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Evolution of the Gynecology Teaching Associate: An education specialist
Evolution of the Gynecology Teaching Associate: An education specialist ROBERT iouw
City.
M. KRETZSCHMAR,
M.D.
Iouu
The traditional pelvic examination instruction method5 wwe reviewed and found to be detiient: the student learning experience was compromised by the triangular setting of patient, student, and instructor for early pelvic examination instruction. Over the past decade, a new educatin speciafist, the Gynecology Tee&ii Aseociate (GTA), ha5 evolved to help improve the initial gynecology teaching experience. The evolution of the GTA is described. The qualities she brings to the irwtructional system include sen5Uivfty as a woman, edu&onal skill in pelvic examination he&don, knowledge of female pelvic anatomy and phyWogy, and, most important, SophisMted interpersonal skills to help medical students learn in a nonthreatening environment. Reinforcement learning theory is the foundation of this educational system. Student acceptance of this system is documented. (AM. J. OBSTET. GYNEC~L 131: 367, 1978.)
GYNECOLOGIC examination has traditionally been taught by textbook assignments,lectures reviewing anatomy, audiovisual materials, and modeling of specifictechniquesby faculty. As studentsnear the time of clinical involvement, plastic models become useful aids to practice newly acquired skills (the “Gynny” pelvic and “Bets? breast models are still popular in gynecology). These lack authenticity, however, compared to the student’s first encounter with a live patient. Some institutions let students examine anesthetized patients, but in most schoolsmedical students begin examining real patients under direct faculty supervision by their junior year. Often the instructor models the examination on the patient, instructs the student in correct technique, and then guides the student through the sameexamination. In the last decade the author carefully reviewed this teaching system and focused on its inadequacies.The teaching effectiveness of the triangular setting of patient, student, and instructor was critically analyzed. The following observations were made. Communication between student and instructor was inhibited by THE
From the Department University of Iowa.
of Obstetrics
and Gynecology,
Central Association Award paper, presented at the Forty-jifth Annual Meeting of th- Central Association Obstetricians and Gynecologi&, Bifmi, Micsksippi, October 6-8, 1977. Reprint requests: Robert M. Kretzschmar, Department of Obstetrics and Gynmology, Iowa Hospitals, Iowa City, Iowa 52242. OOOZ-9378/78/04131-0367$00.70/O
@I 1978
The
M.D., University
C. V. Mosby
of
of
Co.
the presenceof the patient and by the anxiety of the student in the performance pressure atmosphere of this system. The patient wasexploited by the teaching system,asstudent examinations at this level do not contribute to patient care. Students are very sensitiveabout this factor. There was a lack of feedback and reinforcement from the patient, because shewasnot skilled in these areas.The instructor never knew, for instance, if the student had recognized a retroverted uterus or palpated ovaries. Clearly, then, theseskillscould not he appropriately evaluated. The emphasis of the traditional instructional system was on technical skills. Little or no emphasiswas placed on the interpersonal skills necessaryto do a quality pelvic examination, such as how to help the patient relax, or how to cope with her anxiety. It was obvious that a better instructional system could be devised based on proved learning theory. Although these phenomena apply to most clinical areas, we feel that gynecology presents perhaps the most challenging doctor-patient encounter becauseof the sensitivity of the subject, the sexual overtones, and the anxiety to be coped with by both student and patient. Thus, we proceeded to evolve, in increasingly sophisticated stages,an effective system f‘or teaching the gynecologic examination which could in turn be adapted to other areas of medical education. Three main areas of deficiency for which a solution was sought were: (1) absenceof patient feedback, (2) lack of opportumty for open communication between the student and instructor in the presence of‘ a real patient, 367
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Kretzschmar
and (3) lack of control over the quality of the patient for attaining optimal educational goals. In 1964 the author began a medical interview instruction program. This program has continued to evolve and is briefly described here, for it is from this experience that the “professional patient” concept developed. A group of intelligent, motivated women were trained to simulate gynecologic syndromes by history. They were also able to simulate the appropriate personality problems associatedwith the syndromes, such as anxiety or depression. Students interview the “patient,” the interview is recorded, and the “patient” and student then conduct a critique of the interview. The simulated patient is skilled in communication theory and technique. She is ableto divide the communication content into small increments to be learned. She gives direct feedback and reinforcement in the learning system. These basiccomponents of learning theory have been clearly demonstrated by Skinner.’ In 1968, in the Department of Obstetrics and Gynecology, an educational program was begun, experimenting with a new idea for improving pelvic examination instruction to junior medical students who rotated through the clerkship every six weeks. The basisfor this new program wasthe “simulated patient,” first defined by Barrow.? as a “person who has been trained to completely simulate a patient or any aspect of a patient’s illnessdepending upon the educational need.” We sawthis asa potential tool for correcting the inadequaciesof traditional medical education by freeing the real patient from the time and embarrassment involved in pelvic examinations by a beginning student, and by structuring the educational setting with a voluntary, cooperative, “professional patient” to examine in a lessthreatening situation. The program wasbegun by hiring a nurse clinician in the role of “patient.” She did not possess any unique skills related to the pelvic examination per se other than her nursing background. She was familiar with the clinical setting where the instruction was to take place and agreed to submit to repeated examinations. However, it was necessaryto compromise open communication with her, asshe wasdraped at her request in such a way as to remain anonymous. At this stageof development, pelvic examination instruction for junior gynecology studentsconsistedof an instructor modeling a pelvic examination on the simulated patient; each student in turn mimicked the examination. The patient’s responsibility wasto note the various motions and sensationsof the physician’s examination and compare each student’s performance against these criteria. She therefore gave minimal feedback to the student on his technique, i.e., how well
June 15, 1978 Am. J. Obstet. GywcoI
he could imitate the instructor’s examination. This particular teaching form was later described by Perlmutter and Friedman3 as the “live mannequin” foi pelvic examination instruction. The simulated patient concept, in this rudimentary form, succeededin providing a conducive environment for instruction with a relaxed, live model, but it did little to enhance communication between student and patient or reliably evaluate a student’s technical performance. Gynecology Teaching Associate characteristics After experimenting with this program for several years, the Department initiated a new pelvic examination instruction program in 1972, retaining the simulated patient but defining for her a much more sophisticated role. Termed “professional patient” or, more currently, Gynecology Teaching Associate(GTA), this new type of simulatedpatient added two major dimensions to the evolution of the pelvic examination instruction program: (1) she became 6& patient a& instructor and (2) she began stressingthe equally important (and often ignored) area of interpersonal skills integrated with the technical skills to provide a quality pelvic examination. From its inception, this professionalpatient program drew approval from schoolsacrossthe country. Stenchever and his co-workers4at Utah began experimenting with a similar program. Holzman and associates5 of Michigan State recently provided positive data supporting the effectivenessof such teaching programs. To explain the successof this particular program, now in its fifth year of refinement, one must focus on the GTA herself-who she is, where she comesfrom, and what her role is. The uniqueness of the GTA lies primarily in her ability to articulately communicatewith and teach medical students. It is her job to effectively teach students how to perform a quality pelvic examination, and through constant, direct, positive feedback and reinforcement to help them retain these learned skills in the future. All of the six young women currently functioning as GTA’s are working toward or have received advanced degrees in the behavioral sciences.They are hired primarily as establishedteachers,and receive compensation equal to that of a teaching assistantwithin the University system.These women are dedicated to education. Rather than applying their skills elsewhere, whether it be through free medical clinics or women’s health centers, the GTA’s prefer to work within the existing system.6They try to teach and reinforce good doctor behaviors early in medical education, seeking through their efforts not only to instruct medical stu-
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Gynecology
Teaching
Associate:
Education
specialist
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4
dents but also to effect better health care for women. Though not created in response to the Women’s Health Movement, the program has been sensitive to it, as most of the GTA’s are in some way involved in it. This has been of benefit to the program, since each woman has educated herself also-learning what it is to be a woman, exploring her own anatomy and physiology, and coming to terms with her sexuality, her attitudes, and her role in life. Indeed, this is a prerequisite to employment as a GTA: that she be comfortable with herself in these areas and comfortable in discussing them with others. These women are constantly undergoing a process of self education and growth in their reading, working, and living. Another dimension which the GTA adds to the existing medical education system is that of sensitivity or humanism. She is able to add her sensitivity as a woman. It is her responsibility as a trained communications specialist and educator to ascertain the particular needs of each individual student whom she encounters, and find the educational strategy with which to reach and teach that student the necessary skills. In summary, the GTA is singled out from the behavioral sciences environment of the University and is selected for her teaching and communication skills, her personal motivation to educate herself and others, and her sensitivitv to the need for health care for women.
