Training of the gynaecological examination in the Netherlands

Abstract

Background: Competent performance of the gynaecological examination requires good technical and interpersonal skills, which are best mastered in an educationally sound atmosphere. Research has shown that effective teaching sessions of the gynaecological examination require the presence of gynaecological educated professional patients. But to what extent is this methodology currently used at Medical Schools? Currently there is no overview of how this type of training is provided by the eight Dutch medical schools.

Objectives: To describe design, content and problems encountered in relation to gynaecological examination training in medical education in the Netherlands.

Design: Descriptive pilot study with a written questionnaire.

Participants/setting: The coordinators of gynaecological skills teaching of all eight Dutch Medical schools.

Main outcome measure: The questions addressed aim, preparation, format, content, organization and evauation of training.

Results: After a reminder all eight coordinators returned the survey. Objectives varied between schools. Some schools focus on technical skills whereas other schools place emphasis on overcoming students’ shyness towards this intimate examination. Some schools pay special attention to students’ attitudes towards women. Training formats differ also. In most schools three-hour training sessions involve two gynaecological educated professional patients and three students. A common problem is the recruitment of gynaecological educated professional patients. Schools do not have formal contacts.

Conclusions: It would be interesting to compare the outcomes of different teaching formats used by the different medical schools, including comparing the differences in the teaching programmes in detail. It is ineffective that there is so little collaboration between the coordinators of the medical schools.

Introduction

In addition to knowledge, medical students must acquire the skills and professional attitudes needed to practice medicine competently. Skills can be divided into communication and technical skills. Both types of skill are needed to perform a competent gynaecological examination. This part of the physical examination is performed regularly in both primary and secondary care. At the same time it is a special examination because it involves a highly sensitive and intimate area for patients and doctors. Thus it is important that patients feel at ease and have confidence in their doctor's interpersonal and technical competence. The intimate and highly personal nature of many gynaecologic conditions requires sensitivity from the doctor (Berek et al. 2002). Hence, an improperly conducted examination is likely to have a strong negative impact on both patient and doctor. That is why students should be adequately trained to master the interpersonal and technical skills for performing a competent gynaecological examination and feel more confident about it (Wanggren et al. 2005; Ker 2003). Training should preferably take place in a safe atmosphere (Kneebone 2003). Therefore this examination features prominently in most medical undergraduate curricula. (Beckman et al. 1988).

Table

Practice points
•Teaching gynaecological examination skills to undergraduate medical students is important. All medical schools in the Netherlands have special locally developed teaching programmes for this purpose.
•There is considerable variation in design, content and execution of training.
•All schools have difficulty recruiting women who want to act as gynaecological teaching associates.
•Studies should compare the outcomes of different teaching formats and investigate if more national collaboration will improve students’ gynaecological examination skills.

The use of simulated patients (SP) for gynaecological examination training was described as early as 1974 (Godkins et al. 1974). Simulated patients are healthy persons or actual patients who have been trained to accurately and consistently portray a particular patient case (Barrows 1993). At first, SPs had only a passive role, but gradually their role developed into a more active one, with SPs giving feedback to students about both medical technical aspects and affective and communication aspects of the gynaecological examination (Kretzschmar 1978).

Over the years the role of SPs has evolved into that of gynaecological teaching associates (GTAs) (Kretzschmar 1978).

The difference between SPs and GTAs is that GTAs have received special training for the gynaecological examination including a detailed course on the relevant anatomy, physiology and feedback. In fact, GTAs are teachers whereas SPs are not.

In the Netherlands, the design for GTA-mediated training in gynaecological examination was introduced in 1986 (Van Lunsen 1986). From examining women in patient-centred clinical settings, the format changed into a student-centred educational setting. For the first time the possibility was created for providing adequate feedback to students.

Today, GTAs have been introduced in all Dutch medical schools. This type of training of the pelvic examination has proved to be more effective than using pelvic manikins only (Rochelle 1982; Guenther et al. 1983) or even learning the examination on clinical patients taught by gynaecological residents (Guenther et al. 1983).

