“GAMMS”: - Go away, male medical student

With the number of doctors opting for careers in obstetrics and gynaecology dwindling, Alexander Hamilton expresses his views about male medical students being turned away from clinical examinations

Anyone who has read Samuel Shem’s novel The House of God will remember the insensitive but memorable term GOMERS (Get out of my emergency room). I have coined a new acronym — the GAMMS (Go away, male medical student). GAMMS describes the exasperating patients who refuse dashing young students from observing their most intimate areas and the invasive techniques that doctors apply to them, to the detriment of medical education, solely because the student is male. They are the polar opposite to SALs (student allowing ladies), who heroically expose their nether regions to the speculum wielding student, promoting experiential learning.

Acronym applies to both sexes

You may have noticed the acronym can be applied to either sex. This is because, in my experience, the husband or partner is often more active in refusing a medical student than the woman patient herself. Recently I experienced this kind of rejection first hand: a midwife introduced me to a couple in advanced labour. I attempted my usual rapport building conversation, and when the midwife asked the million dollar question—“May he observe the birth?”— the husband shouted “No!” I felt like reminding him I was actually standing right in front of him, and that he did not need to shout, but instead I fled as the baby decided to crown. I was terrified that I had spoiled their birth experience and felt guilty that my request had provoked such a strong reaction.

Currently only 0.2% of newly qualified male doctors are choosing obstetrics and gynaecology as their chosen clinical specialty, and as 90% of UK registrars did their training outside the United Kingdom¹ fresh British male input is sorely needed. This will allow developing countries to keep their own doctors, rather than losing them to the NHS (having had to fund their training in the first instance).

All doctors need to learn special skills

So why recruit men? Why not make it a speciality for women only? Primarily because that would be like saying all geriatricians should be elderly² and patients may request a male doctor or have no preference as to their doctor’s sex (some female patients find it less embarrassing to expose themselves to a man than to another woman).³ As doctors we are not limited by the nature of our specialty, and the Hippocratic oath means that our patients are protected by our promise to treat without harm or condition.

The traditional reasons for avoiding obstetrics and gynaecology still stand—unsociable hours, litigation, and bullying⁴—yet the lack of exposure for male students in their obstetrics and gynaecology attachments while at medical school may have far reaching consequences, giving rise to many more barriers to a career in the specialty. Nobody will enjoy or persevere against continued rejection, which can lead to self doubt and unhappiness at what can be seen as failure.

Negative outcomes

When a male student is refused permission to attend a consultation or observe or perform an examination or attend a delivery, multiple negative outcomes occur. Part of this may be due to the way in which the refusal occurs—for example, patients or their partners may be rude or aggressive, making the male student feel degraded, guilty, disappointed, and unwanted. Subsequently, the student then lacks experience and therefore confidence, hindering future progress. In addition, the student’s enthusiasm may dwindle—spending clinics sitting outside because each patient refuses permission for you to examine her is not a productive experience. A further consequence is that competition between some male and female students means that male students will inevitably give way to female ones when they themselves have been refused permission to attend a patient, leading to jealousy and bitterness.

Equal opportunities

It is well documented that male medical students perform less well than their female peers in assessments in obstetrics and gynaecology.^{5 6} This alone may prove enough to put some students off what they perceive to be a field dominated by women. As a consequence of equal opportunities legislation, medical schools and even the Royal College of Obstetricians and Gynaecologists need clearer guidelines to prevent discrimination against men.

Why are patients reluctant?

Why are women patients reluctant to allow male medical students to perform intimate examinations? The idea that men lack female organs and therefore cannot relate to disorders of those organs ignores our ability as human beings to empathise and support one another. This bypasses the fact that those men can still effectively treat women, even though they will never be able to experience the pain or discomfort of childbirth. Most female medical students have not experienced pregnancy either; and if they do, they will, on average, be 85% as productive as men in obstetrics and gynaecology.⁷ Men’s motives for choosing this specialty are often questioned. Scenes such as the male doctors talking about “freaky fannies” in Jed Mercurio’s television series Bodies, and the sexual assault by a gynaecologist on his patient in the 1992 film The Hand That Rocks The Cradle don’t help to dispel the idea that some male doctors have something other than a mere clinical interest in the female genitalia.

