The Storytelling Aspect of Being a Physician

Baruch J. Doctors as Makers. Academic Medicine. 2017;92(1):40.

 First impressions: (Student Perspective) Medical student education focuses on factual learning and problem-solving skills. Upon entering third year clerkships, medical students apply these skills to patients that are not as clear cut as the clinical vignettes they have become so good at deciphering.
Doctors as Makers is a commentary on the role of creativity, storytelling, and acceptance of the unknown in the life of a physician. Dr. Baruch states in the article “I rely on my story making skills more often than any other clinical skill in my practice” and “I am first and foremost a professional story listener”. He goes on to say that physicians feel the need to “create a recognizable story”.  After pondering these statements as well as my minimal experience in the clinical world, I realized that the key to an ideal medical student on clerkships is the ability to communicate, or as Dr. Baruch would say, to tell stories. Medical students tend to have less patients than attendings/residents and thus more time to spend on each, therefore some may believe that the medical student is the supreme listener. However, coming fresh out of the textbook descriptions of first and second year gives the medical student the challenge of deciphering through the immense amounts of information that patients love to tell, putting us further into the trap of editing symptoms/stories to match our potential diagnosis. This often leads us to misconstrue information and allows the attending to obtain a completely different story upon leaving the room.
Dr. Baruch advocates the importance of normalizing uncertainty in the medical field therefore opening the medical student mind to induce creative learning. The type A medical student in me disagrees because there is always a right answer to test questions, and I believe the desire to know and understand is what drives physicians and researchers to push science farther and achieve better care for patients. However, everything in medicine is constantly changing, therefore accepting that you do not fully know the answer to all problems makes you more adaptable to change. Maybe he has a point.
The faculty at MCG is very adaptable to change, and as the years progress they continue to bring about changes that are in line with the vision of this article. The “problem based learning” class is probably the main example of creativity in which students are intentionally given cases with missing information, in an effort to inspire creativity and critical reasoning. This forces them to deviate from the robotic memorization of lists and textbooks and transition into the reality of their looming clerkship years. Other changes include first and second year students writing multiple choice questions for their classmates, and physical diagnosis classes where students enter patient rooms with no prior history/knowledge given. Potential future changes could include instituting art areas/projects for mental health and healing, revamping or eliminating the monotonous “OLDCARTS” pneumonic to challenge students, creating art instead of a presentation about a patient, and changing the style of each module in the first year to teach adaptability.
Further research in the benefits in art/creativity in medical education needs to be studied to prove its efficacy. However, I do agree that we need to think about how we can apply the teaching point of this article: how to train our students to think creatively and feel comfort in the unknown.

Kiley Fagan, BS
MD Candidate, 2019
Medical College of Georgia
Augusta University

Abstract:  Traditional skills and expertise are not enough to prepare future physicians for the complexity, instability, and uncertainty of clinical practice. Responding and making meaning from ill-defined or unusual problems calls for, even demands, creativity. In this article, the author suggests expanding the traditional role of doctor as science-using, evidence-based practitioner to include that of doctor as a “maker” (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients’ stories, as well as a new appreciation for “not-knowing” as a generative, creative space in medicine. Creative thinking deserves a central place in the training of doctors, driven by a reconceptualization of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.

Rerouting the Empathy Train’s Path of Excitement, Shock, and Survival

Holmes, C. L., Miller, H, Regehr, G. (Almost) forgetting to care: an unanticipated source of empathy loss in clerkship. Med Educ, 2017;51: 732–39. doi:10.1111/medu.13344

First impressions: (Student Perspective) “Burnout’ is a word that medical students begin hearing on their very first day of orientation. It is an ever-looming occurrence that I, as a second-year student, find hard to comprehend with the continuity of these first two didactic years of medical school. This article specifically examined the idea of burnout related to empathy during the clinical clerkship years. Although eight months away from a clerkship experience, I see the topic of empathy as very relevant to all aspects of medical education and frequently consider the importance of empathetic practice as a physician. Standardized patients are our first introduction to the practice of empathy while establishing rapport and an immediate patient-physician connection has been highly emphasized during these first two years. With little clinical experience, I always strive to make up for what feels like a lack of clinical knowledge by focusing on this potential to become an expert in rapport, just as the article mentioned. This is all in preparation for that journey “across the street” and in through the doors of the hospitals for third and fourth year. It is hard to grasp the idea that I might undergo the stages of “excitement, shock, and survival” and become numb to the idea of utilizing empathy in practice as this article suggests. Students that admitted to facing these feelings during their clinical rotations more than likely were warned about burnout and loss of empathy as a freshman medical student and thought the same. Knowing medical students are likely to fall into the mechanical-like structure of repeated patient interaction, we as a school should not only promote discussion of burnout and empathy-loss, but should also proactively educate faculty and students on effective medicine that includes compassion and care for patients. With the article’s mention of negative role models, we also should consider hospital faculty members that will be navigating medical students through their clerkship experiences. These first observations could either contribute in a positive or a negative way towards the development of a medical student’s practice of empathy. Discussion of empathy while prevalent in first and second year could continue over into the clerkship years and promote compassionate care without the fear of burnout. Overall, this article identifies an important problem that every medical student has the potential to face. Empathy is an emotion emitted and experienced differently by many, but vitally important to establishing rapport with all patients. Keeping this in mind, students should strive to overcome the fluctuating feelings that come with the clerkship years and yearn for constructive patient interactions that will positively influence their future practice as a physician.

