So You Want to Change the World

The Podcast

Episode 1: Feminism & Radical Gynecology

“I want to take my pants off for science.” At the age of 23, Alexandra Duncan turned her fierce feminism into a business and career empowering women through humanizing gynecology. Three years later, her company, Praxis Clinical, is helping leading universities rethink reproductive health training. In this interview, she shares the story of her vision, successes, and struggles.

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Interview Transcript

Robin: 00:00 I first came to know Alexandra Duncan in 2008 when she joined our very first Global Gap Year class. I was also fortunate to be one of her Program Leaders that year. Since that time she graduated from the Gallatin School at NYU with a concentration in Medical Anthropology and Narrative Medicine. She's also the founder of Praxis Clinical a company advancing reproductive health and social justice through teaching clinical skills to practitioners including gynecological exams and male urogenital exams through the use of Clinical Teaching Associates. Alexandra welcome to the podcast.

Alexandra: 00:35 Thank you Robin. It's exciting to be here.

Robin: 00:35 What is a Clinical Teaching Associate?

Alexandra: 00:42 So Clinical Teaching Associates basically are people who use their own bodies to teach clinical skills to students. And usually what we'd consider intimate clinical skills. Because you can't have someone who's not prepared for it like teaching gynecological exams to students. That can look like a lot of different things. But in the case of say gynecological exams that's a Clinical Teaching Associate working with maybe three students and actually using their own body to teach them how to place a speculum and find their uterus and ovaries because that person can say "you know that's not my uterus. Like move over here let me help you with your hand. That's my ovary." When I'm trying to be shocking about it I would say you know like I walk into your room and I take my pants off, and I'm like "all right let's learn this you know taking your pants off for science and medicine." I mean the most powerful part of it is you're the person on the table with your pants off. And so you're like you're the patient and the teacher and the students sort of have to form that bond with you where you're the source of authority and the students can't look to another professor in the room they have to look to the patient to be telling them what to do and explaining it.

Robin: 01:41 So why does this matter why is this part of social justice?

Alexandra: 01:47 It's kind of complicated but there's a very weird and frankly horrifying history of gynecology. And, I'm talking about gynecology here because it's the one I personally have the most experience with. We also teach the male exams and other exams. Students learning how to do these exams have historically they've learned on anesthetized patients who didn't realize that was going to happen. They learned on mannequins which you know at least the consent isn't a problem but they are not anatomically great. And I've had students who've learned on mannequins first work with the CTAs later and be like "I have no idea what to do with your legs" because mannequins don't have legs. Back quite a while ago a doctor comes into the room to give the woman her exam and you know he doesn't he says "Oh and I have these seven medical students with me. You don't mind if they all do it too right?"

Robin: 02:31 How did you get into being a Clinical Teaching Associate?

Alexandra: 02:36 I went into college with like all these courses lined up and like fairly advanced ones about international development and I was like "Oh God, what now?" But I sort of retreated back to interests that I had and things I cared about that were in the US and things that I felt more confident in. So I started being the full spectrum doula working with patients who are having abortions, which is a fairly radical thing and not too widespread. But, I moved to New York for a semester to be an intern for the Doula Project. In that setting people who choose to do that I think of it as kind of the radical gynecology world.

Robin: 03:07 What were the factors that drew you into that work?

Alexandra: 03:13 Youthful emphatic feminism.

Robin: 03:16 How did that feel like the right venue for that?

Alexandra: 03:21 Very firm belief in the right to choose what happens to your own body and abortion rights and righteous indignation all the time about politics and people trying to take away that right.

Robin: 03:30 So it really felt like the front line of feminism in some ways for you.

Alexandra: 03:35 One of many front lines. I mean I didn't think that like I was you know the God of feminism or that this was the only thing to do, but it was the thing that I felt like was the right thing for me to do that I didn't have questions about. Like everything else. I wasn't sure if it was right. I wasn't sure I was doing no harm, basically.

Robin: 03:51 And your role as a doula just to be clear wasn't to do any of the clinical work per se. You were really supporting the patient in the process. Is that correct?

