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Student Pelvic Examination Clinic: Teaching with innovation

Sandra Carr, Alex Tregonning and Dianne Carmody
Department of Obstetrics and Gynaecology
The University of Western Australia



Introduction

Historically, it appears to have been difficult for medical students to gain experience and therefore competence at performing digital and speculum vaginal examinations during their training. This lack of experience was demonstrated in a program evaluation of the 5th year obstetric and gynaecology rotation at University of Western Australia in 1998 and is supported in current gynaecology literature (Abraham, 1995, 1996). Research also indicates that women and practitioners find pelvic examinations anxiety provoking (Frye, 1994). This feedback highlights the possibility of graduates lacking confidence in their pelvic examination technique, increasing unnecessary discomfort for women and reduced efficacy of results obtained.

In response to this evaluation the Department of Obstetrics and Gynaecology at the University of Western Australia (UDO&G) proposed the introduction of an educational program to address these problems in the area of Obstetrics and Gynaecology. This program is based upon a teaching package developed by Suzanne Abraham from the University of Sydney (Abraham, 1997). The program embraces the UDO&G philosophy that knowledge and skills are best learned through experience. Learning from experience enables students to apply knowledge within a social context and as such can form the basis of group consciousness raising and social change (Weil and McGill, 1996).

In January 2000, the Student Pelvic Examination Clinic (SPEC) was introduced to increase the amount of experience students obtain in performing sensitive and competent pelvic examinations. This educational program utilises Gynaecological Teaching Associates (GTAs) who facilitate student achievement of the stated objectives through role play.

Patients have been used in clinical medical education for many years, with traditionally, a relatively passive role (Stacy and Spencer, 1999) or as standardised patients for assessment purposes (Lane et al, 1999). Gynaecological Teaching Associates conversely actively participate as teachers and assist in student development of not just clinical skills but improve confidence in areas of counselling and complex communication (Wijma, 1998).

Purpose

The purpose of this paper is to document the results of process evaluation for the first year of the program in 2000. The difficulties of implementing such a program will be discussed and the applicability of this method of teaching to the development of other clinical skills for medical education considered.

Program objectives

  1. Improve the competence of students digital and speculum vaginal and pelvic examination technique.

  2. Increase sensitivity of examination technique to minimise client discomfort.

  3. Improve efficacy of Pap smears to minimise patient inconvenience and maximise cost effectiveness.

  4. Reduce student anxiety related to conducting gynaecological examinations.

Program outline

One hundred and twenty seven medical students rotated through their Obstetrics & Gynaecology Term in five, eight-week blocks during the year 2000.

Every student attended a two-hour theoretical session in preparation for the Student Pelvic Examination Clinic. This theoretical session had a 45 minute lecture on the process of performing a pelvic examination, revision of normal anatomy and alerted students to abnormal findings. The lecture was followed by the opportunity to practice their examination technique through the use of mannequins . During this clinical workshop students are asked to rotate through four stations that direct them in preparing their equipment, performing an abdominal examination, passing a speculum to locate the cervix and take a Pap smear, conduct a bi-manual examination and finally to document the language they would use to explain the procedure to a woman.

Subgroups of between 6 and 8 students then attend a two-hour clinical teaching session. During this session the students take a history from and perform a pelvic examination of two Teaching Associates under supervision of a doctor or nurse practitioner. The GTAs provide feedback for the students on their communication skills and examination technique. The GTA is the clinical teacher and the health professional present has a role in supporting the teaching associate only. During the remaining weeks of the obstetric and gynaecology term students are asked to document any pelvic examinations they perform and are assessed during one of these occasions.

Methods of evaluation

The methods of evaluation have been triangulated to improve the validity and reliability of information obtained.
  1. The processes surrounding the implementation of the SPEC has been evaluated using both student and teaching associate perceptions of the program.

  2. Additionally the reflections of the project officer and program director have been summarised to reflect the progression of implementation.