The ethics of internal examinations on patients have long been debated.⁸ As for examining patients under anaesthetic, we are currently expected to clerk patients on a theatre list and obtain written consent in a pro forma provided in our course guide. The requirement of a chaperone protects both the practitioner and the patient and should be mandatory for female practitioners as well as male ones, to establish a universal system. Ethically, we must examine patients for diagnostic purposes, and whether this is Kantian (what are the means to an end—that is, it is wrong to use a patient for personal gain; http://en. wikipedia.org/wiki/Immanuel_Kant#Example_of_the_second_formulation) or utilitarian (the greatest good for the greatest number of people—that is, training medical students allows more doctors, so patients should be examined; http: //en.wikipedia.org/wiki/ Utilitarianism#Types_of_utilitarianism) does not matter if the patient consents.

Role of expert patients

This brings into focus the idea of expert patients, who teach students how to examine them internally. I have already met and received teaching from expert patients in rheumatology and in obstetrics, which was extremely useful and provided a strong humanitarian approach to their situations. This may prove key when performing a pelvic examination. Guy’s, King’s, and St Thomas’ medical school already makes use of gynaecology teaching associates,⁹ who allow students to perform bimanual and pelvic examinations on them, the emphasis being on communication skills as well as the practical side.

The current dip in interest in obstetrics and gynaecology as a specialty is the opposite of five years ago, when too many registrars were trained. New consultant posts failed to materialise, and many doctors were left unable to find a job and so ended up in general practice. This is a direct contrast to men in midwifery: male midwives accounted for more than 10% of UK midwives in 2001, and this has steadily increased to 10.73% in 2005.¹⁰ Attitudes towards male midwives are changing, with many fathers postulating the idea that men can communicate the process to them better and help fathers to get more involved in labour.¹¹

Educating patients

The patient’s right to refuse a student to take part in their healthcare experience opens a debate about educating patients about the requirement for student learning, whether they be male or female. Some say that patients should not be allowed to choose. If they are seen by a doctor at no cost at the time of delivery, they ought to make certain sacrifices—for example, “enduring” the presence of a medical student. After all, how are we supposed to learn otherwise? Consent should be assumed, with patients given the choice to opt out rather than in.

Various techniques exist to encourage patients to agree to consent. The most effective and perhaps the most appropriate way would be to clerk a patient first, to build the doctor-patient relationship. The patient has faith in you as you have explored her symptoms in a professional way and asked pertinent questions relevant to her, and you have the opportunity to empathise with her, strengthening the bond. By the time you ask her if its OK to examine her, she will see that it is a necessary step in her diagnosis and be willing to help you to help her. Simply sitting in a clinic and expecting to be allowed behind the curtain is not good enough, but sadly clinics are busy and often overbooked, and there is not always time for students to see new patients and both student and doctor to examine them. The limitation to this approach is that some patients prefer to expose themselves for a gynaecological examination by someone whom they will not see again, rather than by a student with whom they have established a relationship.

Midwives make the best allies

The key to obtaining obstetric consent is undoubtedly the midwife (as long as you are not competing with a midwifery student). Not only can you learn practical skills from them, but they literally open the door to patients. It is unfortunate if they ask patients, “Can the male student come in?” while you wait outside, as the patients invariably say no. But if they allow you to enter into the circle of trust created between a couple and their midwife, you can begin to forge a link with the couple that will lead to a positive outcome. One particularly student oriented midwife I encountered actually tells patients she needs the student to document the observations (opt out), overcoming their initial objections as often they are happy once they realise you are here to help them in their birthing experience, as well as learn. Perhaps exploring issues of consent and specific training for medical students should be given more attention in the midwifery curriculum?

Another technique is to attend antenatal clinics regularly and to take part in antenatal ward rounds. When women come to the delivery suite and see a familiar face it helps ease the tension they might feel during labour. As examining the abdomen of a pregnant woman doesn’t usually pose a problem, you have already made physical contact with the patient. The patient has also seen you in a shirt and tie and so has a better idea of what you look like when you don’t have bloodshot eyes and theatre blues.

