Initial pelvic examination instruction: The effectiveness of three contemporary approaches

Initial pelvic examination instruction: of three contemporary approaches GERALD

B.

DIANNE

SINGLEI‘ON.

THOMAS JACK Emt

HOLZMAN,

F‘. HOLMES, L.

La rising.

MAATS(:H.

The effectiveness

M.D PFI.D. Pri.1). PH.1).

A4 i( ,/I iga II

Initial pelvic examination skills were taught to 38 second-year medical students who were assigned to one of three study groups. The cognitive posttest scores of all groups were nearly identical, but the students who had received training from professional simulated patients rated significantly better in psychomotor and interpersonal skills than did those who received simulated outpatient instruction by a gynecologist. Thirty-five per cent of the psychomotor and interpersonal ratings attained by the latter and 5 per cent of those attained by the former were marginal or inadequate. It was concluded that a program involving professional simulated patients is an effective method of teaching pelvic examination skills to beginning students. (AM. J. OBSTET. GYNECOL. 129: 124, 1977.)

structor present and all three interacting. guidance f’rom the physician and feedback from the patient regarding the student’s performance are, at best. compromised. In this triadic relationship, the practic c of interpcwonal skills is nearly impossible and is fi-ccluently ignored. The learner and the instructor are apt to f’ocus upon the technical aspects of the examination and overlook the needs of the patient. III this clinical situarion, the student’s initial anxieties can be increased to tile point that even the learning of primary psyc homotor skills is inhibited. In short. for some students this initial outpatient learning experience may not bc productive and, for other students, it ma) C~VPII be ~ollntcrproductive. The use of simulated or programmed patients to teach initial pelvic examination skills has been proposed as an alternate method by Kretzschmar.” i\t first, the professional simulated patient (PSP) \\as used as a patirnl substitute with all the instruction coming from the physician.” li More recently, Kretzschmar devel-

-I‘HE PF:KFORMAN(:~. OF aIt effective pelvic cxamination involves an interactive se]-ies of cognitive. psichomotor. and interpersonal skills.‘. ’ ‘I‘hr initial csposure to this task can be an emotional experience. not only for the student who is concerned about his or herability to perform in a professional manner bur also t01. the patient who quickly becomes a!vare that this is ;JJJ initial training cxpericnce fOJ- the student. M:ith an in-

124

Volume

Pelvic examination instruction

129

Number 2

oped an instructional unit based on the concept that the PSP should act as both the patient and the instructor. He postulated that with no physician present the interpersonal and psychomotor interactions between PSP and student were more likely to be open and realistic. At Michigan State University, a similar instructional program was offered to all sophomore students during the 1974 and 1975 school years. The students’ reactions to this approach were overwhelmingly positive, but the program’s effectiveness in enhancing student learning had not been empirically evaluated. It was hypothesized that students participating in a program utilizing PSP’s would perform better during a subsequent examination than students participating in a program designed to simulate a traditional outpatient setting with a gynecologist, patient, and student present.

Material and methods Subjects. A total of 42 second-year students at the Michigan State University College of Human Medicine volunteered to participate in the research. Inclusion in the study substituted for the regular pelvic examination training received in the second year. Reassurance was given that individual participant performance would remain confidential since group rather than individual data were the focus of the study. Subjects completed a demographic data questionnaire and research participation consent form. Six volunteers were eliminated from the study because they had previously conducted five or more pelvic examinations. The mean age of the 38 subjects, 20 women and 18 men, was 25.8 years. Twenty-six students had never conducted a pelvic examintion prior to the study, and the mean number of previous pelvic examinations performed was 0.79. Procedures. With the use of the demographic data, the 38 subjects were divided into three treatment groups by matching on variables of gender. age, and previous pelvic examination experience. Experimental treatments were randomly assigned to groups. PSP 1 and PSP 2 consisted of 14 subjects each while the outpatient experience group (OPE) consisted of 10 subjects. The research was conducted during a six-week period. Students in the OPE group read the chapter on pelvic examination in the book by Bates,7 watched a 16 mm. film by Hunter entitled “Female Pelvic Examinawith a faculty tion. “* and spent one hour individually *Available from Dr. Obstetrics and Gynecology, dianapolis, Indiana.