Alexandra: 04:03 Yeah. Doulas are totally non-medical. We'd say it's like providing physical, emotional, and informational support, and it's something where we like we do it volunteer like you do a couple shifts a month usually unless you are the intern. If a patient doesn't want you in the room, you leave. Or, if someone's not responding to you, step back. But, almost all the time the patient wants you there, and the connection forms very strongly and it makes a big difference. But, that also means you've got a really clear view of what else is happening in the room.

Robin: 04:30 How do you go from being a doula assisting with abortions to being a CTA?

Alexandra: 04:40 People who are doulas are specific, and I kind of think like you know radicle gynecology is a small world. So everyone is doing all the things. So a lot of other doulas were already CTAs, were teaching gynecological exams, and so I found out about it, and I was like "yes that is me." I went to take my pants off for science, which is not everyone's response. You know it's a small subset of people some people hear about it and are like "umm, know that is so strange," and other people hear it and are just like "yes." And I was one of those.

Robin: 05:16 Why do you believe in the importance of CTAs?

Alexandra: 05:20 My belief in it kind of developed out of my my work as a doula and I doula'd a lot because I took a semester off school and moved to New York to be the intern. I was doula'ing, you know, four days a week and being with people through a lot of procedures, and the more I was there the more I was seeing of the interactions between patients and doctors and hospitals and the whole system. And I started to feel like I did actually have thoughts about it. Like I didn't feel like I was inserting myself somewhere I didn't actually know what was going on. I started feeling like you know OK I don't like this and this could be better and I really disagree with this part of the paradigm or whatever.

Robin: 05:54 So having this upfront look at the process that it sounds like hundreds of women went through over the course of that first semester, you really came to have a deeper understanding of what was working in the medical system and one wasn't around reproductive health. Is that right?

Alexandra: 06:10 Yeah. Again I still wouldn't say everything, but I did have this one field where I felt like I was starting to to have opinions that I felt like were based in reality and that were opinions that I had the right to have, sort of. And so as I was thinking this as I had these thoughts, because I also saw so many different doctors working with patients, I got a vibe for what I thought was you know, interactions I liked, the things that I found that I didn't like. And so being a CTA is like a step back -- you're the person teaching future providers how to do these exams, and you're teaching them the exams and how to be comfortable and how to have the patients comfortable, how to have the patients empowered, and you're teaching them how to communicate with patients. So that's this incredible opportunity to be the first exam they ever do and kind of shape how they think about it going forward.

Robin: 06:59 So, being a CTA it sounds like it is a mix between teaching physical clinical skills, medical skills, with the anthropological understanding of how this affects humans.

Alexandra: 07:12 Yeah it's mixing the medicine with the person on the table. I mean that's what's so vital. There was something that I used a lot during my work with Gallatin where I was I was working on things related to all of this work. I think it's from Becoming Doctor by David Riser. I think that's it. But, he talks about how it used to be that the first patient med students worked with was the freshman year anatomy cadaver which kind of forms the expectation of like what a perfect patient is because it's their first one you know, and that's a patient who lives completely still, doesn't speak, doesn't interfere, is flat on the table, and you do whatever you want. And when you change it to this model your first patient is somebody who is the source of knowledge and authority about their own body. That's the pattern you're laying down for future encounters.

Robin: 07:56 Are these clinical skills -- thinking very specifically about the exam skills, setting aside relational skills in these exams -- are these clinical skills are not skills that doctors are picking up at medical school?

Alexandra: 08:08 I mean they are learning them, they're learning them academically, sometimes they're practicing them on the plastic models. But, I mean, we're how they're picking them up. We're intentionally how they're taught. This model is very widespread, and we are who teaches in these exams. You know you have to. You have to learn them like some places and some people still actually learn them on real patients you know some people only learn them for the first time shadowing physicians and then being invited to do an exam on a patient which is a really terrible way to start learning an exam. That poor patient. These are intimate exams. They can be uncomfortable if you're not doing them right. And people come in with so much baggage. It's so hard to have a female body in this world and not have baggage. You know that's not even considering people who have a history of trauma.

Robin: 08:54 Can you tell us the story of your first time as a CTA?