It is students’ interpersonal skills and attitudes in particular that benefit from training with GTAs (Kleinman et al. 1996). This type of training is also highly appreciated by students, as it creates a safe learning environment with the benefits of direct feedback and attention for anxiety reduction (Wanggren et al. 2005).

Due to the rising numbers of medical students and the ageing of the current pool of GTAs, Maastricht University is facing an impending shortage of GTAs. We needed to know how other medical schools were handling gynaecological teaching programmes. Do they have the same problems? And how do they cope with them? We wanted to get an overview of the design, content and problems encountered with regard to the pelvic examination in the Dutch medical schools. The results of this pilot study may be of help to medical schools in other countries who want to improve or set up effective training programmes for the gynaecological examination.

Methods

For logistical reasons we decided to develop a questionnaire.

An alternative would have been to conduct semi-structured interviews, however this

Methodology did not fit into our time-schedule.

Questionnaire

After studying the literature on the teaching of the pelvic examination, we developed a questionnaire in consultation with experts on the pelvic examination at Maastricht University. Questionnaire items asked about the aim, preparation, format, content, organization and evaluation of gynaecological examination training. In a pilot study one coordinator of gynaecological examination training commented on aspects of the questionnaire such as readability and length and this led to some adjustments. The final questionnaire contained 36 questions, open as well as multiple-choice questions. The questionnaire is in attachment I.

Coordinators

Each of the eight medical schools in the Netherlands has appointed a coordinator for gynaecological examination training. All coordinators were sent a hard copy of the questionnaire. After sending a reminder four weeks later, we obtained a response of 100%.

Analysis

We sorted the data by medical school. Data analysis was done by descriptive statistics. For each of the multiple choice questions frequencies were calculated. For open questions one of the auteurs listed the answers and grouped them if possible by content. This analysis was discussed in the project group. In that way we were able to interpret the answers and compare the medical schools.

Results

The main results of the questionnaire are presented in Table 1. The eight medical schools have different protocols for gynaecological examination training, with differences in objective, preparation, format, organisation and evaluation, although they all use GTAs.

Table 1.  Comparing characteristics of gynaecology education in Dutch medical schools

	Rijksuniversiteit Groniingen	Universiteit Utrecht	Rijks Universiteit Leiden	Katholieke Universiteit Nijmegen	Vrije Universiteit Amsterdam	Universiteit van Amsterdam	Universiteit Maastricht	Erasmus Uninversiteit Rotterdam
Place in curriculum	5th or 6th year	4th year	5th or 6th year	4th year	5th or 6th year	5th or 6th year	4th year	5th or 6th year
Aim of the training	Technical aspects	Attitude towards  women	Technical aspects	Technical aspects	Attitude towards women	Overcomming shyness	Technical aspects	Attitude towards women
Preparation (beside literature and pelvic manikins)		Film and lecture	Film	Film and lecture	Film			Film and lecture
Format (staff present)	2 GTAs	2 GTAs	2 GTAs	2 GTAs	2 GTAs	2 GTAs	1 GTA and 1 physician	5 GTAs
Number of students	3	3	3	3	3	3	1	10
Duration (minutes)	180	180	180	180	200	180	60	180
Content of the training (beside speculum and VT)*	Rectal toucher and  ractovaginal toucher	None	None	None	None	None	None	Breast examination
Training of GTA (hours)	35	36	24	30	27	20	25	10
Payment during training (Euro)*	4	7	5	28	12	23	11	0
Payment during work (Euro)*	27	35	23	28	28	36	11	34
Evaluation with students by means of	Evaluation form	Discussion and  evaluation form	Evaluation form	Discussion	Evaluation form	Discussion and evaluation form	Discussion and evaluation form	Discussion
Problems finding GTAs	Yes	Yes	Yes	Not mentioned	Yes	Yes	Yes	Yes

Abbreviations used in the table: *VT = vaginal toucher; *GTA = gynaecological teaching associate; *Payment in euro/hour.

In six schools gynaecological examination training is scheduled in Year 5 or 6. Training is often part of the preparation for the Gynaecology/Obstetrics clerkship.

Aim of training and preparation

As can be seen from the table, aims vary between the medical schools.

