The other side of the speculum

My husband and I came across letters to the editor in our local newspaper about this article which only made us want to look it up and read it for ourselves. As a woman, I found this article to be incredibly funny and applaud anyone who can be brutally honest about a procedure that is quite invasive and uncomfortable! I feel that this article reminded me that doctors are only human and commend him on his honesty about his own apprehensions. He admits that it made him uncomfortable and that he felt he was not prepared for the experience of conducting a pap for the first time. What one gets out of this article is a reflection of oneself. If you read it and only see a young man poking fun at women, then I feel it is your own insecurities that have created your opinion. On the other hand, I see a young doctor who is admitting a slight flaw in the education he is receiving to prepare himself for such situations.

Several recent responses to Mr. Thoma's article make reference to a lack of professionalism, while completely missing the point that his writing is entirely concerned with the issues of lack of professionalism, and the difficult journey from non-professional to professional. Medical students are in the process of learning to be professionals, they are not yet professionals. Some aspects of professionalism are easily learned and practiced, e.g. the need for patient confidentiality. Others are much more complex and require a considerable amount of apprenticeship and experience to master; the physical examination of members of the opposite sex is one of these. It is also, for many of us, the most uncomfortable to learn. Mr Thoma's article is an honest account by a not-yet-professional of this uncomfortable learning process. To pillory him for lack of professionalism is entirely inappropriate.

For those who have not read the entire text of “The Other Side of the Speculum”, I suggest that you do so and form your own opinion on the intent and character of the writer, Brent Thoma (Canadian Family Physician, Vol. 55, No.11, November 2009, p.1112) My take is that Brent Thoma is a privileged, well-educated young man, fortunate enough to gain access to a Canadian medical school to earn an excellent education funded in significant part by taxpayers, (half of whom are female), culminating in one of society’s most highly respected and well-remunerated professions. I find his comments directed toward women and women’s bodies to be disrespectful at best, nasty and misogynistic at worst. Not once in several readings did the purported intent of humour enter into my thinking.

Thoma’s use of the words “detest, worst nightmare, perils of the vagina, horrid ritual”, do not make me laugh, but instead, reflect something unfortunate about his views of women. If this article, whether meant to be humourous or not, had been written by a practicing physician, I have no doubt that a complaint to the Saskatchewan College of Physicians and Surgeons would arise. I suspect that the College would find the article to be inappropriate and unprofessional, perhaps even discriminatory.

As to Canadian Family Physician’s decision to publish Thoma’s piece, it remains a mystery to me that this national professional journal chose to reflect society’s continued tolerance of such negative attitudes toward women, while similar words used to describe a racial or religious group would not be tolerated. Re-read the article, inserting Indian or Muslim in place of woman/patient and you will see what I mean.

Any suggestion that we should have pity on Thoma as a young male doctor who must examine female patients, overlooks the parallel challenges that face young female doctors who must do testicular examinations and respond to male complaints about erectile dysfunction. Further, any exception that might be made for Thoma’s stated discomfort in talking to his supervising doctor or reluctance to raise his hand in class to discuss performing Pap tests, is ridiculous given his bravado in writing, distributing and publishing this article with his name and photo proudly attached to it. Such difficulty with a Pap test, a routine procedure, also makes me wonder how the future Dr. Thoma would react to the request to see a woman here in Canada suffering due to female genital mutilation inflicted in a far off land.

It saddens me to think that Brent Thoma’s brilliance as a student is not accompanied by an appropriate amount of sensitivity, kindness and respect. Rather than harden his position, I hope that this experience softens his boldness and increases his wisdom.

I think it's important to keep in mind that young people frequently blur personal and professional roles. In their search for their authentic voice, they express ideas and philosophies that more experienced doctors cringe at. Unfortunately Dr. Thoma wrote an article in a professional forum that has gone viral. I first heard about the article when it was sent to me by friends from New Zealand and the UK on Twitter, my daughter read the article on Facebook.

