A Quiet Revolution

A Quiet Revolution

by Lila A. Wallis, MD

A quiet revolution has been taking place in American medical schools during the last decade. Learning from patients has long been the basis of medical education, but the patients’ traditional role in this process has been passive: to be just a body for examination and a voice to answer questions. This method of teaching prepared future physicians to expect passivity from their patients— and dominance from themselves.

The consumers’ and women’s movements of the 1960s challenged these expectations. Patients discovered that doctors are not infallible. Doctors’ persistence in treating patients as objects generated anger that occasionally took the form of malpractice suits, many of which were brought, not because of the doctor’s incompetence, but because of his or her failure to listen to and communicate with the patient.

The ways in which many physicians conducted the so-called “sensitive” examinations were among the most common occasions for anger. Women patients were angry, even if they did not complain, when breast and pelvic exams were painful; thoughtlessly, cavalierly, insensitively, or incompetently performed; or incomplete. Primary care physicians frequently omitted the pelvic exam and Pap smear from the comprehensive examination and referred the patient to a gynecologist instead. Those of us who teach physical diagnosis to second year students also realized that excluding breast and pelvic examinations from the curriculum taught the young doctor to regard these exams as difficult, unnecessary and “all right to omit” from the general comprehensive physical.

In 1972. the gynecology teaching associate program was born of the combined efforts of academic physicians and small groups of non-physicians who joined forces to improve medical education and to sensitize medical students to the needs of women patients.

In the TA program, women educators were trained to teach breast and pelvic examinations to medical students; they acted as both instructors and subjects, emphasizing not only technical skills and anatomic information, but also the proper attitude, sensitivity, language, and nonverbal behavior. The idea of approaching the patient as a partner in her care was central to the philosophy of the TA workshop.

Students have responded enthusiastically to all the TA programs that have been introduced throughout the country since 1974. Those who were taught by the TAs displayed more democratic egalitarian attitudes, increased respect for the mind and body of the patient, willingness to educate as well as to learn, and acceptance of the patient as a partner in her care.

When TA-taught medical students reached the clinics and wards, their skill and sensitivity in examining patients earned them the gratitude of patients and approval from nurses and faculty. It became apparent that in order to maintain uniformity of standards, house staff also needed TA training. At the New York Hospital Cornell Medical Center, medical and gynecology interns have been given the opportunity to participate in TA conducted workshops as part of their orientation day. The program has also been extended to nurse practitioners and MD-PhD and surgeon assistant students with positive results. TA workshops have also become part of the continuing medical education program for staff and outside physicians.

In 1980, about 75 U.S. medical schools had TA programs. It is heartening to see that in 1983.93% of the 116 U.S. and Canadian medical schools responding to Beckman’s survey (unpublished data. 1983) used “live models or teaching associates” in place of, or in addition to, traditional methods. And 82% of the schools rated the teaching associate method as “extremely effective.”

As could be predicted, teaching practicing physicians is a greater challenge for the TAs. Although the doctors have responded enthusiastically, the TAs have frequently found it difficult to progress smoothly in the face of the ingrained bad habits and sensitive egos of practicing physicians. Interruptions, masquerading as questions, are frequent: “In my office, I do it thus . .” Tact and insistence on getting through the demonstration are constantly required. As a result, the sessions can stretch interminably.

The TAs have risen to the challenge, and have adopted the “no interruptions” policy. They have also developed ways to terminate tangential comments. All in all, however, the doctors have indicated that they plan to use what they have learned to change breast and pelvic exam procedures in their practices.

One of the goals of the TA concept is to influence the development of students’ attitudes toward their future patients. Producing physicians with more democratic-egalitarian attitudes, increased respect for the patient’s mind and body, a willingness to educate as well as to learn, and acceptance of the patient’s partnership in his or her care—all are hoped for results. By examining and influencing students’ attitudes early—in the sophomore year—the TA program represents the foundation of an ongoing effort to change the attitudes of the entire medical profession.

The American Medical Women’s Association 1983 Woman of the Year, LILA A. WALLIS, M.D. is the organizer of the Cornell University Medical College Teaching Associates Program, and is president of the New York Regional Council of Women in Medicine, an organization whose conferences are dedicated to exchanging information about, and improving the standard of, women’s health care throughout the country. Thanks to efforts of Dr. Wallis, a TA program for the male reproductive system has been established at Cornell.