Medical actors help doctors learn how to do “those” exams

NORFOLK, Va. — For her next lesson, the teacher, a petite, dark-haired woman named Anna C. Sosa, shrugs off her red robe, kicks her striped socks into the footrests and steels herself for yet another potentially disastrous pelvic exam.

It’s a sweat-soaked summer morning outside Eastern Virginia Medical School’s Sentara Center for Simulation and Immersive Learning, and inside this mock hospital room, three medical students in starched white lab coats stand wordlessly between Sosa’s feet.

The room feels microscopic, with fluorescent lights and functional carpet, its beige walls sterile and sparse save for three mounted boxes of latex gloves. Then there’s Sosa, who breaks the silence by hoisting a pair of speculums like six-shooters into the frigid, antiseptic air.

These cliched “medieval torture devices” are nothing to be afraid of, she says. In fact, this duck-billed tool, with all the sleekness of a caulking gun, is a thing of wonder, she says: the guide to the gateway of all human creation, that staggeringly important part of the body most women will never see.

“This may not be the first time you capture the live cervix,” Sosa says, smiling encouragingly, “but either way, we’re in this together. Go, team cervix!”

Sosa is a gynecological teaching associate, and she holds one of modern medicine’s most awkward jobs, using her body to guide med students through some of its most delicate, dreaded exams. Every week, she lies back for dozens of the next medical generation’s first pelvic and breast screenings, steering gloved fingers through the mysteries of her own anatomy and relaying the in-depth feedback they’ll need out in the wild.

She is not, in the traditional sense, a medical professional herself: A 31-year-old theater actor, she has also worked recent jobs at a bakery and Barnes & Noble. Yet what she lacks in faculty prestige, she and her compatriots — including a squad of male urological teaching associates, who teach genital and prostate exams — make up for in humor, candor and endurance. For nervous students, she is like an enthusiastic surgical dummy, awake through the operation and cheering them on.

Christina Starks Hall, a 36-year-old student on her last day of physician-assistant school, pulls a stool close and gently lifts the white drape crumpled across Sosa’s waist. Starks Hall has worked on hospital rotations before, but the speculum is still, as she says, “a complicated li’l piece of equipment,” and this is still a stranger’s anatomy she is about to explore.

“You’re going to feel my hands on your tissue, and it’s going to be cold gel and lots of pressure,” she tells Sosa, who spectates via a small hand mirror with a cartoon girl on the back. Starks Hall aims the speculum, saying, “I want you to take a deep breath … and exhale.” Sosa breathes out and says, “Very appropriate verbalization and a safe, smooth insertion,” and only then does Starks Hall exhale, too.

Sosa attempts to lighten the mood, telling the three students not to “hold speculums gangster-style” but rather to, as some texts recommend, “hold it like a cigar, which is a horrible reference.”

But it is a nerve-racking experience, nonetheless. In Starks Hall’s first exam, two years ago, she forgot to release the speculum during its removal, leading the patient to jolt with pain — and Starks Hall to wake up on a stretcher, headed for the hospital, having fainted.

For anyone familiar with these tests’ indignities — the snapping of a latex glove, the frosty surprise of a speculum, the barks to “bend over” — what these teachers do may seem almost messianic, like a sacrifice for the betterment of the rest of us, taking hundreds for the team. That doesn’t necessarily make it any easier for the teachers and students in these tense exam chambers, where questions seem to echo off the walls: Does this hurt? Am I doing this right? And the one the teachers hear the most: What kind of person does such a thing?

• • •

There is no true substitute for the squishy grotesquerie of the imperfect human form. Blemished and unsculpted, it is rife with surprises, each lump and bump like a tiny opportunity for the learner to explore.

But the live body is a recent addition to the medical classroom, and its placement there is preceded by a dark and awkward history. Some doctors today began their careers practicing pelvic exams on patients zonked on anesthetics, many of whom were poor walk-ins to outpatient clinics, never asked to give consent. In the late ’60s, realizing passed-out guinea pigs didn’t offer the best critiques, medical schools started recruiting untrained pelvic models, including prostitutes. Improvements to the program’s ickiness and patient feedback were negligible, at best.

The practice of training and paying gynecological teaching associates, or GTAs, is only a few decades old, and for years it went unnoticed even at the highest levels of the medical world. Gayle Gliva-McConvey, a former president of the Association of Standardized Patient Educators, remembers trying to spread the word at an American College of Physicians conference in the ’90s, blocking off space with a velvet curtain and asking passing doctors, “Would you like to refine your breast and pelvic examination skills?”

“Nobody even knew what GTAs were,” she said. “I got one guy who looked me up and down and said, ‘Sounds intriguing.’ “

The programs have grown rapidly over the years, including at Eastern Virginia, considered a pioneer. Its simulation center now employs 130 “standardized patients,” the broader group of workers who fake medical ailments for education’s sake.

The school also routinely crowds its GTAs and male urological teaching associates, or MUTAs, into vans and planes for sessions at 65 medical schools from North Carolina to New York. At a recent three-day seminar, teachers sat through 900 practice exams.

In New York and Los Angeles, the simulated patients are often actors; here, in eastern Virginia, they are part-time or former professors, baristas, retail workers and house spouses, all contract workers paid by the session, and not extraordinarily so. Gliva-McConvey, the program director, said wages were confidential but added, “All I can say is, we don’t pay them enough.”

