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

A Delphi-Style Evaluation of a Skin Assessment Simulation Using Clinical Vignettes and a Breast Health Training Tool

INTRODUCTION

Breast and skin assessment are both required clinical skills across health professional training programs. The breast is an ideal "canvas" for the development of a simulation exercise focused on the identification and diagnosis of skin conditions that could present anywhere on the body alongside unique conditions specific to the breast and nipple-areolar complex. A skin assessment simulation on a breast model has not been described.

METHODS

Investigators developed 20 clinical vignettes for breast and skin conditions (ie, features) depicted on a set of 10 single silicone breast models in 4 skin tones. A modified Delphi approach was used to evaluate the appropriateness of the clinical vignettes and realism of features. A convenience sample of 136 licensed physicians was recruited online. In round 1, participants rated the realism of features and suggested descriptors for each feature. In round 2, participants rated their agreement with descriptors from round 1, selected a diagnosis based on clinical vignettes, and assessed the utility of the Breast Health Training Tool for health professionals.

RESULTS

In round 1, participants (n = 38) agreed (5.1/6) that the features were realistic. In round 2, participants (n = 24) agreed (4.6/6) with the descriptors. Most (>50%) participants agreed on a diagnosis for each feature. Participants (n = 27) agreed (5.3/6) that this tool is useful for health professional education.

CONCLUSIONS

This is the first evaluation of a simulation tool for teaching breast examination and identification of skin conditions on the nipple-areolar complex and breast tissue in multiple skin tones, simultaneously filling the gap in women's breast, lactation, and skin health education.

COVID-19 related disruptions to medical education and perceived clinical capability of new resident physicians: a nationwide study of over 1200 first-year residents

The COVID-19 pandemic transformed the final year of undergraduate medical education for thousands of medical students across the globe. Out of concern for spreading SARS-CoV-2 and conserving personal protective equipment, many students experienced declines in bedside clinical exposures. The perceived competency of this class within the context of the pandemic is unclear. We designed and distributed a survey to measure the degree to which recent medical school graduates from the USA felt clinically prepared on 13 core clinical skills. Of the 1283 graduates who matched at HCA Healthcare facilities, 90% (1156) completed the survey. In this national survey, most participants felt they were competent in their clinical skills. However, approximately one out of four soon-to-be residents felt they were clinically below where they should be with regard to calling consultations, performing procedures, and performing pelvic and rectal exams. One in five felt they were below where they should be with regard to safely transitioning care. These perceived deficits in important skill sets suggest the need for evaluation and revised educational approaches in these areas, especially when traditional in-person practical skills teaching and practice are disrupted.

Utility of Gynecological Teaching Associates

Introduction Gynecological teaching associates (GTAs) are trained to teach the pelvic exam using themselves as models, and it has been hypothesized that their use can improve learners' confidence and interpersonal skills. This study aims to gain greater insight into whether the use of GTAs is associated with increased medical students' confidence when performing the pelvic exam during clinical rotations. Methods An email survey was distributed to medical students in two different classes at a single United States Medical Licensing Examination (USMLE)-accredited medical school: one that learned the pelvic exam using GTAs and one that did not. A Fisher's exact test was performed to determine associations between the use of GTAs and confidence in performing the pelvic exam, with a p-value of <0.01. Results Out of the 85 survey participants, 68 had performed a pelvic exam in the clinical setting and thus rated their confidence level. Of the 38 students who learned using a GTA, 66% (p<0.0024) reported a confidence level of four or five (out of five) compared to 50% of the 30 students who were not able to practice using a GTA. There was a statistically significant difference in the confidence levels of students who practiced on GTAs compared to those who did not. Discussion Our findings demonstrated that students who were able to learn the pelvic exam using GTAs reported higher confidence levels when subsequently performing a pelvic exam in a clinical setting. Conclusion Our findings support investment in GTA programming for teaching the pelvic exam in medical school curricula.

Teaching vulval anatomy in the twenty-first century: The Australian experience

Anatomy has often been regarded as an immutable discipline where everything that needs to be known is known. This article focuses on the teaching of vulval anatomy, the diversification of gender in contemporary society, and the increasing popularity of the Female Genital Cosmetic Surgery (FGCS) industry. The binary language and singular structural arrangements contained in lectures and chapters on "female genital anatomy" are nowadays rendered exclusive and incomplete. A series of 31 semi-structured interviews with Australian anatomy teachers identified barriers and facilitators for teaching vulval anatomy to contemporary student cohorts. Barriers included lack of connection to contemporary clinical practice, time and technical difficulty involved in regularly updating online presentations, the crowded curriculum, personal sensitivity to teaching vulval anatomy, and reluctance to introduce inclusive terminology. Facilitators included lived experience, regular use of social media, and institutional initiatives toward inclusivity including the support of queer colleagues.

