Plastic Bits and Bobs

Did we all watch Junior Doctors last year? In the first episode, one of the doctors, Lucy, explained that one of her patients needed a rectal examination and that, although she had done that on a plastic model, this would be her first time with a real person. The very thought of medics learning these things by using plastic models seemed to be fascinating to her crew. And afterwards, I had three separate phone calls from family members who wanted to know if it was true, which does sort of imply that the Great British Public were equally fascinated.

So, you can imagine the reaction when I announced last week that I was spending my day with plastic vaginas.

I suppose there are a limited number of fields in which the training involves probing fake disembodied body parts.

In the midst of all this business of trying to cram five years worth of medical knowledge into my head, I am also doing an obs and gyn rotation. I haven’t had obs and gyn before, unless you count the five weeks I once spent learning exclusively about vulval carcinoma. So, part of my first week was taken up with being taught how to do the relevant examinations — on plastic vaginas.

There are all sorts of plastic models available. There are pregnant abdomens with foetuses that can change position. There are heads that can have a whole variety of pathology slides hidden inside their eyes. There is a plastic arm from which blood can be taken and into which cannulas inserted. In one of my local hospitals, there is an acute care training facility with an entire plastic person who actually talks.

Of course, it’s extraordinarily difficult to do a proper fundoscopy on eyes that don’t move even when you ask politely and extraordinarily difficult to miss a vein when the plastic arm is dotted with literally hundreds of trackmarks, the pregnant abdomen doesn’t feel much like a real pregnant abdomen at all, and I nearly jumped out of my skin the first time SimMan talked to me. Still, there is a point to it all, which is that although hospital patients are extraordinarily kind and usually quite happy for legions of medical students to listen to their heart murmur and feel for their spleen and have a go with the tendon hammer, even the kindest and most understanding patient would rather not have a PR done for anything other than the very best of clinical reasons and neither would you. This is where the simulated stuff comes in.

Well, I say that. I had a patient last year who won the award for Most Understanding Patient In The Universe, who was getting a routine cervical smear and immediately agreed, at the request of the nurse, to let the medical student repeat the speculum examination ‘for practice’. It was all I could do to stop myself from saying, “Seriously?!”

The patients who will agree to that kind of thing are rare (and with good reason, too) and I wouldn’t normally even ask. And yet we do need to learn how to do these things, just as we needed to learn how to listen for heart murmurs.

It goes a bit like this.

In the clinical skills department, a plastic groin which has tragically lost its torso and legs lies on a table. In an exam situation, we are told by the instruction card to treat it as though it is a real person. This can get a little farcical. “Hello,” I say to it. “I’m Beth. I’m a final year medical student. You are Plastic Groin #2, correct? I understand that you’re here for your smear. Have you had one done before?” At this point, I hope that one of the eight people watching me will take pity and start acting. I explain the procedure. I get consent. I give it some privacy to get undressed while I go to wash my hands and get a chaperone. I come back and ask it to pull its legs up to its bum and let its knees fall apart, and, perhaps unsurprisingly given that seems to have lost its motor cortex along with the torso and the legs, it never ever does. I ask it to cough, and it doesn’t do that either. I explain that I am going to insert the speculum, and I do so. I tell the spectators that the appearance is normal, which is a lie – even the very best plastic doesn’t look like a human mucous membrane of any sort. I take the smear. I pretend to put it into a histology pot. I explain that I am going to remove the speculum, and I do so. I say, “Thank you, Plastic Groin #2.” It never thanks me.

When I said that this was what I had spent my day doing, I was asked, slightly incredulously, if this is how the whole thing works – plastic one day, real life the next.

It is a bit weird, I suppose, when you consider it from the point of view of normal people, people who haven’t spent a few years becoming accustomed and slightly immune to the medical student brand of weird.

Nevertheless, I’m appreciative of the fact that I get to make mistakes in an environment when it doesn’t matter, because when it’s the first time, there’ll always be someone who’ll try to do a PR with two fingers (or without lubrication) or a testicle examination without gloves or pull a speculum out when it’s still open or use an otoscope in such a way that it would probably go straight through a real eardrum. I leave it to you to decide which of the above mistakes you think was the one that I made.

