Key messages

• Medical students have long been taught how to do pelvic examination using plastic pelvic models (pictured)
• An alternative approach has seen lay clinical teaching associates teaching students how to conduct sensitive and effective pelvic examinations using their own bodies
• Building mutual trust and respect between lay teaching associates and the medical faculty has enabled the initiative to develop further and now the lay associates play the leading part in the formal assessment of students skills

Clinician and educators’ perspective

Patients need their doctors to be able to perform sensitive and skilled clinical examinations, not least gynaecological examinations. Traditionally, the principles have been taught at most medical schools by using a plastic pelvic model (pictured above) and then students’ skills are further developed in outpatient clinics. The clinic is not, however, an ideal learning environment. Many patients are apprehensive, students are nervous, and the supervising clinicians are busy and focussed primarily on timely assessment, diagnosis, and treatment.

Informed by innovations in patient-led teaching of intimate examinations in other universities, our medical school established a gynaecology teaching programme, which trains lay people to become Clinical Teaching Associates (CTAs) who teach students how to conduct a sensitive and effective pelvic examination using their own bodies. [1] The CTAs, recruited by general advertisement and selected by interview, are trained by gynaecologists and educationalists over several months and are then able to teach students the technical, practical, and communication skills needed to perform a cervical smear, a bimanual pelvic examination, and a related consultation. They are formally employed as members of the teaching staff by the University.

Two students are taught by two CTAs for a two hour session at the start of their obstetrics and gynaecology rotation. No clinicians are present during this teaching. The CTAs first demonstrate a consultation about cervical screening followed by a speculum and bimanual examination with one CTA taking the role of the doctor and one of the patient. The students then each replicate the consultation and examination, taking the doctor role. In this way every student learns to conduct a consultation and a pelvic examination while receiving expert feedback.

The teaching programme started in 2007 and so far approximately 1800 students have been trained by CTAs. The approach has been well received by students, but we wondered whether the assessment at the end of their eight week rotation could also be improved. Students are taught with feedback on their skills from the subject of the examination, but were then tested in the Objective Structured Clinical Examination (OSCE) using the plastic pelvic model. We were conscious of a lack of alignment between teaching and assessment and, more importantly, thought that information from the person being examined was crucial to any judgement about a student’s skills and competence. [2] As clinicians and educators, we did not doubt that the CTAs would assess students’ skills at least as consistently and accurately as consultants. Rather, we felt that it was unfair to ask the small team of CTAs to assess, as it would involve 28-30 students performing a pelvic examination in one afternoon. However, by discussing the challenges with the CTAs rather than assuming it would not be possible and by piloting various options, we were able to find a way forward.

Clinical teaching associate’s perspective

When the possibility of the CTA-led OSCE programme was broached with the Oxford CTA team, it seemed like a logical step to build on the teaching we were already doing. The more we learned about the way that these exams were run at the time, the more we were surprised that it had taken so long for CTAs to become involved. How could the students’ skills in communicating with and examining human beings be assessed properly when they were being observed carrying out examinations on a plastic model? More specifically, how could the consultant-examiner know whether the student had conducted a “comfortable” speculum examination?

As CTAs, we were sure that we wanted to go ahead with this; we just had to work out the details. We would be having more speculum examinations during an OSCE than we were used to having in a teaching session, but these examinations would be shorter without the teaching component, and there would be no bimanual examinations either. The main uncertainty that we needed to address was at what point it would be acceptable to “step in” if a student were making a mistake that would be likely to cause the patient pain, while still maintaining exam conditions and parity. In conversation with clinicians we established guidelines on where to draw this line, and we ensured that such a decision could come from both the patient-CTA and the observing, chaperone-CTA (discussed further below). We clarified what each CTA’s role would be in the room, which aspects of the examination each would be able to comment upon, and, through trial sessions, how the whole OSCE would work practically.

Where we are now

In the current OSCE station, one CTA acts as the patient throughout, while another CTA observes the consultation and then acts as the chaperone during the physical examination. Each CTA has a mark sheet to complete, and they each grade the student independently at the end of the OSCE. The chaperone-CTA’s mark sheet is very detailed, covering awareness of and attention to hygiene, use of appropriate language, each aspect of correct information that should be covered during the consultation, and technical skill during the physical examination. The patient-CTA’s mark sheet is simpler, with broad areas covering patient comfort, dignity, and communication.

We run two OSCE stations concurrently, each lasting twelve minutes and timed independently of the other stations. Six CTAs cover this station: two in each room (as the patient and chaperone respectively), and two outside the rooms. The two CTAs who stay outside run the timings of each OSCE, collect the students from the waiting room, give them instructions, and are ready to take over in either room if it should prove necessary. Usually each CTA remains in the same role for three students before rotating to another role, and the maximum number of physical examinations for each CTA in an afternoon would usually be six (although in practise it is often fewer).

What we have learnt

More things are possible than you may initially imagine. The clinicians in the team made the mistake of assuming that it would be inappropriate to ask the CTAs to take part in the formal assessment of students’ skills as this would involve too many speculum examinations. Although clinicians were aware of the deficits of the old examination, they underestimated how strongly the CTAs felt about the importance of an appropriate, patient-centred assessment of students’ gynaecological examination skills. We came to understand each others’ perspectives through discussion in our regular meetings. The successful implementation of both the teaching and assessment programmes have depended on developing mutual trust and respect, between the CTAs who work closely together and between clinicians and CTAs. The CTAs are empowered to make decisions about what will and will not work for them and set limits on what is acceptable. The clinicians trust the CTAs to let them know if arrangements are not working for them, without feeling any pressure to undergo more examinations than is comfortable. The students are now taught and tested on their gynaecological examination skills by experts in the performance and experience of this procedure. A skilled observer, however expert, can by definition only comment on the technical, observable proficiency of the student and not on the experience of the patient. Our current teaching and assessment takes account of both perspectives and we believe this prepares students well for their careers as doctors, in gynaecology, and in wider clinical practice.

Helen Salisbury is a GP in Oxford and is jointly responsible for the patient and public involvement strategy of at the medical school there.

Elizabeth Swift works as a Clinical Teaching Associate in Oxford. She is also a Lecturer in the Humanities.

Competing interests: None declared.

References:

Pickard S, Baraitser P, Rymer J, Piper J. Can gynaecology teaching associates provide high quality effective training for medical students in the United Kingdom? Comparative study. BMJ : British Medical Journal. 2003;327(7428):1389-1392.

Wilkinson Emma. The patients who decide what makes a good doctor BMJ 2018;361:k1829