as significant for the physical examination.
Furthermore, the small number of study participants, 31 in total, may have influenced this outcome. To solve the current problem in the medical training process, which fails to prioritize the ability to perform routine and complete clinical examination, focusing on teacher preparation and awareness in relation to this competency at undergraduate degree level is the most highly recommended strategy 32 , In addition, the authors of the present study suggest that training with the simplified guide for PhD students and early stage interns in the presence of a teacher is another simple and probably very effective strategy.
Establishing an integrated program with the discipline of Semiology to accompany the students until the end of the course could be an initiative of easy implementation. But it is valid to reinforce the need to test, in addition to face-to-face instructions and printed materials, other resources, such as electronics, which may include the internet and applications 34 , Highlighting the efficacy of the simplified physical examination guide, students in the present study clearly improved their clinical semiotics, with a In this sense, a standard physical examination sequence that contemplates all the systems has been shown to be effective for almost all the clinical assessment items analyzed.
The teaching of clinical skills, especially clinical assessments, physical examinations or other situations of health care practice, may be influenced by different teaching styles, differences in the teaching staff of an institution, local administrative characteristics, degree of individualization and characteristics of the patient and the assesor 36 , Despite these influences, in addition to certain subjective factors, objective instruments, in a checklist format, are extremely promising and recommendable for future studies in this area, as a viable means for the teaching-learning process of clinical assessments In addition to the use in the training of undergraduate medical students, the proposed instrument could also be used in continuing medical education actions in various health services, presumably making them more efficient and responsible in the use of diagnostic technologies, especially in low income areas It is interesting to note that, in the present study, the students exercised the activities independently, without the presence of a teacher, at the exact moment of the assessments Unlike the Structured Clinical Examinations and Objectives, the simplified clinical assessment guide was applied in circumstances consistent with the actual demands of the health service in which the study was conducted Jean Bitar Hospital Complex.
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Since , the methodology of Structured Clinical Examinations and Objectives has incorporated a wide variety of activities in very different cases, scenarios and situations, but all of them in simulation conditions, including with the participation of actors, when necessary This point was emphasized by Weller et al 42 , in , in the article Can I leave the theater?
A key to more reliable workplace-based assessments. In this study, the authors emphasize that assessment methods in situations of greater student independence, in real situations, can be a reliable means of evaluation, without burdening the routine of both teaching and service staff. One evident limitation of this study is that the simplified guide was only applied for only three weeks. For a better analysis and deeper intervention, it would require a longer experimental period.
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