Charles Hunter, Indiana School

Department of Medicine,

of In-

125

gynecologist, his nurse, and one of two women who were paid to be patients for this research. The gynecologist demonstrated how to perform a pelvic examination on the “patient” just as he would have if this had been his private office, and the student then conducted a pelvic examination with supervision and feedback from the gynecologist. Each student in the PSP 1 group: (1) read the description in Bates.’ (2) worked through the OMNI selfinstructional unit,* (3) reviewed pelvic examination procedures for one hour with another PSP 1 student and a physician using a Gynny mannequin (a tutorial), and (4) immediately thereafter, with the PSP 1 student-partner from the tutorial, attended a one-hour training session with two PSP’s. During this experience, the PSP’s introduced themselves to the students, enumerated their educational background, and established the objectives for the session. One of two students then performed the examination while the other observed. When the first student completed the examination, the two PSP’s switched roles; the nursechaperone-instructor became the patient-instructor and vice versa. The student who had been the observer examined the “new” patient and the other student observed. Students were encouraged to repeat procedures until they reached some degree of comfort. All the PSP’s were either PH.D. candidates in counseling and psychology or registered nurses. Most had past experience in interpersonal skill training, and all had been taught to perform a pelvic examination. Each student in PSP 2 had the same training that the PSP 1 students had except that the hour-long tutorial with a physician was deleted. Within 24 hours of this training, all students in all groups underwent a final evaluation at which time the student performed a pelvic examination in the presence of two evaluators, recorded his or her findings, completed an 86 point objective test, and also completed two self-evaluation rating forms, one on psychomotor pelvic examination skills and the other on interpersonal skills. The pelvic examination evaluators were the “patient” being examined and the “nurse” who M’as assisting. Assignment of the two teams of patient-nurse

evaluators

counterbalanced evaluators training

prior Similarly,

did programs

training none

group

was

with respect to the three groups.

The

not

to students participate

and

they

in had

of the students of the

faculty

in each the

experimental

no knowledge

they were

of the

to evaluate.

participating

*OMNI Module. Pelvic Examination: Submodule, ination Procedures-a self-instructional programmed mm. film, and plastic pelvic mannequin, Gynny, through Ortho Pharm. Corp., Raritan, New Jersey.

in

the

in-

Examtext, 16 available

126

Holzman et al.

September Am. J. Ohstet.

401

questionnaire

n=lO

one

%

of the other

potential

ing

performance Two

outcomes

scores

for

produced

training

student

by three

pelvic

Cognitive Objective

PsP2* (No. = 14)

OPE (No. =10)

skill

Performanre

tests*

51.8

PSP 1* I (No. = 14)

58.9

59.4

1ntrrpersonai Nurse Patient/model Student

6.7 5.8 6.4

8.8T 9.2t 7.9t

9.17 8.5’r 7.3t

Psychomotor Nurse Patient/model Student

7.3 6.3 6.6

9.0t 9.9t 7.9t

9.0t 8.5 7.7

* PSP 2 data are not significantly t Indicates score is significantly OPE score. f Maximum possible score, 86.

different different

asked

to

evaluated.

All

ously

and

were

emphasizing terpersonal

had

taught

told

pelvic

how this

to proceed anatomy

or

skill

what

to students

in their and

was

usual

student

questionnaires,

jective test, and two rating forms were developed used in the study. A 20 item student demographic questionnaire education, pelvic

included such questions medical work experience,

examination

experience,

and the student’s performance in

prediction the project.

of the quality The student

“All instruments request.

are available

from

the senior

with

could

the

“nurse,”

form

contained

from

the patient

rating

external

genital.

examinations.

listed whether

under the

rach, specific

and be-

the

i.e.,

skills

rating

and

in-

form.

Training

an

ob-

senior

two

use

medical

student.

each

all four

examinations

The

the psychomotor calculated from 0.39, of

and

rat-

asked

to

end of

at the

examination “nurses.”

pelvic

first

was

the reliability

was

done

done

student evaluator

for

of the

cx1i)1

discrepancies

four

interrater

by the

by a fourth-

of each

reviewed

rating cat 11 on

medical

ratings ratings

skills

examinations

the

second

Ivere

examination

interpersonal

“nurse”

with Rater

for

also

pelvic

pelvic examination the experimental

respectively, reliability.h

of Each

calling

were

and

of t\to

were

to standardize

“patient”

items

the

the

The

evalua-

education.

