Carlos's patient-doctor group learned to palpate the inguinal lymph nodes, which were in the groin. I asked him how the session had been. "Revealing," he said.

Carlos acted as the patient for the group. As the patient he sat in his boxer shorts in front of a mixed-sex group of our classmates as the instructor demonstrated the exam and the students practiced. Both male and female classmates in his group had to feel under his shorts to palpate the nodes. Roy wore double underwear -- Jockeys and boxers -- to minimize the invasiveness and embarrassment inherent in the situation.

After all the buildup for the event, my first internal pelvic exam was not such a big deal. I think one reason for my fear was that as a woman and unlike a man, I had never really seen my own genitalia. This was foreign territory. And since I experienced my own exams as a humiliating procedure, I feared inflicting the same humiliation on another person.

Lisa, our professional patient, was completely at ease. These "patients" were trained to teach us the genital exams, using themselves as models. Because I arrived a little early, I met Lisa outside the examining room just as she was coming in. Lisa was probably only five or six years older than I was. An obese woman, she had permed shoulder-length mousy hair and pale blue eyes. As we waited for the administrator organizing the evening program, I felt compelled to make conversation. "Thank you for doing this for us. We really appreciate your coming to teach us," I told her.

"Oh, yeah, well, I like coming. And it's a great way to make money," she said. Lisa had burned out in her teaching job a few years ago. Looking to change professions, she had come across an advertisement for volunteers to act as patients for medical students. "It just seemed like a great opportunity at the time. And so many women die of breast cancer that I think it's important that you guys know how to do a good exam. I'll probably do this for a few more years before I move on to something else."

When our turn came to examine Lisa, Scott and I entered the room to find her in a johnny sitting on the examining table. Lisa had been trained both to show us how to do a proper exam and to act as the patient. She knew exactly how each part of the exam was supposed to feel and helped modify our technique to improve our skills. First, she carefully described the necessary motions women must make to obtain an adequate visual exam of the breasts. Then she lowered the top of her johnny to reveal her pendulous breasts. She flexed her arms as we watched, and then lifted them and clasped her hands behind her head. We watched her breasts change shape as the chest wall muscles behind them tightened and relaxed. Then she lay back so we could practice the breast exam. Scott went first. "No, you have to press harder. I could still have a lump there that you wouldn't feel."

As his fingers worked meticulously across her breast, he found dense fibrous scar tissue at the base of her breast. "That's from my breast reduction surgery. It's completely normal. But you should feel it so that you know what it's like." As he lifted her breast to reach the tissue better, I noticed the three-inch ruddy crosshatch scar.

Then it was my turn. I carefully moved my fingers in small circles across the entire surface of her breast. "That's good. The pressure is just right." I found the fibrous shelf of scar tissue at the base of her breast, and I ran my fingers across the scar.

Now came the part I dreaded. I arranged the light for Scott as Lisa pulled her johnny up to cover her shoulders and then spread a paper sheet across her lap. She pulled out a blue plastic hand mirror while I ran warm water over the speculum, the gray metal instrument used to open the vagina and visualize the cervix, the opening of the uterus. She showed Scott how to feel her labia and the soft mound of her mons over the pubic bone for masses. She told him how to spread her labia majora to reveal the wrinkled pink labia minora inside.

As Scott inserted the speculum into her vagina, Lisa held the blue plastic mirror so she could see what he was looking at. "Okay, now that the speculum is in, you have to rotate it ninety degrees and push it toward the back of the vagina. And most important, be careful to keep pressure toward the floor on the speculum. You don't want the speculum to ride up and hit my clitoris. That's excruciatingly painful for women."

Scott advanced the speculum. Small beads of sweat accumulated on his brow.

"Oh ... you need way more pressure. You're getting close to my clitoris," Lisa warned.

When it was my turn, I tried to follow the directions she had given Scott. I inserted the metal speculum and then rotated it ninety degrees.

"Watch my clitoris. A little more pressure."

I pushed the speculum to the end of her vagina and then opened the lips of the speculum. I saw a pink tissue wall with streaks of creamy white mucus. This didn't look at all like the cervix.

