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Medical students' gender-specific examination performance.

Research on gender differences in medicine has centered on the position of women as better communicators, more involved with psychosocial problems and female-specific problems. Hardly any research has examined the interaction between a doctor's gender and gender-specific examinations (Zaharias, Piterman, & Liddell, 2004).

The importance of physician gender in patient health outcomes has been recognized for some time in the West. However, there is little known about the contribution of different gender identities to a variety of positive health outcomes in non-Western countries (Tavakol, Rahamei-Madeseh, Torabi, & Goode, 2006). There may be a powerful interaction between a medical student's gender and degree of comfort in certain intimate physical examinations. This requires further investigation in the real clinical situation because it has implications for the outcome of physical examinations.

Studies on the performance of medical students in pelvic, breast, male genital and prostate examinations have shown that students did not have equal opportunities and did not have enough confidence in performing these examinations (Lawrentschuk & Bolton, 2004; Powell, Bridge, Eskesen, Estrada, & Laya, 2006).

The aim in this study was to evaluate the performance of final-year medical students in pelvic, breast, male genital and prostate examinations in a medical school in Central Anatolia, Turkey. In addition, investigation was expected to reveal whether or not gender had an effect on performing these examinations.

METHOD

Questionnaire

A comprehensive standardized questionnaire, designed by Powell et al. (2006) to evaluate gender-specific examinations, was used in this study. The questionnaire--which included 17 questions--was given to the 212 final-year medical students of Erciyes University Medical Faculty. All of the final-year students had completed the core obstetrics-gynecology, general surgery, and urology rotations in the fourth and fifth years of their medical education.

Data included pelvic, breast, male genital and prostate examinations. In the questionnaire, the students were asked to approximate the number of pelvic, breast, male genital and prostate examinations they had performed by checking one of the five categories: 0, 1-5, 6-10, 11-15, and >15. They were asked to estimate the percentage of these examinations that had been observed by a supervising physician by checking one of the following four categories: <25%, 25-50%, 5175%, >75% for each question. In addition, students were asked whether or not examinations had been repeated by a supervising physician. Definitions of the examinations were provided. Students were asked to select if they were confident or not confident about performing each of these examinations. Finally, student gender was elicited.

The questionnaire was written in Turkish. A pilot study was performed before commencement of the study in December 2006.

Statistical Analysis

Data were analyzed by using SPSS Version 12.0 (SPSS, Inc.). A Chi-square test was used to determine the significance of the data on male and female students performing gender-specific examinations. The effect of gender for each type of examination regarding the number of examinations performed, percentage of examinations observed by a supervising physician, and percentage of examinations repeated by a supervising physician was evaluated. A Chi-square test was also used for each type of examination for the questions assessing confidence. Univariate logistic regression analysis was used to evaluate the effects of gender, number of examinations performed, performance under supervision, and examinations repeated by a supervising physician on self-confidence. Multiple logistic regression analysis (Method: Backward-Wald; Hosmer & Lemeshow, 2000) was performed for the factors with p values of less than 0.10 at univariate analysis. Students who had not performed examinations were excluded from all of the statistical analysis. Values of p < 0.05 were considered statistically significant.

RESULTS

Student Characteristics And Performance

Two hundred (94.3%) final-year medical students responded to the questionnaire. Of these students, 38.5% (77) were female and 61.5% (123) were male. The percentages of the examinations that had not been performed by the students were: 52.5% for pelvic examination, 17% for breast examination, 23.5% for male genital examination and 17% for prostate examination.

The self-reported numbers of pelvic, breast, male genital and prostate examinations performed by the final-year medical students are shown in Table 1. Female students had performed significantly more breast examinations (p = 0.039). There was no statistically significant difference in the performance of the other examinations.

Thirty-one percent of pelvic examinations, 30% of breast examinations, 37% of male genital examinations, and 27% of prostate examinations were supervised more than 75% of the time (Table 2).

Female students had performed more prostate examinations under supervision than had male students (p < 0.001).

The percentage of examinations repeated by a supervising physician was 67% for pelvic, 77% for breast, 73% for male genital and 69% for prostate examinations. There was no statistically significant difference in the approval of the examinations (Table 2).

Male students were more confident than were female students performing male genital and prostate examinations (p = 0.040, and p = 0.030, respectively) (Table 3). There was no difference in the confidence levels in breast examination.

When the relationship between number of examinations and confidence was evaluated, there were statistically significant differences for all the examinations (p < 0.001).