Gynecology Teaching Associate recruitment and training With these criteria established, the GTA’s must then learn the integral techniques of the pelvic examination. They undergo a training period lasting approximately 6 to 8 weeks, learning what the students will in turn learn from them: a review of female anatomy and physiology, the technique of the breast examination and breast self-examination instruction, the abdominal examination, and the pelvic examination. The emphasis throughout the teaching program is on normal, hea!thy female anatomy. The educational objective is for students to learn how to perform a quality pelvic examination. While it must be remembered that the GTA will equally stress communication skills between student and patient during the examination process, she must know her technique extremely well, for it is through her expertise in imparting technical skill instruction to the student that the GTA gains credibility within the existing medical educational system. The fairly standard selection and training process of the GTA can be briefly summarized. These women are most often recognized by other Teaching Associates as women in the University community who meet the basic criteria described above. The interested candi-
dates are invited to a group meeting with the Teaching Associates and program director, who performs introductions and outlines the format and pm-pox of the program. After his initial presentation, the director leaves the room in order to allow the women to more openly exchange questions of a personal nature about the program and how it affects the lives of‘ the women. The candidates are encouraged to view pilot videotapes made of past teaching sessions to see how they are conducted. The director then individuallyinterviews each candidate, screening problems and answering any new questions. After receiving feedback from the Teaching Associates about their encounter with the candidates, he makes his final selection. Each accepted candidate must undergo an intake physical and pelvic examination. This time is also used as a beginning point of instruction. The new GTA then attends a session where the director models the examination procedure on one of the women and discusses the process in detail. From that point, training sessions are scheduled (in the director’s absence) where the GTA’s educate the new participant in role playing, technique, and communication skills pertinent to the pelvic examination. In time the new GTA will herself perform practice examinations on the other women. The program director carefully monitors and contributes to this educational process. Interspersed with the training sessions, the new Associate is requested to observe actrlal teaching sessions. She is encouraged to actitel) participate verbally in these sessions. She is next scheduled into the regular sessions, taking on an active role. generally first as “patient” and then later as “instructor.” The new GTA inevitably feels unsure of her ability at this point, but she receives reinforcement from her peers. The women report this to be a constant learning experience. It has been estimated that roughly $500 is needed IO fully train a GTA. This does not include faculty or administrative time. At any point in training she is given the option to drop the program without consequence if she feels uncomfortable with the program 01 her reaction to it. If she elects to remain in the program, she must be in good health with relatively normal anatomy, be able to function in both the patient and
instructor
role,
be able
to commit
the appropriate
amount of time to the position, and he able to work comfortably with all other Associates. These requirements are deemed essential to maintaining the quality of the program.
Educational method The program initially involved only junior medical students who rotated through the gynecology clerk-
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ship every 6 weeks, and the framework has remained fairly consistent. Two junior students per day are assigned to an afternoon session with two GTA’s. An examination room in the regular outpatient clinic is reserved for the teaching session. This provides a convenient and nonthreatening setting for the student and lends credibility to the program. Each session runs undisturbed for approximately 2% hours each afternoon. One GTA acts as “patient” and the other as “instructor.” These titles are fairly ill defined, since both women actively participate in instruction. Simply, one is examined as “patient” while the other helps the “patient,” assists the student with the examination, and gives specific instruction regarding technique,’ The teaching session is designed to simulate an ideal doctor-patient encounter, but in order to provide quality instruction it must necessarily sacrifice some “realness.” The GTA’s introduce themselves by name, describe the program, themselves, their attitudes, and in general try to have the students relax and establish rapport with them. No faculty are involved in these sessions. After one of the GTA’s models an examination on the other, they guide each student in turn through the technical skills of actually performing a breast examination, instructing the patient in breast self-examination, an abdominal examination, and a pelvic examination. Students are taught in detail how to hold instruments, which hand and/or fingers to use, how to palpate various structures, what to look for, and what is normal. As each student goes through the steps of the examination, the GTA reinforces his actions, giving constructive feedback and making suggestions. At any point in the session any of the four people may call a “time out” to repeat, discuss, or clarify a particular point. Each student is specifically treated as an individual with unique skills, anxieties, and attitudes. It is the task of the GTA to find the most effective teaching strategy to help that student, to teach him, to help him learn new or better skills and to retain this knowledge for the real patient setting. The fundamental learning concept of the use of small increments of knowledge, immediate feedback, reinforcement, and individualization of instruction dates back to Socrates, and is the basis of the Socratic style of education. As used in this program, it is very similar to the learning theory currently used in programmed instruction.* While the student is usually most concerned with learning and performing the technical skills of the breast and pelvic examinations, the GTA has the added responsibility of em~ploying her unique communication skills to impart to the student the crucial role of interpersonal skills during each part of the examination.
June .4m. J. Obstet.
15, IYTH Gyned.