The motivation for a doctor, whether male or female, to undertake a career in obstetrics and gynaecology is that it provides a mix of medicine and surgery and the opportunity to make a substantial difference to someone’s life.¹² It also overlaps with endocrinology and paediatrics (among others), covering a wide range of skills and knowledge. This shouldn’t be confined to women, and moreover, female patients should be made more aware of equal rights for doctors as well as patients, and the need for training and progression, so that the next generation might benefit too.

 

Alexander J Hamilton, fifth year medical student, Imperial College London
Email: alexander.hamilton@imperial.ac.uk


studentBMJ 2006;14:89 - 132 March ISSN 0966-6494

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3. Johnson AM, Schnatz PF, Kelsey AM, Ohannessian CM. Do women prefer care from female or male obstetrician-gynecologists? A study of patient gender preference. J Am Osteopath Assoc 2005;105: 369-79.
4. Franzcog PM. Why young doctors should career in obstetrics. Obstet Gynecol 2003;5:180-1. ranzcog.edu.au/prospective/pdfs/WhyACareerSept03.pdf (accessed 3 Feb 2006).
5. Groves T. Do male medical students get a raw deal in obstetrics and gynaecology training? studentBMJ 2004;12:89-132 (March.)
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7. Pearse WH, Haffner WH, Primack A. Effect of gender on the obstetric-gynecologic work force. Obstet Gynecol 2001;97: 794-7.
8. Coldicott Y, Pope C, Roberts C. The ethics of intimate examination—teaching tomorrow’s doctors. BMJ 2003;326: 97-101.
9. Cowdrey L. Gynaecological teaching associates. studentBMJ 2004;12:468. (December.)
10. Nursing and Midwifery Council. Statistical analysis of the register 1 April 2004 to 31 March 2005. London: NCM, 2005 www.nmc-uk.org/(bjcyhozvkmgvbazziegalh55)/aFrameDisplay.aspx?DocumentID= 856 (accessed 3 Feb 2006).
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	Responses published this month

Articles	Responses
CAREERS “GAMMS”: - Go away, male medical student       Alexander J Hamilton (March 2006)	Shahbaz Malik (March 14th, 2006) Read this response
CAREERS “GAMMS”: - Go away, male medical student       Alexander J Hamilton (March 2006)	Dave Ejibe (March 11th, 2006) Read this response