Pelvic Examination And Confidence

Univariate logistic regression analysis revealed no effect of gender on confidence. However, supervision and approval of the examination by the supervising physician did affect confidence. When multiple logistic regression analysis was performed for these two variables, examination performed by the supervising physician was found to be the most significant risk factor in affecting confidence. The students who were not approved after examination were 3.07 times less confident [odds ratio (OR) (95% CI) = 3.07 (1.246-7.574)]. Number of pelvic examinations was excluded from the statistical analysis due to the presence of 0 value at some levels.

Breast Examination And Confidence

Univariate logistic regression analysis revealed no effect of gender on confidence, but supervision and approval of the examination by the supervising physician did affect confidence. When multiple logistic regression analysis was performed for these two variables, examination performed by the supervising physician was found to be the most significant factor in affecting confidence. The students who were not approved after examination were 2.4 times less confident [OR (95% CI) = 2.4 (1.134-5.043)]. Number of breast examinations was excluded from the statistical analysis due to the presence of '0' value at some levels.

Male Genital examination and confidence

Univariate logistic regression analysis revealed the effect of gender, number of examinations and approval of the examination by the supervising physician. Supervision was not a significant factor. Gender and approval were found to be significant risk factors at multiple regression analysis. Female students were 2.4 times less confident than male students [OR (95% CI) = 2.4 (1.197-4.826)]. Students who were not approved after the examination were 2.8 times less confident.

Prostate Examination And Confidence

Univariate logistic regression analysis revealed the effect of gender, number of examinations, supervision and approval of the examination by the supervising physician. Gender, number of examinations and approval were found to be significant risk factors after multiple regression analysis. Female students were 2.3 times less confident than male students [OR (95% CI) = 2.3 (1.067-4.750)]. Students who were not approved after examination were 3.8 times less confident [OR (95% CI) = 3.3 (1.758-8.284)]. Students who performed between 6-10 prostate examinations were 6.9 times more confident than students who had performed 5 or fewer [OR (95% CI) = 6.9 (2.127-22.727)]. Students who had performed 11-15 examinations were 11.9 times more confident than students who had performed 5 or fewer [OR (95% CI) = 11.9 (1.426-100.000)]. Students who had performed 16 or more examinations were 6.1 times more confident again [OR (95% CI) = 6.1 (1.213-31.250)].

DISCUSSION

This is the first study to report on gender-specific examinations performed by medical students from Central Anatolia, Turkey. It was demonstrated that: (1) many students had not performed gender-specific examinations (52.5% pelvic examinations, 17% breast examinations, 23.5% male genital examinations and 17% prostate examinations); (2) female students had performed more breast examinations than had males; (3) female students had performed more prostate examinations under supervision than had males; (4) there was suboptimal exposure for performing gender-specific examinations, resulting particularly in less confident female students; and (5) confidence increased with the number of examinations performed.

This study had some limitations. Students were surveyed from a single medical school only. One advantage for the study was that they had received their clinical teaching at Erciyes University Medical School hospitals, which supply health services to nearly all of Central Anatolia and may give students the opportunity to practice gender-specific examinations. The advantage is due to the limited number of places available at this University's Medical School, so those who do not get places are disadvantaged.

In a study recently performed in Iran, results indicated that both male and female students were more comfortable conducting intimate physical examinations on patients of the same gender as themselves. Performing a testicular examination was significantly disagreeable for both genders, particularly so for female students (Tavakol et al., 2006). Another study on residents reported that male residents were significantly more comfortable than female residents in performing or managing prostate examinations, testicular examinations, and prostatitis, whereas female residents were significantly more comfortable with clinical breast examinations and breast disease (Paluska & D'Amico, 2000). In the present study, only breast examinations were performed significantly more by female students, and there was no gender difference in pelvic, male genital and prostate examination performances.

In the United Kingdom, studies have shown that the number of digital rectal examinations performed by medical students during clinical training fell between 1990 and 2000 from a median of 11-30 to a median of 3-5 (Hennigan, Franks, Hocken, & Allen-Mersh, 1991; Turner & Brewster, 2000). In a study in Australia, the median number of digital rectal examinations performed was two, while 17% of students had performed none, and only 8% of students had performed 10 or more. There were no statistically significant sex differences in the number of digital rectal examinations performed. Of the students who had performed one or more digital rectal examinations, 92% said they were supervised most of the time, while 80% had their findings confirmed most of the time, and almost half the students (48%) were not at all confident of giving an opinion based on their digital rectal examination findings (Lawrentschuk & Bolton, 2004). The percentage of students who had not performed prostate examinations in this survey of final-year students at the University of Erciyes medical school was the same (17%) as that reported from Australia. The percentage of students who had performed prostate examinations more than 10 times (15%), the number of those who received approval (69%), the number of those were were less confident (49.5%) and the lack of gender differences in performance were all similar to the results found by Lawrentschuk and Bolton, however performance under supervision was lower (only 22% were observed more than 75% of the time).