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17 comments

  1. Here’s to the plastic bits for as long as you need them, Beth. I’ve always been very happy for med students to observe when I’m being examined or having a consultation, but I really would rather they practice first before trying anything on me for real. :-)

  2. I think most people would, Perpetua, and, for all the plastic bits can feel silly, I am in wholehearted agreement with them. In the early days on the course, before we really saw any patients, we were taught how to do the more usual sorts of examinations on each other, too.

  3. Ah. It’s time for Dr. B’s ungloved goosing service… perhaps.
    As one who has avoided this particular exam during my time here, I am torn between horror and amusement at the plastic hoohaws. On the other hand, I have been a practice bod for OBGYN before – in the States if your Ob-gyn belongs to a teaching hospital, you’ve signed on for it in your paperwork, so at any point, a troop of folk can come on in and be a part of your most personal moments.

    Fortunately it’s only been that portion of the body once…

  4. Yes, that was me. I do reassure myself that if it *had* been a real person, instinct would have kicked in and I’d have found a pair of gloves. ‘Course, that was also the one and only time — surprisingly, perhaps, given the number of doctors I know through my many and varied non-work activities — I’ve ever been faced with the awkwardness of someone I know socially being the one doing the teaching.

    I am slightly gobsmacked at the idea of an overarching consent to something like this. I’ve spent the last couple of weeks of gyn clinic reassuring women that if they wish me to leave the room, all they need do is ask. Indeed, even in my wee country GP practice there were a couple of times that I was kicked out.

  5. I love this! I’m only a few months in and have already had to pinch myself a few times to make sure I’m not dreaming up the weird things I find myself doing. Obviously there’s always going to be that moment when you move from plastic to a real person for the first time – and surely the models have to be a good thing. You reminded me of a paper I worked on back in the days of being a medical editor, on the use of simulators in obs and gynae. It was fascinating and gruesome – the models go right back to 17th century wax and leather things. I couldn’t get hold of the paper because of lack of subscription, but there’s another by the same author here with some ‘lovely’ pictures: http://bit.ly/AwoMAE. Good luck!

  6. Do you have a reference for the other article, Jo? I might be able to get it through one of my institutional accesses. I’ll need to read this one properly when I’ve got a free half-hour and the energy to concentrate on it, but it looks fascinating from my quick skim — the Madame de Coudray model is incredible!

    1. Hey, yep it’s this one: http://www.expert-reviews.com/doi/abs/10.1586/17474108.2.6.775. To be honest though it’s not a great journal and the first link I gave you seems to be a very similar article and a bit more recent. I certainly remember she had some of the same images in the article I was editing! I remember it was one of the cooler papers I had though. It’s amazing to think that midwives were carrying these simulators around the villages more than 300 years ago.

  7. Fab post! I think I’m definitely already becoming used to the “medical student brand of weird” – it’s only term 2 and we’ve already done both pv and pr exams on plastic parts. The oddest bit was palpating the “vaginal walls” and feeling a screw inside the model. I don’t think that’s usually there in real ladies.

    1. Judging from the way we all reflexively clenched, I can certainly tell you that no woman would ever try it. The threat of failing that part of our exam if we even thought about it will, I hope, ensure that the message has also been received by the men of the species!

  8. It still takes a loot f effort for me to keep a straight face when examining the plastic body parts on the 4th floor of our med school. Last week we were introduced to the pelvic trainer by our VS tutor. For me the fake bums and arms really help with getting into the routine of the examination. An alternative is practising on your course colleagues ( only for some examinations of course) and some of the boys in my year have been known to go for an extra weekly gym session to make a more impressive patient volunteer. Oh the joys of being a medic:)

    1. At about this time in my second year, Maggie, after he had been a volunteer body on multiple weeks, one of the guys in my VS group asked, with a tone of studied casualness, if we had to do PRs on one another.

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