December 7, 2020

Pelvic exams play a pivotal role in medical education, often representing the first time medical students touch real humans in a professional manner. In her new book “Feeling Medicine,” published by NYU Press, medical sociologist Kelly Underman, PhD, takes us inside gynecological teaching programs — drawing from in-depth interviews with students, faculty and the gynecological teaching associates who use their own bodies to teach the exam.

As a medical sociologist, can you tell us about your background and what led you to write this book?

I was attracted to becoming a medical sociologist because I had long had questions about the nature of medical power and authority. Prior to starting graduate school, I worked as a gynecological teaching associate (GTA), which is the topic of the book. GTAs are trained laypeople who simultaneously teach the pelvic exam while allowing medical students to practice on their (the GTAs’) bodies. I've long been committed to reproductive justice, so that type of work, and later my academic work, were important to my values. I thought it was an interesting case and set out to do my dissertation on it. That led me to my postdoctoral work in a department of medical education, where I focused on the fundamental questions that shaped the book: what does it mean to be a “good doctor” today, and how does medical education train students to embody those values?

You write that the pelvic exam is “a fundamental procedure for medical students to learn.” Could you elaborate on its significance in the field?

The pelvic exam is a small part of medical training and, later, practice. Most physicians won't do them in clinical practice. And yet, the pelvic exam raises all kinds of interesting challenges for students in terms of emotion and intimate bodily contact. It's often the first time they'll examine another human being in such a vulnerable and sexually charged area of the body. As such, learning the pelvic exam becomes a two-fold process of learning to manage emotion: a medical student has to learn to manage their own emotions and the patient's emotions.

What might we be surprised to learn about gynecological teaching practices? Did anything surprise you in researching this book?

Frankly, I think most people are just surprised that GTAs exist. Very few people who haven't gone to medical school have given any thought to how medical students learn to do the pelvic exam, and yet, they have to start somehow.

Whenever I talk about my work, that’s the thing people find the most exciting and interesting: there are people who are well trained (and well paid) and willing to allow novice medical students to give them pelvic exams. What surprised me the most in researching the book is the history of how standardized examinations of clinical communication skills came to be in medical education.

You did a great deal of interviews and qualitative research for the book. Can you tell us more about the research process and what this experience was like for you?

I interviewed 56 GTAs, medical students and medical faculty, and I gathered thousands of pages of documentary sources such as medical journal articles, meeting minutes and lecture notes. I studied three medical students in Chicago. The really challenging part was collecting information on the history of these gynecological teaching programs. Not a lot made it into “official” archives like medical journals, so I had to locate people who were essential to the formation of the programs and hope they kept their records.

Can you put the book in context for us — what does it contribute to the field?

The book makes three key contributions. First and foremost, by studying emotional socialization in the 21st century, my book contributes to the resurgence of the sociology of medical education. This was a subfield that was central to the development of medical sociology — indeed, the broader field — in the 1950s and 1960s. But for various reasons, it fell away. That's been changing, and I'm excited to be part of a group of early-career scholars reviving it. I update questions about emotional norms and values in medical training considering the shift toward patient consumerism and clinical empathy.

Second, I bring work on affect theory into sociology. Affect is a broader and more useful term than emotion for studying relationships between and within bodies. It captures our capacities to feel, sense and relate, which are increasingly being shaped and targeted by systems of expert knowledge and control. Patient-centered medicine, as I show in the book, is a great example. It produces feelings of trust and comfort in the patient in order to achieve greater compliance with medical authority.

Third, my book contributes to the sociology of science and knowledge by looking at how scientific and medical knowledge grapples with and attempts to measure, standardize and render knowable fundamentally subjective phenomena like affect and emotion. I do this in the book by examining the development of the checklist that GTAs use to rate students' performance of empathy and other emotional skills.

Do you think more attention should be paid to the emotional and social dimensions of medical training? What does it take to be a “good doctor”?

To be a good doctor currently involves learning to embody the norms in the profession about clinical empathy. As I show in the book, this often involves a lot of routinized performance of communication skills, like making eye contact and using key phrases intended to convey empathy. Medical students are tested on these skills in a standardized fashion on the United States Medical Licensing Exam, which they must pass to become a practicing physician.

Of course, being a good physician also means mastering scientific knowledge about the human body, but this emphasis on emotion is new. I'm critical of these shifts. Certainly, I think empathy and centering the patient is extremely important, but I'm critical of how routinized this has become. It misses the bigger picture of human experience. It misses the structural constraints on the medical profession and on healthcare, such as inequalities in access. These are especially important as the profession grapples with the COVID-19 pandemic and the legacy of structural racism. How do you really teach medical students to be with patients in these structures?

What’s next for your research and scholarship?

I am continuing my interest in the tension between affect and scientific ways of knowing by examining well-being initiatives in the health professions. I'm interested in how well-being has emerged as an object of expert attention in the health professions, as a response to widespread concern about burnout.

The first piece of this is funded by the Drexel Faculty Scholarly and Creative Activities Award and will examine the development and use of wellness apps in the health professions. I've also submitted a National Science Foundation grant for an ethnographic study of this. I started working on this before the pandemic, and unfortunately it will only become more urgent and more timely as health professionals grapple with the ongoing trauma they're experiencing as a result of COVID-19.

Want to learn more about the book? Check out the episode of the New Books in Medicine podcast featuring Underman and her book.