Powell et al. (2006) reported that female students performed significantly more pelvic and breast examinations than did male students, the percentage of examinations that were repeated by a supervising physician was low, and only 45% of students had greater than 75% of their breast examinations repeated by a supervising physician. Male students were less confident in performing pelvic examinations and female students were less confident performing male genital examinations; the only predictor of confidence in performing each of these examinations was the number of examinations performed, and confidence did not correlate with the percentage of examinations observed, percentage of examinations repeated by a supervising physician, or student gender (Powell et al.). These results match results of this study.

When family physicians were evaluated for the effect of gender (Lurie, Margolis, McGovern, & Mink, 1998), it was reported that female physicians were more likely to report being "very comfortable" performing breast examinations. Conversely, only 6% of female family physicians believed that their skill in performing a prostate examination was excellent, compared to 49% of male family physicians. Another study reported that women residents had less experience than men with treating prostatic/testicular problems and male health maintenance (Blake, 1990). The results of this study performed with medical students revealed similar conditions for examinations. An option for increasing exposure to these examinations is practicing gender-specific examinations after graduation, but this may happen only when these examinations are evaluated in the resident training program. Sabir, Goodwin, and Birtwhistle (1997) reported that in an attempt to achieve better skills, family medicine programs should supply exposure levels that are sufficient for both men and women residents, which might be obtained by gender-balanced patient populations and ensuring gender-balanced clinical teams. However, on many occasions, this may not be practically possible. Therefore, it is better to help students acquire gender-specific examination skills before graduation.

Moreover, Lawrentschuk and Bolton (2004) have suggested possible strategies such as campaigns to encourage doctors and nurses to supervise students, a logbook quota system, formal assessment of skills using models, and appointment of teaching associates in gender-specific examinations. They cautioned, however, that although logbooks might provide more reliable data, they are time-consuming and expensive to keep, and are still open to inaccuracies (Lawrentschuk & Bolton, 2004).

As final suggestions, models may be used for both training and examining the gender-specific examination skills. Student logbooks should be used more accurately and efficiently to eliminate gender disparity in opportunities to perform gender-specific examinations.

REFERENCES

Blake, R. L., Jr. (1990). Gender concordance between family practice residents and their patients in an ambulatory-care setting. Academic Medicine, 65, 702-703.

Hennigan, T. W., Franks, P. J., Hocken, D. B., & Allen-Mersh, T. G. (1991). Influence of undergraduate teaching on medical students' attitudes to rectal examination. British Medical Journal, 302, 829.

Hosmer, D. W., & Lemeshow, S. (2000). Applied logistic regression (2nd ed.). New York: Wiley.

Lawrentschuk, N., & Bolton, D. M. (2004). Experience and attitudes of final-year medical students to digital rectal examination. Medical Journal of Australia, 181, 323-325.

Lurie, N., Margolis, K., McGovern, P. G., & Mink, P. (1998). Physician self-report of comfort and skill in providing preventive care to patients of the opposite sex. Archives of Family Medicine, 7, 134-137.

Paluska, S. A., & D'Amico, F. J. (2000). The comfort of family practice residents with health care of patients of the opposite gender. Family Medicine, 32, 612-617.

Powell, H. S., Bridge, J., Eskesen, S., Estrada, F., & Laya, M. (2006). Medical students' self reported experiences performing pelvic, breast, and male genital examinations and the influence of student gender and physician supervision. Academic Medicine, 81, 286-289.

Sabir, S., Godwin, M., & Birtwhistle, R. (1997). Men and women residents' experiences with women's health care in a family medicine center. Academic Medicine, 72, 293-295.

Tavakol, M., Rahemei-Madeseh, M., Torabi, S., & Goode, J. (2006). Opposite gender doctor-patient interactions in Iran. Teaching and Learning in Medicine, 18, 320-325.

Turner, K. J., & Brewster, S. F. (2000). Rectal examination and urethral catheterization by medical students and house officers: Taught but not used. British Journal of Urology International, 86, 422-426.

Zaharias, G., Piterman, L., & Liddell, M. (2004). Doctor and patients: Gender interaction in the consultation. Academic Medicine, 79, 148-155.