Caroline C. Ray, BSA
MD Candidate, 2020
Medical College of Georgia
Augusta University

Abstract:  Context: The erosion of empathy in medical students is well documented. Both the hidden curriculum associated with poor role modelling and a sense of burnout have been proposed as key factors, but the precise mechanisms by which this loss of empathy occurs have not been elaborated. Objectives: In the context of a course designed to help students manage the hidden curriculum, we collected data that raised questions about current conceptualizations of the aspects of medical training that lead to loss of empathy. Methods: We held nine sessions in the first year of clinical clerkship, in which we asked students to bring to the group their experiences of the hidden curriculum for reflection. Course sessions were recorded, transcribed and qualitatively analyzed, and themes were generated for further exploration. Results: We identified an identity developmental trajectory in early clerkship in which students started with feelings of excitement, transitioned quickly to ‘shock and awe’, progressed into ‘survival mode’ and then passed into a stage of ‘recovery’. Interestingly, in the early stages, students’ sense of empathic virtuosity was reinforced. It was not until later, when students were more comfortable in their clinical role, that they reported their tendency to connect with the patient only as an afterthought to the encounter, or not at all, and needed to remind themselves to care. Conclusions: We offer new data for consideration with regard to medical students’ loss of empathy during early clinical training that suggest it is the process of making patient care routine that shifts the patient from the status of an individual with suffering to the object of the work of being a physician.

 

Thinking of Learning Communities as “Learner Centered Medical School Homes”

Smith SD, Dunham L, Dekhtyar MD, Dinh A, Lanken PN, Moynahan KF, Stuber ML, Skochelak SE. Medical Student Perceptions of the Learning Environment: Learning Communities Are Associated With a More Positive Learning Environment in a Multi-Institutional Medical School Study. Academic Medicine.  2016;91(9):1263-9.

First Impression:   Medical schools are constantly striving to improve the quality of medical education in an ever-evolving environment.  Simultaneously these schools seek to protect student well-being and altruism/compassion by combating insidious but progressive deleterious effects of training, including the “hidden curriculum.”   Learning communities (intentionally organized longitudinal groups of students and faculty) are becoming increasingly popular in medical education as a way of improving the learning environment by providing community and fostering long-term mentoring and camaraderie in an increasingly fast-paced and fractured medical environment.  Smith et al. compared the perceptions of first and second-year medical students at schools with and without learning communities (LCs) on the quality of their learning environment.  The researchers found that first and second year students at medical schools with LCs perceived their learning environments more positively than those at schools without LCs, most notably the environmental aspects allowing “interests outside of medicine,” student activities and informal gatherings, and the degree of competition between students for grades.  Notably, the differences in learning environment perception between students at schools with and without LCs was greater as exposure to medical school increased. The researchers acknowledge limitations to their study, including the heterogeneity of the LCs at these programs, multitude of outside factors, and limited response data (two time points).   Despite these limitations, the study is worthy of examination by medical schools.  These findings could also suggest modifications to other stages of medical training including medical residency programs.  We are now accepting of the concept that patients do better when they have a “medical home” providing a base for care and stable relationships.  This study raises the intriguing suggestion that providing a long-term “medical school home” can be protective to students and counteract some of the negative effects of medical education.   The researchers plan to follow their cohort into the clinical years of their training and it will be interesting to see if these differences in learning environment perception are maintained or dissolve in the face of increasingly workloads and clinical stressors.

