Can physicians be replaced with gynecological teaching women to train medical students in their first pelvic examination? A pilot study from Northern Sweden

Improving Medical Student Comfort and Competence in Performing Gynecological Exams: A Systematic Review

PURPOSE

Performing a gynecological exam is an essential skill for physicians. While interventions have been implemented to optimize how this skill is taught in medical school, it remains an area of concern and anxiety for many medical students. To date, a comprehensive assessment of these interventions has not been done. The authors conducted a systematic review of the literature on interventions that aim to improve medical student education on gynecological exams.

METHOD

The authors searched 6 databases (Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, Scopus, Web of Science Core Collection, and ERIC [Proquest]) from inception to August 4, 2020. Studies were included if they met the following criteria: focus on medical students, intervention with the purpose of teaching students to better perform gynecological exams, and reported outcomes/evaluation. Extracted data included study location, study design, sample size, details of the intervention and evaluation, and context of the pelvic exam. All outcomes were summarized descriptively; key outcomes were coded as subjective or objective assessments.

RESULTS

The search identified 5,792 studies; 50 met the inclusion criteria. The interventions described were diverse, with many controlled studies evaluating multiple methods of instruction. Gynecological teaching associates (GTAs), or professional patients, were the most common method of education. GTA-led teaching resulted in improvements in student confidence, competence, and communication skills. Physical adjuncts, or anatomic models and simulators, were the second most common category of intervention. Less resource-intensive interventions, such as self-directed learning packages, online training modules, and video clips, also demonstrated positive results in student comfort and competence. All studies highlighted the need for improved education on gynecological exams.

CONCLUSIONS

The literature included evaluations of numerous interventions for improving medical student comfort and competence in performing gynecological exams. GTA-led teaching may be the most impactful educational tool described, though less resource-intensive interventions can also be effective.

The association of standardized patient educators (ASPE) gynecological teaching associate (GTA) and male urogenital teaching associate (MUTA) standards of best practice

Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs) instruct healthcare professional learners to perform accurate and respectful breast, speculum, bimanual vaginal, rectal, urogenital, and prostate examinations. During such sessions, the GTA/MUTA uses their own body to instruct while providing real-time feedback. While GTAs/MUTAs fall under the broader umbrella of Standardized Patient methodology, the specificity of their role indicates need for establishment of Standards of Best Practice (SOBP) for GTA/MUTA programs. On behalf of the Association of Standardized Patient Educators (ASPE), the Delphi process was utilized to reach international consensus identifying the Practices that comprise the ASPE GTA/MUTA SOBP. The original ASPE SOBP was used as the foundation for the iterative series of three surveys. Results were presented at the ASPE 2019 conference for additional feedback. Fifteen participants from four countries completed the Delphi process. Four of the original ASPE SOBP Domains were validated for GTA/MUTA programs: Safe Work Environment, Instructional Session Development, Training GTAs/MUTAs, and Program Management. Principles and Practices were shaped, and in some instances created, to best fit the distinct needs of GTA/MUTA programs. The ASPE GTA/MUTA SOBP apply to programs that engage GTAs/MUTAs in formative instructional sessions with learners. Programs that incorporate GTAs/MUTAs in simulation roles or in summative assessment are encouraged to reference the ASPE SOBP in conjunction with this document. The SOBP are aspirational and should be used to shape Practices within the program's local context. The ASPE GTA/MUTA SOBP will continue to evolve as our knowledge-base and practice develop.

Factors of importance for developing a trustful patient-professional relationship when women undergo a pelvic examination

We examined gynecological teaching women's perception on what factors are important for developing a trustful patient-professional relationship when women undergo a pelvic examination. A qualitative research design was conducted with repeated focus group discussions. Our results show that healthcare professionals' communications skills can strengthen a trustful patient-professional relationship. Treating women with dignity could make them feel less vulnerable and make the relationship trustworthy based on respect. Thus, having the ability to identify factors important for a trustful relationship may support healthcare professional's ability to strengthen women's health issues. A trustful relationship might also affect quality of care.

Patient-centred education: How do learners' perceptions change as they experience clinical training?

The use of patient educators is one of many teaching strategies meant to foster principles of patient-centred care. We previously found that early patient educator exposure helped to shape the understanding of patient-centredness in pre-clerkship learners. We now expand on this work to evaluate whether there is persistence of initial perceptions and to explore general reflections on longer-term impacts of early patient educator exposures once learners are immersed in the clinical phase of their training. In this follow-up study, we conducted group interviews with a sample of learners who wrote reflections as part of their pre-clerkship patient educator experience. We explored how perspectives on patient educators changed over time, and determined which themes identified during pre-clerkship remained relevant to clinical trainees. Audio recordings were transcribed and analyzed thematically using a hybrid inductive and deductive analysis to construct a thematic framework derived through a method of constant comparison. We identified three new themes: "value of early clinical experience", "change in learners' perspectives", and "valuing and applying CanMEDS roles other than Medical Expert". Themes from pre-clerkship that remained relevant included: "patients' perspective humanizes disease", "patients' experiences with navigating the healthcare system", "learners' perceptions of the learning strategy", and "inaccuracies and inconsistencies in the learning experience." Many themes identified in pre-clerkship learners remain relevant in early clinical trainees. Further, insights from pre-clerkship experiences with patient educators evolve as learners experience clerkship with definite shifts in emphasis and new perspectives. This work illuminates the utility of patient educators for those considering this strategy for supporting the development of patient-centredness in undergraduate medical education.