Alexandra: 08:58 So I went through, I mean CTAs in general we go through a very thorough training. It's very much a depth of knowledge. It's not necessarily broad but this specific thing like we know this thing and we know our bodies. So I've been to the training, I've done lots of practice teaching. I did some team teaching with another CTA. And my first solo session was at a Jewish medical school where we weren't allowed to teach if we had our periods. First of all. And I was sitting on the exam table and usually we have about three maybe, four students in a room at least with Praxis, which is my business. But at that time I was working for a different program, and I was sitting on the table, and they knocked on the door, and I called them, and five very tall male students came in, several of them wearing wedding rings, and two of them wearing yarmulkes, and they all filed in, and I'm sitting on the table in like my gown and my drape. And they were so nervous, they were so nervous. I mean it's never stopped, it's always been the same, but it's just like unbelievably powerful feeling that you're in this crazy vulnerable position and everyone else is terrified. You're totally in charge. And you know I talked and like you talk through the show at first you talk their language they can use of patients and how to start the session. And then you say you know like OK now you've tried the breast exam and you pretty much just immediately lower your gown because you need to start a breast exam, and all the students were like staring at the wall, staring at the ceiling, they're blushing, and it's like "thank you for your respect, but I need to look at my breasts right now."  They're so nervous. They come in. Somebody did a study on this about students working with CTAs and how nervous they were. And the thing they're most afraid of is hurting us. Then they're afraid that they're going to become aroused. Then they're afraid we will remind them of their mother or sister. So those are the top fears. But they come in you know and they're really nervous and some of them are kind of resistant. You know like "I'm going to go into research, why am I here?" But usually within the first like you know even 10 minutes of a session everyone suddenly like wow like really engaged. They kind of imprint on you like ducklings. You're kind to them. You welcome the questions, and it's not something they're used to. And it's another reason that having a CTA as your first teacher for these is so important because you do form this impression like you have the positive associations with it. If you're getting your first pelvic exam you definitely want it to be from a provider who feels positively about it versus someone who has always felt kind of nervous and squigged out.

Robin: 11:17 You talk about that giving a sense of control. Was that different than what you expected before you went into your first your first teaching session?

Alexandra: 11:26 No. I mean I went in with such enthusiasm. I didn't have any questions or concerns about this. I was really excited to do it. I felt very confident about doing it. One thing I didn't expect actually was during the training the way we did it was we would learn about part of the exam. And our trainer would have us do it as if we read the med students and she was the CTA. Then the next session we would role play as if we were at the CTAs, and then we would learn the next part of the exam with her being the CTA. So each time it was learned one and perform one. So we learned the pelvic exam with the teacher and the next time she was like okay we're going to have two of you guys next time be the first people to practice teach the pelvic exam. And I was like "Me. I'll do it. Let me take my pants off first." And the thing I didn't expect there, I think, you know, obviously like you're about to be, you know, very unclothed with these people. But I was changing and like I had my drape wrapped around me, and I like backed up on the table. So I was like, I didn't want them to see my bum, kind of, even though they about to do like I was about to have them do a gynecological exam. It was you know nervous and kind of shy. And then I got on the exam table, and I had to teach it and kind of immediately the thing that was there is like I can be stressing out about my body right now or I can be teaching. And there's all this stuff to remember you know the exam it was like either you freak out or teach. And you know I chose to teach. That's what I was there for and it felt like you know putting down these bags that I've been carrying all the time. You just put it away. It can't be there anymore. And that's something that's been true every time I teach this feeling like you just have to put it down, you can't carry the baggage in with you. So that's something that I didn't really expect but that's been amazing.

Robin: 13:07 Is it fair to say you're trying to take the tension out of that gynecological exam and open it up so that there can be more conversation that ultimately is instructive in that there can be better exams happening and ultimately better outcomes for everyone? Is that a fair way to talk about it?