If medical schools take any lesson from this article,let's 1. improve our patient-centered teaching of intimate exams and 2. help our young doctors learn to present themselves appropriately in public forums. At the same time, I want them to be aware of the risks to themselves and colleagues of expressing themselves in ways that counter accepted practice, so they are prepared for the backlash.

After having heard through the grapevine about Brent Thoma's article a few months ago, I finally took the time to read it and reflect on the responses already written about it.

I must agree that I am disappointed that it was even published in the Canadian Family Physician Journal in the first place. It made me cringe to read it, and I felt embarrassed that the article reflects upon the medical school I attend, which I am proud of. This article also reflects upon me, a fellow medical student and future physician.

I think it is unfair to question Mr. Thoma's character, and I will not do the same, since I do know him personally and respect him. I do commend him for having apologized and taken responsibility for the reactions his article has caused. However, the greatest lesson to be learned from this article is the lesson of "the proper time and place". I am certain that many medical students echo Mr. Thoma's feelings of discomfort and lack of preparedness at certain times in the clinical setting. However, the kind of jokes he used would be best suited among his friends, in a private setting, and not in a national journal read by patients and physicians alike.

As a former nurse, I understand the importance of using humour as a coping mechanism because of the extremely challenging situations health care professionals are faced with. This humour is often referred to as "black humour". There have been several articles written about black humour, and while it can help professionals do a better job in serving their patients by enabling them to cope, it too, has a proper time and place. An insensitive comment in front of a vulnerable patient can be disastrous, making patients feel disrespected and calling into question the integrity and professionalism of the health care workers involved. Even black humour at the right time and place should involve certain boundaries and limitations, in order to keep health care workers in a professional, compassionate and caring mindset.

I read in other people's responses that Brent Thoma's article was not for naught in that it has triggered important discussions about the need for the adequate preparation of medical students to face difficult and uncomfortable situations. While this may be true, I would argue, instead, that even MORE importantly, Mr. Thoma's article reminds us of the need to be professional at all times.

We cannot forget that physicians are not trusted by the public as they once were, and mistakes we make are carefully scrutinized, and rightfully so. The recent proceedings involving an Ontario surgeon mistakenly performing mastectomies on two of her patients is a case in point.

I challenge my fellow medical students both here in Saskatchewan and across Canada (myself included), to pay extra close attention to your own professionalism and behaviour, both in and out of the clinical setting. While I strongly believe that medicine is a noble profession, which enables us to do much good for our patients and their families, we need to earn our patients' respect. Respect is not something we are entitled to just because we are part of the medical profession.

As a fellow male third-year medical student, I'd like to share my perspective on Mr. Thoma's Reflections piece - and the ensuing fallout (both defensive and vitriolic in nature). The subsequent condemning letters – while entertaining at the expense of Mr. Thoma – broach a complicated issue in a superficial way. Clearly there needs to be some form of discussion about topics that are “not perfect”, like the awkwardness that a male medical student may feel while performing a Pap test. At the same time, those who defend Mr. Thoma use self-reflection as a cart blanche defense for expressing an insensitive and offensive opinion. The truth of the matter occupies a deeper space in medical education that isn’t as clear-cut.

Throughout medical school, trainees are exposed to numerous lectures, seminars, assignments, and workshops designed to make us more reflective and thoughtful. These are helpful and have great value. However, the quality and nature of our reflections are rarely challenged. The simple expression of an opinion normally suffices passing through one of these training hoops. At most schools we are expected to have an extensive background in basic science, but the same cannot be said about the arts or language abilities. Passing the verbal component of the MCAT or writing an essay to gain acceptance to medical school do not count as deep reflective exercises.

What Mr. Thoma expressed in his article was a real, genuine opinion that deserves discussion. But the way that it was written and expressed was clearly flawed. Because a feeling is reflected doesn’t mean that it has been well reflected. If we’re to be serious about improving our reflection skills as a profession, I think we should consider improving our abilities to express ourselves.

I am actually infuriated at the multiple complaints I am hearing about Mr. Thoma's article.