She gains credibility for this by showing that a patient who is comfortable with the relationship and the situation is more physically relaxed, and thus more cooperative and easier to examine. The GTA goes into detail during the physical examination, reminding the student that patients are more thanjust bodies to examine, that they have feelings and emotions to cope with in the doctor-patient relationship. Areas emphasized include letting the patient control her own body actions as much as possible, talking with the patient and explaining what the student is doing and finding, explaining to and showing the patient various instruments before they are used, asking the patient for feedback on how she feels (i.e., if she is uncomfortable), and in general trying to create an equal psychological-emotional relationship between student and patient. The student is encouraged to perceive the vulnerability that a patient feels during an examination. In like manner, students recognize and learn to cope with their own anxieties and emotions during the examination procedure. These are not necessarily sexually oriented, but rather relate to anxieties such as insecurity, sensitivity to patient discomfort, or embarrassment, which are experienced with learning any new technical skill. Interestingly, it has been observed that female medical students are just as anxious as male medical students in this situation. Because of the favorable response to the junior program, student interest, and availability of time in the Introduction to Clinical Medicine course curriculum, a gynecology examination instruction program was begun at the sophomore level 4 years ago, not in place of but in addition to the junior program. During this course sophomore students now rotate through the pelvic examination teaching program. Unlike the juniors, the sophomore students review a movie on the pelvic examinations and receive some small group introductory instruction from the program director by reviewing anatomy and discussing the goals of the program. Students are not expected to be expert after one teaching experience. Four students participate per afternoon with two GTA’s in their respective roles. The director is not involved in the small group teaching session. These sessions, because of inexperience and sheer numbers, grow lengthy-usually 3 to 3% hours. As in the junior program, the students are guided through the abdominal, speculum, and pelvic examinations, individually performing these techniques and learning technical skills along with the interpersonal skills. The junior and sophomore programs differ in content, goals, and design. The sophomore program is more structured, and serves as a basic introduction to
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the gynecologic examination. The junior program is more advanced, and designed to be more individualized. In both programs the dimension of direct “patient” feedback and reinforcement is stressed, improving the quality of the learning experience. This instructional system bridges the textbook and clinical experience. The clinic patient is no longer part of the initial pelvic examination teaching program. Both the junior and sophomore programs have emerged as efficient, competent educational systems. Transfer of training to patient care in the Gynecology Clinic has been observed. Both faculty and nurses empirically note student improvement after the teaching sessions. The GTA’s have become credible, accepted members of the medical education program in the Department, and are now given great responsibility for pelvic examination instruction. On occasion the program director will monitor a session; otherwise, he is not involved directly in the teaching session. Monthly staff meetings are held with the director and the GTA’s to discuss teaching strategies, curriculum content, problems that arise in the program, and administrative matters. As a secondary benefit, the faculty time for pelvic examination instruction is reduced. Experience over the past 4 years with cost accounting indicates that at the current pay scale, the cost per teaching session per junior student is $45.00. The cost per sophomore student is $25.00. We feel that this is an educational bargain. Evaluation The GTA’s, with their integral knowledge of the examination and their closecontact with the studentson a one-to-one basis, seem the most likely to effectively evaluate the students’ performance. Recently a pelvic examination evaluation form has been used by which the GTA’s rate the student’s performance on each segment of the examination. The minimum competency-based evaluation helps the women identify students who need remedial help in specific areas. This representsa very few studentswho need additional instruction. As yet, an effective objective assessmentof interpersonal skillshas not been developed, and this is an area for further research in the program.‘O The evaluation system is not used as a device to threaten students; rather it is stressedthat the teaching experience should be characterized by positive feedback and reinforcement for the student to learn in a nonthreatening environment. An attempt hasbeen made to receive feedback from the students themselves about the program and the GTA’s. For example, a questionnaire distributed to sophomore and junior students rotating through the
GynecologyTeachingAssociate:Educationspecialist 371
I. 1976 feedback on pelvic examination instruction questionnaire results (selected questions)* Table
sopklQuestion
Respotue
Would you recommend these sessions for the next class? Did the GTA have a good grasp of the examination procedure? Did it bother you to he instructed by nonmedical personnel? *Number Juniors.
mows (o/d
Jwaiors f%)
Yes NO
No answer Yes No No answer Yes NO No answer
of students responding:
I 99
8; IO
0
121 Sophomores,
150
II. Introduction to Clinical Medicine: over-all course evaluation*
Table
Teaching
session
Gynecology Subject B Subject C Subject D Subject E
I976 rating
I977 rating
4.66 4.02 3.87 3.45 3.28
4.80 4.21 4.06 3.40 3.46
*In 1976,88 per cent of the students in the introduction to Clinical Medicine course responded to a questionnaire ranking the small group afternoon teaching sessions; in 1977, 90 per cent responded, The rating scale used was 1 to 5, with 5 being excellent. The lowest ranking received was 2.54 for 1976; for 1977, it was 2.38.
Department of Obstetrics and Gynecology in 1976and returned anonymously has been most useful. As illustrated by Table I, the students felt that this was a worthwhile learning experience by recommending that it be continued. In addition, the course evaluation for the entire Introduction to Clinical Medicine sophomore program in 1976 and 1977 rated the afternoon gynecology teaching sessionsthe best in the medical school, with over-all ratings of 4.66 and 4.80, respectively (5 being excellent).
(See Table
II.)
as described
provides
Comment The teaching
program
an edu-
cational systemwhich is much lessthreatening to students because of the absence of a faculty person
and
real patient. The early gynecologic examinations by students are done in a controlled teaching systemwith high-quality
“teachers-patients,”
eliminating
the use of
real patients for the teaching experience. The teaching specialist, in either the “instructor” or the “patient” role, gives immediate feedback and reinforcement to the student about both interpersonal and technical skills.The quality and nature of this feedback offers a
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Kretzschmar
new dimension in the gynecology curriculum which medical faculty, as nonpatients, have not been able to teach (e.g., how much pressure to use, are ovaries being palpated, etc.). The transfer of training of interpersonal and technical skills has been demonstrated during the gynecology clerkship, as observed by nursing staff and faculty. Moreover, the teaching system can be cost accounted to demonstrate cost effectiveness. An effective educational system for teaching the gynecologic examination has thus been established,
REFERENCES
1. Skinner, B. F.: Science of learning and the art of teaching, Harvard Educ. Rev. 24: 86, 1954. 2. Barrows, H. S.: The development and use of a new technique in medical education, in Simulated Patients (Programmed Patients), Springfield, Illinois, 1971, Charles C Thomas, Publisher, pp. 3-42. 3. Perlmutter, 1. F., and Friedman, E. A.: Use of a live mannequin for teaching physical diagnosis in gynecology, J. Reorod. Med. 12: 163. 1974. 4. Ste’nchever, M. A., et ai.: Teaching pelvic examination to second-year medical students using programmed patients, AM.J. OBSTET. GYNECOL. 121: 714, 1975. 5. Holzman, G. B., et al.: Initial pelvic examination instruction: The effectiveness of three contemporary approaches, AM. J. OBSTET. GYNECOL. 129: 124, 1977.
Discussion DR. ROBERT A. MUNSICK, Indianapolis, Indiana. Dr. Kretzschmar has provided the world with his experience in using a radical new approach to teaching the gynecologic examination. He questioned the timehonored methods-students examining anesthetized women or their sensitive, sentient equivalents-cadavers, or assigning them perfunctorily to a gynecology clinic. Fortunately, he also took the next steps: he thought of a much better way, experimented with it, and perfected it despite ridicule and criticism. The fruits of his travails have already resulted in the adoption of similar programs by a few medical schools: hopefully, more will now follow. Our program at Indiana University has evolved slightly differently from Iowa’s but owes its success to Dr. Kretzschmar and his colleagues. Briefly, we were confronted with the problem of having to deal with a gigantic student body-300 per class. Students finished their second year without any instruction or information regarding the pelvic examination and often did not take their Ob/Gyn clerkships until late in the third year. What did they do about pelvic examinations in their other rotations? Often the same thing their residents (former students) did-nothing. In their ObiGyn clerkship they did receive instruction on the Gynny model but after this, due to shortage of time and faculty, they swam or sank-often the latter-in the clinic.