A different

patient.

the fol-

scale.

evaluators:

amined

required

patient

“patients”

the

self-

had

establishment

Raters

began,

and

and

they

evaluations

consisted

“patient”

that

psychomotor

form

author

in order

and

12 point

the

the during

areas:

specific

the

several

indicate

form

three

performance project

and

group.

scale.

the

“pa-

student

also included

completed

rating

contained

with

to

their

the

form

to verify

comfort.

summary

trained

used

following

areas

either

form

1.

contained

medical

could

had

skills

a five-point

previ-

by

\vas mar-

(9.10,1

form

The

student

students

for

ings

area

outstanding

on the nurse

they

protocol

of these

year

the

scale

(C),1.2),

rating

observed

The

was also

patient on

be

form. units

the

rapport.

and

at the

This

inadequate

or the student.

interpersonal in

evaluations scale.

of this

best

so that

the

evaluators,

upon

psychomotol-

rectovaginal

(6.7.8).

all items

This

to be

of his or her interaction

psy-

interpersonal required

a 12 point

versions

that

tions

women,

author

good

three

items

The

and data

affrct-

evaluate

The

performance

categories;

tient,”

lowed

as address, age, career choice,

comfort

make

four

The

the Two

and

into

project.

skills.

Instruments.*

and

abdominal,

on

a checklist

fashion,

psychomotor

areas:

area

(3,4,5),

12).

make

knew

to

skills instrument

each

Before component

(covariates)

evaluation.

skills

bimanual,

of

each structional

final

five

instructional

from PSP 1 data. (p < 0.05) from

the

analysis

haviors were either adequate, i.e., done correctly, 01 inadequate, i.e., done incorrectly or omitted. Raters

ginal

programs

of

ad hoc

used

These areas had specific items the raters were asked to check

divided

examination

were

examination

the

following

end

performance

in

to assess

Both

in an

variables

forms

examination

were

I. Mean

It was used

used

in-

outcomes.

during

speculum,

Fig. 1. The percentage of unacceptable psychomotor skill ratings (five or more) achieved by students taught in a simulated outpatient setting (OPEI compared with the two combined PSP groups (Simi.

much

students

contamination.

were

pelvic

pelvic the

group

rating

skills

other

groups.

independent

chomotor

how

from

treatment

questionnaires

for

regarding

obtained

treatment

above

OPE Psychomotor Skills

items

students

possible

Unacceptable Ratings

Table

contained

formation

15. 1975 Gvnecol.

evaluators.

reliabilities

for

skills form Jvcre data to be 0.57 and

Cronbach for

alpha the

coefficient

interpersonal

Volume Number

Pebic

129

examination

instruction

127

2

skills

rating

form

inter-class

was calculated

correlation

The

objective

test,

matching

examination,

anatomy, estimate

pathology, of reliability

Cronbach

alpha

Statistical

an 86 point

student

cation,

and

coefficient

medical that

mance

outcomes.

Therefore,

interpersonal and jected to a one-way

The

findings

I. In general.

simulation the

sex,

age,

edu-

did

affected

cognitive

not

perfor-

test

scores

and subon

differences

could

instructional

of

this

study and

programs, instruction

significant

differences

chomotor

and

1 and and

with

The

identical. two

cognitive

test

No

scores

simulation

tutoring

session

not

2, over

dents

materially

improve

the

data

chomotor

reported

skills scale. that

Inspection

both

shown

of

ratings

ry

and

achieve

all

groups observed

in

that

PSP

levels

based

1 did

of these

two

and on

the

group simulation

low-outstanding

indi-

program

Fig.

3.1 6.3 9.3 Cl.3 8.7

9.5 9.2 10.1 10.0 6.4

to

category

group

scores

limited is even

instructional of students

performance more important

1 compares,

reflect

on

the

performance

objectives to the 12 point

dif-

programs, the toward meeting under educator. scale,

the

each

nearly

DIF

2.6* 2.4* 2.1* 6.-k* 2.9* 0.8 (N.S.) 0.7 (N.S.) -2.3*

of confidence

the

cent

cent

of

rate the pro-

*ANOVA were mn on both the five-point and 12 point scales used in the rating forms with nearly identical results. For expository clarity, only statistical data related to the 12 point scales are presented.

ratings

were

students interpersonal

in each

skill

taining

several

items

or judgments

pelvic

examination

abilities.

the “nurse” not identical vational

the

evaluator because

of

vantage

use of the

points.

12 point

Students significantly personal

in

the

Table

rating

by

the

The

PSP three the

skills

that

required

into

five

skill

ratings

evaluator in their

comby

were obser-

the

categories

mean

with

the

groups

(Sim)

rated

components ot interexternal genital and

components “patient”

differences

the bimanual

con-

to

scale.

of psychomotor

evaluator

these categories were also statistically the same direction as those reported for

was comeach

contrasts

skill

combined

examination

OPE-

relevant

II

evaluator

higher in all skills and in

Ratings

skills

divided

by

65 per

the

abilities,

psychomotor

in

attained while

and the “patient” of the differences

of the “nurse”

students

ratings

psychomotor were

However,

that

given the only 5 per Likewise,

ratings

component

as

group

indicate

acceptable

students were acceptable. rating format for interpersonal

Similarly,

groups,

given

skill

were

different

evaluator

per-

two

unacceptable.

of three

evaluator.