  3. The impact of SPEC on the amount of clinical experience students obtain has been described through a comparison of the number of pelvic examinations students have documented in the ward folders in 1999 and 2000.

  4. A summary of the budget for the program has been included to assist in cost benefit estimations.

Student Evaluation

The students were asked to complete a 12 item, 5 point Likert scale type questionnaire where 1= strongly disagree and 5= strongly agree at the end of their eight week Obstetric & Gynaecology Term. The items asked students to rate the processes around the program such as whether the objectives were clear and if the program was well organised and if the program was provided in a supportive environment. Additionally students were asked to evaluate the use of teaching associates as a method of teaching and the teaching associates themselves, if they felt more prepared for the clinical setting, more confident in their clinical skills and less anxious at performing a pelvic examination.

The frequencies of each score were then recorded and means calculated. It was pre determined that the results would be interpreted as being positive if the mean score for each item was 3.5 or above and negative if the mean score was below 3.0. This is in alignment with the University of Western Australia's Centre for Staff Developments interpretation of the 5 point Likert scale as used to assess student perceptions of teaching related to curriculum evaluation. The cumulative frequencies for the percentages of students who agreed or strongly agreed with items, were not sure or disagreed with the item are also represented to indicate the spread of agreement.

Gynaecological Teaching Associate perceptions

In 2000 there have been twelve women who have participated consistently as GTAs. These GTAs were asked to complete an 11 item, 5 point Likert scale questionnaire at the end of the academic year to record their perception of the training they had received and their perceptions of SPEC as a method of teaching pelvic examination to medical students. They were also asked to evaluate overall student communication skills and clinical behaviour and comment on how the program could be improved for 2001. The data was examined using the same interpretation of the mean and cumulative frequencies as described above. Comparisons of the mean scores between the students and GTAs did not occur because of the large difference in sample sizes and structure of the questionnaires.

Impact of SPEC

Medical students in Year 5 of 1999 and 2000 have been asked to record the clinical experience they obtain in many areas including pelvic examination during their Obstetric and Gynaecology Term. The number of recorded pelvic examinations has been compared as a mean number per student.

In addition to this students in Year 6 during 1999 and 2000, have been asked to complete a questionnaire that records not only the number of examinations students have performed but asks them to record their own perceptions of how competent they feel to perform a pelvic examination independently and to rate their anxiety at performing this procedure. Data pertaining to this aspect of the evaluation will not be ready for analysis until the end of 2001 when the first cohort of students attending SPEC will complete their medical degree.

Results and discussion

Student perceptions of SPEC

Of the 127 students who attended the SPEC clinic throughout the year, 101 returned the completed survey, which is an overall response rate of 80%. Table One documents a summary of the results obtained from the students. These results demonstrate mean scores of between 3.8 and 4.9 for each item. There is a high level of agreement between students of these mean scores as depicted in Figure 1.

Figure 1

Between 92 and 99% of students either agreed or strongly agreed that the program had clear learning objectives, was well organised, was a useful and appropriate method of teaching which helped prepare them for the clinical setting, improved their confidence and reduced their anxiety. Similarly the students reported the GTAs to be good teachers that provided and welcomed feedback. Ninety eight percent of students agreed that SPEC provided a supportive learning environment.

The lowest scoring item asked students to rate whether this method of teaching promoted teamwork. With a mean of 3.8 and a wider range of agreement between students this item requires further consideration as to how this result may be interpreted. It may be that students did not consider the team approach that is required of the community members and health professionals to provide the program. This aspect of the program may need to be explicitly identified in the future.

All of the mean scores were above 3.5 and as such have been interpreted as demonstrating positive student perceptions of SPEC. These results were supported further by the high level of agreement between students and open ended feedback received from students. There were no negative comments received. Many made statements such as the following:

Excellent! Takes the edge off the first clinical encounter requiring a pelvic. Much more confident, knew what it felt like and looked like. Very, very worthwhile.

