Urology: An unfairly neglected discipline of medical training
CMAJ 1999;160:986
I would like to draw attention to the differential emphasis and importance given to examination and management of male and female genitourinary problems in medical school curricula. I studied medicine at Queen's University, where medical students are required to do a 3-week rotation in gynecology. In contrast, urology is not a mandatory rotation. Is gynecology more important than urology? Approximately equal numbers of gynecologic and urologic patients visit outpatient clinics, and I imagine that most men would argue that medical conditions affecting their intimate anatomy and its function are as important as those affecting women. I would suggest that the discrepancy reflects the historical perspective that construed many of women's medical conditions as resulting from their dysfunctional "hysterical" wombs. Thus acquisition of gynecological examination skills became fundamental. But times have changed and so should the gender differences that exist in the way we teach and learn medicine.
During medical school, I was one of 2 women in my class who chose urology as a component of the surgical specialty training requirement. I wanted to confront my discomfort and lack of experience with examination of the male genitalia, and, as a future psychiatrist, I thought the rotation would prepare me for discussions about sexual dysfunction with my future patients.
In an informal poll of a number of my female colleagues, my suspicion that we could leave medical school without ever examining male genitalia was confirmed. Some of my classmates had never inserted a Foley catheter in a man. As residents, we will be called upon to do so by nursing staff, should they have difficulty placing the catheter. How are we to diagnose epididymitis without experience in examining the normal epididymis? During my family medicine rotation, supervised by a male physician, I was always asked by the patient to leave the room when there was a concern necessitating an examination of the genitals. Although I recognize that it is every patient's right to refuse to allow a student to be involved, I suspect that it was my gender, and not my status as a student, that precipitated these requests.
Historically, women have had no choice but to consult a male specialist about their genitourinary conditions, whereas men have been referred to a specialist of their own gender. Why are so few women encouraged to pursue a career in urology and why are so few accepted into urology specialty training programs in Canada? It may be that the predominantly male urologists wish to protect men from the anxiety provoked by talking with a woman about their most intimate medical conditions. With few exceptions, male urology patients are obviously anxious when I enter the room. Their response is tri-phasic: first, a look of terror; next, an embarassed and intent gaze at the floor; and finally, the smirk of shame as his gaze returns to me and he beings to descibe his urologic condition. Once this tri-phasic hurdle is crossed, the interview proceeds as almost any other medical encounter. I contend that male patients do not need to be spared the anxiety and discomfort that female patients have long dealt with out of necessity; in fact, they might benefit from the interaction. They learn that they will not be shamed when talking about their most intimate concerns (erectile dysfunction, for example) with a woman, and this realization may improve their ability to communicate with female partners.
I met my educational goals during this rotation, and I think I learned to address sensitively the concerns of the patients in whose care I was privileged to be involved. Unfortunately, many of my female colleagues have not had the opportunity to acquire the skills they are expected to have. One of the urologists I worked with commented, "Female physicians aren't very skilled at investigation of men's urologic conditions." Quelle surprise! If all medical schools make urology a mandatory rotation, not only would future physicians benefit, but the change would also confer an equal importance to medical conditions of the male and female genotourinary systems, and would be another step toward achieving equality of men and women in the teaching and practice of medicine.
Kelly Louise Driver, MD, BSc
Toronto, Ont.
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