The

the data

posed

skills.

(Sim).

the student

skill ratings In contrast,

of the interpersonal

rectovaginal percent-

28),

skill

groups

the

trained The

stu-

the numbers

psychomotor

PSP-trained

by

with

in these

of the

95 per

received

(OPE)

combined

identical (10 versus

simulation

less)

because

I. Although small

or

programs

cent

ratings mean

PSP

a third of the psychomotor group were unacceptable.

ponent

(nine),

(five program

about OPE

by the

interpercategotended

in the low-good

was

component.

programs

category

in the outpatient

of performance

psy-

12 point

ratings

performance levels for skills in the high-good

in the

the students levels

in the

ferences of the three of success or failure same gram

7.9 10.3 9.0

are combined

in Table

both

(six). While

5.3 7.9 6.8

outpatient

two

PSP groups

are relatively

differstatistical

interpersonal

I are

of the mean

the students achieved psychomotor

while

for

in Table

generally sonal and (eight)

of “nurse”

SIM (No. = 28)

ratings

the

in the

formance

indicating

performance

in

psy-

for

provided

unacceptable

to the

students.

cates

scores

combined

OPE = 10)

education comfort

of

two

were

programs,

physician

age

statistically

ratings

differences

in

students

self-assessment

the

rating

(No.

II. Psychomotor External genital Rectovaginal Bimanual Speculum Abdominal

the two

PSP

respect

skills

Student

were

the

presented favor

the direction of the reported general. do not reach

significance. nearly

are

ratings

PSP

existed

evaluators.

The

skill

DIF, Differences; N.S., not significant. *Differences are significant at the 0.05 level with a one-way analysis of variance.

programs.

(OPE),

interpersonal

tend to confirm ences but, in

between

e.g.,

experience,

all scores

training

outpatient

trained

Skill

Patient Patient Rapport

analy-

data,

to the

component

the outpatient and training programs

I. Interpersonal

work

performance

Mean

of the data

major

Table

An the

psychomotor skill ratings were analysis of variance (ANOVA*) that

II.

raters for simulation

pelvic

procedures. obtained with

systematically

be attributed

Analysis

Table

and

about

A multiple-regression

background prior

assumption

Ebel’s

of reliability.’

covariates

probably

questions

and examination of 0.81 was

reveal

the

with

multiple-choice

included

procedures.

sis of

to be 0.80

coefficient.g

reported examination

in

significant by the by

the

were

each

of

and in “nurse” ‘nurse” not

statis-

128

Holzman

September

et al.

tically

significant.

However,

the

who

was in a better

position

to sense

bimanual the

examination,

simulation

cally

significant to

evaluator cally

at the

level.

The

did

not

influence

use

a speculum

since

nor

the

evaluator

significant

“patient”

differences

of the

were

neither

the

in the

perfi)rmance

task. The OPE group, on the other tically higher levels of performance

of this

tient.

While

the two

simulation

of performance

groups

also

was

spent

more

determined

by

spent

studying

group

spent

film,

plus

average OMNI

one

of

hours

program.

and

one

hour

The

PSP

from

the

the

average,

OMNI,

of

plus

No

other

among

of

time

first

the

OPE

included

and

propriatc.

that assigned

PSP

with

the

assigned

with

the

with

which 1 group

in

text

PSP’s

not

the

hours

with

the

text

hour

with

the

PSP’s

The fact more time than

did

ences

with

the

assignments.

(4.6

hours).

were

the

of this

pelvic

instructional

of

performance was nearly

training the

previous

and

associates,”

two

simulation

tive

use of several

ables.

the

to

a more

traditional

of

Penta

and

generally

Kretzschmar,” Kofman’”

those of Schneidman.” outcomes recorded can be attributed instructional

simulation

progressively Practice of

the

only

and direct and accurate feedback. to sense and provide meaningful

structure

and

whether

that

from

the

dents

to the effec-

train

design

oversrc

vari-

subjected and

realistic skills on PSP’s. at-

A PSP is feedback

skills. She can asdid palpate a parstudent

average

was

too

basic

pelvic

PSP is paid faculty

the

per

skills hour.

the

offset

in

the

administrative to employ

use

of

must

A final seem tient

of

of

stu-

initial

need

annually

to to

the

PSP

approval PSP’s. Faculty

program

and ;I supresistance

and an inherent for clinical I-ealitJ,

be overcome. point

to prove method

abdominal

the

absence

level.