Blurred boundaries: sexuality and power in standardised patients' negotiations of the physical examination

Background

Working with standardised or simulated patients (SPs) is now commonplace in Simulated Learning Environments. Embracing the fact that they are not a homogenous group, some literature suggests expansion of learning with SPs in health professional education by foregrounding their personal experiences. Intimate examination teaching, whether with or without the help of SPs, is protected by a particular degree of ceremony given the degree of potential vulnerability. However, other examinations may be equally intrusive for example the close proximity of an eye examination or a chest examination in a female patient. In this study, we looked at SPs' experiences of boundary crossing in any examinations, sensitised by Foucault's concept of the clinical gaze. We wished to problematise power relations that construct and subject SPs as clinical tools within simulation-based education.

Methods

We collected data from 22 SPs, through five focus groups. Analysis was an iterative process, using thematic analysis. Data collection and reflexive analysis continued iteratively until concepts were fully developed and all theoretical directions explored.

Results

Students and SPs construct simulated teaching consultations by negotiating the unequal distribution of power between them. The SPs themselves discussed how they, perhaps unknowingly, acted in accordance with the discourse of the clinical gaze. However, SPs became disempowered when students deviated from the negotiated terms of consent and they used their agency to resist this. The SPs used strong sexual metaphors to express the subjugation they experienced, as discourses of sexuality and gender played out in the Simulated Learning Environment.

Conclusion

We demonstrate that power dynamics and the clinical gaze can have important consequences within the Simulated Learning Environment. Every physical examination can be potentially 'intimate' and can therefore be underpinned by discourses of sexuality and gendered undertones. In partnership with SPs, simulation-based education should create a teaching space that no longer fosters the discourse of the clinical gaze but facilitates students to learn to reflectively navigate, in the moment, the fine line between touching patients versus touching loved ones, and the blurred boundaries that exist in the gulf between sexual contact and benevolent touch.

Pelvic and breast examination skills curricula in United States medical schools: a survey of obstetrics and gynecology clerkship directors

BACKGROUND

Learning to perform pelvic and breast examinations produces anxiety for many medical students. Clerkship directors have long sought strategies to help students become comfortable with the sensitive nature of these examinations. Incorporating standardized patients, simulation and gynecologic teaching associates (GTAs) are approaches gaining widespread use. However, there is a paucity of literature guiding optimal approach and timing. Our primary objective was to survey obstetrics and gynecology (Ob/Gyn) clerkship directors regarding timing and methods for teaching and assessment of pelvic and breast examination skills in United States medical school curricula, and to assess clerkship director satisfaction with current educational strategies at their institutions.

METHODS

Ob/Gyn clerkship directors from all 135 Liaison Committee on Medical Education accredited allopathic United States medical schools were invited to complete an anonymous 15-item web-based questionnaire.

RESULTS

The response rate was 70%. Pelvic and breast examinations are most commonly taught during the second and third years of medical school. Pelvic examinations are primarily taught during the Ob/Gyn and Family Medicine (FM) clerkships, while breast examinations are taught during the Ob/Gyn, Surgery and FM clerkships. GTAs teach pelvic and breast examinations at 72 and 65% of schools, respectively. Over 60% of schools use some type of simulation to teach examination skills. Direct observation by Ob/Gyn faculty is used to evaluate pelvic exam skills at 87% of schools and breast exam skills at 80% of schools. Only 40% of Ob/Gyn clerkship directors rated pelvic examination training as excellent, while 18% rated breast examination training as excellent.

CONCLUSIONS

Pelvic and breast examinations are most commonly taught during the Ob/Gyn clerkship using GTAs, simulation trainers and clinical patients, and are assessed by direct faculty observation during the Ob/Gyn clerkship. While the majority of Ob/Gyn clerkship directors were not highly satisfied with either pelvic or breast examination training programs, they were less likely to describe their breast examination training programs as excellent as compared to pelvic examination training-overall suggesting an opportunity for improvement. The survey results will be useful in identifying future challenges in teaching such skills in a cost-effective manner.

Genital examination training: assessing the effectiveness of an integrated female and male teaching programme

BACKGROUND

Learning to undertake intimate female and male examinations is an important part of medical student training but opportunities to participate in practical, supervised learning in a safe environment can be limited. A collaborative, integrated training programme to provide such learning was developed by two university teaching departments and a specialist sexual health service, utilising teaching associates trained for intimate examinations in a simulated clinical educational setting. The objective of this research was to determine changes in senior medical students' self- reported experience and confidence in performing male and female genital examinations, before and after participating in a new clinical teaching programme.

METHODS

A quasi-experimental mixed methods design, using pre and post programme questionnaires and focus groups, was used to assess the effectiveness of the programme.

RESULTS

The students reported greatly improved skill, confidence and comfort levels for both male and female genital examination following the teaching programme. Skill, confidence and comfort regarding male examinations were rated particularly low on the pre-teaching programme self- assessment, but post-programme was rated at similar levels to the female examination.

CONCLUSIONS

This integrated female-male teaching programme (utilising trained teaching associates as simulated patients in a supervised clinical teaching environment) was successful in increasing senior medical students' skills and levels of confidence in performing genital examinations. There were differences between female and male medical students in their learning. Suggestions for improvement included providing more detailed instruction to some clinical supervisors about their facilitation role in the session.