Alexandra: 13:24 Definitely yeah. And so we're trying to not just take the tension out, we're trying to make it positive and positive associations which then obviously carries over to your patients. It's like you know it's a it's a trickle effect. We teach the student. They work with the patient eventually, like that patient hopefully feels more positive about their own body. And something we teach students is to finish each part of the exam saying "OK, you know, I finished the breast exam. Everything appears healthy and normal." Obviously not lie if something isn't normal, but that might be the first time the patient has heard their body described as "normal." So that's kind of important. The other part of that is trying to change just sort of an overall vibe with how doctors are perceived in sort of the way doctors interact and kind of the cultural buildup around that. Something else we say to them you know it's like you don't have to know everything. The first time you go into the room you don't have to know. You just can't panic about that. The most important thing is not to freak out. If you're anxious and you're trying to make contact with somebody anxious touch is creepy touch. You know be confident and it's fine to say you know "I want to make sure I give you the best care possible. I'm going to step out and get my attending to double check." It's when people feel defensive like they have to know everything that the dynamic starts feeling really negative and that people get hurt. So we're very much trying to change that dynamic in the room.

Robin: 14:41 So, why did you start Praxis Clinical?

Alexandra: 14:47 I really liked being a CTA. I loved it. Like the feeling of kind of that empowerment doing it working with students. So for me I had been changed so much. And like I said I really loved it and I graduated school and I wanted it to be my full time thing and I didn't want a 9 to 5. I didn't feel like that was going to work, and I didn't feel like I would be successful at it. Like knowing how I learn and how I work and I wanted to do this. So I took a year to kind of see what I can make of it. Which was a really stressful year and there really wasn't any mechanism to do CTAing full time. I was looking for different ways. And as I was doing it I was working on kind of my own curriculum because you know I started out with you know seeing ways I thought that doctor patient interactions can improve. So then I moved up and now I was like well how could we improve CTA doctor relations and teaching. So it's kind of working on my own curriculum and my own session styles while I was working with other programs teaching and a lot of things fall into place at once sort of toward the end of of that year. And I had been working with Yale as a CTA after their program and then they were changing how their program worked and right as I had been setting up my own LLC with the idea that I was going to try to make a go of this. They needed someone new they spoke to me and suddenly it just took off the whole thing.

Robin: 14:47 What's the mission of Praxis Clinical?

Alexandra: 16:04 So like a buzzy concept in medical education is patient centered care. That's the idea people are working around and trying to build their medical school trainings and systems and education around. And obviously it's a lot better than care that isn't focusing on the patient which for a long time it wasn't. Patients were the objects he practice medicine upon not people who need health care. And so while patient centered care is definitely an improvement, we actually would prefer a patient directed care. You know patients are clients. Patients are coming in with needs, and we kind of think of care is like a package that you give a patient and you know if they ignore part of it then they kind of ignore all of it. And it goes back to the idea of like the anatomy cadaver being the perfect patient because it's like still and silent. It kind of sets up this idea that you know a patient that isn't still, that doesn't accept the entire package of care, is a disobedient patient. And, that shouldn't be the case. A patient comes in with needs and it should be patient directed. You should be meeting their needs. And like yes, the doctor is the expert, but that should be someone who's giving the information and the knowledge that the patient can work with, you know. And then you work with them. Like, what are the things that matter to you in your life? OK. Why is this part of the care not working for you? How do we adjust? The health care system's really not set up to trust patients at all. You know I think they always ask you when you go in for your checkup "Do you smoke?" The way it's filled out is "the patient denies smoking." Like the assumption is they smoke in there and they're denying it. Versus patient doesn't smoke.

Robin: 17:34 Wow. So when we think about particularly women's reproductive health, what's the link between this ownership of health and a patient patient directed health and feminism?  

