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Medical students' patients paid to be probed


© St. Petersburg Times, published December 3, 2000

TAMPA -- The pockets of their white lab coats stuffed with new stethoscopes, a gaggle of earnest young medical students fidgeted as they waited their turn outside a suite of examining rooms. One thumbed through her blue examination handbook, another filed a fingernail.

Inside the rooms, a handful of volunteers heard the snap of rubber gloves, the instructions to lean over and relax. Felt a doctor check the prostate gland to make sure it wasn't enlarged.

For most men, the only good thing about a rectal exam is that it happens just once a year. Last week, John Grannan and several other men endured it about 20 times, at the hands of 20 doctors-in-training.

"I got to admit, the money was good. But I also felt that I was doing something that would help others, too. I knew they had to practice on someone," said Grannan, 53, who volunteered for the exam two days last fall and two days last week.

Grannan is one of about 30 men and women who each year serve as surrogate patients, providing real-life practice for prostate, genital, hernia, breast and pelvic exams for second-year medical students at the University of South Florida.

Some will undergo 10 to 15 pelvic or prostate exams in one day, up to three days in a row. They are paid $37.50 an hour. They insist it is not as bad as it sounds.

"I felt like it was real important for them to learn to do these exams and be comfortable doing them," said Grannan, who works at the Louis de la Parte Florida Mental Health Institute at USF. "The prostate exam is something most men don't want to go through."

The genital-urology, or GU, exams take place each fall for two weeks during an expansive course called Physical Diagnosis. It lasts 18 months and is designed to help medical students make the transition from studying books to examining people. They learn to check the eyes, feel for the condition of internal organs and muscles, listen for common heart and lung ailments.

Usually they can practice on each other, or on real patients with known ailments who are willing to sit still while the students learn how to detect, for instance, a heart murmur. But for the sensitive task of GU exams, when the patient and the student both may feel a bit uneasy, paid surrogates are best, said Dr. Daniel J. Van Durme, associate professor of family medicine and the course's director.

"They're invaluable. There's no other way that we have that students can really learn and master those skills," he said. "The biggest challenge for the students is really getting over the psychological aspect. They're 22, and this may be the first time they've felt someone's genitals before."

Beth Hyde-Hood, the education coordinator for the course, said it is difficult to find volunteers, and she's always looking for more. Most surrogates are USF students or staff who answer her campuswide calls for volunteers and who can use the extra cash. Some are retirees who just like to help. Others sign up because a family member or friend had a disease, such as testicular cancer or breast cancer, that went undiagnosed for too long, and they want to have a part in better training tomorrow's physicians.

Some volunteers have suffered through ham-handed pelvic exams by full-fledged physicians, and they want to help young doctors learn to do it right.

"So many of my female friends just describe this yearly ordeal as horrific and violating and humiliating," said McKell Moorehead, 30, a USF graduate student in social work and public health who volunteered for the female exams about two weeks ago.

Moorehead once worked for Planned Parenthood, often sitting with women who were getting a pelvic exam and teaching young women about what to expect from their first one.

"I'm very comfortable in that setting, and so many woman aren't," she said. "I didn't think of it as any kind of scary hardship or traumatic thing. Instead, I thought of it as an opportunity for future doctors to get better training from real people."

The exams are held at the USF Medical Clinic off Fletcher Avenue. Each patient is sequestered in a small examining room with three or four students and a doctor, who demonstrates the exam first. If the students do it differently than the doctor, the surrogate is advised to say so.

"Many of our patients do it repeatedly, and they will tell the students, "You're being too rough, or you need to push harder here,' " Van Durme said. "The surrogates are not just a piece of meat for the students -- they teach them."

The patient's input is key, because the doctor can't easily tell whether the student really has found the prostate, or has located the right spot to check for a hernia. "I can always tell, because I flinch," Grannan said.

Hiring surrogates is common at the nation's 125 accredited medical schools, as is the use of so-called standardized, or programmed, patients, who are assigned an illness and then act it out. The goal is teach the student to extract information from the patient, which is often difficult, then use it to determine what may be ailing them, Hyde-Hood said.

Grannan said he was nervous the first time he volunteered. "I didn't know what it would be like to have one done after another," Grannan said. "I had 10 done yesterday, plus the two doctors, so 12. It wasn't bad. I don't think I'd want to do it more than two hours."

Last week, as 10 students in lab coats waited their turn, Celestine Mararac of Jacksonville thumbed through her Physical Examination Handbook and admitted the prospect of her first real male GU exam was a bit nerve-racking. She had studied the exam in books and on videotape and had practiced on a model.

"A lot of the students are nervous," Mararac, 25, said. "It's kind of invasive. Just the idea of having a real person there, it's different. We don't want to hurt them."

A fellow student, Ali Shistik, 23, bounded up and borrowed a nail file from her, then set to work on a ragged fingernail. "It's good to do this under supervision the first time," she said.

During the female GU exams, the surrogate patients were understanding about their inexperience, and instructive, students said. They hoped the men would be, too.

"Most patients are very kind and show us what's wrong," said Sherene Shalhub, 28, of Tampa. "We appreciate it. It's awesome they want to do it."

The Physical Diagnosis course marks a most welcome beginning to working with actual patients at USF clinics, the nearby veteran's hospital and indigent care clinics. For students who have spent their careers so far buried in books and lectures, finally getting hands-on experience is exciting and fun. "Everything applies," said K Sharma, 26, a student from Miami.

Forty-five minutes later, after Sharma, Shalhub and the third student in their group, Tejas Rajendra Mehta, each finished performing a GU exam on a middle-age volunteer, they emerged discussing whether they had actually found the prostate.

"It's difficult. It just all felt the same," said Mehta, 23, of Orlando.

The patient "let you know if you did anything wrong," Sharma said. "If it was uncomfortable for him, he'd flinch, and you'd know."

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