Educational experience and ethical tensions in pelvic examination training: a mixed-methods study in the obstetrics...

The pelvic examination is used in the evaluation of many gynecologic complaints. Providers across all specialties should be able to perform this examination accurately with an emphasis on consent and patient comfort. The obstetrics and gynecology clerkship is an important time for medical students to develop the technique and interpersonal skills necessary to perform pelvic examinations on patients assigned female at birth. Graduating students should be able to independently perform these examinations accurately and sensitively; however, students report limited exposure in the clinical setting.

To explore medical student and preceptor experiences with pelvic examination learning and teaching during the obstetrics and gynecology clerkship and to identify barriers to student participation in pelvic examinations on awake patients in the clinical setting.

This was a prospective, mixed-methods study of medical students and obstetrics and gynecology preceptors at a large academic center between June 2024 and March 2025. The authors developed surveys using a modified Delphi process and refined them through cognitive interviews. Students logged the number of pelvic examinations they performed and completed a survey at the end of the 5-week clerkship. Preceptors were surveyed via e-mail. Quantitative analysis included descriptive statistics and nonparametric tests. Qualitative data from open-ended survey responses were analyzed inductively to identify key themes.

Among 93 student respondents (of 102, 91.2% response rate), the average number of examinations performed per student was 4.25 speculum and 2.17 bimanual examinations. Students at the academic center performed significantly fewer examinations than those at the community hospital (P<.01). More than half of students (51.6%, 48 of 93) did not perform any bimanual examinations. Cisgender male students performed fewer speculum examinations than cisgender female students (P<.01). Students reported increased confidence and reduced anxiety with pelvic examinations after the clerkship. Simulation and gynecologic teaching associate sessions were rated as helpful, but students emphasized the need for real clinical opportunities. Among 89 preceptor respondents (of 171, 52.0% response rate), barriers to student participation included patient preference, examination complexity, time constraints, and institutional culture. Preceptors at the academic center cited time constraints (P<.01) and institutional culture (P<.01) more often than those at the community hospital.

In this single-institution study, despite improved confidence, many students performed few pelvic examinations during the obstetrics and gynecology clerkship. Preceptor behavior, institutional culture, and clinical context significantly impacted student opportunity. While these findings may not be generalizable to all institutions, they underscore the importance of supplementing clinical training with simulation, engaging preceptors, and clarifying policies around student participation and patient consent so that students can meet pelvic examination learning objectives-particularly in settings where institutional policies limit student involvement in specific settings.