Mary Gregory, MD
Assistant Professor
Department of Neurology and Pediatrics
Medical College of Georgia at Augusta University

Abstract:  Purpose: Many medical schools have implemented learning communities (LCs) to improve the learning environment (LE) for students. The authors conducted this study to determine whether a relationship exists between medical student perceptions of the LE and presence of LCs during the preclerkship years. Method: Students from 24 schools participating in the American Medical Association Learning Environment Study completed the 17-item Medical Student Learning Environment Survey (MSLES) at the end of their first and second years of medical school between 2011 and 2013. Mean total MSLES scores and individual item scores at the end of the first and second years in schools with and without LCs were compared with t tests, and effect sizes were calculated. Mixed-effects longitudinal models were used to control for student demographics and random school and student effects on the relationship between LC status and MSLES score.  Results: A total of 4,980 students (81% of 6,148 matriculants) from 18 schools with LCs and 6 without LCs participated. Mean [SD] MSLES scores were significantly higher in LC schools compared with non-LC schools at the end of year one (3.72 [0.44] versus 3.57 [0.43], P < .001) and year two (3.69 [0.49] versus 3.42 [0.54], P < .001). The effect size increased from 0.35 (small) at the end of year one to 0.53 (medium) at the end of year two.  Conclusions: This large multi-institutional cohort study found that LCs at medical schools were associated with more positive perceptions of the LE by preclerkship students.

The Perceived Value of EBM in CME

Davis NL, Lawrence SL, Morzinski JA, Radjenovich, ME. Improving the Value of CME: Impact of an Evidence-based CME Credit Designation on Faculty and Learners. Family Medicine. 2009;41(10):735-740.

First Impression – The purpose of this article was to evaluate the perceived value of CME that is evidence-based vs non-evidence-based.  The article used Dr. David Sackett’s definition of Evidence-Based Medicine (EBM), which is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patient.”  Evidence-Based CME (EB-CME) were based on scientific evidence from AAFP-approved EBM sources, listed in the article.

EB-CME that met criteria started receiving double CME credit in 2005 to encourage more participation using the highest strength of evidence.  EBM only applies to clinical topics thus non-clinical topics are not eligible for EB-CME.

The research included surveying faculty and learners that attended the 2006 AAFP Annual Scientific Assembly.  The assembly had more than 4,800 family physicians attended with 351 total CME activities over 5 day conference.  There were 255 total non-EB-CME sessions and of that only 19 addressed clinical topics (non-EB-CME).  There were also 96 total EB-CME sessions. 50 faculty presenters were randomly picked from the EB-CME sessions and all 19 of the non-EB-CME clinical topics faculty presenters were selected. Surveys were given to these 50 EB-CME + 19 non-EB-CME faculty totaling 69, with a response rate of 82%(n=41) and 68%(n=13) respectively.  The session participants in 20 of the most attended EB-CME sessions (n=281) 20 selected randomly to fill out survey. The session participants in 19 non-EB-CME sessions (n=233) 20 selected randomly to fill out survey.

The surveys used a 5-point Likert-type response scale and the Mann-Whitney non-parametric test was used to determine statistical significance (p<.05).  The results were statistically significant that high-quality scientific evidence was rated higher and valued more with learners/participants.

Therefore, more evidence based CME will better equip the practicing physician to apply new knowledge to practice.  It will help further educate residents and medical students that the practicing physician mentors, shadows or precepts for.  It was also improved the practice of medicine that is ever evolving.

Jason Varghese, MD, ThD
Assistant Professor
Department of Family Medicine
Medical College of Georgia at Augusta University

Abstract:  Background and Objectives: The American Academy of Family Physicians (AAFP) designates enhanced continuing Medical education (CME) credit (evidence based [EB] CME) to activities that meet specific criteria incorporating EB medicine principles. However, little is known about the effect of this innovation on EB-CME faculty or their learners. Methods: Subjects were faculty presenters and participants at the 2006 AAFP Annual Scientific Assembly. We compared presenters and participants of sessions with EB-CME approval to those without, assessing faculty preparation and participants’ perceptions of CME quality and value. Results: EB-CME faculty preparation was more likely to use evidence-based medicine (EBM) resources and less likely to rely upon books, journals, or personal experiences. There were statistically significant differences in session participants’ perceptions with regard to scientific evidence presented, perception of commercial bias, and application of information to practice, with EB CME sessions more favorable in all dimensions. Main faculty barriers to EB- CME application were time constraints and limited understanding of the application and approval process. Conclusions: The AAFP’s EB-CME designation is associated with greater faculty use of EBM sources, while EB-CME participants perceive EB-CME as higher in quality and value.

Practical Teaching Strategies to Engage Today’s Learners

Wolff M, MD, Wagner MJ, Poznanski S, Schiller J, Santen S. Not Another Boring Lecture:  Engaging Learners with Active Learning Techniques. Journal of Emergency Medicine, 2015;48:85-93.

First Impression – The article reviews various methods that can be effectively used to teach today’s (millennial) learners, with specific focus on medical students.  The article concludes that there are identified techniques, that when used, will be more effective in reaching Millennial learners.