Our First Experience Implementing “Clinical Embryology and Reproductive Medicine” as a Curriculum Course of the Study Program General Medicine at the Faculty of Medicine in Bratislava, Slovakia

There is no separate course in the medical curriculum summarizing all aspects of human reproduction in most medical school curricula. At the same time, such a course would logically connect knowledge from clinical embryology and assisted reproduction, encompassing the issue of female and male infertility, mechanisms of birth defect formation, their prenatal diagnosis and subsequent specialized neonatal care. The aim of a wide team of university teachers comprising embryologists, gynecologists, neonatologists, endocrinologists, geneticists and others was to create and implement a new course entitled "Clinical Embryology and Reproductive Medicine" into the fourth-year curriculum of the study program General Medicine at the Faculty of Medicine, Comenius University in Bratislava. There has been a great interest in the course, as evidenced by the number of medical students enrolled. The lecture syllabuses have been divided into several thematic areas: 1) Clinical embryology including a laboratory part of assisted reproduction, 2) Cause and treatment options of female and male infertility, 3) A comprehensive view of the issue of birth defects, 4) The issue of preconception education, prenatal and childbirth training, family planning, 5) Reproductive immunology and endocrinology. Despite the complexity of human reproduction being a mainstay of gynecology and obstetrics, it is underemphasized in the medical school curricula worldwide. It is often reflected in shorter hospital / practical trainings during undergraduate studies and lower requirements at the final exam. Therefore, as students almost unanimously valued, this new course is extremely helpful in preparing for the final state exam.

Our First Experience Implementing "Clinical Embryology and Reproductive Medicine" as a Curriculum Course of the Study Program General Medicine at the Faculty of Medicine in Bratislava, Slovakia

There is no separate course in the medical curriculum summarizing all aspects of human reproduction in most medical school curricula. At the same time, such a course would logically connect knowledge from clinical embryology and assisted reproduction, encompassing the issue of female and male infertility, mechanisms of birth defect formation, their prenatal diagnosis and subsequent specialized neonatal care. The aim of a wide team of university teachers comprising embryologists, gynecologists, neonatologists, endocrinologists, geneticists and others was to create and implement a new course entitled "Clinical Embryology and Reproductive Medicine" into the fourth-year curriculum of the study program General Medicine at the Faculty of Medicine, Comenius University in Bratislava. There has been a great interest in the course, as evidenced by the number of medical students enrolled. The lecture syllabuses have been divided into several thematic areas: 1) Clinical embryology including a laboratory part of assisted reproduction, 2) Cause and treatment options of female and male infertility, 3) A comprehensive view of the issue of birth defects, 4) The issue of preconception education, prenatal and childbirth training, family planning, 5) Reproductive immunology and endocrinology. Despite the complexity of human reproduction being a mainstay of gynecology and obstetrics, it is underemphasized in the medical school curricula worldwide. It is often reflected in shorter hospital / practical trainings during undergraduate studies and lower requirements at the final exam. Therefore, as students almost unanimously valued, this new course is extremely helpful in preparing for the final state exam.

Medical Student Perspectives on the Ethics of Pelvic Exams Under Anesthesia: A Multi-Institutional Study✰

OBJECTIVE

Pelvic examinations under anesthesia (EUAs) are routine components of gynecologic surgery and often used to educate students about female pelvic anatomy. This multi-institutional survey study aims to describe students' experiences with conducting educational pelvic EUAs and their attitudes around the ethics of informed consent for these exams.

DESIGN

An anonymous survey of Likert and open-text response questions about institutions' practices around educational pelvic EUAs was sent to medical students.

SETTING

Medical schools included Vanderbilt University School of Medicine, Indiana University School of Medicine, Emory University School of Medicine, University of New Mexico School of Medicine, Meharry Medical College, and Warren Alpert Medical School of Brown University.

PARTICIPANTS

A total 305 medical students who had completed their obstetrics and gynecology (OB/GYN) clerkship between June 2019 and March 2020 filled out the survey (33% response rate).

RESULTS

Overall, 84% of students performed at least 1 pelvic EUA during their clerkship. Of the 42% (142) of students that observed patient informed consent processes most or every time, 67% reported they never or rarely witnessed an explicit explanation that a medical student may perform a pelvic EUA. Analysis of open-text responses found that students wanted to uphold patient autonomy but felt they did not have the personal autonomy to object to performing pelvic EUAs that they believed were unconsented. They faced significant emotional distress when consent processes were at odds with their personal ethos and professional ethical norms. Students favored more standardized and explicit patient consent processes for educational pelvic EUAs.

CONCLUSIONS

While students regularly perform pelvic EUAs, their involvement is inconsistently disclosed to patients, causing significant distress to students and risking erosion of students' attitudes about upholding patient autonomy and informed consent. Medical institutions must develop consistent, ethical, and patient-centered processes for trainee disclosure around pelvic EUAs.

