- Email: [email protected]
Reliability Study for Pediatric and Adolescent Gynecology Case-Based Learning in Resident Education
J Pediatr Adolesc Gynecol (2010) 23:102e106
Original Study Reliability Study for Pediatric and Adolescent Gynecology Case-Based Learning in Resident Education Jennifer E. Dietrich, MD, MSc1, Nirupama K. De Silva, MD2, and Amy E. Young, MD1 1
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; 2Department of Obstetrics and Gynecology, University of Oklahoma-Tulsa, Oklahoma, USA
Address correspondence to: Jennifer E. Dietrich, MD, MSc, Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6620 Main St, Ste 1450, Houston, Texas 77030; E-mail: [email protected]
adolescent female.1 The comfort level among Obstetrician Gynecologists may vary, depending on the degree of exposure to children and adolescents during residency training.2 Pediatric and Adolescent Gynecology (PAG) has been a part of residency training for many years in the fields of Pediatrics and Obstetrics and Gynecology (OB/GYN), but degree of exposure is not consistent in all programs. Standards for residency education in PAG have been outlined by the Council on Resident Education in Obstetrics and Gynecology (CREOG) as objectives for OB/ GYN residents each year, including PAG learning goals.3 Ob/gyn training programs adhere strictly to these criteria as these are frequently criteria by which training can be objectively measured.3 Furthermore, competency may be required for credentialing forms following residency training.3 Some OB/GYN residency training programs have focused education in PAG, in part because of its increasing importance, but also due to increased need, as the population age burden has shifted to younger age groups.2 Traditionally, didactic lectures have been considered acceptable training substitutes. However, in the absence of an expert to provide organized teaching in this sub-specialty, didactic lectures may be inadequate. One study showed that only three hours of lecture time were dedicated to PAG in residency training within a 4-year program.4 The limitations placed on the work duty hours by the Accreditation Council of Graduate Medical Education (ACGME) further limit time allowed for teaching this subspecialty. Alternatives to lectures and direct patient care include simulated patient cases to enhance clinical learning.5 These simulated case experiences also meet the criteria set forth by the ACGME practice-based learning model. Simulated cases may occur in a variety of formats, one of which is an electronicbased modality.6,7 This modality allows for flexibility in gaining exposure to PAG material without risking
Ó 2010 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
1083-3188/10/$36.00 doi:10.1016/j.jpag.2009.09.002
Abstract. Objective: To assess web-based teaching as a tool for resident education in pediatric and adolescent gynecology. Study Design: Prospective Cohort involving 12 third year OB/GYN residents in a large university-based program. A second look reliability study on a previously utilized, web-based teaching case series in Pediatric and Adolescent Gynecology topics was evaluated. Residents’ knowledge regarding the subject matter was assessed by pretest. After completion of the web-based teaching tool, a post test was administered. Residents were also given an opportunity to provide feedback regarding improvements to address future case series development for the tool and resident satisfaction in using this resource for resident education. Results: The pre-test group mean score was 11.2 (58.9%), SD 5 1.9. The post-test group mean score was 15.2 (80%), SD 5 1.70. (P 5 0.0002). Resident participants universally reported the case series was a useful teaching tool. Pooled results from 2005e2006 and 2007e2008 also yielded statistically significant scores from pre test to post test (power of O80% at the 95% confidence interval). Conclusion: A computer-based learning tool is an effective resource to improve baseline knowledge among ob-gyn residents in the subspecialty field of Pediatric and Adolescent Gynecology.