I think he has honestly attempted to express his true feelings and sense of vulnerability as a student asked to do an uncomfortable procedure. As a recent graduate his article reminded me greatly of my past experiences, struggles and embarrassements as male physician in training. I see his points beyond his humour - which incidentally I believe is a matter of interpretation. Some people enjoy crude humour of the immensely popular "Family Guy" series, some just don't.

At the risk of being stoned myself, I don't see anything dehumanizing in Mr. Thoma's essay. I actually see much "humanizing" if you will, in admitting our own weaknesses, identifying our own fears, and recognizing our inner demons.

To nullify one's experience, especially when one has taken such a vulnerable position to discuss, what seems to be, a taboo subject and exposed his own self, is to me an insult in our attempt at understanding humanity.

Should have his writing be further edited to suit our "proper" audiences? Maybe. Should he have modified his style of humour? Sure, why not. Maybe most of us in our noble and "professional" profession doesn't agree with his sense of humour. Point taken. However, that should still not invalidate his experience and the point he is trying to make.

To Ms. Greenberg's high expecation ("A third year medical student should: know how to express ambivalence thoughtfully ; have the skill to begin to develop rapport in 2 minutes"), let me say this: give him a break. I still struggle to develop rapport in 2 minutes. And seriously, do you?

I have to admit that Mr. Thoma's personal narrative "The other side of the speculum" made me reflect about the medical profession as a whole and how we might be failing students such as Mr. Thoma. Although I find his narrative dehumanizing and insensitive, I think we are failing young students at the level of the "informal" curriculum, which refers to the attitudes, skills and behaviours that trainees acquire from interactions with their colleagues. Students and residents can be taught to examine their own attitudes, skills, values and behaviours to optimize the care they provide for patients. Students and residents should be encouraged to openly discuss emotionally challenging situations that they encounter in the clinical setting with the aim to foster professional behaviour and ability to self- monitor.

I had missed Mr. Thoma's original article, but the subsequent responses had enough of an effect on me that I felt the need to reply publicly, to bring attention to what I feel is a key message. I wish to applaud Christine Tai in pointing out that the needs of the patient need to be foremost in our minds. I think we can all agree that Mr. Thoma's article contained offensive and unnecessary attempts at humour. However, to his credit he has written a very eloquent and sensitive reply that I believes demonstrates what was felt to be lacking in his initial piece.

That said, I am dismayed that my senior colleage Dr. Ogle could write a reply containing so many spiteful adjectives, but fail to recognize the core issue that Mr. Thoma was struggling with. Furthermore, I don't see any greater editorial indiscredion in publishing the original article than I do in publishing Gail Greenberg's response. The none too subtle use of the "FIFE" mnemonic to teach Mr. Thoma a "lesson" comes off as insincere and smug, as Ms. Greenberg has not been in Mr. Thoma's position and is missing the relevant perspective needed to assess his progress as a learner. Her reply is merely the equivalent immature reply from the other side of theraputic relationship, but is also potentially damaging to interprofessional collaboration.

My faith in the system is thankfully restored by Dr. Andres' reply. What I hope we can take from this piece is that there is a very real and very important struggle with junior learners (myself included), and sensitive examinations. We tolerate Ms. Greenberg commenting on the difficulty she has with her new male physician performing her pap smears, but would we be so passive if she were discriminating on the basis of race, religion, or nationality? It is an unfortunate truth that sexism towards both genders still exists in our professions. Frankly, it is influencing my decision not to provide obstetrical care as part of my practice. Nobody will argue that inappropriate innuendo is harmful to the patient, but it is ultimately ignorant to believe that male learners do not have more difficulty establishing rapport and gaining opportunities to learn these important, cancer-detecting skills. Perhaps when an issue like this is identified, those with the knowledge and experience should try and educate and overcome barriers, rather than adding to them.

We are aiming to be resources to our communities. If we do not use our resources wisely, we do risk losing them. Is this really the best way to serve our patients' needs for skillful, accurate, and respectful cervical cancer screening?