Students are asked to prepare in different ways for gynaecological examination training. Lists of recommended readings are provided in all schools, varying from newspaper articles to gynaecology textbooks. Pelvic manikins are used in all medical schools for practising manual techniques. Five schools use the same instruction film by Van Lunsen (Van Lunsen 1986) who introduced GTA mediated education in the Netherlands. In three schools an introductory lecture is offered. Preliminary discussions are held in all schools immediately before training sessions. The following topics are covered: Medical instrumentation, students’ attitudes towards patients, sexuality, personal experiences with gynaecological examination and problem situations like virginity, sexual abuse, vaginism and cultural differences. Privacy is a special discussion topic in three schools. Pathology is not discussed in preparation for training in any of the schools.

Format

In all schools but one, students participate in three-hour training sessions with two GTAs and three students. At Maastricht University one GTA meets with one student in a one hour training session, always followed by a second one-hour session with a different student. These sessions are facilitated by a physician, who is a teacher at the skills department.

Content of the examination

In one training session each of the two GTAs undergoes two bimanual examinations and two speculum examinations. The session starts with one GTA examining the other GTA. Next, the students perform both examinations on one of the two GTAs. In Maastricht GTAs undergo one speculum examination and one bimanual examination. At Groningen University, students also perform the rectal and rectovaginal examination. At Erasmus University Rotterdam, breast examination is included in the session.

Organization

GTAs are mostly recruited through word of mouth information by other GTAs. Advertisements in national newspapers are used as well. Candidates should meet the following criteria: they should not have personal problems with gynaecological examination; they should be highly motivated and often available. They should also ‘be at ease with their own body and be able to talk freely about sexuality’.

Training of GTAs varies between schools from 10 to 36 hours, with a median of 26 hours. GTAs receive a fee of €0 to €28 per hour with a median of €9 per hour while they are being trained. For performance in training sessions with students they receive between €11 and €36 per hour with a median of €28 per hour. Most medical schools do not ask GTAs to take part in more than two training sessions per week.

Seven out of eight medical schools are facing a shortage of GTAs. Due to the rising number of medical students more laywomen will have to be recruited.

Evaluation

In all schools gynaecology examination training is evaluated after sessions. In five schools there is a discussion and in five schools students complete an evaluation form, i.e. two schools use both discussion and form. All coordinators reported comparable satisfaction ratings. Characteristically, student appreciation of these sessions is very high. ‘It has been a long time since I have learnt as much as I did during this training session’ is one of the many positive comments, which GTAs hear from students. Although this evaluation results come from the coordinators, the results are very similar to the evaluation outcomes of our students, known to us in Maastricht.

Discussion

We described how the eight Dutch medical schools teach students gynaecological examination skills. This inventory represents a cross-sectional overview of gynaecological examination training in the Netherlands, based on the answers of the eight coordinators of this educational component. We realise that there are several limitations to this study. First it is small, however all Dutch medical schools participated. Secondly the results may be biased because they only come from the side of the coordinators. GTAs and students were not questioned. Only using coordinators answers gives an one-sided perspective, with the risk of getting too positive results. For the matter of fact results this is not an issue (f.e. duration of a training session), but for more complicated items it would be interesting to find out about student and GTA opinions as well.

All medical schools used professional patients for their gynaecological training, although in different ways. The differences were most interesting for us and even more the reasons behind them.

We found that the objective of training as noted by the coordinators differed among the schools. In fact, we can conclude that there is no national collaboration and even less consensus in this area. In schools where awareness of the attitude towards women and overcoming shyness are the main aims of the GTA session, the emphasis is on communication. In schools where the main objective is the improvement of technical skills, training focuses on medical technical aspects. A reason for this difference could be that medical schools, such as those of Groningen and Maastricht, which offer communication skill training early in the curriculum, do not see interpersonal aspects as the primary learning objective for this type of training. Because their skills training programmes cover both interpersonal and technical skills, gynaecology examination training can focus on technical aspects.