to change from traditional methods distrust of simulation as preparation also

because

and

in-

method

instruction by the

in ot

faculty

The

replacements,

by

hour

direct

at an administrative

involved

include obtaining plementary budget

stutlcnt

differences

a cost-effective.

in

to train

program

Problems

involving

examination

partially

later

rather because

the amount

an additional

involvement

is, however, PSP’s,

Given to each

to only

$15.00

h mighr

skills

the

(not

skills.

whit

to attribute

be considered

Exam-

program

PSP’s,

PSP 2 program

on studv

Pelvic

psychomotor

the

of teaching and

the

differ-

spent

self-instructional on Gynny.

must

time

differences

provided

direct

programs

more complex basic psychomotor

regarding the student’s psychomotor certain whether the student actually ticular

hand,

(2.4 HOLC-

interpersonal

feedback

The

ap-

on the cogni-

“Female

practicing

struction)

findings

program well

stress

1~;~s spent

These

Gynny prepared students for instruction by the PSP teams provided a supportive, anxiety-reduced mosphere best able

movie not

skills

moht

to attribute

to the

do

examination

the that

outcomes.

quality

pelvic

during

seemed

equally

the

it is difficult

of the

rrinforcc-

experience

traditional

OMNI

of

the pa-

ob,jective

it is difficult

are

dc-

psychomotor

is the

different

time

self-instruction.

important two

which

the

skills

PSP’s

on

a va-

some.

introduced

and

on a test of purely cogidentical, regardless of the

and

programs

First.

superior-

programs

observations

not at variance with The superior learning

students simulation.

over

program.

support

the

training

simulation

Johnson are

demonstrate

examination

method. Student nitive knowledge type

study

in the

to the

to the

\*as

trained by the PSP’s spent study (3.4 and 3.6 hours)

performed

other

a wide

anesthetized

control

Bates,7

be attributed

findings

in the

and

and

an

University skills

in interpersonal

ination,” On

reported

Comment

include

explain

examination.

than

ity of two

students

on

groups.

The

the

this

are In

an important

that the students in independent

might

conditions

that

bv various

of an outpatient

ob,jective

all students

tive

offered

State

interpersonal

this

fart

is entirely

Since

the selection

spent, and

skills.

of the year.

ever,

hours).

significantly

one

merit

hours)

tutorial,

performance.

differences

an

and

(j.4

differ

3.6

study-activity

spent

physician

the

did

in an am-

1 group

hour

It

text

instruction

The

training

2 group, PSP

training.

the

these

standardiza-

gynecology.

emphasis

at Michigan

and

of formal

one

cognitive

self-reports materials

rated,

program

in study

student

hours).

and

higher

skill

studying

hour (3.4

produced

every

assigned

hours

setting 3.4

time

the

the 2.4

the

bulatory

programs

on almost

the

needs.

to represent

There

is with

share feelings

these

the

and

encounter

Here

The

under

programs

of obstetrics first

arbitrary.

experience.

of instructional

student’s

examination. levels

riety

outpatient

partments

hand, yielded statison the abdominal

office

outweigh

also

emotional

doctor’s

achieved

than

can

negative

to her

was not be

to more

simulated

statisti-

and

attention

could

She

positive

of a simulated training

that

enough.

her

student’s

choice

seemed

“nurse”

detected

the

tion

students’

aggressive

student

traditional

training

the

not

the

The

statisti-

different

or

with about

favoring

differences

0.05

rough

evaluator,

the accuracy

differences

These

apparently

ability

“patient”

reported

groups.

programs

1.5, 19i7 Gynecol.

Am. J. Ohster.

involves the rule. resulted

examination.

the

one

exception

that

It was observed that in better performance Post hoc review

would

the outpaon the

of the training

Volume Number

I Xi 2

programs indicated that the gynecologist in the traditional outpatient program had stressed the abdominal examination while the PSP’s had not. The fact that independent raters, having no knowledge of the previous training programs of the students being evaluated, could detect a contradictory difference in performantes on this specific skill lends credence to the other differences found favoring the simulation programs.

Pelvic examination instruction

We are indebted to Thomas H. Kirschbaum,M.D., William Kiekhofer, M.D., Sumer Verma, M.D., Janice Layton, R.N., Susan Darlington, Andrea Van Steenhouse, Mary Lachniet, R.N.. Margaret Parsons. and Kristine Steensma for their participation in this study. M’e also wish to thank Norman Kagan, Ph.D.. John Schneider, Ph.D., and Robert Kretzschmar, M.D., for permission fc) use and alter their rating scales.

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