An excellent session. Really good for overcoming initial anxieties about doing pelvic examinations. Feedback from tutors was constructive and encouraging.

Great chance to let (especially students) to do a VE. Women in clinic are often reluctant. Very good and appreciate having the volunteers giving up their time.

The ideal way of teaching. Highly worthwhile.

Please keep this as part of the course. It is very useful to actually be given the opportunity to practise clinical skills. I personally have done more SPECS as a result.

This was very helpful for us to get direct feedback about our approach, technique and attitude towards patients. Finally, we get a subjective response to whether or not one feels uncomfortable, in pain during the exam, or how we could improve on how we approached or explained something to a patient. Absolutely essential and useful for future clinical stuff.

The only suggestion for change to the program made by students related to enabling students to see the instructional video again closer to their allocated clinic time.

Table 1: Year 5 Student Perceptions of SPEC, 2000

Item Mean (/5) Strongly Agree/ Agree (%) Not Sure (%) Disagree/ Strongly Disagree (%)
1. Learning objectives for SPEC were clear 4.4 97 3 0
2. SPEC was well organised 4.6 98 2 0
3. SPEC is a useful way of teaching pelvic exam 4.9 99 1 0
4. Content was appropriate for this method of teaching 4.7 98 2 0
5. SPEC helped prepare me for the clinical situation 4.8 99 1 0
6. SPEC made me feel more confident of my clinical skills 4.7 97 2 1
7. SPEC helped reduce my anxiety at performing a pelvic exam 4.6 92 6 2
8. This method of teaching promoted teamwork 3.8 64 30 6
9. I found the teaching associates to be good teachers 4.5 94 5 1
10. Feedback about student performance was appropriate 4.5 96 2 2
11. SPEC provided a supportive learning environment 4.6 98 1 1
12. Students were encouraged to give feedback about the clinic 4.3 93 7 1

Gynaecological Teaching Associate perceptions

Eight of the 12 GTAs returned completed questionnaires. This is a response rate of 66%, which is just adequate. All of the respondents agreed or strongly agreed that the training they received was adequate. The only suggestion for the training program was to introduce a role play of the clinical session to improve understanding of the clinic process for each week.

Similarly to the students responses, all GTAs agreed or strongly agreed that the clinic was well organised, that SPEC is a useful way of teaching pelvic examination and prepares students well for the clinical setting. One or two respondents were not sure or disagreed that all students had explained the procedure correctly, used appropriate language, obtained appropriate consent or were competent with their examination technique by the end of the clinic session. These responses are not unreasonable as SPEC is a training program and as such it should be expected that not all students would be competent with all of the learning objectives by the end of the four-hour training program. Each GTA has the opportunity to provide feedback to the student about these skills, which assists the student to develop competence and confidence while obtaining further practice in the clinical settings during the remainder of their Obstetrics and Gynaecology Term.

All of the GTAs agreed the students treated them with appropriate respect and 100% strongly agreed that SPEC should continue in 2001. These results as summarised in Table 2 and Figure 2 provide reassuring feedback about how the GTAs perceive their preparation for their role, the processes surrounding the SPEC and the way in which students view the GTAs role and respond to the teaching they provide.

Table 2: Gynaecological Teaching Associates Perceptions of SPEC, 2000

Item Mean (/5) Strongly Agree/ Agree (%) Not Sure (%) Disagree/ Strongly Disagree (%)
1. I understood what was involved with SPEC after the training program. 4.6 100 0 0
2. The training program prepared me for my role as Teaching Associate. 4.5 100 0 0
3. Overall I found SPEC to be well organised. 4.9 100 0 0
4. I think SPEC is a useful way of teaching pelvic examination to medical students. 4.9 100 0 0
5. I believe SPEC helps to prepare students for the clinical situation. 4.9 100 0 0
6. Overall the students have explained the procedure correctly to me. 4.0 88 12 0
7. In general the students have used appropriate language. 3.8 75 25 0
8. The students gained appropriate consent before proceeding with the examination. 3.8 75 12.5 12.5
9. I found students to be competent with the examination technique by the end of the clinic. 3.6 75 12.5 12.5
10. The students have treated me with appropriate respect as their Teaching Associate. 4.8 100 0 0
11. I believe the SPEC clinic should continue in 2001. 5.00 100 0 0