June
1.5. 197x
Am. ,I. Obstet. (;ynect,l.
using the basic educational principles of immediate feedback, reinforcement, and individualization of instruction as used early in history by Socrates. If one reflects on this educational system a moment, a legitimate question can be asked: Why hasn’t this system been used before? I wish to express my appreciation to Mrs. Beth Neumeg for her assistance in the preparation of this manuscript.
6. Keettel, W. C.: Discussion of Gray, M. J., and Tyson, J.: Evolution of a women’s clinic: An alternate system of medical care, AM. J. OBSTET. GYNECOL. 126: 766, 1976. 7. Kretzschmar, R. M.: Newsletter No. 2 of the Steering Committee for Cooperative Teaching in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Utah College of Medicine, January, 197 1. 8. Lysaught, J. P., editor: Programmed Instruction in Medical Education: Proceedings of the First Rochester Conference, Rochester, New York, 1965, The Rochester Clearinghouse, pp. 3- 10. 9. Hunter, C.: Female pelvic examination, University of Indiana School of Medicine, Indianapolis, Indiana (Film). 10. Andrew, B.: An International View of Qualification for the Practice of Medicine, National Board of Medical Examiners, 1977, pp. 102-106. In 19’75 we began our program during the Introduction to Medicine segment of the second year. We advertized locally for our GTA’s-we call them Surrogate Patient Instructors (SPI’s). In three evening sessions at no cost we had trained nine women whose occupations and educations varied from housewife to librarian. They were provided with exacting instructions and objectives. Students were given handouts detailing the technique of history taking, the examination, and how to record it, and the faculty received a separate but similarly exacting description of what was expected of them. Eight students are scheduled each afternoon for about 8 weeks. For 1 hour they view two movies: (1) the pelvic examination and breast self-examination and (2) a tape-slide program on cytology and the gonorrhea culture. In the next hour they learn individually and as a group from a faculty member who teaches informally, instructs them with the Gynny model, answers questions, and introduces the two SPI’s at the end of the hour. In 5 to 10 minutes the SPI’s convince the students that they are there to teach and help, not to embarrass or threaten them. The faculty member then models the examination on one or both SPI’s while all students watch. A nurse is present to assist with instruments and duplicate a professional office atmosphere. Students then proceed one at a time, four for each SPI, to introduce themselves and conduct the examination. This consists first of a thorough handwashing. Then breast examination and breast self-examination. fol-
Volume 13 I Number- 4
lowed by abdominal, pelvic, and rectovaginal examinations. A Pap smear is prepared and inspected for its proper thickness. The SPI gives reassurance, encouragement, and instruction as the student proceeds and at the end checks off a critique sheet with comments for the student, who must wash his hands again as he leaves. The average time spent by each student with a SPI is 20 minutes. Finally, the student writes up his findings according to the required format and this is critiqued on the spot with the faculty member. Our results? In 3 years 824 second-year medical students and 104 nurse clinicians have had the opportunity to learn properly and professionally this most important keystone of gynecologic diagnosis. What’s more, 25 beginning ObiGyn house officers have learned from the same SPI’s not only these fundamentals but the techniques of clinical pelvimetry and the fitting of diaphragms. Most students find this the most rewarding educational experience in their first 2 years of medical school. This is proved by questionnaires for the past 3 years but even more so by their beaming faces and extolling, laudatory remarks as they complete their sessions. After this experience they are far more at ease and prepared to learn with supervision in the clinics and wards. We have now trained a total of 17 SPI’s. The cost of rhe SPI’s in our program for 1977 was $7.91 per student. Dr. Kretzschmar, we owe you a great debt of gratitude. I have only one question to ask: Have you devised a way of measuring accurately the effect your program has had on students’ later pelvic examination performance, or their acceptance or attitude regarding gynecologic history-taking and examination? DR. JOSEPHC. SCOTT, JR., Omaha, Nebraska. What we have heard today is a very detailed description of the evaluation of a program that has dramatically altered the methods of instruction in over 50. medical schools. It must make us reflect upon what is the most important aspect of our specialty that all disciplines should knou. I believe it is the very elements of this program. The ability to obtain an accurate obstetric and gynecologic history, the ability to perform a precise pelvic examination, and the cognizance of each clinician of his or her own limitations is what we are about. Dr. Kretzschmar has described in detail the recruitment, selection, and training of devoted women who are a unique type of educator. The method of evaluation of the program is based on medical student evaluations of this clinical experience that has built into it several exposures at distinct times in the curriculum. Reinforcement is the pillar of this learning program. At Nebraska we have utilized a similar program that has evolved over 5 years and has been stable for the past 3 years. Our students also feel that this is one of the most meaningful experiences in their clerkship.
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Our program differs from the Iowa program in only two facets. Ours is conducted totally during the period of an 8 week clerkship in the clinical years, and we utilize a graded format for objective evaluation of the medical student. Each aspect of the examination has a numerical equivalent, so an objective grade can be given to each student. In addition. this has helped us to identify areas for improvement in instruction. There can be no debate that this formal ot‘ education is now well established in many schools. II respects the dignity of women and facilitates medical students learning the basics of our discipline. 1 would hope all departments will evolve a program of this sort. DR. JAMESG. BLYTHE, St. Louis. Missouri. 1 was a Fellow at the University of Iowa during the time that this program was in its inception and was asked as a member of the faculty to participate in the program. My first question, as I suspect yours ma! be, was, “What kind of woman lets four or five novice medical students examine her?” And the answet’ was that the women did a very good job, they were selected very carefully by Dr. Kretzschmar, and the\, did participate actively in the students’ learning. I think we need to keep in mind that we can identify abnormal pelvic pathology only by knowing the normal pelvic anatomy, and this program gives c‘\‘erv medical student the opportuniry to learn normal anatomy. It is very distressing ;o me to have an internist admit a patient to the hospital, order an upper atlcl lower GI series, with the patient’s abdomen markedlx, distended, and not have the ability to diagnose a possible o\;arian carcinoma because he does not know hole trt do a pelvic examination, so 1 think this program 1s vc1.1 important. I hope more medical schools will use it. DR. WILLUMKIEKHOFER, East Lansing, Michigan. I would suggest you read an article by m) associates, Holzman and co-workers.’ 1 was ihe principal control for that study. I found it a humbling experience to recognize that four young women wct’c better leachers than I. REFERENCE
1. Holzman, G. B., Singleton, D., Holmes, T. E‘., ,tnd Maatsch, J. L.: Initial pelvic examination instruction: The effectiveness of three contemporary approaches, AM. J (h3STE.r. GYNECOL.
129: 124.1977.
DR. KRETZSCHMAR(Closing). In response to Dr. Munsick’s question about the long-range ef’fect of this educational program, I can only respond with anecdotal information. The director of one Family Practice residency program where they do videotapes of their residents’ initial physical examinations called me and stated that he could identify which of rhe residents were from Iowa by the quality of the pelvlr: examinations they did. I assumed they were of hqh quality. More follow-up data are needed, and it will be forthcoming in the future.