Vocabulary becomes hugely important to avoiding clumsy wording. Teachers are taught to neutralize sexual language — it’s a “table,” not a “bed”; a “drape,” not a “sheet” — and cut back on awkward phrases: Say “footrests” instead of the too-equestrian “stirrups”; “lots of pressure” instead of “this is going to hurt.” Students aren’t supposed to “grab,” “stick in” or “pull out” anything, though in the moment, instructor Kelene Williams said with a laugh, “sometimes neutral doesn’t come out.”

For all their pedantry over word choice, the sessions can be surprisingly laid-back. When Jim Sandloop leads what he calls a “guided tour of the male genital examination,” the 69-year-old retired salesman and Army veteran, who learned of the job 10 years and 1,000 exams ago from a friend in the Porsche Club of America, is always ready to cut the tension with a joke, even at the expense of his own nerves.

Lying on his side before his first prostate check of the day, he tells three students: “There’s no need for speed here. We don’t need to turbocharge our way up to the umbilicus,” or bellybutton. “If this is their first examination,” he said later, “they’re going to be trying to stare a hole through the wall over here, because their world’s about to end as they know it.”

Many of the teaching associates flake out, from stage fright or spooked spouses or the fear of nine genital exams a day. And GTAs are reluctant to bare all the details about what they do after they clock in: One said it felt like being in the closet.

But many also say the job can feel incredibly empowering. Temple West, a former GTA who started as a standardized patient when she was 60 on a recommendation from her Jazzercise instructor, called her first discovery of her body’s inner workings “just about the neatest thing I’d ever done.”

That reaction is surprisingly common. Students who have only read about the cervix in medical texts, teachers said, have been brought to tears or exclaimed, “It’s so beautiful!” or “Oh my god!” As GTA Alexandra Duncan wrote in an essay on BuzzFeed, “At this point in my life, my uterus has made more people cry than I have.”

If we didn’t believe in it, you couldn’t pay us enough’

Anna Sosa’s primary education about her down-there parts stemmed mostly from the neighbors’ kids. She didn’t get her first well-woman exam until she was in her 20s and married. Her husband, Yohn Sutton, offered her sushi and ice cream for when it was over, fearing she would be traumatized.

A theater graduate from Virginia Commonwealth University, Sosa was “living the hipster dream” then, working at a bookstore and acting at the Generic Theater, a Norfolk playhouse.

After an audition, she met Jeannette Rainey, a bubbly real estate agent who started working at the medical school as a side gig during the housing bust. The job sounded more intellectually stimulating than stacking novels and would allow more time to work on shows. Sosa was in.

The tricky first sessions were full of clumsy maneuvers and moments of insecurity. But now, Sosa said she feels as if she has taken control of her body for a noble cause, and is making money by saving nurses, doctors and patients from chagrin. She has done the job for about five years now and sees about six medical students a day.

When she leaves her cozy Cape Cod home in Norfolk and travels to a new school, she packs all her own gear: her gown and gloves, her mirror and speculums, nail clippers for her students, and epsom salt for her warm post-session recovery baths. Often, she and other GTAs will travel in vans, looking like a big, happy church group.

Her husband, a zoo biologist, understands there’s something objectively scientific to the work. But family members, who tittered when she acted in the “The Vagina Monologues,” still have a hard time getting why she does it. Even her mom, a nurse’s assistant, questions why she puts herself in such a vulnerable position.

Sometimes Sosa wonders how much longer she’ll do it, whether she can really save enough money to pursue her artsy dreams. But when she gets discouraged, she remembers there are women suffering from conditions that could be caught through early detection, from tests like the ones she’s paid to teach.

Rainey puts it another way: “If we didn’t believe in this work, you couldn’t pay us enough.”

•••

In this mock hospital room, the three students in their coats and latex gloves are breathing a little bit easier, letting their shoulders sink and laughing a little.

One of the students, 30-year-old physician-assistant hopeful Kirstin Grant, said later, “Each and every time, I feel like your comfort level adjusts, you breathe a little deeper, you say, ‘OK, OK, I can do this.’ You get greedy, almost. Like, can I do it again? Can I do it again?”

Sosa guides the other two students through how to lead the test, pointing out features on a rubber uterine mold. The drape is lifted and the exam begins again. The speculum goes in, the light turns on and, amazingly, there it is: the cervix, looking like a tiny ring.

No one cries or faints, but the students crowd inward for a better look, and Sosa grins like a magician who just aced a trick.

BY THE NUMBERS

130: Number of “standardized patients” employed by Eastern Virginia Medical School’s Sentara Center for Simulation and Immersive Learning

65: Number of medical schools that Eastern Virginia’s standardized patients travel to for seminars and special teaching sessions

8-10: Number of sessions a gynecological teaching associate (GTA) might work a month

9-12: Number of breast and pelvic exams a GTA facilitates within a session

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Video:

Inside a mock hospital room at the Eastern Virginia Medical School in Norfolk, Va., specially trained instructors act as patients, helping guide future doctors through breast and pelvic screenings. (By Jorge Ribas/The Washington Post)

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http://wapo.st/1EBE0CX

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The Associated Press

09/09/15 10:30

130: Number of “standardized patients” employed by Eastern Virginia Medical School’s Sentara Center for Simulation and Immersive Learning

65: Number of medical schools that Eastern Virginia’s standardized patients travel to for seminars and special teaching sessions

8-10: Number of sessions a gynecological teaching associate (GTA) might work a month

9-12: Number of breast and pelvic exams a GTA facilitates within a session