Key Words. Web-based education—Resident—Relia bility—Teaching
Introduction Obstetrician Gynecologists are frequently called upon to perform a gynecologic evaluation on a child or an
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education Table 1. Cases Included in the Web-based Case Series on Pediatric and Adolescent Gynecology Case 1 Case 2 Case Case Case Case Case Case Case Case Case
3 4 5 6 7 8 9 10 11
Case Case Case Case Case Case
12 13 14 15 16 17
Case 18 Case 19 Case 20
Labial adhesions in a prepubertal child Diagnosis and management of uterus didelphys with a non-communicating horn Precocious puberty Foreign body in the vagina Mayer-Rokitansky-Ku¨ster-Hauser syndrome Dysfunctional uterine bleeding in an adolescent Menorraghia in an adolescent resulting in anemia Polycystic ovarian syndrome in the adolescent Asymptomatic ovarian cyst in a child Neonatal ovarian cysts Menstrual disorders in an adolescent with developmental disabilities Lichen sclerosus in a prepubertal child Straddle injury in a child resulting in a vulvar hematoma Chronic pelvic pain and endometriosis in the adolescent Urethral prolapse in a child Case of cervical agenesis in an adolescent Patient with uterus didelphys with an obstructed hemivagina Adolescent with asymptomatic hypothyroidism and consequent irregular menstrual bleeding Vulvovaginitis in the prepubertal child Breast cyst in an adolescent
103
Table 3. Time Spent Per Case Mean Time (minutes, SD) Range (minutes) % Completed in !5 minutes % Completed in 5e10 minutes % Completed in O10 minutes
14.1, 6.5 1.5e20 8% 42% 50%
basic topics in PAG (See Table 1). At the completion of the series, residents were asked to answer the same 20 questions as a post-test evaluation. Residents were not given the answers to their pre-test prior to submitting the post-test answers. Comparisons regarding residents’ scores were then made between pre and post-test scores as well as inter-resident variability, using simple t-tests and descriptive statistics. Approximately one year after completion of the PAG rotation, all third year residents who participated in the webbased case series were asked 5 questions regarding satisfaction with the teaching tool. Finally, to demonstrate reliability, data was compared to data obtained in the 2005 study using a paired t test. Results
work hour violation, because this type of exercise can be completed at home, outside the parameters set forth by the ACGME.8 Methods An electronic-based PAG case series was developed in 2005 at the Baylor College of Medicine in the Department of OB/GYN, based on criteria set forth by CREOG for in-training examinations.6 This case series was utilized as an adjunct to a formal one-month resident rotation in PAG. As a follow-up to the study in 2006, a second-look study was performed in 2007e2008. This second-look study was deemed exempt by the Baylor College of Medicine Institutional Review Board. Twelve third-year OB/GYN residents were asked to answer 20 questions on basic knowledge of PAG at the beginning of their rotation. Residents were then instructed that the PAG case series should be utilized throughout the PAG rotation and to work through each of the 20 included cases on Table 2. Residents’ Scores who completed Pre and Post Tests Resident 1 2 3 4 5 6
Pre-Test Raw Score
Post-Test Raw Score
P value
9 10 11 13 14 13
14 15 15 17 13 15
0.05 0.003 0.0004 0.0004 NS 0.001
Twelve third-year residents (9 females and 3 males) between the years of 2007e2008 utilized the casebased teaching series throughout their PAG rotation. Six residents completed pre and post-tests. Three residents completed the pre-test only, one resident completed the post test only, and 2 residents failed to complete either test. One question on both pre and post-tests was discarded due to a problem with question validity. Therefore, scores were compared between pre-test and post-test groups based on a total of 19 questions. The pre-test group scores ranged from 9 to 14, with a mean score of 11.2 (58.9%), SD 5 1.9. The post-test group ranged from 14 to 18, with a mean score of 15.2 (80%), SD 5 1.7. The difference between groups was statistically significant (P 5 0.0002). Residents who completed both pre and post-tests exhibited statistically significant personal improvement in five out of 6 cases (Table 2). The average time residents reported the series required per case ranged from 1.5 to 20 minutes, with a mean of 14.1 minutes (SD 5 6.5) (Table 3). All (12/12) of residents reported the case series enhanced their learning and that they would do more cases like this in the future. Additional satisfaction questions addressed question-validity, use of images or graphics, clear discussion points and ability to address key points on a 5-point scale ranging from useless to priceless. Fig. 1 demonstrates that overall residents viewed the teaching case series as ‘‘priceless,’’ with residents marking O4 on the 5-point scale for clarity of questions (83%), clarity of case discussions (92%),
104
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education Rated responses for Case-based learning tool in Pediatric and Adolescent Gynecology
Number of residents rating on scale (1-5 from useless to priceless)
7 Series1 Series2 Series3 Series4 Series5
6
5
4
3
2
1
0 Clear questions
Images and Graphics
Discussion clear
Key points addressed
Feature
Fig. 1. Rated responses for case-based learning tool in Pediatric and Adolescent Gynecology.
and addressing key points (75%). However, approximately 50% of residents felt the images and graphics could be improved upon, with a mean overall score of 3.6 on the 5-point scale. Furthermore, residents had an opportunity to provide direct feedback on areas of improvement they identified following completion of the teaching module (Table 4). Finally, data from the 2005 study was pooled and compared to determine reliability (Table 5).9 Both groups from 2005e2006 (Group 1) and 2007e2008 (Group 2) demonstrated improvement in test scores.9 Based on pooled data for residents who completed both pre and post tests, residents still improved their test scores significantly (P ! 0.0001). Normal distributions were demonstrated for pooled data set (Fig. 2). With the pooled sample size, power was O80% at the 95% confidence interval. Table 4. Areas Identified by Residents for Improvement in the PAG Case Series
Identified Area for Improvement
Discussion The evaluation of children and adolescents is different than the evaluation of adult women and may be challenging to providers without formal training.1,2,10,11 OB/GYNs caring for this population should be familiar with basic diagnoses and develop skill in managing common problems.5,10,11 Regardless of opportunities for formal training in PAG, residents can learn basic principles through teaching modules, similar to the one utilized for our residents.8 The future in medical education will involve many modes of learning for residents. A new CD-ROM produced by the American College of Obstetricians and Gynecologists is another available tool that residents may use during their training.6 Our case-based learning module on PAG is also a means by which OB/ Table 5. Pooled Data Sets on Resident Web-Based Case Series Mean % (SD)
Number of Residents Reporting, n 5 12 Data Set
Change nothing Active discussion following completion of series Add cases Add more graphics/pictures/ algorithms/specific details Unsure
3 1 3 4 1
Pre Test Scores
Post Test Scores
P value
2005e2006 Group 1 (N 5 11) 50.4 (13.1) 69.5 (10.1) !0.0001 2007e2008 Group 2 (N 5 10) 58.9 (1.9) 80 (1.7) 0.0002 Pooled Paired Set* (N 5 17) 54.3 (13.0) 72.5 (9.8) !0.0001 *This included paired pre and post test scores among residents who completed both tests (11 residents from Group 1 and 6 residents from Group 2).
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education
105
Pre Test Distribution of Scores 6 Series1
5
Number of Residents
4
3
2
1
0
0
20
40
60
80
100
120
-1 Percent (%)
Post Test Distribution of Scores 8 Series1 7
6
Number of Residents
5
4
3
2
1
0 0
20
40
60
80
100
120
-1 Percent (%)
Fig. 2. Pre and Post Test Distribution
GYN residents may learn at their pace, and avoid work-duty hour conflict. Similar to our findings, many studies now support the need for formal education in this sub-specialty, affording residents both basic knowledge and skills to perform gynecological exams in this special population.10,12 Without formalized training, lack of knowledge in pattern recognition and treatment for common problems was evident.8,9 A well-defined program in PAG would enhance resident education and meet objectives as set forth
by CREOG, which is particularly important given the change in population demographics.3,10 Statistics demonstrate that O72% of OB/GYNs in practice will see adolescents.12 In a recent survey, many practitioners felt their residency training was adequate to address concerns regarding puberty, menses, and sexually transmitted diseases, but primary care topics in adolescents, such as immunizations, eating disorders, and confidentiality were not adequately addressed during residency training.12 Finally, ~80% of
106
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education
respondents included in the survey reported they had no training or inadequate training in evaluation of the female child from birth to menarche, and 40% reported no or inadequate training in the evaluation of developmental anomalies of the reproductive tract.12 While this data are encouraging, our study has several limitations. First, only the third year residents in our program rotate through PAG at our institution, resulting in a small sample size for this follow-up study. In addition, these results cannot necessarily be generalized because this was a single institutional experience. Finally, pooled group scores were used to demonstrate reliability, because only six out of 12 residents completed pre and post-tests in Group 2 and 11 out of 12 residents completed pre and post tests in Group 1.
Conclusions The description of our experience at Baylor College of Medicine is limited in that it represents the experience of only third year residents at one institution and may not be representative of other residents at other programs. Another limitation of the study may be that it is difficult to separate knowledge gained from this tool from other forms of interactive teaching and patient care over the course of the rotations. Additional centers need to document experience in teaching PAG as set forth in CREOG objectives. A computer-based learning tool is an effective mean by which residents may gain additional knowledge in the subspecialty field of Pediatric and Adolescent Gynecology. Finally, further needs assessments in the area of PAG will allow this web-based tool to be adapted in conjunction with the progression of this subspecialty.
Acknowledgments: This study was undertaken at Baylor College of Medicine in Houston, Texas.
References 1. Sanfilippo J: History of pediatric and adolescent gynecology revisited. J Pediatr Adolesc Gynecol 2002; 15:263 2. Muram D, Simmons KJ: Pattern recognition in pediatric and adolescent gynecologyea case for formal education. J Pediatr Adolesc Gynecol 2008; 21:103 3. CREOG Council on Resident Education in Obstetrics and Gynecology. Available: www.acog.org/departments/dept_web. cfm?recno51. Accessed June 23, 2009. 4. Wagner EA, Schroeder B, Kowalczyk C: Pediatric and adolescent gynecology experience in academic and community OB/GYN residency programs in Michigan. J Pediatr Adolesc Gynecol 1999; 12:215 5. Beyth Y, Hardoff D, Rom E, et al: A simulated patientbased program for training gynecologists in communication with adolescent girls presenting with gynecological problems. J Pediatr Adolesc Gynecol 2009; 22:79 6. Laufer MR, Goldstein LS, editors: ACOG CD-ROM: Clinical Cases in Pediatric and Adolescent Gynecology. American College of Obstetricians and Gynecologists, 2008. 7. Criley JM, Keiner J, Boker JR, et al: Innovative web-based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med 2008; 3:124 8. Kakarla N, Zurawin RK, Young AE: Pediatric and adolescent gynecology learned via web-based computerized case series. Association of Professors of Gynecology and Obstetrics. Orlando, FL, Abstract and Poster, March 4-6, 2006. 9. De Silva N, Dietrich JE, Young AE: Pediatric and adolescent gynecology learned via web-based computerized case series. J Pediatr Gynecol Adoles (in press) 10. Muram D, Jones CE, Hostetler BR, et al: Teaching pediatric and adolescent gynecology: a pilot study in one institution. J Adolesc Pediatr Gynecol 1996; 9:12 11. Ladson S, Johnson C, Doty R: Do physicians recognize sexual abuse? Am J Dis Child 1987; 141:411 12. Goldstein LS, Chapin JL, Lara-Torre E, et al: The care of adolescents by obstetrician gynecologists: a first look. J Pediatr Adolesc Gynecol 2009; 22:121
Original Study Reliability Study for Pediatric and Adolescent Gynecology Case-Based Learning in Resident Education Jennifer E. Dietrich, MD, MSc1, Nirupama K. De Silva, MD2, and Amy E. Young, MD1 1
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; 2Department of Obstetrics and Gynecology, University of Oklahoma-Tulsa, Oklahoma, USA
Address correspondence to: Jennifer E. Dietrich, MD, MSc, Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6620 Main St, Ste 1450, Houston, Texas 77030; E-mail: [email protected]
adolescent female.1 The comfort level among Obstetrician Gynecologists may vary, depending on the degree of exposure to children and adolescents during residency training.2 Pediatric and Adolescent Gynecology (PAG) has been a part of residency training for many years in the fields of Pediatrics and Obstetrics and Gynecology (OB/GYN), but degree of exposure is not consistent in all programs. Standards for residency education in PAG have been outlined by the Council on Resident Education in Obstetrics and Gynecology (CREOG) as objectives for OB/ GYN residents each year, including PAG learning goals.3 Ob/gyn training programs adhere strictly to these criteria as these are frequently criteria by which training can be objectively measured.3 Furthermore, competency may be required for credentialing forms following residency training.3 Some OB/GYN residency training programs have focused education in PAG, in part because of its increasing importance, but also due to increased need, as the population age burden has shifted to younger age groups.2 Traditionally, didactic lectures have been considered acceptable training substitutes. However, in the absence of an expert to provide organized teaching in this sub-specialty, didactic lectures may be inadequate. One study showed that only three hours of lecture time were dedicated to PAG in residency training within a 4-year program.4 The limitations placed on the work duty hours by the Accreditation Council of Graduate Medical Education (ACGME) further limit time allowed for teaching this subspecialty. Alternatives to lectures and direct patient care include simulated patient cases to enhance clinical learning.5 These simulated case experiences also meet the criteria set forth by the ACGME practice-based learning model. Simulated cases may occur in a variety of formats, one of which is an electronicbased modality.6,7 This modality allows for flexibility in gaining exposure to PAG material without risking
Ó 2010 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
1083-3188/10/$36.00 doi:10.1016/j.jpag.2009.09.002
Abstract. Objective: To assess web-based teaching as a tool for resident education in pediatric and adolescent gynecology. Study Design: Prospective Cohort involving 12 third year OB/GYN residents in a large university-based program. A second look reliability study on a previously utilized, web-based teaching case series in Pediatric and Adolescent Gynecology topics was evaluated. Residents’ knowledge regarding the subject matter was assessed by pretest. After completion of the web-based teaching tool, a post test was administered. Residents were also given an opportunity to provide feedback regarding improvements to address future case series development for the tool and resident satisfaction in using this resource for resident education. Results: The pre-test group mean score was 11.2 (58.9%), SD 5 1.9. The post-test group mean score was 15.2 (80%), SD 5 1.70. (P 5 0.0002). Resident participants universally reported the case series was a useful teaching tool. Pooled results from 2005e2006 and 2007e2008 also yielded statistically significant scores from pre test to post test (power of O80% at the 95% confidence interval). Conclusion: A computer-based learning tool is an effective resource to improve baseline knowledge among ob-gyn residents in the subspecialty field of Pediatric and Adolescent Gynecology.
Key Words. Web-based education—Resident—Relia bility—Teaching
Introduction Obstetrician Gynecologists are frequently called upon to perform a gynecologic evaluation on a child or an
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education Table 1. Cases Included in the Web-based Case Series on Pediatric and Adolescent Gynecology Case 1 Case 2 Case Case Case Case Case Case Case Case Case
3 4 5 6 7 8 9 10 11
Case Case Case Case Case Case
12 13 14 15 16 17
Case 18 Case 19 Case 20
Labial adhesions in a prepubertal child Diagnosis and management of uterus didelphys with a non-communicating horn Precocious puberty Foreign body in the vagina Mayer-Rokitansky-Ku¨ster-Hauser syndrome Dysfunctional uterine bleeding in an adolescent Menorraghia in an adolescent resulting in anemia Polycystic ovarian syndrome in the adolescent Asymptomatic ovarian cyst in a child Neonatal ovarian cysts Menstrual disorders in an adolescent with developmental disabilities Lichen sclerosus in a prepubertal child Straddle injury in a child resulting in a vulvar hematoma Chronic pelvic pain and endometriosis in the adolescent Urethral prolapse in a child Case of cervical agenesis in an adolescent Patient with uterus didelphys with an obstructed hemivagina Adolescent with asymptomatic hypothyroidism and consequent irregular menstrual bleeding Vulvovaginitis in the prepubertal child Breast cyst in an adolescent
103
Table 3. Time Spent Per Case Mean Time (minutes, SD) Range (minutes) % Completed in !5 minutes % Completed in 5e10 minutes % Completed in O10 minutes
14.1, 6.5 1.5e20 8% 42% 50%
basic topics in PAG (See Table 1). At the completion of the series, residents were asked to answer the same 20 questions as a post-test evaluation. Residents were not given the answers to their pre-test prior to submitting the post-test answers. Comparisons regarding residents’ scores were then made between pre and post-test scores as well as inter-resident variability, using simple t-tests and descriptive statistics. Approximately one year after completion of the PAG rotation, all third year residents who participated in the webbased case series were asked 5 questions regarding satisfaction with the teaching tool. Finally, to demonstrate reliability, data was compared to data obtained in the 2005 study using a paired t test. Results
work hour violation, because this type of exercise can be completed at home, outside the parameters set forth by the ACGME.8 Methods An electronic-based PAG case series was developed in 2005 at the Baylor College of Medicine in the Department of OB/GYN, based on criteria set forth by CREOG for in-training examinations.6 This case series was utilized as an adjunct to a formal one-month resident rotation in PAG. As a follow-up to the study in 2006, a second-look study was performed in 2007e2008. This second-look study was deemed exempt by the Baylor College of Medicine Institutional Review Board. Twelve third-year OB/GYN residents were asked to answer 20 questions on basic knowledge of PAG at the beginning of their rotation. Residents were then instructed that the PAG case series should be utilized throughout the PAG rotation and to work through each of the 20 included cases on Table 2. Residents’ Scores who completed Pre and Post Tests Resident 1 2 3 4 5 6
Pre-Test Raw Score
Post-Test Raw Score
P value
9 10 11 13 14 13
14 15 15 17 13 15
0.05 0.003 0.0004 0.0004 NS 0.001
Twelve third-year residents (9 females and 3 males) between the years of 2007e2008 utilized the casebased teaching series throughout their PAG rotation. Six residents completed pre and post-tests. Three residents completed the pre-test only, one resident completed the post test only, and 2 residents failed to complete either test. One question on both pre and post-tests was discarded due to a problem with question validity. Therefore, scores were compared between pre-test and post-test groups based on a total of 19 questions. The pre-test group scores ranged from 9 to 14, with a mean score of 11.2 (58.9%), SD 5 1.9. The post-test group ranged from 14 to 18, with a mean score of 15.2 (80%), SD 5 1.7. The difference between groups was statistically significant (P 5 0.0002). Residents who completed both pre and post-tests exhibited statistically significant personal improvement in five out of 6 cases (Table 2). The average time residents reported the series required per case ranged from 1.5 to 20 minutes, with a mean of 14.1 minutes (SD 5 6.5) (Table 3). All (12/12) of residents reported the case series enhanced their learning and that they would do more cases like this in the future. Additional satisfaction questions addressed question-validity, use of images or graphics, clear discussion points and ability to address key points on a 5-point scale ranging from useless to priceless. Fig. 1 demonstrates that overall residents viewed the teaching case series as ‘‘priceless,’’ with residents marking O4 on the 5-point scale for clarity of questions (83%), clarity of case discussions (92%),
104
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education Rated responses for Case-based learning tool in Pediatric and Adolescent Gynecology
Number of residents rating on scale (1-5 from useless to priceless)
7 Series1 Series2 Series3 Series4 Series5
6
5
4
3
2
1
0 Clear questions
Images and Graphics
Discussion clear
Key points addressed
Feature
Fig. 1. Rated responses for case-based learning tool in Pediatric and Adolescent Gynecology.
and addressing key points (75%). However, approximately 50% of residents felt the images and graphics could be improved upon, with a mean overall score of 3.6 on the 5-point scale. Furthermore, residents had an opportunity to provide direct feedback on areas of improvement they identified following completion of the teaching module (Table 4). Finally, data from the 2005 study was pooled and compared to determine reliability (Table 5).9 Both groups from 2005e2006 (Group 1) and 2007e2008 (Group 2) demonstrated improvement in test scores.9 Based on pooled data for residents who completed both pre and post tests, residents still improved their test scores significantly (P ! 0.0001). Normal distributions were demonstrated for pooled data set (Fig. 2). With the pooled sample size, power was O80% at the 95% confidence interval. Table 4. Areas Identified by Residents for Improvement in the PAG Case Series
Identified Area for Improvement
Discussion The evaluation of children and adolescents is different than the evaluation of adult women and may be challenging to providers without formal training.1,2,10,11 OB/GYNs caring for this population should be familiar with basic diagnoses and develop skill in managing common problems.5,10,11 Regardless of opportunities for formal training in PAG, residents can learn basic principles through teaching modules, similar to the one utilized for our residents.8 The future in medical education will involve many modes of learning for residents. A new CD-ROM produced by the American College of Obstetricians and Gynecologists is another available tool that residents may use during their training.6 Our case-based learning module on PAG is also a means by which OB/ Table 5. Pooled Data Sets on Resident Web-Based Case Series Mean % (SD)
Number of Residents Reporting, n 5 12 Data Set
Change nothing Active discussion following completion of series Add cases Add more graphics/pictures/ algorithms/specific details Unsure
3 1 3 4 1
Pre Test Scores
Post Test Scores
P value
2005e2006 Group 1 (N 5 11) 50.4 (13.1) 69.5 (10.1) !0.0001 2007e2008 Group 2 (N 5 10) 58.9 (1.9) 80 (1.7) 0.0002 Pooled Paired Set* (N 5 17) 54.3 (13.0) 72.5 (9.8) !0.0001 *This included paired pre and post test scores among residents who completed both tests (11 residents from Group 1 and 6 residents from Group 2).
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education
105
Pre Test Distribution of Scores 6 Series1
5
Number of Residents
4
3
2
1
0
0
20
40
60
80
100
120
-1 Percent (%)
Post Test Distribution of Scores 8 Series1 7
6
Number of Residents
5
4
3
2
1
0 0
20
40
60
80
100
120
-1 Percent (%)
Fig. 2. Pre and Post Test Distribution
GYN residents may learn at their pace, and avoid work-duty hour conflict. Similar to our findings, many studies now support the need for formal education in this sub-specialty, affording residents both basic knowledge and skills to perform gynecological exams in this special population.10,12 Without formalized training, lack of knowledge in pattern recognition and treatment for common problems was evident.8,9 A well-defined program in PAG would enhance resident education and meet objectives as set forth
by CREOG, which is particularly important given the change in population demographics.3,10 Statistics demonstrate that O72% of OB/GYNs in practice will see adolescents.12 In a recent survey, many practitioners felt their residency training was adequate to address concerns regarding puberty, menses, and sexually transmitted diseases, but primary care topics in adolescents, such as immunizations, eating disorders, and confidentiality were not adequately addressed during residency training.12 Finally, ~80% of
106
Dietrich et al: Reliability Study for Case-Based Learning in Resident Education
respondents included in the survey reported they had no training or inadequate training in evaluation of the female child from birth to menarche, and 40% reported no or inadequate training in the evaluation of developmental anomalies of the reproductive tract.12 While this data are encouraging, our study has several limitations. First, only the third year residents in our program rotate through PAG at our institution, resulting in a small sample size for this follow-up study. In addition, these results cannot necessarily be generalized because this was a single institutional experience. Finally, pooled group scores were used to demonstrate reliability, because only six out of 12 residents completed pre and post-tests in Group 2 and 11 out of 12 residents completed pre and post tests in Group 1.
Conclusions The description of our experience at Baylor College of Medicine is limited in that it represents the experience of only third year residents at one institution and may not be representative of other residents at other programs. Another limitation of the study may be that it is difficult to separate knowledge gained from this tool from other forms of interactive teaching and patient care over the course of the rotations. Additional centers need to document experience in teaching PAG as set forth in CREOG objectives. A computer-based learning tool is an effective mean by which residents may gain additional knowledge in the subspecialty field of Pediatric and Adolescent Gynecology. Finally, further needs assessments in the area of PAG will allow this web-based tool to be adapted in conjunction with the progression of this subspecialty.
Acknowledgments: This study was undertaken at Baylor College of Medicine in Houston, Texas.
References 1. Sanfilippo J: History of pediatric and adolescent gynecology revisited. J Pediatr Adolesc Gynecol 2002; 15:263 2. Muram D, Simmons KJ: Pattern recognition in pediatric and adolescent gynecologyea case for formal education. J Pediatr Adolesc Gynecol 2008; 21:103 3. CREOG Council on Resident Education in Obstetrics and Gynecology. Available: www.acog.org/departments/dept_web. cfm?recno51. Accessed June 23, 2009. 4. Wagner EA, Schroeder B, Kowalczyk C: Pediatric and adolescent gynecology experience in academic and community OB/GYN residency programs in Michigan. J Pediatr Adolesc Gynecol 1999; 12:215 5. Beyth Y, Hardoff D, Rom E, et al: A simulated patientbased program for training gynecologists in communication with adolescent girls presenting with gynecological problems. J Pediatr Adolesc Gynecol 2009; 22:79 6. Laufer MR, Goldstein LS, editors: ACOG CD-ROM: Clinical Cases in Pediatric and Adolescent Gynecology. American College of Obstetricians and Gynecologists, 2008. 7. Criley JM, Keiner J, Boker JR, et al: Innovative web-based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med 2008; 3:124 8. Kakarla N, Zurawin RK, Young AE: Pediatric and adolescent gynecology learned via web-based computerized case series. Association of Professors of Gynecology and Obstetrics. Orlando, FL, Abstract and Poster, March 4-6, 2006. 9. De Silva N, Dietrich JE, Young AE: Pediatric and adolescent gynecology learned via web-based computerized case series. J Pediatr Gynecol Adoles (in press) 10. Muram D, Jones CE, Hostetler BR, et al: Teaching pediatric and adolescent gynecology: a pilot study in one institution. J Adolesc Pediatr Gynecol 1996; 9:12 11. Ladson S, Johnson C, Doty R: Do physicians recognize sexual abuse? Am J Dis Child 1987; 141:411 12. Goldstein LS, Chapin JL, Lara-Torre E, et al: The care of adolescents by obstetrician gynecologists: a first look. J Pediatr Adolesc Gynecol 2009; 22:121