Alexandra: 17:48 I mean, I guess like I think of feminism -- it should be intersectional: feminism and race and class and ableism and just a million different things that all intersect because it's all systems of, its hierarchies and systems of oppression. And all of this is about kind of stepping out of those and what individuals need and trying to work with that people are real people and it shouldn't be having to make some sort of crazy accommodation for someone's needs. The idea should be directed by people. The idea should be the assumption that people deserve to have their needs met and that the goal is to meet those needs. We talk about having patients who are trans or gender queer. We teach students you know simple language they can use because most of them won't have heard it before. At your introduction you're saying you know I am Dr. Duncan. What name would you like me to call you? I ask all my patients, what pronouns do you use? Just like simple stuff but people shouldn't be treated like they're an inconvenience when they have something that deviates from statistical normal. I mean even in men's health, one of the biggest problems with men's health access is that men don't access health care. That's the biggest issue with it. And a lot of the things that keep men away are are things of like what we'd consider toxic masculinity which is also a feminism thing. Feminism isn't just about, I mean this is always the fight and feminism, feminism isn't just about rich white women. Feminism is about intersecting systems of power. And we have this toxic masculinity stuff that you know men should not need help and like that keeps them out of the doctor's office.  But other aspects of hetero normative, typical ideas of masculinity actually bring men in if you tap into the idea of like providers and like your family needs you, that brings people in. And again I'm talking like a very typical hetero normative stereotypes here. All of this stuff really ties in and all of that is feminism. Being a CTA, it's not volunteer, it's paid really well. As it should. I mean there's something really radical on its own about like vagina work being paid really well as it should be. And that's like that's how it should be and it's awesome that these quite powerful institutions are the ones paying. You know we've been saying like men's and women's exams because it's very hard to find the words, but we do try to be as inclusive as possible. And you know, we talk about gynecological exams but most places will then talk about male urogenital exams. But we don't use that language because everyone has a urogenital system, and people who aren't men also have penises. You know, trans people need health care. We decided to use anthropological exams to refer to penile testicular scrotal prostate exam. So like the CTAs who teach those we consider the Andrological Teaching Associates just because that wording mirrors gynaecological. But that's not working that you'll hear elsewhere. But that's the best we've been able to come up with.

Robin: 20:30 So really trying to work to create a more inclusive language in this field.

Alexandra: 20:35 Yeah. Just trying to -- it's not built around this. It's built in really horrifying ways and I mean I haven't even said about the history of the speculum yet, but it is horrifying. So just doing our best to try and change the language around it because the language and how we think about it so shapes how we do it.

Robin: 20:53 What is the history of the speculum?

Alexandra: 20:55 Brace yourself. It's terrifying and awful. The guy who invented the speculum was J. Marion Sims. He's a doctor. He also was the one who figured out how to cure vaginal fistulas which is a big deal. And he did all of it by experimenting on enslaved women without consent and without anesthesia. One woman, Anarka, he performed over 30 surgeries on, and that's how he did all of that. And he didn't, you know, curing vaginal fistulas is really important because those are a terrible thing. But the goal of that wasn't to improve women's lives. The goal of it was to to make sure that people were getting the most out of their slaves, basically because slaves who had fistulas were losing people money for poor investments. So you have this absolutely horrifying thing that I mean again fits into systems or oppression. But you know he has schools named after him and there are statues of him. He he's still a big deal in a lot of ways and he did this terrible stuff. You know the speculum is the core of gynecology in a lot of ways and that's how it came about.

Robin: 21:59 Wow. To what degree are you trying to prepare practitioners to deal with the trauma and/or, as you called it, baggage that their patients are coming in with?

Alexandra: 22:11 It is integrated into everything we do. You know all the language we teach, all the set up, is very carefully designed. The sentences we use as examples are so thoroughly workshopped. Everything we do is designed to make a neutral experience that's not triggering. You don't always know what people are coming in with. Actually I think you were the person who told me the most important thing for you to know is the last thing people will tell you. I think you said that to me when I came to you for desperate advice the first time we ran a five day CTA training and I had not realized just how much people were coming in with I think I called you afterward panicking and like how do I make sure everyone gets through this in one piece. It's very likely you won't know what your patient's history is. So to start with we want to make sure everything is neutral and that's things like for anyone who's had a GYN exam there's the bit that's like OK put your feet in the stirrups spread your legs, you know, scoot down until you feel like you're going to fall off the table. You know, and we say things like "OK, so first they're foot rests, they're not stirrups, there are no horses in this room. Even just you know basic changes where we say like first of all leave the drape covering them and then rather than saying "spread your knees open your legs" we just say like OK put your hands really wide out to either side and ask them "please move your knees toward my hands." Really basic change that can really change the dynamic if someone has that history or for anyone. Again simple things. You know we'd say like try to avoid using the word "feel." It's such a normal word, but it can make really weird sentences in this context you know "I'm going to feel your breasts now." Use "check" or "inspect." But then there are a lot of specific things that we do, too. You know we talk about ways to empower your patient. We talk about ways to deal with it if a patient seems to be struggling a lot. One thing that I love that we try to teach patients and demonstrate to them and demonstrate to the providers how they can incorporate it is self self speculum insertion. Which sounds really weird but you can have the patient insert the speculum themselves and often it can actually make it easier to find their cervix. It sounds weird but they actually did a study on this and 91 percent of the people said they'd asked to self-insert every time they went back to the doctor. I mean it can be empowering, it can be more comfortable, and if someone's really struggling that can be a really great tool so that someone else is not placing something in their vagina. It's your body so if you're feeling discomfort you're just going to stop. So we talk to providers about that and we kind of model for them how they could talk to a patient about it. You know because it is kind of a weird concept to get your head around. We all demonstrate how often self-insertion works. So I think that's, you know, an amazing tool and a pretty simple one if you know how to use it.