There are striking differences between the schools in the time devoted to training GTAs for their role, which varies from 10 to 36 hours. It would be interesting to further compare GTA training and find out about exact differences and reasons/motivations for differences. Furthermore it would be interesting to learn more about the differences between the training sessions at the different medical schools, and to get a deeper insight in the relationship between the way GTAs are trained and the content of the training sessions with students. A detailed description of GTA training programmes may be a good addition to recent literature concerning the use of GTAs in gynaecological education. Doing so it is clear what we are ‘comparing’ when we use the term GTA. This information will also be quite useful for medical schools wanting to start up a GTA-mediated gynaecological program.

Fees also vary considerably among schools. This may be due to the scant communication about this subject between the schools. A problem that is common to all schools is the difficulty of recruiting GTAs. Although this problem will obviously be related to the intimate nature of this area of the physical examination, there may also be other reasons. We know from experience that, currently, female SPs are hard to find, especially in the age range of 20–40 years. This is mainly attributable to the growing labour participation of women.

In conclusion, we found many differences between the Dutch medical schools in the way they train students to perform gynaecological examination, although they all use professional patients for their trainings. There appears to be neither national collaboration nor consensus. We did not address the effects of these differences. Students in all schools are highly appreciative of the training they receive, which may indicate that despite the differences all trainings suffice well and the differences are merely details in (good) GTA programs. Further study of other effects seems warranted. There is definitely a need to study how the different training formats impact on student performance of the gynaecological examination.

Despite the fact that gynaecological examination training with GTAs is a very labour intensive educational format, it is used by all Dutch medical schools. The finding that students are very enthusiastic about this type of training may be an incentive for other medical schools worldwide to introduce this form of education. However, this type of training is clearly subject to strong cultural influences. Therefore, we would advise schools to contact other schools in their country to exchange views/experiences, learn from each other and carefully examine the impact of different teaching formats of the gynaecological examination.

Acknowledgements

We thank Agnes Diemers, Marjo Franssen and Mereke Gorsira for their help in editing this article.

Additional information

Notes on contributors

Hiske Van Ravesteijn

HISKE VAN RAVESTEIJN is an undergraduate medical student at the Medical School of the University of Maastricht.

Emer Hageraats

EMER HAGERAATS is a medical doctor and teacher at the Skillslab of the Medical School of the University of Maasticht.

Jan-Joost Rethans

JAN-JOOST RETHANS is general practitioner by training and is an associate professor at the Skillslab of the Medical School of the University of Maastricht.

Appendix I: Questionnaire used

Gynaecological skills education in the Netherlands

Please give one answer per question. If multiple answers are possible this will be mentioned.

1. At which medical school are you currently employed?

   • Groningen

   • Utrecht

   • Leiden

   • Nijmegen

   • Amsterdam (VU)

   • Amsterdam (UVA)

   • Maastricht

   • Rotterdam

Format of gynaecological skillstraining

1. Who is present during the training (besides students)? (Multiple answers possible)

   • Gynaecological teaching associate (GTA) number

   • skills teacher

   • otherwise (please specify)

2. Who teaches during the training session? (Multiple answers possible)

   • GTA

   • skills teacher

   • otherwise (please specify)

3. Who will undergo the gynaecological examination? (Multiple answers possible)

   • GTA

   • another medical student

   • person brought along by student

   • otherwise

4. How many students attend training sessions?

5. How long do sessions last?

6. How many vaginal touchers are performed on one GTA per training session?

7. How many speculum investigations are performed on one GTA per training session?

Student preparation before training

1. How do students prepare for the skills training?

   • literature (please specify)

   • video

   • college

   • skills training on manikin (gynnie)

   • communication skills training starting from year … … .

   • otherwise (please specify)

2. Is there a preliminary discussion?

   • no, go to question 14

   • yes

3. Who will lead the preliminary discussion?

   • skills teacher

   • gynaecologist/obstetrician

   • psychologist

   • GTA

   • otherwise (please specify)

4. What is the number of students attending the preliminary session?

   • number

5. What topics are (always) covered in the preliminary discussion? (multiple answers possible)

   • medical instruments used

   • pelvic anatomy

   • sexuality

   • problem situations:

   • virginity

   • sexual abuse

   • vaginism

   • cultural differences

   • student attitude

   • own experience with gynaecological examination

   • medical indications for pelvic examination

   • privacy and patient-doctor confidentiality

   • pathology

   • otherwise (please specify)

Content of the training session

1. Is this the first training covering the topic of communicative skills?

   • yes

   • no: Communication skills are taught starting from year … .