	CAREERS “GAMMS”: - Go away, male medical student       Alexander J Hamilton (March 2006)
	Shahbaz Malik (March 14th, 2006)       4th year Medical Student, college of Medicine, Cardif University shahb.malik@gmail.com
	I wholeheartedly agree with Alexander with the issues raised in the article. I am currently on O+G rotation in Rhyl, North Wales. I am in my 4th week, and have one more week to go. Being a male I have had same issues as discussed, although i have been lucky in some ways and I have managed to attend some normal vaginal deliveries as well as got consents to do VEs under anaesthesia. There are few reasons, partly there are only three of us on the rotation in the whole of O+G department. This means there is less competition among us to attend a delivery. Secondly there are relatively few midwife students, so this makes life even easier when we are on the labour ward. Midwives are very sympathetic and are happy to bleep us if there is a delivery or an interesting case. I must mention one of the midwives, who really impressed me. As a patient was in second stage of labour, this particular midwife invited to come and witness the labour. she even allowed me to get a hands-on experience. However the patient in this case was very reluctant to allow another person come to del room. Midwife, politely mentioned the fact that there are usually two people delivering the baby and there could be more, if any complication was to arise. Patient however was unhappy about the fact, without giving a clear reply as to whether she wanted me stay or go. I, however, in my scrubs, stood to one side and put an apron and pair of gloves on. As the patient went into labour, it was noticed the head was in PA position and delivery was not as easy as it would have been for a para3 lady. Anyhow the birth took place some 2 hours later, in which I wholly took part and had the pleasure of taking placenta out. Its only after everything was done, the mother said, right then, you can stay, to which I smiled and left the room as quietly as I entered. My point is that most of the time, it all depends on how you are introduced to a patient. Some midwifes or nurses and even experienced doctors fail to convince a patient to allow a student to observe a delivery or an examination. Some of the consultants who are in a teaching hospital for long enough time, would use terms such as 'student doctors, or 'senior clinical student' or even 'trainee doctor'. None of these terms are deceptive in any way but give a medical student more of a professional status that just calling a '4th yea medical student'. I myself have seen a difference when I introduce myself as a 'student dr or trainee dr, part of a particular team', patients hearts melt and seem to be more co-operative somehow. Lastly I must also mention that there are more male consultants in O+G than females. I recently read an article in doctor's mess, where RCOG is clearly failing to attract students from the UK universities. Unless recruitment improves there will be insufficient obstetricians to deliver the NHS service. http://www.rcog.org.uk/index.asp?PageID=97&PressReleaseID=113 "However, in recent years the specialty has seen a decline in the numbers of UK graduates entering its ranks. In 1995 O&G was the main career choice of 26 out of 545 doctors, in 1998 this was 16 out of 509 and by 2002, only six out of 487. In 2004, 171 candidates were admitted to the Membership of the RCOG. Only 12 were graduates of UK universities, and of these, only three were male." http://www.rcog.org.uk/index.asp?PageID=97&PressReleaseID=113 RCOG is clearly failing to attract the medical students from UK to the speciality. When one considers that a medical student may only experience 6-8 weeks out of 60 months of student life, then you really have to sell and market the specialty very well to us. Some of my colleagues, who have not been as lucky as me, have had negative experiences in the specialty as a student. Some attribute it to bad attitude of midwives and others blame it the way their consultants attitudes. Lastly, in Glan Clywd Hospital, Rhyl, all the SHO and SpR posts in O+G are filled with overseas doctors. Some of them are fairly new to the system themselves and yet do not know the healthcare system well enough, let alone making it attractive to students, while others have been here long enough to contribute positively. In my experience of attending gynae or ANC clinics, each patient is seen by a junior and then that case is discussed again with the consultant. Some doctors don't even know how to communicate effectively an efficiently with the patient. How is this supposed to attract a medical student to O+G speciality? "The reasons for this decline are many-fold, and numerous studies have been conducted to establish the root causes. But at the heart it seems to be negative perceptions around career opportunities, as well as undergraduate experience of the specialty, uncertainty around future consultant responsibilities and issues around training and particularly work-life balance's. The College's recent publication and recommendations of, The Future Role of O&G consultants covers the areas of concern and enables a flexible and varied approach to training and modern service delivery. Increased consultant presence on the labour ward is essential to improve care whilst at the same time, individuals will have the opportunity of tailoring their training to areas of specialist interest and aptitude http://www.rcog.org.uk/index.asp?PageID=97&PressReleaseID=113

	CAREERS “GAMMS”: - Go away, male medical student       Alexander J Hamilton (March 2006)
	Dave Ejibe (March 11th, 2006)       Final year medical student, university of Calabar daveejibe@yahoo.de
	I read the 'GAMMS' article with quite a lot of interest because the often exclusion of male medical students during gynaecological examination of patients is one that I believe that most medical students who are in or have passed through obstetrics and gynaecology postings can relate to. I was however surprised to learn from the article that Obs and Gyn was a female dominated field. This is quite contrary to my personal observations as I have not met many female gynaecologists and indeed, in the majority of hospitals in Nigeria, it is a male dominated field and one which continues to draw a lot of followers, its lucrative prospects often contributing to this attraction.These contrary observations do not negate the authors assertion as they are based only on local findings. Again in my medical school, the exclusion of male medical students from observing or performing clinical examinations on the the obs&gyn patient is almost exclusively seen in the out-patient setting, whereas opportunities abound in the labour wards for the reason that a woman in labour would seldom worry about the sex of the doctor or student examining her considering the ordeal of the experience. Furthermore, the fact prospective fathers are not allowed into the labour room in this part of the world excludes the possibility of them denying medical students the opportunity of experiencial learning. Also here medical students are expected to assist a minimum of a certain number of deliveries in the course of their obs&gyn postings thereby providing equal opportunities for both male and female students and alas, the male students usually do better here. perhaps this system ought to be adopted by other medical schools.