One of the biggest challenges faced by teachers of all subjects is ‘getting through to the learner’ in a way that allows them to retain the information given during a learning experience, whether it be the traditional didactic lecture or the newly innovative ‘webinar’.  Several specific methods were reviewed by the authors; those that work versus those that don’t seem to work as well.  The article supports research that shows that didactic learning is no longer effective, it has become increasingly important to ‘pause’ during learning sessions and in some way or another ‘engage’ the learner; creating an active learning event that encourages the learner and motivates them to engage in a way that creates active engagement and discussion by the educator and learners, thus creating an atmosphere for reflection and retention.  “Didactic sessions can be an effective tool to contextualize content [and] explain difficult concepts…”² however more creative methods are needed to motivate and keep learner engagement.

The article discusses several techniques to engage active learning.  The methods found to be most effective were Problem Based Learning, Small Group Learning sessions and various “pause techniques”.  These techniques were proven to be more effective than the traditional lecture method of ‘sit, listen and learn’ and took little effort or modification to already existing sessions or lectures to make them effective. Pause techniques are probably the easiest way to ‘jazz up’ an old school didactic session by taking periodic pauses during teaching sessions that engage students in the topic being taught.

Several excellent techniques were studied; the common theme in each of the techniques is learner engagement. Hands on learning, where the learner is involved in the process of teaching or other method that stimulates learner interaction and engagement.  The article goes on to give many examples of how the techniques that were found to be effective, pause techniques, problem based learning, and small group division can be incorporated with traditional methods, that are often sacred to educators, thereby maintaining the knowledge and information while allowing learners to absorb and retain the information in a way that appeals to their learning style.

This is a good article in general, but I feel would certainly benefit ‘old school’ educators who often find their students have tuned out before the knowledge is able to get through.  I think we can all agree that the practice, and therefore the education of, medicine is far too important for even the smallest morsel of knowledge to be lost; as educators it is our job to dress the knowledge however necessary so that it may be well-received by those we choose to teach.

Additional reference: 

Anderson LW, Krathwohl DR, Airasian PW, et al. A taxonomy for learning, teaching, and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Pearson, Allyn & Bacon; 2000.

Dayna Seymore, BS
Family Medicine Clerkship Coordinator
Medical College of Georgia at Augusta University

Abstract:  Background: Core content in Emergency Medicine Residency Programs is traditionally covered in didactic sessions, despite evidence suggesting that learners do not retain a significant portion of what is taught during lectures. Discussion: We describe techniques that medical educators can use when leading teaching sessions to foster engagement and encourage self-directed learning, based on current literature and evidence about learning. Conclusions: When these techniques are incorporated, sessions can be effective in delivering core knowledge, contextualizing content, and explaining difficult concepts, leading to increased learning.

Moving Beyond Cause and Effect when Measuring Curriculum Outcomes

Van Melle E, Gruppen L, Holmboe E, Flynn L, Oandasan I, Frank J. Using Contribution Analysis to Evaluate Competency-Based Medical Education Programs: It’s All About Rigor in Thinking. Academic Medicine: Journal Of The Association Of American Medical Colleges. 2017;92:752-758.

First Impressions (Student Perspective): This article introduces the reader to a new method for evaluating the effectiveness of a system or intervention. The traditional and perhaps intuitive way of evaluating the effectiveness of an intervention involves looking at outcomes – specifically whether specific outcomes can be causally linked to the intervention that is being examined. The authors refer to this method as attribute analysis. An initial overview of this article allows one to ponder the notion of a different type of analysis, which they call contribution analysis. This method allows one to examine complex processes in which specific outcomes and cause-effect relationships may be difficult to measure. A 6-step process is proposed for approaching the evaluation of competency-based medical education(CBME) that accounts for the complex nature of medical education.  (Step 1: Set out the cause-and-effect issue to be addressed, Step 2: Develop a postulated theory of change, Step 3: Gather existing evidence, Step 4: Assemble the contribution story, Step 5: Seek out additional evidence, Step 6: Revise and strengthen the contribution story.)

Lessons Learned: Specific lessons to take away from this article include the differences between traditional means of evaluating a process and the contribution analysis. Generally speaking, the paper proposes looking at whether interventions are associated with an increased probability of desired outcomes. It acknowledges that interventions (in this case, CBME) are multidimensional, influenced by multiple external factors, and that the impacts unfold over time. This is in contrast to looking at a single unidimensional intervention and reproducible, measurable outcomes. Rather than measuring specific outcomes (such as improved patient care delivery) and relating them to specific interventions in a cause-effect manner, contribution analysis seeks to emphasize the development of evidence-based theories to explain how the new intervention increases the probability of desired outcomes. As such, there is an emphasis on the ‘rigor of thinking’ in the process and opposed to a ‘rigor in methodology’ (which would be traditionally used to analyze how specific interventions produce specific outcomes, i.e., by controlling for certain variables, comparing controls and experimental groups, etc.).