City.
M. KRETZSCHMAR,
M.D.
Iouu
The traditional pelvic examination instruction method5 wwe reviewed and found to be detiient: the student learning experience was compromised by the triangular setting of patient, student, and instructor for early pelvic examination instruction. Over the past decade, a new educatin speciafist, the Gynecology Tee&ii Aseociate (GTA), ha5 evolved to help improve the initial gynecology teaching experience. The evolution of the GTA is described. The qualities she brings to the irwtructional system include sen5Uivfty as a woman, edu&onal skill in pelvic examination he&don, knowledge of female pelvic anatomy and phyWogy, and, most important, SophisMted interpersonal skills to help medical students learn in a nonthreatening environment. Reinforcement learning theory is the foundation of this educational system. Student acceptance of this system is documented. (AM. J. OBSTET. GYNEC~L 131: 367, 1978.)
GYNECOLOGIC examination has traditionally been taught by textbook assignments,lectures reviewing anatomy, audiovisual materials, and modeling of specifictechniquesby faculty. As studentsnear the time of clinical involvement, plastic models become useful aids to practice newly acquired skills (the “Gynny” pelvic and “Bets? breast models are still popular in gynecology). These lack authenticity, however, compared to the student’s first encounter with a live patient. Some institutions let students examine anesthetized patients, but in most schoolsmedical students begin examining real patients under direct faculty supervision by their junior year. Often the instructor models the examination on the patient, instructs the student in correct technique, and then guides the student through the sameexamination. In the last decade the author carefully reviewed this teaching system and focused on its inadequacies.The teaching effectiveness of the triangular setting of patient, student, and instructor was critically analyzed. The following observations were made. Communication between student and instructor was inhibited by THE
From the Department University of Iowa.
of Obstetrics
and Gynecology,
Central Association Award paper, presented at the Forty-jifth Annual Meeting of th- Central Association Obstetricians and Gynecologi&, Bifmi, Micsksippi, October 6-8, 1977. Reprint requests: Robert M. Kretzschmar, Department of Obstetrics and Gynmology, Iowa Hospitals, Iowa City, Iowa 52242. OOOZ-9378/78/04131-0367$00.70/O
@I 1978
The
M.D., University
C. V. Mosby
of
of
Co.
the presenceof the patient and by the anxiety of the student in the performance pressure atmosphere of this system. The patient wasexploited by the teaching system,asstudent examinations at this level do not contribute to patient care. Students are very sensitiveabout this factor. There was a lack of feedback and reinforcement from the patient, because shewasnot skilled in these areas.The instructor never knew, for instance, if the student had recognized a retroverted uterus or palpated ovaries. Clearly, then, theseskillscould not he appropriately evaluated. The emphasis of the traditional instructional system was on technical skills. Little or no emphasiswas placed on the interpersonal skills necessaryto do a quality pelvic examination, such as how to help the patient relax, or how to cope with her anxiety. It was obvious that a better instructional system could be devised based on proved learning theory. Although these phenomena apply to most clinical areas, we feel that gynecology presents perhaps the most challenging doctor-patient encounter becauseof the sensitivity of the subject, the sexual overtones, and the anxiety to be coped with by both student and patient. Thus, we proceeded to evolve, in increasingly sophisticated stages,an effective system f‘or teaching the gynecologic examination which could in turn be adapted to other areas of medical education. Three main areas of deficiency for which a solution was sought were: (1) absenceof patient feedback, (2) lack of opportumty for open communication between the student and instructor in the presence of‘ a real patient, 367
368
Kretzschmar
and (3) lack of control over the quality of the patient for attaining optimal educational goals. In 1964 the author began a medical interview instruction program. This program has continued to evolve and is briefly described here, for it is from this experience that the “professional patient” concept developed. A group of intelligent, motivated women were trained to simulate gynecologic syndromes by history. They were also able to simulate the appropriate personality problems associatedwith the syndromes, such as anxiety or depression. Students interview the “patient,” the interview is recorded, and the “patient” and student then conduct a critique of the interview. The simulated patient is skilled in communication theory and technique. She is ableto divide the communication content into small increments to be learned. She gives direct feedback and reinforcement in the learning system. These basiccomponents of learning theory have been clearly demonstrated by Skinner.’ In 1968, in the Department of Obstetrics and Gynecology, an educational program was begun, experimenting with a new idea for improving pelvic examination instruction to junior medical students who rotated through the clerkship every six weeks. The basisfor this new program wasthe “simulated patient,” first defined by Barrow.? as a “person who has been trained to completely simulate a patient or any aspect of a patient’s illnessdepending upon the educational need.” We sawthis asa potential tool for correcting the inadequaciesof traditional medical education by freeing the real patient from the time and embarrassment involved in pelvic examinations by a beginning student, and by structuring the educational setting with a voluntary, cooperative, “professional patient” to examine in a lessthreatening situation. The program wasbegun by hiring a nurse clinician in the role of “patient.” She did not possess any unique skills related to the pelvic examination per se other than her nursing background. She was familiar with the clinical setting where the instruction was to take place and agreed to submit to repeated examinations. However, it was necessaryto compromise open communication with her, asshe wasdraped at her request in such a way as to remain anonymous. At this stageof development, pelvic examination instruction for junior gynecology studentsconsistedof an instructor modeling a pelvic examination on the simulated patient; each student in turn mimicked the examination. The patient’s responsibility wasto note the various motions and sensationsof the physician’s examination and compare each student’s performance against these criteria. She therefore gave minimal feedback to the student on his technique, i.e., how well
June 15, 1978 Am. J. Obstet. GywcoI
he could imitate the instructor’s examination. This particular teaching form was later described by Perlmutter and Friedman3 as the “live mannequin” foi pelvic examination instruction. The simulated patient concept, in this rudimentary form, succeededin providing a conducive environment for instruction with a relaxed, live model, but it did little to enhance communication between student and patient or reliably evaluate a student’s technical performance. Gynecology Teaching Associate characteristics After experimenting with this program for several years, the Department initiated a new pelvic examination instruction program in 1972, retaining the simulated patient but defining for her a much more sophisticated role. Termed “professional patient” or, more currently, Gynecology Teaching Associate(GTA), this new type of simulatedpatient added two major dimensions to the evolution of the pelvic examination instruction program: (1) she became 6& patient a& instructor and (2) she began stressingthe equally important (and often ignored) area of interpersonal skills integrated with the technical skills to provide a quality pelvic examination. From its inception, this professionalpatient program drew approval from schoolsacrossthe country. Stenchever and his co-workers4at Utah began experimenting with a similar program. Holzman and associates5 of Michigan State recently provided positive data supporting the effectivenessof such teaching programs. To explain the successof this particular program, now in its fifth year of refinement, one must focus on the GTA herself-who she is, where she comesfrom, and what her role is. The uniqueness of the GTA lies primarily in her ability to articulately communicatewith and teach medical students. It is her job to effectively teach students how to perform a quality pelvic examination, and through constant, direct, positive feedback and reinforcement to help them retain these learned skills in the future. All of the six young women currently functioning as GTA’s are working toward or have received advanced degrees in the behavioral sciences.They are hired primarily as establishedteachers,and receive compensation equal to that of a teaching assistantwithin the University system.These women are dedicated to education. Rather than applying their skills elsewhere, whether it be through free medical clinics or women’s health centers, the GTA’s prefer to work within the existing system.6They try to teach and reinforce good doctor behaviors early in medical education, seeking through their efforts not only to instruct medical stu-
Volume Number
131
Gynecology
Teaching
Associate:
Education
specialist
369
4
dents but also to effect better health care for women. Though not created in response to the Women’s Health Movement, the program has been sensitive to it, as most of the GTA’s are in some way involved in it. This has been of benefit to the program, since each woman has educated herself also-learning what it is to be a woman, exploring her own anatomy and physiology, and coming to terms with her sexuality, her attitudes, and her role in life. Indeed, this is a prerequisite to employment as a GTA: that she be comfortable with herself in these areas and comfortable in discussing them with others. These women are constantly undergoing a process of self education and growth in their reading, working, and living. Another dimension which the GTA adds to the existing medical education system is that of sensitivity or humanism. She is able to add her sensitivity as a woman. It is her responsibility as a trained communications specialist and educator to ascertain the particular needs of each individual student whom she encounters, and find the educational strategy with which to reach and teach that student the necessary skills. In summary, the GTA is singled out from the behavioral sciences environment of the University and is selected for her teaching and communication skills, her personal motivation to educate herself and others, and her sensitivitv to the need for health care for women.
