Blurred boundaries: sexuality and power in standardised patients’ negotiations of the physical examination

Abstract

BackgroundWorking with standardised or simulated patients (SPs) is now commonplace in Simulated Learning Environments. Embracing the fact that they are not a homogenous group, some literature suggests expansion of learning with SPs in health professional education by foregrounding their personal experiences. Intimate examination teaching, whether with or without the help of SPs, is protected by a particular degree of ceremony given the degree of potential vulnerability. However, other examinations may be equally intrusive for example the close proximity of an eye examination or a chest examination in a female patient. In this study, we looked at SPs’ experiences of boundary crossing in any examinations, sensitised by Foucault’s concept of the clinical gaze. We wished to problematise power relations that construct and subject SPs as clinical tools within simulation-based education.MethodsWe collected data from 22 SPs, through five focus groups. Analysis was an iterative process, using thematic analysis. Data collection and reflexive analysis continued iteratively until concepts were fully developed and all theoretical directions explored.ResultsStudents and SPs construct simulated teaching consultations by negotiating the unequal distribution of power between them. The SPs themselves discussed how they, perhaps unknowingly, acted in accordance with the discourse of the clinical gaze. However, SPs became disempowered when students deviated from the negotiated terms of consent and they used their agency to resist this. The SPs used strong sexual metaphors to express the subjugation they experienced, as discourses of sexuality and gender played out in the Simulated Learning Environment.ConclusionWe demonstrate that power dynamics and the clinical gaze can have important consequences within the Simulated Learning Environment. Every physical examination can be potentially ‘intimate’ and can therefore be underpinned by discourses of sexuality and gendered undertones. In partnership with SPs, simulation-based education should create a teaching space that no longer fosters the discourse of the clinical gaze but facilitates students to learn to reflectively navigate, in the moment, the fine line between touching patients versus touching loved ones, and the blurred boundaries that exist in the gulf between sexual contact and benevolent touch.

“Please let me know when I do not realize it myself”: a qualitative analysis of senior simulated patients’ experiences

“…Given these fundamental differences in work demands, their responses still had much in common. Finally, senior SPs were not part of the research team for this study, and as noted by other researchers [35], SPs are key stakeholders in this type of study and should be considered for inclusion as part of the research team for future studies related to aging SPs.…”

“…In addition, there are best practices for working with older volunteers [28]. Senior SPs have shared experiences of their practice identified in other investigations of SPs of all ages [18, 29–35]. For example, Schlegel et al [18] undertook a qualitative study that sought perspectives from SPs on workplace satisfaction and work-related relationships with the intention that these findings might lead to a broader understanding of the SP viewpoint and provide insight and information for practical implementation.…”

‘Poorly relaxed women’: A situational analysis of pelvic examination learning materials for medical students

“…It is uncertain when and how extensively medical schools began hiring sex workers for PE practice; however, reports in American medical journals and from doctors in Canada have suggested this approach occurred in the early 1970s and as recently as 1985 (Hall, 2012;Godkins, 1974;Kapsalis, 1997;Kearney et al, 2018). Narratives from these women are difficult to uncover, but a report from an Iowa institution suggested their feedback -that the exams were too rough and speculums too cold -was negative (Kapsalis, 1997).…”

Into the uncanny valley: Simulation versus simulacrum?

“…The notion of simulacra can be considered within the domain of assessment (particularly more behavioural forms of assessment, such as the OSCE), where aspects of clinical practice are simulated in order to facilitate judgements on competence. We have previously extensively problematised the industrialisation and standardisation of this type of assessment practice, citing unintended negative consequences of OSCEs in terms of identity and pedagogy 10‐13 …”