Figure 2

Reflections of the Project Officer and Program Director

When the program was developed it was anticipated that the most difficult area of implementation would be recruitment of suitable GTAs. This anticipated difficulty has indeed become a reality. The original proposal suggested a figure of 50 women to run the program successfully. The recruitment strategies such as placing advertisements in the Australian Nurses Journal, Division of General Practice Newsletters and canvassing special women's interests groups commenced around eight months before the program was due to start. While many people came forward in support of the program, very few women wanted to participate as GTAs.

The most successful avenues of recruitment have been through advertisements in local and community newspapers and advertising with university based student employment services. All women have been invited to attend a training session before deciding to join the program and each GTA has been allowed to self select their participation. Self selection was chosen as the most appropriate mechanism as it was believed it may assist in forming a group of GTAs more representative of the community at large than if they had been chosen in accordance with pre-determined selection criteria. The only exclusion criteria have been if a woman has had a hysterectomy so that all students are able to examine a woman with a uterus before encountering variations of normal. To date 12 women have participated on an ongoing basis as GTAs for 2000.

The ongoing need for recruitment and training has significantly shifted the focus of the role of Project Officer so that this ongoing function comprises a large amount of her duties and has meant that the amount of expenditure for advertising is triple that originally budgeted for.

Similarly it was anticipated that once the GTAs had been trained and had some sessions with the guidance of qualified health professionals they would be able to work more independently in pairs with the supervision of the Project Officer between two or three consulting rooms. Because of the difficulties recruiting GTAs the support provided them by the health professionals has been seen to be essential to the long term success of the program. This again has meant that the costs have been higher than expected and has resulted in the recruitment of more nursing staff with appropriate backgrounds and training as opposed to continuing with only medical staff support because of the cost involved.

These experiences together with the day to day difficulties of coordinating attendance of students, GTAs and health professionals provide insightful background for others contemplating using this method of teaching in other areas of clinical skill development.

Impact of SPEC

The records of students self reported pelvic examination experience obtained during their Obstetric and Gynaecology Term has been reviewed for 1999 when students attended a theoretical session only and 2000 where students have also participated in SPEC as part of their Term. Tables three and four below summarise the difference in the mean scores. In 1999 the mean number of pelvic examinations students performed was 2.6 compared with 4.1 in 2000 during their Obstetric and Gynaecology Term. This is statistically significant at < 0.005. It is important to note that the students in 2000 were asked not to include pelvic examination experience obtained at the SPEC in their records. It is also interesting to recognise that the proportion of students who performed three or more examinations has increased considerably between 1999 and 2000 as depicted in Table 5.

Table 3: Pelvic examination experience for students in 1999 and 2000

GroupNMeanStd. deviationStd. error mean
1999542.6111 1.7420.2371
20001284.1094 1.8065.1597

Table 4: Pelvic Examination Experience - comparison of mean scores for 1999 and 2000

Table 4

Table 5: Pelvic examination experience - comparison of frequencies for 1999 and 2000

1999 number of
pelvic exams
Percentage2000 number of
pelvic exams
Percentage
01104
12015
222213
314312
411417
520516
62633

This data demonstrates evidence of the positive impact of SPEC upon the amount of experience students obtain during their Obstetric and Gynaecology Term. Further evidence regarding student experiences obtained in 6th year will be collected at the end of 2001 when the current students finish their studies.