Robin: 24:35 So it really sounds like you're talking about intentionally shifting the power dynamic in the relationship among the doctor the patient and the patient's body.

Alexandra: 24:45 That is definitely the hope I think we have less ability to see how they interact with patients in the future though that's the goal. And from what they say it certainly they leave the sessions with that intent. The places we see it most are working with the students themselves, and when we train new CTAs. Those are kind of the biggest ways we see it. It's not with every student but you know you have students who react very powerfully, who you can see are having their own reactions based on their own experiences and lives. And people will tell you about past traumas and things in their lives they will wait and tell you about that and say this happened to me and we're so confident and comfortable in your body like this is the first time I felt normalized. So you do see that with with the students in terms of how they relate and we see it even more with CTAs. Those of us who do this especially when we're training new CTAs people bring this in and people have their experiences and histories. And obviously those things involve their bodies. It's very powerful and people will tell you very intimate and personal things because it does create this safe space where you're ok like that's kind of the big thing like hey you're OK and you're normal whatever that looks like. This is your normal and that can be kind of earth shattering.

Robin: 25:52 So it's been four years since you founded Praxis Clinical. How is it being a founder? What age were you when you started and what's the process been like?

Alexandra: 26:03 I started it when I was 23 and that was the year that I finished school and was working on it. Basically the point where everything kind of started to come together. I pretty much walked into Yale and was like OK you know what I can do this better. Let me do it. They said yes. So yes I was 23 setting this up and it has been... I think many other founders would agree. We were talking about this the other day. Right. Being a founder is not easy.

Robin: 26:34 No it's not.  

Alexandra: 26:37 It is not easy. Even talking about it the other day it was like oh thank goodness. It's just nice to hear it to hear from someone else again.

Robin: 26:46 What have been the hardest parts of it for you?  

Alexandra: 26:49 There have been different hard parts but all along I would say overall the hardest part has been myself. There are lots of this that I feel very confident and you know there are things that I know I can do. That's why I was able to walk into Yale and say I can do this better because I knew that that I could do like the curriculum the trainings. I knew I could do that. I'm good at the broad picture. I am not so good at the details and there are a lot of details and management work. And so things that I know are my weaknesses. And you know time like my energy very much ebbs and flows. There are times where I'm like I'm going to spend three days sitting up till 4 am hammering this out because I'm so excited. And then there are other periods where it's like I'm taking three days to achieve this one very small thing because I'm not able to turn that up right now. It's part of why I didn't want a 9:00 to 5:00. I wanted a system that I knew worked better for me. And mostly this does this does work but I have definitely put myself in some jams before. I've been my biggest problem.

Robin: 27:47 Yeah I definitely relate to that. I think that one of the biggest challenges that I've felt over the 12 years since we founded TBB was that sense that I was never I was never good at any of the things that we had to do. You know as a founder you have to do all of the things. Tou have to know how to do that H.R. and the bookkeeping or at least manage those processes if other people are leading them. You have to know how to do the marketing, the programming, leading a team of people, bringing them together around a mission -- all of those things. And I felt like I have always been mediocre at all of them because I've just had so many different things on my plate I couldn't focus on any one long enough to become an expert.

