Educational Experience and Ethical Tensions in Pelvic Exam Training: A Mixed-Methods Study in the Obstetrics and Gynecology Clerkship.

Abstract

BACKGROUND The pelvic exam is used in the evaluation of many gynecologic complaints. Providers across all specialties should be able to perform this exam accurately with an emphasis on consent and patient comfort. The OB/GYN clerkship is an important time for medical students to develop the technique and interpersonal skills necessary to perform pelvic exams 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. OBJECTIVES To explore medical student and preceptor experiences with pelvic exam learning and teaching during the obstetrics and gynecology (OB/GYN) clerkship, and to identify barriers to student participation in pelvic exams on awake patients in the clinical setting. STUDY DESIGN This was a prospective, mixed-methods study of medical students and OB/GYN 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 exams they performed and completed a survey at the end of the 5-week clerkship. Preceptors were surveyed via email. Quantitative analysis included descriptive statistics and nonparametric tests. Qualitative data from open-ended survey responses were analyzed inductively to identify key themes. RESULTS Among 93 student respondents (out of 102, 91.2% response rate), the average number of exams performed per student was 4.25 speculum and 2.17 bimanual exams. Students at the academic center performed significantly fewer exams than those at the community hospital. Over half of students (51.6%, 48 of 93) did not perform any bimanual exams. Cisgender male students performed fewer speculum exams than cisgender female students (p<.01). Students reported increased confidence and reduced anxiety with pelvic exams 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 (out of 171, 52.0% response rate), barriers to student participation included patient preference, exam 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. CONCLUSIONS In this single-institution study, despite improved confidence, many students performed few pelvic exams during the OB/GYN 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 exam learning objectives-particularly in settings where institutional policies limit student involvement in specific settings.