Budget summary for 2000

While the program did not commence until January 2000 the preparation for its commencement began in 1999. The program director sought and obtained financial assistance to cover the cost of setting up the program. The West Australian Cervical Cancer Screening Prevention Program agreed to the then estimated costs of recruiting and training the GTAs. The University Teaching and Learning Initiatives Scheme agreed to support the program in the form of providing funding toward the cost of equipment and to pay the salary of the project officer during 1999.

The Faculty of Medicine and Dentistry has provided the ongoing costs of SPEC for the year 2000 allocated a sum of $18,800. Funds have been spent in slightly different proportions to anticipated mainly due to the fewer than expected number of GTAs employed, the need for ongoing health professional support and subsequently higher than expected recruitment cost. Despite these difference SPEC has run with a small budget surplus which is in part due to monies received from outside parties. The Student Pelvic Examination Clinic would like to acknowledge the ongoing support of King Edward memorial Hospital in the form of the provision of physical resources for the weekly clinic and Dr Amanda Barnard from the Department of General Practice for assisting the clinic since inception without cost.

Future directions - Implications for other areas of education

It would appear from the data obtained that the Student Pelvic Examination Clinic has been well received by both the students and women who act as Teaching Associates. The feedback has been overwhelmingly positive. While the cost of the program is about $130 per student - the benefits are there. This is reassuring in times when it is becoming more and more difficult to provide students with meaningful clinical opportunities in the health setting. It would appear that three of the four program objectives are being met. The directions for the future include evaluating further the outcomes of SPEC in the form of recording student and graduate behaviours and evaluating postgraduate perceptions of their competence with performing pelvic examinations and Pap smears. Meanwhile the constant process of recruitment and training of GTAs continues.

It is important to recognise the far reaching implications that programs such as SPEC can have on the ability of future practitioners to develop interpersonal skills that are appropriate within varied social contexts. These skills relate not only to pelvic examination but transcend all areas of women's health. Neither should we under-estimate the potential such programs have in bringing about attitudinal and behavioural shifts through positive role modelling which includes and emphasises the importance of members of the community/patients/clients as collaborative partners in health care provision.

References

Abraham, S. (1995). Vaginal and Specula examination in medical curricula. Australian and New Zealand Journal of Obstetrics and Gynaecology, 35, 56-60.

Abraham, S. (1996). The effect of sexual experience on the attitudes of medical students to learning gynaecological examinations. Journal of Psychosomatic Obstetrics and Gynaecology, 17, 15-20.

Abraham, S. (1997). Scorpio Gynaecological examination: An educational package integrating assessment and learning. Ashwood House Medical: Melbourne.

Frye, C. A. and Weisberg, R. B. (1994). Increasing the incidence of routine pelvic examinations: behavioural medicine's contribution. Women & Health, 21(1), 33-55.

Lane, J. L., Ziv, A. and Boulet, J. R. (1999). A pediatric clinical skills assessment using children as standardized patients. Archives of Pediatrics & Adolescent Medicine, 153.

Stacy, R. and Spencer, J. (1999). Patients as teachers: A qualitative study of patients' views on their role in a community-based undergraduate project. Medical Education, 33(9), 688-694.

Weil, S. and McGill, I. (ed). 1996. Making Sense of Experiential Learning: Diversity in Theory and Practice. Buckingham: Open University Press.

Wijma, B., Gullberg, M. and Kjessler, B. (1998). Attitudes towards pelvic examination in a random sample of Swedish women. Acta Obstetrica et Gynecologica Scandinavica, 77(4), 422-428.

Please cite as: Carr, S., Tregonning, A. and Carmody, D. (2001). Student Pelvic Examination Clinic: Teaching with innovation. In A. Herrmann and M. M. Kulski (Eds), Expanding Horizons in Teaching and Learning. Proceedings of the 10th Annual Teaching Learning Forum, 7-9 February 2001. Perth: Curtin University of Technology. http://lsn.curtin.edu.au/tlf/tlf2001/carr.html


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