Alexandra: 28:28 Yeah. You know that sounds that sounds pretty relatable. Fortunately, I love research. I am an obsessive researcher like I'm very good at finding information or finding the people with information and and learning from them you know. Like I don't I don't know if anyone if people would disagree. But personally I don't feel like I claim to be an expert in stuff that I'm not. You know I find that people who are. I so enjoy learning new things and so enjoy finding information and can really hyperfocus on it.

Robin: 28:55 Yeah. Particularly for your generation, for Millennials, it seems that being a founder or being part of a startup is almost the brass ring that everyone is trying to reach for. What have been good parts of that process for you? What's been the most exciting aspect of it?

Alexandra: 29:11 I mean one thing I've loved all along is that in some ways Praxis is a platform that I can use and direct toward the things I'm I'm passionate about and that can evolve with me. And that's a really amazing thing because this field is growing and and I grow with it a lot like that. The thing is we learn all these new things and we create a product that I end up being really proud of that we get really good at. Our training is down. Our system is down. The curriculum is down and then we can be expanding and there are all these things that I'm really excited to expand into in some new dimensions. But right now they are a little bit on pause because of some of the hard parts of being the startup in terms of having to get what we have right now a little more streamlined the way we are with Praxis, we have this extraordinary access that I mean really you can find elsewhere we have we're tied into so many different universities and in hospitals we have amazing contacts and people who who work very closely with us. This field is very niche, and people don't know how to manage it. Normal situations, normal professors and deans, normal clinical skills and standardized patient set ups don't really know how to manage CTAs because it's totally different. The problems you get with see CTAs you do not get with any other places you know. So we do have this expertise, so we get brought in at very high levels, and we get to work with people who are very high level, and knowledgeable on different projects and that's really amazing. Get really big experts in their fields working with us on curricula or articles and that access is amazing.

Robin: 30:34 Who have been some of the more interesting clients you've worked with over the years?

Alexandra: 30:38 Recently we worked with the New York City Department of Health. They wanted a refresher pelvic training because they were bringing all these new providers on board. And that was a really interesting one that was not our usual group. Often we work with students who are in second or third years or nurse practitioners who've already worked as nurses and are in maybe their second year of school. But we also work with first year med students and the problems they have are very different than other groups. You know with first years, they don't always know all the anatomy and you want to set it up as like OK you know we're not going to let you hurt us we're going to take care of ourselves. We need you to take care of yourselves you know sit down step out get a drink or a snack you know whatever you need. We're going to try to avoid anyone fainting. We know you have a hard days and long lives and blood sugar drops and genitals can be intimidating. But you know it's going to be fine. Let's not faint.

Robin: 31:29 Can you tell us the scope of Praxis Clinical's work? What are what are all the different things you do?

Alexandra: 31:36 The biggest part of our work has been clinical skills where we work with MDs, PAs, MPs, whomever. The core that we started with was the gynecological teaching, and you know the second year Yale Med asked us if we would develop the what we call the Andrological Program which is usually thought of as male urogenital. So we developed a program that mirrors those GTA sessions. That's something that I'm very proud of. It's not something people are doing really. We really included a lot more about men's access and how to work with those male patients because they're kind of unicorn's you don't get them that much. So that's something I'm proud of. We've also recently been doing some phlebotomy trainings which fits in kind of differently and it's a different project on its own and has also intersected uncomfortably with the challenges. I give myself as founding a business so that's an ongoing project.

Robin: 31:36 And phlebotomy is blood draws essentially.

