Mexico Medical Student |

Maria was a woman in her late 30s,simple and poor, like most of the people in the clinic. She didn’t have much to say about anything regarding the possible abnormalities found in her cervical cells 6 months prior, the moderate dysplasia (CIN II) that would probably cause most women to worry in the extreme until the next pap smear.

The doctor with whom we were rotating today motioned for her to go behind the screen and get undressed to prepare for today’s exam. He keeps talking to us, and we both unconsciously take positions on the other side of the screen so as not to see anything. We didn’t know if we could see or participate, since nothing was ever asked of the patient, but I assumed when the time was right the doctor would ask if we as students could join and at that time would motion us to foot of the table if she gave the OK.

There was nothing of the sort. As soon as she was ready, he heartily motioned us over as he prepared the kit, like, “Don’t just stand there, what are you waiting for?” After laying out the items, he was futzing with the light with gloved hands, so I said, “let me do that, you’re gloved,” to which he replied, “Oh don’t worry, it’s not sterile, it’s just for my protection, not hers.” That was only the beginning. From that point on, Maria wasn’t a patient: she was a practice dummy, a specimen from which to learn. As the doctor patiently explained the proper technique for inserting the speculum, I looked up to find Maria covering her face with her elbow and forearm, I assumed from shame but perhaps also from discomfort as I noticed rather obviously that no KY or lubricant was used on the speculum–<sarcasm>perhaps that’s too expensive given the free clinic.</sarcasm>.

For the rest of the exam, the doctor meticulously explained the proper technique for sampling the cervical cells, for avoiding the outer cervix while getting the inner cells, all the while quizzing on anatomy at the most basic level (I mean, come on…how much can you ask about the vagina and cervix?! It was ridiculous), everything about her under scrutiny, within earshot, pointing out various things. After fixing the samples and completing the pathetic attempt to quiz/educate us on anatomy, the speculum was removed, and the doctor said the first words to the patient since she went behind the screen, “All done. Get dressed and come back to the desk.”

Maria refused to look at us the whole time. I learned a lot in this experience, but I couldn’t help feeling like an accomplice in a violation, certainly not physical, but if nothing else a violation of decency. From the time she was sitting there waiting for her prescriptions (unrelated to Pap) to the time she left, I wanted to go over, look her in the eye and say, “I’m sorry for what happened. I didn’t know he was going to be that way.” I felt guilty about having been there, having seen her in an open-bare way that her husband probably hasn’t even seen, and also for having actually learned things paid for by her dehumanization.

I know teaching hospitals, VAs and county/community clinics in the US have to some degree a lot of the same environment, with different doctors being more or less empathetic towards their patients when rotating with students and/or residents. Stories of patients feeling dehumainzed during rounds with attendings are numerous and perhaps I am thinking about this way too much. The people here are seriously thankful for any help you give them, and as I’ve said before, they don’t see a big line in the sand between med student and doctor, so perhaps I’m over-reacting. I know what my standards are, what I would expect of myself as doctor and what I would demand (and have) as patient, and that was simply unacceptable.

To end on a positive note, I will say that this happened early in the week and was an isolated incident. I sat through a couple more Paps, a general pelvic exam and an IUD removal (they are still widely used here), and none of the other doctors–all male–ever ignored the patient in the way described above. They would explain something to me or to us, but they would also keep talking to the patient, warning them of something moving or a possible point of discomfort, etc., never making them feel like a specimen. One can learn from a patient, one can teach using a patient, and still remember the patient is a person.

I hope Maria’s dysplasia does not progress. She had no significant risk factors (HPV, early age of sexual activity, etc) so I hope that it’s just a matter of aberrant histology rather than the ticking time bomb of cancer. I hope also that she forgets about what happened; perhaps it wasn’t the first time if that guy’s been her doctor for a while. I know I’ll never forget her.

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