Gynecology Teaching Associate recruitment and training With these criteria established, the GTA’s must then learn the integral techniques of the pelvic examination. They undergo a training period lasting approximately 6 to 8 weeks, learning what the students will in turn learn from them: a review of female anatomy and physiology, the technique of the breast examination and breast self-examination instruction, the abdominal examination, and the pelvic examination. The emphasis throughout the teaching program is on normal, hea!thy female anatomy. The educational objective is for students to learn how to perform a quality pelvic examination. While it must be remembered that the GTA will equally stress communication skills between student and patient during the examination process, she must know her technique extremely well, for it is through her expertise in imparting technical skill instruction to the student that the GTA gains credibility within the existing medical educational system. The fairly standard selection and training process of the GTA can be briefly summarized. These women are most often recognized by other Teaching Associates as women in the University community who meet the basic criteria described above. The interested candi-
dates are invited to a group meeting with the Teaching Associates and program director, who performs introductions and outlines the format and pm-pox of the program. After his initial presentation, the director leaves the room in order to allow the women to more openly exchange questions of a personal nature about the program and how it affects the lives of‘ the women. The candidates are encouraged to view pilot videotapes made of past teaching sessions to see how they are conducted. The director then individuallyinterviews each candidate, screening problems and answering any new questions. After receiving feedback from the Teaching Associates about their encounter with the candidates, he makes his final selection. Each accepted candidate must undergo an intake physical and pelvic examination. This time is also used as a beginning point of instruction. The new GTA then attends a session where the director models the examination procedure on one of the women and discusses the process in detail. From that point, training sessions are scheduled (in the director’s absence) where the GTA’s educate the new participant in role playing, technique, and communication skills pertinent to the pelvic examination. In time the new GTA will herself perform practice examinations on the other women. The program director carefully monitors and contributes to this educational process. Interspersed with the training sessions, the new Associate is requested to observe actrlal teaching sessions. She is encouraged to actitel) participate verbally in these sessions. She is next scheduled into the regular sessions, taking on an active role. generally first as “patient” and then later as “instructor.” The new GTA inevitably feels unsure of her ability at this point, but she receives reinforcement from her peers. The women report this to be a constant learning experience. It has been estimated that roughly $500 is needed IO fully train a GTA. This does not include faculty or administrative time. At any point in training she is given the option to drop the program without consequence if she feels uncomfortable with the program 01 her reaction to it. If she elects to remain in the program, she must be in good health with relatively normal anatomy, be able to function in both the patient and
instructor
role,
be able
to commit
the appropriate
amount of time to the position, and he able to work comfortably with all other Associates. These requirements are deemed essential to maintaining the quality of the program.
Educational method The program initially involved only junior medical students who rotated through the gynecology clerk-
370
Kretzschmar
ship every 6 weeks, and the framework has remained fairly consistent. Two junior students per day are assigned to an afternoon session with two GTA’s. An examination room in the regular outpatient clinic is reserved for the teaching session. This provides a convenient and nonthreatening setting for the student and lends credibility to the program. Each session runs undisturbed for approximately 2% hours each afternoon. One GTA acts as “patient” and the other as “instructor.” These titles are fairly ill defined, since both women actively participate in instruction. Simply, one is examined as “patient” while the other helps the “patient,” assists the student with the examination, and gives specific instruction regarding technique,’ The teaching session is designed to simulate an ideal doctor-patient encounter, but in order to provide quality instruction it must necessarily sacrifice some “realness.” The GTA’s introduce themselves by name, describe the program, themselves, their attitudes, and in general try to have the students relax and establish rapport with them. No faculty are involved in these sessions. After one of the GTA’s models an examination on the other, they guide each student in turn through the technical skills of actually performing a breast examination, instructing the patient in breast self-examination, an abdominal examination, and a pelvic examination. Students are taught in detail how to hold instruments, which hand and/or fingers to use, how to palpate various structures, what to look for, and what is normal. As each student goes through the steps of the examination, the GTA reinforces his actions, giving constructive feedback and making suggestions. At any point in the session any of the four people may call a “time out” to repeat, discuss, or clarify a particular point. Each student is specifically treated as an individual with unique skills, anxieties, and attitudes. It is the task of the GTA to find the most effective teaching strategy to help that student, to teach him, to help him learn new or better skills and to retain this knowledge for the real patient setting. The fundamental learning concept of the use of small increments of knowledge, immediate feedback, reinforcement, and individualization of instruction dates back to Socrates, and is the basis of the Socratic style of education. As used in this program, it is very similar to the learning theory currently used in programmed instruction.* While the student is usually most concerned with learning and performing the technical skills of the breast and pelvic examinations, the GTA has the added responsibility of em~ploying her unique communication skills to impart to the student the crucial role of interpersonal skills during each part of the examination.
June .4m. J. Obstet.
15, IYTH Gyned.
She gains credibility for this by showing that a patient who is comfortable with the relationship and the situation is more physically relaxed, and thus more cooperative and easier to examine. The GTA goes into detail during the physical examination, reminding the student that patients are more thanjust bodies to examine, that they have feelings and emotions to cope with in the doctor-patient relationship. Areas emphasized include letting the patient control her own body actions as much as possible, talking with the patient and explaining what the student is doing and finding, explaining to and showing the patient various instruments before they are used, asking the patient for feedback on how she feels (i.e., if she is uncomfortable), and in general trying to create an equal psychological-emotional relationship between student and patient. The student is encouraged to perceive the vulnerability that a patient feels during an examination. In like manner, students recognize and learn to cope with their own anxieties and emotions during the examination procedure. These are not necessarily sexually oriented, but rather relate to anxieties such as insecurity, sensitivity to patient discomfort, or embarrassment, which are experienced with learning any new technical skill. Interestingly, it has been observed that female medical students are just as anxious as male medical students in this situation. Because of the favorable response to the junior program, student interest, and availability of time in the Introduction to Clinical Medicine course curriculum, a gynecology examination instruction program was begun at the sophomore level 4 years ago, not in place of but in addition to the junior program. During this course sophomore students now rotate through the pelvic examination teaching program. Unlike the juniors, the sophomore students review a movie on the pelvic examinations and receive some small group introductory instruction from the program director by reviewing anatomy and discussing the goals of the program. Students are not expected to be expert after one teaching experience. Four students participate per afternoon with two GTA’s in their respective roles. The director is not involved in the small group teaching session. These sessions, because of inexperience and sheer numbers, grow lengthy-usually 3 to 3% hours. As in the junior program, the students are guided through the abdominal, speculum, and pelvic examinations, individually performing these techniques and learning technical skills along with the interpersonal skills. The junior and sophomore programs differ in content, goals, and design. The sophomore program is more structured, and serves as a basic introduction to
Volume Number
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the gynecologic examination. The junior program is more advanced, and designed to be more individualized. In both programs the dimension of direct “patient” feedback and reinforcement is stressed, improving the quality of the learning experience. This instructional system bridges the textbook and clinical experience. The clinic patient is no longer part of the initial pelvic examination teaching program. Both the junior and sophomore programs have emerged as efficient, competent educational systems. Transfer of training to patient care in the Gynecology Clinic has been observed. Both faculty and nurses empirically note student improvement after the teaching sessions. The GTA’s have become credible, accepted members of the medical education program in the Department, and are now given great responsibility for pelvic examination instruction. On occasion the program director will monitor a session; otherwise, he is not involved directly in the teaching session. Monthly staff meetings are held with the director and the GTA’s to discuss teaching strategies, curriculum content, problems that arise in the program, and administrative matters. As a secondary benefit, the faculty time for pelvic examination instruction is reduced. Experience over the past 4 years with cost accounting indicates that at the current pay scale, the cost per teaching session per junior student is $45.00. The cost per sophomore student is $25.00. We feel that this is an educational bargain. Evaluation The GTA’s, with their integral knowledge of the examination and their closecontact with the studentson a one-to-one basis, seem the most likely to effectively evaluate the students’ performance. Recently a pelvic examination evaluation form has been used by which the GTA’s rate the student’s performance on each segment of the examination. The minimum competency-based evaluation helps the women identify students who need remedial help in specific areas. This representsa very few studentswho need additional instruction. As yet, an effective objective assessmentof interpersonal skillshas not been developed, and this is an area for further research in the program.‘O The evaluation system is not used as a device to threaten students; rather it is stressedthat the teaching experience should be characterized by positive feedback and reinforcement for the student to learn in a nonthreatening environment. An attempt hasbeen made to receive feedback from the students themselves about the program and the GTA’s. For example, a questionnaire distributed to sophomore and junior students rotating through the
GynecologyTeachingAssociate:Educationspecialist 371
I. 1976 feedback on pelvic examination instruction questionnaire results (selected questions)* Table
sopklQuestion
Respotue
Would you recommend these sessions for the next class? Did the GTA have a good grasp of the examination procedure? Did it bother you to he instructed by nonmedical personnel? *Number Juniors.
mows (o/d
Jwaiors f%)
Yes NO
No answer Yes No No answer Yes NO No answer
of students responding:
I 99
8; IO
0
121 Sophomores,
150
II. Introduction to Clinical Medicine: over-all course evaluation*
Table
Teaching
session
Gynecology Subject B Subject C Subject D Subject E
I976 rating
I977 rating
4.66 4.02 3.87 3.45 3.28
4.80 4.21 4.06 3.40 3.46
*In 1976,88 per cent of the students in the introduction to Clinical Medicine course responded to a questionnaire ranking the small group afternoon teaching sessions; in 1977, 90 per cent responded, The rating scale used was 1 to 5, with 5 being excellent. The lowest ranking received was 2.54 for 1976; for 1977, it was 2.38.
Department of Obstetrics and Gynecology in 1976and returned anonymously has been most useful. As illustrated by Table I, the students felt that this was a worthwhile learning experience by recommending that it be continued. In addition, the course evaluation for the entire Introduction to Clinical Medicine sophomore program in 1976 and 1977 rated the afternoon gynecology teaching sessionsthe best in the medical school, with over-all ratings of 4.66 and 4.80, respectively (5 being excellent).
(See Table
II.)
as described
provides
Comment The teaching
program
an edu-
cational systemwhich is much lessthreatening to students because of the absence of a faculty person
and
real patient. The early gynecologic examinations by students are done in a controlled teaching systemwith high-quality
“teachers-patients,”
eliminating
the use of
real patients for the teaching experience. The teaching specialist, in either the “instructor” or the “patient” role, gives immediate feedback and reinforcement to the student about both interpersonal and technical skills.The quality and nature of this feedback offers a
372
Kretzschmar
new dimension in the gynecology curriculum which medical faculty, as nonpatients, have not been able to teach (e.g., how much pressure to use, are ovaries being palpated, etc.). The transfer of training of interpersonal and technical skills has been demonstrated during the gynecology clerkship, as observed by nursing staff and faculty. Moreover, the teaching system can be cost accounted to demonstrate cost effectiveness. An effective educational system for teaching the gynecologic examination has thus been established,
REFERENCES
1. Skinner, B. F.: Science of learning and the art of teaching, Harvard Educ. Rev. 24: 86, 1954. 2. Barrows, H. S.: The development and use of a new technique in medical education, in Simulated Patients (Programmed Patients), Springfield, Illinois, 1971, Charles C Thomas, Publisher, pp. 3-42. 3. Perlmutter, 1. F., and Friedman, E. A.: Use of a live mannequin for teaching physical diagnosis in gynecology, J. Reorod. Med. 12: 163. 1974. 4. Ste’nchever, M. A., et ai.: Teaching pelvic examination to second-year medical students using programmed patients, AM.J. OBSTET. GYNECOL. 121: 714, 1975. 5. Holzman, G. B., et al.: Initial pelvic examination instruction: The effectiveness of three contemporary approaches, AM. J. OBSTET. GYNECOL. 129: 124, 1977.
Discussion DR. ROBERT A. MUNSICK, Indianapolis, Indiana. Dr. Kretzschmar has provided the world with his experience in using a radical new approach to teaching the gynecologic examination. He questioned the timehonored methods-students examining anesthetized women or their sensitive, sentient equivalents-cadavers, or assigning them perfunctorily to a gynecology clinic. Fortunately, he also took the next steps: he thought of a much better way, experimented with it, and perfected it despite ridicule and criticism. The fruits of his travails have already resulted in the adoption of similar programs by a few medical schools: hopefully, more will now follow. Our program at Indiana University has evolved slightly differently from Iowa’s but owes its success to Dr. Kretzschmar and his colleagues. Briefly, we were confronted with the problem of having to deal with a gigantic student body-300 per class. Students finished their second year without any instruction or information regarding the pelvic examination and often did not take their Ob/Gyn clerkships until late in the third year. What did they do about pelvic examinations in their other rotations? Often the same thing their residents (former students) did-nothing. In their ObiGyn clerkship they did receive instruction on the Gynny model but after this, due to shortage of time and faculty, they swam or sank-often the latter-in the clinic.