Alexandra: 32:28 Yeah basic training before medical students go on their first rotations so they don't you know the idea is like okay don't butcher yourself don't butcher anyone else. How do you just start an I.V. and do a blood draw? And then something else which right now is the direction that I'm really loving is communities and laypeople. A key part of Praxis all along has been lay people in health care and that counts as patient directed care that the patient should be guiding it, that the doctor should be working with the patient. Of all of our products right now, this is the one I'm most proud of is our Clinical Teaching Associate Training for new CTAs, and we've created this five day training that teaches people obviously like how to teach these exams and teach them about the exams. But we build it all in about reproductive justice and reproductive health and reproductive rights and just social justice and the history of that and the intersection of race and class and able ism in just all of that. We built this very comprehensive training. And it also teaches people not just to teach these specific exams but teaches people how to use their own bodies to teach you so they can take it and go elsewhere and do other things. You know people take it who aren't going to be CTAs because they want that depth of knowledge and the comfort that it helps build with your own body. But we also do a community where you know I've given talks at schools and we're developing an undergrad workshop that I really love. It's like an owner's guide here uterus and ovaries.  What is in your body and like what are your hormones and how are they affecting your day to day life and how do you have a good experience at the doctor? I did a talk at a school and the audience was totally different than usual. It wasn't like the Women's Studies and feminist club it was like all these people with no knowledge or interest but they came because they were going home to get their first pap test and winter break and were really nervous. Bringing that knowledge to people and helping them know what's going on so they can take control. That's something that we really care about. And we get to work on from both sides you know helping people who are patients in some context to have that control and power and then working with the providers so that they're going to respond well to that and that dynamic is going to work.

Robin: 34:23 And I'm assuming that listeners can go to your web site to learn more about all of these different opportunities.

Alexandra: 34:31 They can, and they can get self-speculum instructions

Robin: 34:33 We'll include links to those on the Thinking Beyond Borders website too. What do you think comes next for Practice Clinical?

Alexandra: 34:40 There are companies doing really exciting things with health care with medical education with different programs and actually with with virtual and augmented reality which right now sounds like totally different from what we're doing. But you know there's one company in particular that is doing something with potentially augmented reality where you know like a Google Glass type thing where you can be seeing anatomy that you can be interacting with you can be moving it around you can be blowing it up you can be studying. And I think it would be so cool to be able to integrate that with a CTA session like if you could be working with the CTA and simultaneously seeing the overlay of the anatomy if you could be holding a CTA's uterus while seeing the anatomy overlaying it. You know and the CTA can be saying like well my uterus is tilted forward you know anteverted and then maybe with the augmented reality part of it then you could like change the position of the uterus.  And like OK well if it were in this position how would you need to change your hands to find it. That's something I think would be amazing and there are a couple of other different fields like that integrating technology because that's like the big thing now is medical education is integrating more and more technology in simulation and it's amazing. But I think that the risk is really dropping the personal aspect and especially given the whole patient directed or even patient centered thing. That's a problem. But I think that we could be part of that missing link in terms of how do you do people and technology.

Robin: 35:59 At the end of each episode we ask each of the people that we interview the same question and it's now your turn. What's the most important question you're asking right now?

Alexandra: 36:08 I mean I'm always asking how do we do this better?  And certainly right now I think I'm at a new stage in my own experience of being an entrepreneur. And some of it for me is like how do I adapt my behaviors and my life to be the person I want to be in this field. You know how do I change things around so that I feel confident in what we're doing and also feel confident in myself? At first it was so exciting and I felt so confident in the skill set but we've expanded to the point where I need to figure out how to feel solid in all of this again. I mean, I guess also I'm asking like hey how could we work with virtual reality stuff.  So there's the two sides.

Robin: 36:46 Alexandra, thanks for joining us today.

Alexandra: 36:46 Thanks, Robin.

Robin Pendoley - Host

Robin is Founder & President of Thinking Beyond Borders, an educational institution helping young people develop the capacities to be exceptional social impact leaders. With a BA in International Development at UCLA and an EdM from the Harvard Graduate School of Education, Robin’s work is focused on understanding how meaningful impact is created and replicated. He is humbled and inspired every day by the learning and work of the students, educators, and alumni of the Thinking Beyond Borders community.

Julia Jones - Editor & Producer

Julia is an alumt of TBB’s Global Gap Year class of 2012. She received her Bachelor of Arts in International Relations and Entrepreneurship & Emerging Enterprises from Syracuse University. Having studied and worked around the world, she has now joined the Thinking Beyond Borders staff, supporting our US operations and serving as a Program Leader for our Gap Year Programs. She is thrilled to continue her exploration of social justice, global issues, and deeper cultural understanding alongside students.

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