Implications: The implications of this approach to evaluating a system are significant – it seems to drift away from a traditionally respected method of objectively evaluating interventions which seek to define concrete variables, outcomes, and effects. It almost seems as though the authors are suggesting an approach that is less experimental and more theoretical, which can raise questions about its credibility. Though it may be perceived as a weakness, perhaps this offers a more realistic and intellectually honest approach to evaluating a complex system.

Though no studies or analyses of the sort have been produced yet, evaluations and suggestions for improvement of competency-based medical education would directly affect approaches to medical education. The principles of contribution analysis may also be useful for evaluating other complex processes within medical education (after all CBME is not the only complex component of medical education).

 

Farid Khan, MD
Graduate from MCG Class of 2017

Medical College of Georgia at Augusta University

 

Abstract:  Competency-based medical education (CBME) aims to bring about the sequential acquisition of competencies required for practice. Although it is being adopted in centers of medical education around the globe, there is little evidence concerning whether, in comparison with traditional methods, CBME produces physicians who are better prepared for the practice environment and contributes to improved patient outcomes. Consequently, the authors, an international group of collaborators, wrote this article to provide guidance regarding the evaluation of CBME programs. CBME is a complex service intervention consisting of multiple activities that contribute to the achievement of a variety of outcomes over time. For this reason, it is difficult to apply traditional methods of program evaluation, which require conditions of control and predictability, to CBME. To address this challenge, the authors describe an approach that makes explicit the multiple potential linkages between program activities and outcomes. Referred to as contribution analysis (CA), this theory-based approach to program evaluation provides a systematic way to make credible causal claims under conditions of complexity. Although CA has yet to be applied to medical education, the authors describe how a six-step model and a postulated theory of change could be used to examine the link between CBME, physicians’ preparation for practice, and patient care outcomes. The authors argue that adopting the methods of CA, particularly the rigor in thinking required to link program activities, outcomes, and theory, will serve to strengthen understanding of the impact of CBME over time.

Are Male Medical Students Slighted When It Comes to Educational Opportunities during the Ob-Gyn Clinical Rotation?

 

Jiang X¹, Altomare C, Egan JF, Tocco DB, Schnatz PF.  The ObGyn Clerkship:  Are Students Denied the Opportunity to Provide Patient Care and What is the Role of Gender? Conn Med. 2012 Apr;76(4):231-6.

First Impressions (Faculty Perspective):  As much as I hate to admit it, the male medical students I teach don’t always get a fair shot at learning and honing their skills on their Ob-Gyn rotation.  One would think that this day in age, gender, race, ethnicity, or sexual preference would no longer be a barrier to providing gynecologic health care to patients.  Unfortunately, certain biases and preferences still exist among patients and faculty members and this can hinder a male student’s experience.

During the 6 week clerkship, the student’s mission is to master performance of the breast and pelvic exams and even attempt to deliver a baby.  Often, there are barriers for the male students (for various reasons) and heightened awareness among physician educators is necessary in helping this group have an equal opportunity to participate, learn and practice.

In this article, 157 students (66 males, 91 females) affiliated with the University of Connecticut across 4 hospitals were surveyed and 51% recorded that they were denied the opportunity to participate in routine OBGYN care.   Compared with female students, they found that male students were statistically more likely to be denied the opportunity to be involved in a gynecologic examination (RR 1.69 for all patient encounters and RR 2.07 for clinic patients alone).  Among the 44 male students who listed “male gender” as the primary reason for their denial of participation, 68% (n=30) stated this happened at least three times, 16% (n=7) stated this happened ten to fifteen times and three students state that this happened “once a day” or “several times per week.”

Interestingly, multiple studies have reported that a majority of patients do not have a strong gender preference when choosing Ob-Gyn providers.  Instead, experience, knowledge, and compassion appear to be more important.  Making male students aware of this may help remove any false perception they may have of female patients.  Encouraging them to introduce themselves, initiate interactions and engage in meaningful conversation can help them build rapport with this patient population.

Respect for patient autonomy is paramount and ensuring their comfort and ability to choose their care provider is a must.  However, I have found it helpful in my practice to have the nurse (a third party) ask each patient if they are ok with a medical student asking them questions before I see them.  I specifically have her refrain from using the descriptors “male” or “female,” as this typically results in a response that favors the student.  Choosing the appropriate patient is also key.  A 16 year old who is newly sexually active and scared to have her first speculum exam would not be the ideal candidate for a medical student performing his first pelvic exam.  But a mom with four kids who is very comfortable and relaxed in the office is much more likely to have a positive interaction with the student.

Ob-Gyn faculty awareness of male discrimination in the clinical setting is necessary in overcoming obstacles for male student education.  Implementing a welcoming environment for male students and engaging in open dialogue with them about their experience is very important in ensuring recruitment of both males and females into the discipline and paving a way for its future.

Jennifer T. Allen, MD
Assistant Professor
Department of Obstetrics and Gynecology
Medical College of Georgia at Augusta University

Abstract: We sought to study the frequency, and reasons that third-year medical students on an ObGyn clerkship are denied the opportunity to be involved in patient care.  Students from four hospitals affiliated with the University of Connecticut Medical School completed an anonymous postclerkship survey.  Among the 157 students studied (66 males and 91 females), 51% (n = 80) were denied the opportunity to participate in a gynecologic examination and 47% (n = 73) were denied the opportunity for routine ObGyn care by patients. Among these students, 55% (n = 44) and 38% (n = 28) stated that being male was the reason they were excluded from gynecologic and routine care, respectively. Of the 80 students who were denied involvement in a gynecologic examination, 81% (n = 65) were denied involvement by clinic patients. Of the 44 males who stated they were denied the opportunity to be involved in a gynecologic examination due to their gender, 89% (n = 39) were refused by clinic patients. Compared with female students, male students are statistically more likely to be denied the opportunity to be involved in gynecologic examinations (RR = 1.69 [1.24-2.29]), especially by clinic patients (RR = 2.07 [1.41-3.03]).  A significant number of students were denied the opportunity to be involved in ObGyn care experiences. More frequently male students were denied involvement in care, with a higher incidence among clinic patients. We hypothesize that being denied involvement provides a negative perception of the ObGyn specialty, especially to male students, possibly affecting their decision to choose ObGyn training.

Ensuring the Pelvic and Breast Examination Skills of Medical Students

Dugoff L, Pradhan A, Hueppchen N, et al. Pelvic and breast examination skills curricula in United States medical schools: a survey of obstetrics and gynecology clerkship directors. BMC Medical Education [serial online]. December 16, 2016;16(1):314.

First Impressions (Student Perspective): Breast and pelvic examinations have long been considered more sensitive, if not the most sensitive, portions of the physical exam. However, these exams are critical to providing primary care to women in the outpatient setting and for addressing more emergent concerns, such as vaginal pain, bleeding or discharge, in the hospital setting. As such, medical education has an obligation not only to provide quality instruction on the aforementioned exams, but also to ensure medical students are competent and confident with the exams.

135 Obstetrics and Gynecology (OB/GYN) clerkship directors from LCME-accredited allopathic medical schools were asked to respond to a survey regarding the methods used at their respective institutions to teach the breast and pelvic exam. Questions regarding when in training pelvic and breast examinations are taught, who is responsible for instruction, and whether or not the clerkship directors feel the current instruction is adequate were all included in the survey. From the survey, 40% of clerkship directors assessed their current pelvic examination curriculum as excellent and 18% assessed their current breast examination curriculum as excellent. More details regarding the subsequent breakdown of the perceived adequacy of each exam is available in the article. Given this information, there are obvious grounds for improvement on pelvic and breast examination instruction.

The methods used to teach the breast examination discussed included lectures, three-dimensional models, and standardized patients. Additionally, the breast exam was directly observed and graded by faculty in the clinic setting or objective structured clinical exam (OSCE). The methods used for teaching the pelvic exam were similar. In addition to the aforementioned methods, the author also discussed the use of Gynecologic Teaching Associates (GTAs) for teaching both exams. GTAs are a subset of standardized patients who are also equipped to teach the gynecologic portions of the exam to medical students. The Medical College of Georgia employs each of these methods for teaching the breast and pelvic exams, except for GTAs. The standardized patients who participate in the breast and gynecologic exams have additional training from the Physical Diagnosis preceptors and are well equipped to aid in teaching both exams.

The Association of American Medical Colleges (AAMC) recommends medical students be advanced beginners in performing pelvic and breast exams prior to beginning their clerkships. Currently at the Medical College of Georgia, the pelvic and breast exam are introduced during Phase I Physical Diagnosis using exam models and standardized patients. This approach is again taken during Phase II. During Phase III, medical students are expected to perform a graded breast and pelvic exams under the supervision of an attending physician. Following this “checkpoint,” students are allowed to participate in subsequent breast and pelvic exams, at their comfort level. Given only 14% of responding medical schools stated breast and pelvic exams were taught during the preclinical years, I believe the Medical College of Georgia is well above the curve of early exposure.

It would be of interest to see how adequately students feel they are prepared to perform these exams in a true clinical setting, and whether or not this data aligns with the data gleaned from OB/GYN clerkship directors. Ultimately, primary care providers and emergency medicine physicians use these skills extensively, necessitating adequate instruction during undergraduate medical curriculum.

Ashlee Nicole Sharer Tillery, MD
Medical College of Georgia
Augusta University

Abstract: BACKGROUND: Learning to perform pelvic and breast examinations produces anxiety for many medical students. Clerkship directors have long sought strategies to help students become comfortable with the sensitive nature of these examinations. Incorporating standardized patients, simulation and gynecologic teaching associates (GTAs) are approaches gaining widespread use. However, there is a paucity of literature guiding optimal approach and timing. Our primary objective was to survey obstetrics and gynecology (Ob/Gyn) clerkship directors regarding timing and methods for teaching and assessment of pelvic and breast examination skills in United States medical school curricula, and to assess clerkship director satisfaction with current educational strategies at their institutions. METHODS: Ob/Gyn clerkship directors from all 135 Liaison Committee on Medical Education accredited allopathic United States medical schools were invited to complete an anonymous 15-item web-based questionnaire. RESULTS: The response rate was 70%. Pelvic and breast examinations are most commonly taught during the second and third years of medical school. Pelvic examinations are primarily taught during the Ob/Gyn and Family Medicine (FM) clerkships, while breast examinations are taught during the Ob/Gyn, Surgery and FM clerkships. GTAs teach pelvic and breast examinations at 72 and 65% of schools, respectively. Over 60% of schools use some type of simulation to teach examination skills. Direct observation by Ob/Gyn faculty is used to evaluate pelvic exam skills at 87% of schools and breast exam skills at 80% of schools. Only 40% of Ob/Gyn clerkship directors rated pelvic examination training as excellent, while 18% rated breast examination training as excellent. CONCLUSIONS: Pelvic and breast examinations are most commonly taught during the Ob/Gyn clerkship using GTAs, simulation trainers and clinical patients, and are assessed by direct faculty observation during the Ob/Gyn clerkship. While the majority of Ob/Gyn clerkship directors were not highly satisfied with either pelvic or breast examination training programs, they were less likely to describe their breast examination training programs as excellent as compared to pelvic examination training—overall suggesting an opportunity for improvement. The survey results will be useful in identifying future challenges in teaching such skills in a cost-effective manner.

Hmmm, No Gain for Adding Instructor Feedback onto Preoperative Practice with OB/GYN Residents’ Operative Performance

Kroft J, Ordon M, Po L, el al. Preoperative Practice Paired with Instructor Feedback May Not Improve Obstetrics-Gynecology Residents’ Operative Performance, Journal of Graduate Medical Education, 2017, 9, [2], 190-194

First Impressions (Student Perspective):       With the decreasing resident work hours but no concurrent increase in the length of residency training, it is becoming progressively more important that surgical skills are taught in not only the most effective manner, but also the most efficient.  It is a long studied topic in surgical education, however, there has been little consensus on the optimal techniques to use.  One topic that has received attention is the idea of preoperative practice before entering the operating room.  The authors of this paper pointed out that while it is common for musicians and athletes to practice immediately before a performance or competition, surgeons, who perform comparable feats requiring physical and mental acuity, do not typically practice before a surgery.

The authors of this study wanted to build on prior research that has been done that has shown a benefit of preoperative practice on surgical trainee’s intraoperative performance.  They designed a randomized controlled study to look at the effects of preoperative practice with instructor feedback compared to preoperative practice alone or feedback alone on the score of an assessment of laparoscopic salpingectomy.  The study was performed in the Department of Obstetrics and Gynecology at the University of Toronto and included 18 OBGyn residents in years two through six of training.  The participants were first tested on a virtual reality surgical simulator to be assigned a baseline score of 0-100%.  This was done at least one day prior to their study intervention and outcome assessment. Then before the scheduled operation, they were either allowed 15 minutes of practice on the laparoscopic salpingectomy module or given standardized instructor feedback or both depending on which group they were assigned.   The median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, however, the study failed to find a significant difference in score on the laparoscopic assessment between the groups of trainees.

Unfortunately, the study described in this paper failed to find a significant difference between the groups, and thus was unable to make conclusions about using instructor feedback effectively to train surgical residents.  However, according to the paper, prior studies have provided some evidence that preoperative practice is effective. The paper pointed out that their study had multiple limitations including that they chose to use terminal feedback, but that it could be that a different type of feedback may be better in training. Additionally, the sample size was small and that although the sample size calculation was validated, it may require a larger sample size to show a significant difference.  The main take away from this study is that further research needs to be focused on looking for the most effective techniques in training residents in a surgical setting.

