Medicine and the arts. At the Gynecologist's.

medicine and the arts F or medical students, mastering the art of the pelvic exam presents its own emotional and psychological challenges. In a situation of extreme physical intru- sion, the medical student is encouraged to acknowl- edge only its normalcy. Standardized patients are now rou- tinely used to guide students through the procedure, and to provide explicit feedback when students have been insensi- tive or rough. Nevertheless, adequately preparing young men and women to conduct such an intimate exam requires care- ful attention on multiple dimensions, psychosocial as well as mechanical. In this context, even poetry can be a learning tool to help students apprehend aspects of the pelvic exam that stan- dardized patients may have difficulty verbalizing. Recently, a group of first- and second-year medical students and I read two poems about the gynecologic exam as part of a module on the physical examination in an elective literature and medicine course. The poems offered moving insights into what that exam should and shouldn’t be. ‘‘At the Gynecologist’s’’ by Linda Pastan presents the pel- vic examination as ‘‘memento mori,’’ a reminder of death. This poem helps students be aware that every medical scru- tiny of our vulnerable human bodies, ‘‘contrived for pain,’’ holds the potential to shatter ‘‘the dream of health’’ and bring us face to face with suffering and mortality. In this case, the physician’s inhumane, heartless inspection of the patient only compounds her dread. The overwhelming ex- perience of reading this poem is one of isolation, vulnera- bility, humiliation, and violation. The patient is excruciat- ingly alone, despite the doctor’s presence, metonymically represented by ‘‘hands impersonal as wax.’’ These seemingly disembodied hands, which only mimic flesh and blood, use both the patient’s position (in stirrups) and the tools of the gynecologic trade (i.e., the speculum) to pry into her body. The patient regards herself as trapped, with no hope of es- cape. Her only option is to continue to ‘‘gallop towards death,’’ which, in addition to the ever-present possibility of physical death, may also refer to a death of the spirit brought about by the dehumanizing experience of the exam. Pastan’s poem reminds the students that a ‘‘routine pelvic examination’’ can brutalize and devastate the patient when conducted in an unfeeling manner. Although reading this poem helps make students aware that the pelvic exam can evoke complex emotional issues for both patient and doctor, it also makes the idea of performing such an exam pretty scary. As a corrective to students’ fear, we considered a second poem, ‘‘Riding Chaucer in the Stirrups’’ by Sophie Hughes. While Hughes identifies issues similar to those described by Pastan—vulnerability, isolation, violation—she also rec- ognizes the ludicrousness of her physical predicament, and describes it with ironic humor (‘‘examination of the in- nards’’). In contrast to the cold, mechanical, lifeless physi- cian in Pastan’s poem, the physician in ‘‘Chaucer’’ is a living, breathing human being. In almost comradely spirit, the nar- rator addresses this physician directly in the second person (‘‘you’’). It quickly becomes clear that this pelvic examina- tion is to be a joint project conducted mutually between patient and doctor. Hughes’ sympathetic physician knows that ‘‘the patient should be put at ease.’’ At the moment of her greatest vul- nerability to the geography and implements of his* trade, he chooses to venture into her world—by declaiming a line of poetry! The results are gratifying. Although this physician ‘‘presses and probes,’’ he does not ‘‘pry,’’ suggesting that, given a humane context, patients can gracefully, even hu- morously, accept legitimate invasions of their bodily space. Eventually he ‘‘pats,’’ a medically unnecessary but reassuring human gesture. Further, unlike the woman in ‘‘Gynecolo- gist’s,’’ this patient is not a prisoner in the stirrups. The exam has a beginning and an end, and ultimately the patient is able to shed the ‘‘angel robe,’’ with its intimations of death. In this exam, the rain of Chaucer’s ‘‘Aprille showres’’ nour- ishes not the flowers of death referred to in Pastan’s poem, but a ‘‘flour’’ of ‘‘vertu,’’ in this case a truly good and virtuous doctor, whom the patient gratefully praises. Students are left contemplating two equally powerful, but alternative images of the gynecologic exam. In one, the pa- tient is isolated and depersonalized, the fearful burden of her mortality unrecognized by a callous gynecologist. In the other, patient and physician recite poetry together while the doctor performs the examination in a respectful, dignified manner. Although one literal-minded student worried about what would have happened if Hughes’ doctor hadn’t known any poetry, most understood the metaphor and the message: Avoid exploiting the power differential inherent in the gy- necologic examination. Be careful not to unconsciously bru- talize your patient or leave her emotionally abandoned in a state of vulnerability and discomfort. Instead, risk connecting in ways that recognize your patient’s humanity and that are celebratory and joyful. It is in this way that medical students, indeed all physicians, can attain virtue in medicine. Johanna Shapiro, PhD Dr. Shapiro is professor and director of medical humanities, Department of Family Medicine, University of California, Irvine College of Medicine, Orange, California. *Although the gender of the physician is not clearly established, the quote from Chaucer uses the masculine pronoun. A CADEMIC M EDICINE , V OL . 77, N O . 12 / D ECEMBER 2002 P ART 1