SELCUK MISTIK

Erciyes University, Kayseri, Turkey

Selcuk Mistik, MD, Associate Professor, Department of Family Medicine, Medical Faculty, Erciyes University, Kayseri, Turkey.

The author is grateful for the assistance and statistical expertise of Ahmet Ozturk, PhD, Erciyes University. He also wishes to thank the students who participated in this study.

Appreciation is due to anonymous reviewers

Please address correspondence and reprint requests to: Selcuk Mistik, MD, Associate Professor, Department of Family Medicine, Erciyes University Medical Faculty, TR-38039, Kayseri, Turkey. Phone: +90 352 437 4937/ 23851; Fax: +90 352 437 5285; Email: smistik@erciyes.edu.tr
TABLE 1
Final-Year Medical Students' Self-Reported Numbers of Pelvic,
Breast, Male Genital and Prostate examinations Performed, by
Students' Gender

                 No. (%) of pelvic       No. (%) of breast
                   examinations            examinations
                    performed               performed

                 F*          M**          F           M
Number ***    students    students    students    students
              (n = 45)    (n = 50)    (n = 71)    (n = 95)

1-5            31 (69)     31 (62)     48 (68)     68 (72)
6-10           11 (24)     11 (22)     9 (13)      19 (20)
11-15           1 (2)       3 (6)      12 (17)      4 (4)
>15             2 (4)      5 (10)       2 (3)       4 (4)
p value              0.567                   0.039

                 No. (%) of male          No. (%) of
                     genital                prostate
                   examinations            examinations
                    performed                performed

                  F           M           F           M
Number ***    students    students    students    students
              (n = 55)    (n = 98)    (n = 64)    (n = 102)

1-5            45 (82)     64 (65)     47 (73)     60 (59)
6-10           6 (11)      17 (17)     12 (19)     17 (17)
11-15           3 (5)       6 (6)       3 (5)      13 (13)
>15             1 (2)      11 (11)      2 (3)      12 (12)
p value              0.097                   0.057

* Female ** Male *** Number of examinations performed. Because of
rounding, not all percentages total 100%.

TABLE 2
Final-Year Medical Students' Self-Reported Supervision
While Performing Pelvic, Breast, Male Genital
and Prostate Examinations, by Students' Gender

                   No. (%) of pelvic        No. (%) of breast
                      examinations            examinations
                       performed                performed

                   F*          M**          F           M
Number ****     students    students    students    students
                (n = 45)    (n = 50)    (n = 71)    (n = 95)

<25              11 (24)     11 (22)     17 (24)     22 (23)
25-50            12 (27)     17 (34)     18 (25)     21 (22)
51-75             7 (6)       8 (16)     17 (24)     21 (22)
>75              15 (33)     14 (28)     19 (27)     31 (33)
p value                 0.873                   0.869

Number ****
Yes              33 (73)     31 (62)     54 (76)     74 (78)
No               12 (27)     19 (38)     17 (24)     21 (22)
p value                 0.338                   0.927

                      No. (%) of              No. (%) of
                     male genital              prostate
                      examinations           examinations
                       performed              performed

                    F           M           F           M
Number ****     students    students    students    students
                (n = 55)    (n = 98)    (n = 64)    (n = 102)

<25              10 (18)     28 (29)     15 (23)     29 (28)
25-50            14 (25)     23 (24)     18 (28)     27 (27)
51-75             6 (11)     15 (15)      4 (6)      29 (28)
>75              25 (46)     32 (32)     27 (42)     17 (17)
p value                 0.304                   0.001

Number ****
Yes              43 (78)     69 (70)     46 (72)     68 (67)
No               12 (22)     29 (30)     18 (28)     34 (33)
p value                 0.394                   0.595

* Female ** Male *** Percentage of examinations observed by
supervising physician **** Examinations repeated by supervising
physician. Because of rounding, not all percentages total 100%.

TABLE 3
Final-Year Medical Students Who Reported Having Confidence in
Performing Pelvic, Breast, Male Genital and Prostate Examinations,
by students' Gender

                           No. (%) who had confidence
                            performing examination

                       Female       Male
Type of examination   students    students     p value

Pelvic                 18 (40)     30 (60)      0.082
Breast                 49 (69)     64 (67)      0.955
Male genital           24 (44)     61 (62)      0.04
Prostate               33 (52)     71 (70)      0.03
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Author:Mistik, Selcuk
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:7TURK
Date:Aug 1, 2008
Words:3062
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