Mr Thoma's reflection and the subsequent responses highlight issues that I think are worth exploring.

Medical students are faced with a difficult task. We tell them that they need to be self-aware and to develop their ability to use their relationship with the patient as part of the therapeutic process. Then we castigate them for the attempt.

Young men and women are still sexual beings as well as medical students, yet where in the curriculum do they have the opportunity to ask about the "what if's" of medical exams and procedures. They have their own fears and embarrassments, as well as concerns about the patients' fears and embarrassments.

As senior colleagues, I think we ought to be thankful that someone had the courage to remind us that although we may have found the ways to manage these issues, our newer colleagues still struggle. For every one person who expresses a concern, there are many others who feel the same way but are afraid to seem foolish or ignorant by expressing themselves. If we want sensitive, insightful candidates for Family Medicine, we need to acknowledge their fears and concerns, rather than dismissing them.

It takes courage, insight, and ability to present one's insecurities to national scrutiny. These are qualities that any program director should value and nurture.

The November issue of Canadian Family Physician included an article written by me entitled “Pap Smears: The other side of the speculum” (1). Several responses to its publication questioned both the editorial judgment of this journal and my own character.

My intent in writing the article was to highlight the very real discomfort felt by myself and other male and female medical students when asked to conduct exams such as Pap smears for the first time. For myself, this discomfort stemmed from multiple sources: I was uncomfortable with the authority and respect that I had been given but did not feel I had earned; I did not feel adequately prepared, but was uncomfortable telling my preceptor and I knew that there was an expectation that I perform the procedure. These issues are rarely addressed or raised in a substantive way.

In writing about this discomfort I made use of a common defense mechanism – humor. I regret that some readers may have found the article offensive or insensitive as that was not my intent, but I apologize and accept responsibility for this. I understand that Pap smears are difficult and even traumatic for many women and am particularly sorry for those comments that were made at the expense of patients. Regardless, I will continue, as I always have, to devote myself to providing patients with the best and most respectful care possible.

References

1 - Thoma B. The other side of the speculum [Reflections]. Can Fam Physician 2009;55:1112.

Publication of Mr. Thoma’s miserable attempt at humour represents either an unfortunate printing error or a regrettable and worrisome lapse in CFP editorial judgement. Rarely have we seen such a distasteful confluence of grade-school raunchiness and thinly veiled misogyny between the covers of a supposedly reputable medical journal.

To suggest that crass juvenile observations like “week-old tampons are not what get me up in the morning” even remotely approach acceptable standards for peer-reviewed publication would be like suggesting Mr. Thoma demonstrates even a beginner's understanding of compassionate patient- centered care.

To counter every pathetic instance of misinterpretation, failed learning, social ineptitude and sexually abusive innuendo would be to accord this author’s “reflection” more time and attention than it deserves. I can only hope that he is sincere in his decision to forego a career in Family Medicine, thereby sparing countless future female patients the agony of having to deal with his apparent Neanderthal tendencies. I do worry, however, about what he will be thinking as he looks into the eyes of his Ophthalmology patients.

F=FEELINGS: The first few paragraphs elicited empathy, the next few triggered a sense of foreboding, and by the second half of the article, I was simmering with anger.

I=IDEAS: Appalled that a third year male MEDICAL student would think this way and then put such words to paper, shocked that Canadian Family Physician would print this demeaning reflection piece, and hopeful that this student will discover the respect integral to promoting healing in the doctor-patient relationship.

F= IMPACT ON FUNCTION: I already have to push myself to have a pap exam now that my female family physician has retired. Now I am going to wonder, with slight trepidation, what goes on in the head of my male physician during this examination.

E=EXPECTATIONS: A third year medical student should: know how to express ambivalence thoughtfully ; have the skill to begin to develop rapport in 2 minutes; have an understanding of the "whole person" to the extent that he knows a middle aged women in stirrups does not think, "...a young buck" when about to undergo an internal examination!