Ali Falkenstrom, MD
Medical College of Georgia
Augusta University

Abstract: BACKGROUND: There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied. OBJECTIVE: We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone. METHODS: We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool. RESULTS: A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15–36) compared to the PP group (14.5; range, 10–34) and the F group (21.25; range, 10.5–32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70–0.95) using the intraclass correlation coefficient. CONCLUSIONS: This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Maximizing Operating Room Education for the OB/GYN clerkship

Hampton BS, et al. To the point: teaching the obstetrics and gynecology medical student in the operating room. Am J Obstet Gynecol. 2015 Oct. 213(4): 464-8.

First Impressions (Student Perspective): Student education in the operating room is often a difficult task as there must be a balance of patient care, resident education and student instruction, with awareness of OR and anesthesia time, and ultimately maintaining patient safety. Coordinating multiple tasks can be overwhelming for the attending physician, yet for the student, this OR time is key in the educational process. In Obstetrics and Gynecology specifically, students rank surgical opportunities among the highest factors in declaring OB/GYN as their future specialty.¹ With cases spent teaching residents for 55% of the time, and student education taking up 10% of time, it is imperative that instruction and opportunities in the OR are focused, goal-oriented, and provide positive student experiences.¹

This article reviews actions taken to help students meet ACGME milestones in an effective manner. Firstly, the importance of focused and specific learning objectives is reviewed. Not only should students be fully aware of the learning objectives and expectations of their OB/Gyn clerkship, but it is important that  attending physicians and resident staff are also aware of these goals. I think our OB/GYN clerkship here at MCG does a fantastic job of making students aware of these objectives, yet students need to take more ownership to make sure they are meeting these milestones throughout their 6 week clerkship. The article also discusses the use of a Logbook to cite procedures and experiences,  which we also already have integrated into our curriculum. I think the use of a Logbook helps students to focus on accomplishing key procedures, encouraging  them to be self-motivated to check off these tasks. The Logbook also helps faculty and resident staff to be more open to student participation and learning experiences.

In regards to curriculum improvement, the article discusses a few initiatives that could be added to the Clerkship to maximize student education. Firstly, three 15-minute modules were given to students to teach about culture and function in the OR, how to assist with a total abdominal hysterectomy, and how to assist with a laparoscopic hysterectomy. I think the concepts of teaching students how to best assist in the OR is amazing, as majority of students want to be helpful and involved with cases, yet we are nervous to make mistakes and don’t know how to best assist the team without specific instruction. By providing modules to give tips and instruction on how to be helpful, students can more confidently assist their team, enabling a more positive and comfortable learning environment.

The article also elaborated on the importance of skills training in the OB/GYN Clerkship. Students love getting their hands dirty, and nothing is better than simulations or practice procedures before their time to perform on a real patient occurs. Simulations of vaginal deliveries, IUD placement, suturing, D&C procedures, and even laparoscopic instrument manipulation help students feel more comfortable in using their hands and balancing instruments. As a student who who participated in the OB/GYN Bootcamp Elective during my 4^th year, I was fortunate to participate in simulations of all these procedures, and I feel very confident starting my intern year with at least having seen of all of these procedures once and completed them on models. I realize as always, the biggest obstacle is faculty time and resources, so it is not necessarily possible for all Clerkship students to participate in simulations, but I feel that making simulations a priority in the curriculum is key to student satisfaction and confidence through their Clerkship experience.

Finally, the article included student reflections into curriculum to help maximize Clerkship education. As a student myself, I personally do not find self reflections helpful. I think that with the massive amount of learning occurring on a daily basis during a Clerkship, students are tasked to balance patient care, new procedures and OR experiences, while reading and performing tasks and quizzes required for the standard OB/GYN Clerkship curriculum. I think that self reflections become cumbersome and end up losing their purpose of helping students to reflect on their successes and failures. Instead, the importance of daily feedback and debriefing should be emphasized, as students can make improvements and changes on a daily basis based on direct feedback and comments.

Overall, this article provided great ideas to help improve the student OR learning experience on the OB/GYN clerkship. The learning opportunities students receive in the OR are strongly built on student preparedness, which can be improved with instructions on how to assist properly and skill practice with simulations, while also largely relying on faculty and residents to involve students and promote positive educational environments. Student success is multi-faceted, so it is important that all sides are clearly aware of learning objectives and expectations, while providing students with daily feedback and debriefing to ensure that they are improving and growing throughout the Clerkship experience. If all of these tasks can be completed, students are sure to have positive OR experiences and thus only improve their OB/GYN clerkship and third year experience as a whole.

Jada Fambrough, MD
Medical College of Georgia
Augusta University

Abstract: This article, from the “To the Point” series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of considerations for teaching the medical student in the operating room during the obstetrics/gynecology clerkship. The importance of the medical student operating room experience and barriers to learning in the operating room are discussed. Specific considerations for the improvement of medical student learning and operating room experience, which include the development of operating room objectives and specific curricula, an increasing awareness regarding role modeling, and faculty development, are reviewed.