June
1.5. 197x
Am. ,I. Obstet. (;ynect,l.
using the basic educational principles of immediate feedback, reinforcement, and individualization of instruction as used early in history by Socrates. If one reflects on this educational system a moment, a legitimate question can be asked: Why hasn’t this system been used before? I wish to express my appreciation to Mrs. Beth Neumeg for her assistance in the preparation of this manuscript.
6. Keettel, W. C.: Discussion of Gray, M. J., and Tyson, J.: Evolution of a women’s clinic: An alternate system of medical care, AM. J. OBSTET. GYNECOL. 126: 766, 1976. 7. Kretzschmar, R. M.: Newsletter No. 2 of the Steering Committee for Cooperative Teaching in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Utah College of Medicine, January, 197 1. 8. Lysaught, J. P., editor: Programmed Instruction in Medical Education: Proceedings of the First Rochester Conference, Rochester, New York, 1965, The Rochester Clearinghouse, pp. 3- 10. 9. Hunter, C.: Female pelvic examination, University of Indiana School of Medicine, Indianapolis, Indiana (Film). 10. Andrew, B.: An International View of Qualification for the Practice of Medicine, National Board of Medical Examiners, 1977, pp. 102-106. In 19’75 we began our program during the Introduction to Medicine segment of the second year. We advertized locally for our GTA’s-we call them Surrogate Patient Instructors (SPI’s). In three evening sessions at no cost we had trained nine women whose occupations and educations varied from housewife to librarian. They were provided with exacting instructions and objectives. Students were given handouts detailing the technique of history taking, the examination, and how to record it, and the faculty received a separate but similarly exacting description of what was expected of them. Eight students are scheduled each afternoon for about 8 weeks. For 1 hour they view two movies: (1) the pelvic examination and breast self-examination and (2) a tape-slide program on cytology and the gonorrhea culture. In the next hour they learn individually and as a group from a faculty member who teaches informally, instructs them with the Gynny model, answers questions, and introduces the two SPI’s at the end of the hour. In 5 to 10 minutes the SPI’s convince the students that they are there to teach and help, not to embarrass or threaten them. The faculty member then models the examination on one or both SPI’s while all students watch. A nurse is present to assist with instruments and duplicate a professional office atmosphere. Students then proceed one at a time, four for each SPI, to introduce themselves and conduct the examination. This consists first of a thorough handwashing. Then breast examination and breast self-examination. fol-
Volume 13 I Number- 4
lowed by abdominal, pelvic, and rectovaginal examinations. A Pap smear is prepared and inspected for its proper thickness. The SPI gives reassurance, encouragement, and instruction as the student proceeds and at the end checks off a critique sheet with comments for the student, who must wash his hands again as he leaves. The average time spent by each student with a SPI is 20 minutes. Finally, the student writes up his findings according to the required format and this is critiqued on the spot with the faculty member. Our results? In 3 years 824 second-year medical students and 104 nurse clinicians have had the opportunity to learn properly and professionally this most important keystone of gynecologic diagnosis. What’s more, 25 beginning ObiGyn house officers have learned from the same SPI’s not only these fundamentals but the techniques of clinical pelvimetry and the fitting of diaphragms. Most students find this the most rewarding educational experience in their first 2 years of medical school. This is proved by questionnaires for the past 3 years but even more so by their beaming faces and extolling, laudatory remarks as they complete their sessions. After this experience they are far more at ease and prepared to learn with supervision in the clinics and wards. We have now trained a total of 17 SPI’s. The cost of rhe SPI’s in our program for 1977 was $7.91 per student. Dr. Kretzschmar, we owe you a great debt of gratitude. I have only one question to ask: Have you devised a way of measuring accurately the effect your program has had on students’ later pelvic examination performance, or their acceptance or attitude regarding gynecologic history-taking and examination? DR. JOSEPHC. SCOTT, JR., Omaha, Nebraska. What we have heard today is a very detailed description of the evaluation of a program that has dramatically altered the methods of instruction in over 50. medical schools. It must make us reflect upon what is the most important aspect of our specialty that all disciplines should knou. I believe it is the very elements of this program. The ability to obtain an accurate obstetric and gynecologic history, the ability to perform a precise pelvic examination, and the cognizance of each clinician of his or her own limitations is what we are about. Dr. Kretzschmar has described in detail the recruitment, selection, and training of devoted women who are a unique type of educator. The method of evaluation of the program is based on medical student evaluations of this clinical experience that has built into it several exposures at distinct times in the curriculum. Reinforcement is the pillar of this learning program. At Nebraska we have utilized a similar program that has evolved over 5 years and has been stable for the past 3 years. Our students also feel that this is one of the most meaningful experiences in their clerkship.
Gynecology Teaching Associate: Education specialist
373
Our program differs from the Iowa program in only two facets. Ours is conducted totally during the period of an 8 week clerkship in the clinical years, and we utilize a graded format for objective evaluation of the medical student. Each aspect of the examination has a numerical equivalent, so an objective grade can be given to each student. In addition. this has helped us to identify areas for improvement in instruction. There can be no debate that this formal ot‘ education is now well established in many schools. II respects the dignity of women and facilitates medical students learning the basics of our discipline. 1 would hope all departments will evolve a program of this sort. DR. JAMESG. BLYTHE, St. Louis. Missouri. 1 was a Fellow at the University of Iowa during the time that this program was in its inception and was asked as a member of the faculty to participate in the program. My first question, as I suspect yours ma! be, was, “What kind of woman lets four or five novice medical students examine her?” And the answet’ was that the women did a very good job, they were selected very carefully by Dr. Kretzschmar, and the\, did participate actively in the students’ learning. I think we need to keep in mind that we can identify abnormal pelvic pathology only by knowing the normal pelvic anatomy, and this program gives c‘\‘erv medical student the opportuniry to learn normal anatomy. It is very distressing ;o me to have an internist admit a patient to the hospital, order an upper atlcl lower GI series, with the patient’s abdomen markedlx, distended, and not have the ability to diagnose a possible o\;arian carcinoma because he does not know hole trt do a pelvic examination, so 1 think this program 1s vc1.1 important. I hope more medical schools will use it. DR. WILLUMKIEKHOFER, East Lansing, Michigan. I would suggest you read an article by m) associates, Holzman and co-workers.’ 1 was ihe principal control for that study. I found it a humbling experience to recognize that four young women wct’c better leachers than I. REFERENCE
1. Holzman, G. B., Singleton, D., Holmes, T. E‘., ,tnd Maatsch, J. L.: Initial pelvic examination instruction: The effectiveness of three contemporary approaches, AM. J (h3STE.r. GYNECOL.
129: 124.1977.
DR. KRETZSCHMAR(Closing). In response to Dr. Munsick’s question about the long-range ef’fect of this educational program, I can only respond with anecdotal information. The director of one Family Practice residency program where they do videotapes of their residents’ initial physical examinations called me and stated that he could identify which of rhe residents were from Iowa by the quality of the pelvlr: examinations they did. I assumed they were of hqh quality. More follow-up data are needed, and it will be forthcoming in the future.