Lisa surveyed the situation in her hand mirror. "Why don't you try closing the lips, aiming more toward the floor, and pushing the tip in a little farther?"

I pushed the speculum a little farther and opened the blades again. Still the same pink wall. I could feel my face warm under the hot light of the lamp. I tried one more time, and this time was grateful to see the raised pink doughnut of the cervix with the central red spot identifying the passageway into the body of the uterus.

The bimanual exam was much more difficult for me. I pushed my gloved and lubricated right fingers into her vagina, reaching for the cervix I had just seen. I pressed my left hand into her soft abdomen, trying to press on the uterus and bring the cervix into reach of my finger. I reached with both my hands, but the cervix remained elusive.

"Push your fingers in farther," Lisa said.

I leaned toward her, in part using my weight to force my fingers a few millimeters deeper into her vagina. I couldn't find the uterus in the ample softness of her belly.

"My uterus won't be all the way up there. You've got to press lower. Here." She reached down and rearranged my hand. Finally I was rewarded by what I thought was the light touch of the cervix passing across my finger. Relieved, I finally extricated my fingers from her vagina still a little unsure of what I felt and fairly certain I would not be able to replicate that exam on another patient.

Although I had worried about how I would feel in the room with Lisa, she was so matter-of-fact that she put me at ease. Once reassured that she was comfortable with the exam, I could relax and focus on finding and examining the necessary structures. It was hardest to watch Scott attempt the pelvic exam, knowing that my turn was fast approaching. Once involved in the exam, I became so absorbed in my efforts that I forgot my personal inhibitions. After leaving the room, I thought that while I might be technically incompetent when examining my first patient, I had at least begun to tackle my fear of the exam. I felt confident that I would be able to treat the pelvic as a routine part of the physical exam.

Ironically, I was less afraid of the male genital exam, although I wasn't sure why. Perhaps I had spent so much anxious energy preparing for the female exam that I couldn't get as worked up over the male exam. Or perhaps my experience with Lisa was such a relief that I was no longer worried about learning the male exam.

I recognized our patient's name. Mr. Miller had taught Kate, my roommate, and her partner the genital exam a few weeks previously. He was a tall, thin man in his mid-sixties. He and his wife had trained to be patients a few years ago when his wife was diagnosed with breast cancer after her primary clinician had missed a lump. "We really want you to learn this well so that you won't miss any lumps." His wife was in poor health and had recently stopped acting as a patient.

When Scott and I entered the examining room, Mr. Miller wore a blue pinstripe shirt with blue chinos. We were the second session for the evening; he had already taught two of our classmates. First he quizzed us on the statistics for testicular cancer and made sure we knew what to look for on the physical exam. Then we talked about language.

"Never ask a man to spread his legs. It's too demeaning," he said. "Instead you should ask him to move his legs apart. If he gets an erection, you can just stop the exam and continue later." We discussed how to teach a man to do his own exam.

After the short talk we left the room so Mr. Miller could change. When we returned, he was wearing a white T-shirt, blue chambray boxers, and black dress socks. We practiced the exam on him, all the while demonstrating how we would teach him to do his own self-exam. This exam was much less involved than the female exam, and it took only half an hour to learn.

I palpated the shaft of his penis and practiced rolling back the foreskin. "Never, never forget to replace the foreskin. It's a very sensitive area, and it can be painful if you don't replace it," Mr. Miller reminded me. I released the foreskin and practiced rolling it back between my thumb and first finger again. Afterward I tried my first prostate exam. I had been told the prostate would feel similar in consistency to the tip of my nose. After following his directions, I inserted my finger into his rectum and felt the smooth firmness of the prostate beneath the pad of my finger. I felt across the smooth base of the prostate, but try as I might, my finger would not reach to the top of his prostate. "You've got to really lean into me." I pushed a little harder, still impossibly far from the apex of his prostate. Finally, I removed my finger. I was relieved to have all my first genital exams over.
salon.com | April 14, 1999

- - - - - - - - - - - -

- - - - - - - - - - - -

  Get a printer-friendly version

  E-mail a friend about this article

- - - - - - - - - - - -

Search Salon