New context, new content-Rethinking genital anatomy in textbooks

It has been widely claimed that reductions in allocated teaching time and the widespread implementation of short-cut teaching methodologies have led to a shortfall in anatomy knowledge among graduating doctors. This decline in knowledge is evident in the failure of anatomy content to prepare graduates for contemporary clinical practice. The implications for postgraduate surgical training are addressed in the numerous extracurricular anatomy courses available to surgical candidates. This paper focuses on genital diversity and its relevance to non-surgical graduates, thus highlighting another potential impact of this knowledge shortfall on frontline clinic consultations. As the gender revolution and female genital cosmetic surgery industry flourish, nothing in contemporary anatomy textbooks addresses issues of diversification of female genitalia nor gives medical graduates a realistic view of what is normal regarding female genital appearance.

Implementation and utilization of gynecological teaching associate and male urogenital teaching associate programs: a scoping review

BACKGROUND

Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs) are individuals trained to instruct health professional learners with their own body to conduct accurate, patient-centered breast, pelvic, urogenital, rectal, and/or prostate examinations. Evidence indicates that this results in improvements in technical competence and communication skills, but there is wide variability to how such programs are implemented and engaged within the curriculum. In this scoping review, we mapped evidence regarding (1) how GTA/MUTA programs are utilized with health professional learners, (2) how GTA/MUTA programs are implemented using the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) as a framework, and (3) what broad outcomes are addressed in publications.

METHODS

PubMed, ERIC, PsychINFO, CINAHL, and Sociological Abstracts were searched for all publications addressing instruction of physical examinations with a GTA/MUTA and/or administration of GTA/MUTA programs. Studies were charted in tandem until consensus was identified and then charted individually, using an iterative process. The scoping review protocol was registered prospectively.

RESULTS

One hundred and one articles were identified, and nearly all highlighted positive results regarding GTA/MUTA programs. Most studies addressed medical students within the USA and Europe. During instructional sessions, three (SD=1.4) learners worked with each GTA/MUTA and an average of 32 min (SD=17) was allocated per learner. GTAs/MUTA instructed both independently (n=33) and in pairs (n=51). Thirty-eight articles provided detailed information consistent with one or more of the Domains of the ASPE SOBP, with six providing specific information regarding safe work environments.

CONCLUSIONS

While studies demonstrate consistently positive outcomes for learners, there is wide variability in implementation patterns. This variability may impact learning outcomes and impact both physical and psychological safety for GTAs/MUTAs and learners. Terminology used to refer to GTAs/MUTAs is inconsistent and may obscure relevant publications. Additional research is indicated to explore the pedagogical variables that result in positive learning outcomes and examine methods to ensure physical and psychological safety of GTAs/MUTAs and learners.

TRIAL REGISTRATION

https://osf.io/x9w2u/ .

Teaching the Evaluation of Female Pelvic Pain: A Hands-On Simulation to Reinforce Exam Skills and Introduce Transvaginal Ultrasound

INTRODUCTION

Reproductive-age female patients commonly seek evaluation for pelvic pain in a variety of health care settings. Thus, teaching medical students how to effectively evaluate female pelvic pain is a necessary part of medical education. There are limited opportunities, however, to reinforce the needed skills for this common but sensitive presentation that can be anxiety-producing for preclinical students.

METHODS

The case involved a 23-year-old female presenting with lower abdominal/pelvic pain. Students performed the necessary history, physical examination, cervical sampling, and transvaginal ultrasound evaluation to make the diagnosis of pelvic inflammatory disease (PID) complicated by a tubo-ovarian abscess. The 30-minute simulated patient encounter was followed by a 30-40 minute faculty-led debrief.

RESULTS

This simulation case has been sustained in the curriculum since 2011 for 65 students per year. Through use of a faculty critical action checklist, debrief discussion, examination performance, and student evaluation feedback, this simulation has demonstrated effectiveness. Of students, 93 of 193 students (48%) who participated in the simulation case from 2018-2020 completed a survey in which they rated the degree of agreement with statements about the simulation based on a 5-point Likert Scale (1 = strongly disagree, 5 = strongly agree). All questions had a mean response of 4.5-4.8 in 2018-2020, demonstrating the consistent agreement by students of the clarity, fidelity, and knowledge-enhancing value of the simulation.

DISCUSSION

This simulation provided a useful opportunity and a safe environment for preclinical medical students to acquire knowledge and skills necessary to evaluate a female patient with pelvic pain and PID.

Teaching undergraduate students gynecological and obstetrical examination skills: the patient's opinion

Introduction

Our study assesses the patients’ opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE).

Materials and methods

We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies.

Results

The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases.

Conclusions

There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

To the Point: The expanding role of simulation in obstetrics and gynecology medical student education

This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC), provides educators with an overview of the use of simulation in undergraduate medical education in the field of obstetrics and gynecology. Simulation plays an important role in the education of medical students. Students are increasingly serving as clinical observers and providing less direct patient care. Simulation can help standardize education and ensure quality and comparability across an enlarging educational environment. This article summarizes the expanding role of simulation in undergraduate medical education in obstetrics and gynecology and its effect on important learner outcomes such as confidence, knowledge, skills, workplace behaviors, and translation to patient care.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy

OBJECTIVES

Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences.

METHODS

Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100).

RESULTS

A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01).

CONCLUSIONS

Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination.