Learning intimate examinations with simulated patients: The evaluation of medical students’ performance

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Practice points

Observational study on teaching intimate examinations of male and female patients, with male and female intimate examination assistants (IEAs). Outcomes evaluated: the technical skills, the self-estimated competence of students, the scoring of the students by the IEAs, and the students’ experience with intimate examination during internships. IEA training increases completeness, systematic approach, and proficiency, Self-estimated competence is higher for complicated skills, together with an amelioration of the communication with patients. Triangulation of four measurement methods reinforces the conclusion that an IEA program provides added value in medical education.

short-legendFigure 1.

Table 1.  Basic characteristics of sample objective structured clinical examination (OSCE)

		Total student population in the year group	Global OSCE sample	Chi square tests
Group 1 FC	Number	104	34
No IEA training After internship	Age (mean)	25.4 (SD 2.2)	24.8 (SD 1.0)
	Females	62%	62%	NS
	Males	38%	38%
	Pass	65%	50%	NS
	Pass distinction	25%	32%
	Pass great dist.	8%	15%
	Pass greatest dist.	%	3%
Group 2 NC	Number	71	34
With IEA training After internship	Age (mean)	24.4 (SD 0.9)	24.1 (SD 1.0)
	Females	63%	68%	NS
	Males	37%	32%
	Pass	25%	28%	NS
	Pass distinction	44%	35%
	Pass great dist.	27%	31%
	Pass greatest dist.	4%	6%
Group 3 NC	Number	58	36
With IEA training Before internship	Age (mean)	22.0 (SD 2.1)	22.1 (SD 2.4)
	Females	57%	61%	NS
	Males	43%	39%
	Pass	48%	48%	NS
	Pass distinction	39%	41%
	Pass great dist.	11%	9%
	Pass greatest dist.	2%	2%

Notes: FC, former curriculum; NC, new curriculum; dist., distinction; Group 1, no experience with IEA/tested after internship, 2 months, gynecology obligatory, non-urology; Group 2, experience with IEA/tested after internship 1 month, gynecology and 2 weeks urology, both obligatory; Group 3, experience with IEA/tested before internship.

Table 2.  Scores of the three study groups in the OSCE

	Group 1 FC N global = 34 No IEA training After internship	Group 2 NC N global = 32 IEA training After internship	Group 3 NC N global = 36 IEA training No internship	ANOVA Sig. of complete ANOVA
Station performed by N students	N = 19	N = 18	N = 21
Urology	Mean on 10 (95% CI)	Mean on 10 (95% CI)	Mean on 10 (95% CI)
Global score	5.15 (4.63–5.68)	7.77 (718–8.36)^a	7.63 (7.14–8.12)^c	0.0001
Completeness	4.47 (4.04–4.91)	7.06 (6.43–7.68)^a	7.48 (6.94–8.01)^c§	0.0001
Systematic approach	5.00 (4.55–5.45)	8.17 (7.52–8.81)^a	7.95 (7.44–8.46)^c	0.0001
Proficiency	6.00 (5.20–6.80)	8.11 (7.48–8.75)^a	7.48 (6.91–8.05) ^c	0.0001
Station performed by N students	N = 15	N = 16	N = 15
Gynecology
Global score	7.15 (6.32–7.98)	8.58 (8.13–9.03)^a,b	7.73 (7.28–8.18)	0.003
Completeness	6.73 (5.94–7.53)	8.25 (7.72–8.78)^a	7.53 (6.84–8.22)	0.006
Systematic approach	7.73 (6.76–8.70)	9.06 (8.50–9.63)^a,b	8.00 (7.49–8.51)	0.015
Proficiency	7.00 (6.11–7.89)	8.44 (7.71–9.16)^a	7.67 (7.13–8.21)	0.017
OSCE DATE	November 2003	February 2004	September 2004

Notes: FC, former curriculum; NC, new curriculum; post-hoc test, Student–Newman–Keul's (subset for α = 0.05); ^aGroup 2 significantly higher than Group 1.

^bGroup 2 significantly higher than Group 3.

^cGroup 3 significantly higher than Group 1.

Table 3.  Scores of the three study groups on the intimate examination assistant (IEA) list

	Group 1 FC N = 34 No IEA training After internship	Group 2 NC N = 32 IEA training After internship	Group 3 NC N = 36 IEA training No internship	ANOVA Sig. of complete ANOVA
Urology	Mean on 10 (95% CI)	Mean on 10 (95% CI)	Mean on 10 (95% CI)
Global IEA score	8.16 (7.76–8.55)	8.79 (8.42–9.16) ^b	7.55 (6.74–8.35)	0.011
Global attitude	9.02 (8.45–9.58)	9.2 (8.96–9.53)	8.80 (8.18–9.43)	NS
Global behaviour	7.57 (7.05–8.10)	8.35 (7.77– 8.93)^b	6.70 (5.55–7.85)	0.019
Attitude during IEA contact	7.23 (6.75–7.71)	8.31 (7.65–8.97)^b	6.72 (5.58–7.85)	0.023
Attitude during examination IEA	8.78 (8.19–9.38)^c	8.94 (8.37–9.51)^b	7.60 (6.73–8.46)	0.011
Technical score	8.17 (7.45–8.90)	9.10 (8.41–9.78)	7.91 (6.99–8.83)	NS
Gynecology
Global IEAscore	8.38 (7.99–8.78)	8.57 (8.11–9.03)	8.47 (7.98–8.96)	NS
Global attitude	9.14 (8.66–9.62)	8.88 (7.66–8.75)	9.28 (8.98–9.58)	NS
Global behaviour	7.52 (6.64–8.39)	8.40 (7.73–9.06)	8.13 (7.39–8.87)	NS
Attitude during IEA contact	7.96 (7.37–8.55)	8.30 (7.74–8.86)	7.92 (7.19–8.65)	NS
Attitude during examination IEA	8.55 (7.89–9.21)	8.20 (7.66–8.75)	8.02 (7.41–8.62)	NS
Technical score	8.76 (8.01–9.52)	9.08 (8.46–9.70)	9.02 (8.22–9.82)	NS

Notes: FC, former curriculum; NC, new curriculum; post-hoc test, Student–Newman–Keuls (subset for α = 0.05); ^bGroup 2 significantly higher than Group 3.

^cGroup 1 significantly higher than Group 3.

Table 4.  Scores of the two total study groups for the self-estimated competence list

	Group 1 FC N = 65/104 (62.5%) No IEA training After internship	Group 2 NC N = 48/71 (68.1%) IEA training After internship	t-test for equality of means Mean difference (95%CI)	Sig. t test
	Mean on 10	Mean on 10
Global self-estimated competence score (corrected score on 10)	8.34	9.09^a	−0.75 (−1.09 to 0.41)	0.0001
I feel able to	Mean on 4	Mean on 4
Examine a man without complaints (rectal examination)	3.45	3.55	−0.09 (−0.34 to 0.14)	NS
Examine a man with complaints (rectal)	3.35	3.74^a	−0.39 (−0.64 to −0.14)	0.002
To undertake a pelvic evaluation of a man with urinary complaints	2.17	2.94^a	−0.77 (−1.10 to −0.43)	0.0001
Explain the rectal examination to a man	3.80	3.96^a	−0.15 (−0.26 to −0.04)	0.009
Examine a woman without complaints (vaginal examination)	3.53	3.70	−0.17 (−0.39 to 0.05)	NS
Place a speculum in the vagina	3.62	3.81	−0.18 (−0.37 to 0.00)	NS
Examine a woman with bellyache (vaginal examination)	3.34	3.66^a	−0.32 (−0.58 to −0.05)	0.017
Examine a woman with vaginal discharge (vaginal exam.)	3.45	3.72^a	−0.26 (−0.49 to −0.04)	0.019
To do pelvic evaluation of a woman with urinary complaints	2.17	3.00^a	−0.83 (−1.18 to −0.48)	0.0001
Examine the breasts of a woman without complaints	3.71	3.72	−0.01 (−0.21 to 0.19)	NS
Explain the gynaecological examination	3.71	3.89^a	−0.24 (−0.39 to −0.09)	0.002
Explain the pap-smear	3.76	3.89	−0.13 (−0.29 to 0.02)	NS

Notes: FC, former curriculum; NC, new curriculum; t-test (+ Levene's test for equality of variances) significant at p < 0.05. ^aGroup NC significantly better self-estimated competence than Group FC.

Table 5.  Global scores of the 2 total study groups for the skills list

	Group 1 FC N = 65/104 (62.5%) No IEA training After internship	Group 2 NC N = 48/71 (68.1%) IEA training After internship	t-test for equality of means Mean difference (95%CI)	Sig. t test
Global score for	Mean on 5	Mean on 5
Gynecology performance during internship	3.32	3.62*	−0.29 (−0.55 to −0.03)	0.025
	M – 3.46	M – 3.80
	F – 3.25 – NS	F – 3.52 – NS
Urology performance during internship	3.48	4.02*	−0.53 (−0.77 to −0.29)	0.0001
	M – 3.74*	M – 4.12
	F – 3.36	F – 3.96 – NS

Notes: FC, former curriculum; NC, new curriculum; M, male students; F, female students; NS, not significant; t-test (+ Levene's test for equality of variances).

*Significant at p < 0.05.