2. Which technical skills are learned?

   • speculum examination

   • bimanual examination

   • rectal examination

   • rectovaginal examination

   • mammae examination

   • otherwise (please specify)

3. Is the training session protocolized?

   • yes (please send a copy of the protocol)

   • no

4. What topics are always discussed in the training session? (multiple answers possible)

   • medical instruments used

   • pelvic anatomy

   • sexuality

   • problem situations:

   • virginity

   • sexual abuse

   • vaginism

   • cultural differences

   • student attitude

   • student experience with gynaecological examination

   • medical indications for pelvic examination

   • privacy and patient-doctor confidentiality

   • pathology

   • otherwise (please specify)

5. Please indicate what is viewed upon as most important in the training sessions: (1 is most important, 4 is least important)

   • practicing technical skills of pelvic examination

   • student attitude towards women

   • student attitude towards power en responsibility over a patient

   • reducing anxiety related to the pelvic examination

Organization of gynaecological skillstraining

1. What is the place of the skills training inside the curriculum?

   • first year (Dutch: ‘propedeuse’)

   • ‘doctoral’ phase:

   • year 2 … … .year 3 … .year 4

   • just before clinical phase (clerkships)

   • otherwise (please specify)

2. Which department is responsible for the gynaecological training?

   1. clinical department (please specify)

   2. skills department

   3. otherwise (please specify)

3. How do students submit to the training?

   • the training is planned for each student, students are obligated to go to the training

   • the training is planned for each student, students are not obligated to go to the training

   • students submit themselves, they are obligated to go to the training

   • students submit themselves, they are not obligated to go to the training

   • otherwise (please specify)

4. How often is there an opportunity for students to follow the training during their curriculum?

   • once

   • twice

   • otherwise (please specify)

5. How are GTAs recruited? (multiple answers possible)

   • advertisements in national newspapers

   • from a pool of people working as simulated patients in other area's (not gynaecology)

   • through the hospital

   • advertisements in local papers

   • own request

   • through word of mouth information by other GTAs

   • otherwise (please specify)

6. What way of recruitment has been most effective?

7. Are there selection criteria being used?

   • no

   • yes (please specify) 1.            2.            3.            4.            5.

For instance: Medical knowledge, (bad) experience with pelvic examination, address close to medical school, consensus with partner, willing to commit themselves for at least a year, being comfortable with their own body.

1. How many hours are put into the training of GTAs?

   • (… … . hours (total)

2. Do GTAs receive a fee while in training?

   • no

   • yes, … … . Euro per hour

3. What is GTA payment during training sessions with students?

   • … … . euro per hour

4. How many training sessions can a GTA take part in per week?

   • … … … . sessions

Gynaecological skills training evaluation

1. Do staff and GTAs have evaluation meetings together?

   • no

   • yes, … … . times a year

2. Do GTAs have medical check-ups by a gynaecologist?

   • no

   • yes, … … … . times a year

3. Is the gynaecology examination training evaluated with students after sessions? (multiple answers possible)

   • no

   • yes, discussion

   • yes, evaluation form (please specify)

4. What is the general student satisfaction rating for the sessions?

   • cannot say

   • in general student appreciation is … … … … … . 

5. Are the gynaecological skills, learned in the training formally evaluated after sessions?

   • no

   • yes (in what way) … … … … … .

6. Is your department facing any problems concerning gynaecological skills training at the moment?

For instance: recruitment of GTAs, ethical problems concerning students, technical problems with instruments, relative “shortage“of GTAs.

1. Do you have any additional remarks about gynaecological skills training?

Thank you very much!

Please remember to add requested literature and protocols.

If you have no objections, please fill in your name and address.

Name:

Position:

Telephone number:

E-mail: