Keywords
vaginal examination - medical students - simulation-based training - anxiety - satisfaction
Palavras-chave
exame ginecológico - estudantes de medicina - treinamento por simulação - ansiedade
- satisfação
Introduction
A general practitioner's training involves developing the skills required to perform
pelvic and breast examinations, which are vital for the detection of pathologies of
the breast, of the pelvic cavity, of the vagina and of the vulva during physical examination.[1]
[2] Nevertheless, undergraduate training aimed at teaching students to perform gynecological
examinations can cause discomfort to patients and embarrassment among students.[3] Therefore, to minimize these problems, the use of mannequins and models for pelvic
examination training has been considered a practical and effective teaching strategy
in the initial stages of student training.[4]
[5]
The use of gynecological teaching models is not recent. Indeed, small wax or wooden
figures have already been used for several centuries to demonstrate reproductive processes,
contraceptive techniques and gynecological conditions.[6] Nevertheless, these models and mannequins used for simulation in medical training
have advanced considerably over recent decades, now ranging from simple objects or
devices to the representation of a body part or even an entire patient. Consequently,
these devices now allow a variety of applications, ranging from their use in teaching
a specific skill to the simulation of a wide range of routine clinical situations.[2]
[6]
In a meta-analysis that included 22 studies and 2,036 students, Dilaveri et al[2] showed that mannequin-based simulation involving technological content, conducted
to teach students to perform breast and pelvic physical examinations, resulted in
significant improvements in student learning compared with no intervention.[2] The magnitude of the beneficial effects of this learning strategy differed from
study to study; however, all the studies reported some benefit, leading to the conclusion
that, in general, this type of training is indeed useful.
The advantages of simulation-based training (SBT) were also shown in a study conducted
by Bouet et al[7] in France in which pelvic examination mannequins were used to train medical students.
The level of perceived technical difficulty diminished following training using this
teaching method.[7] Furthermore, the benefits of this intervention became evident when a questionnaire
was used to rate self-evaluation and satisfaction at the beginning and end of a gynecological
simulation training session.[8] In a study conducted by Pugh et al[9] in the United States of America (USA), in which students initially watched a video
on pelvic examination and later participated in training with the use of appropriate
mannequins before performing pelvic examinations on real patients, results showed
significant improvements in student anxiety with respect to all aspects of the examination.[9]
Concerning breast examination, a study conducted in the USA found that medical students
who learned to perform a clinical examination using a breast palpation simulator performed
as well as or better than those who learned on standardized patients. Nevertheless,
an analysis performed on a subgroup showed that the benefit was limited to students
with less clinical experience. No statistically significant differences in self-confidence
were found between the two groups.[10] Another study conducted in the USA attempted to identify sources of student anxiety
when learning to perform clinical breast examination and to evaluate the effects on
anxiety of learning using simulated breast models. Fear of missing a breast lesion
and the intimate/personal nature of the examination accounted for 73.8% of causes
of student anxiety. Anxiety levels in students with respect to performing clinical
examinations decreased significantly following training with SBT.[11]
Most international studies have shown that following SBT students experience a significant
reduction in their initial anxiety at having to perform pelvic or breast examinations.[9]
[11] Nevertheless, few studies have been conducted in Brazil to evaluate the use of SBT
in teaching students to perform pelvic and breast examination. Although cultural and
financial differences may limit the extrapolation of findings from international studies,
it is clear that low-fidelity simulation and examination mannequins for pelvic and
breast examination represent a useful training approach. Bouet et al[7] reported that this low-cost strategy is used in France to prepare students to perform
gynecological examinations. In France, as in Brazil, standardized patients are not
used in simulation training in gynecology for cultural reasons. This practice is certainly
different from those of Anglo-Saxon countries where standardized patients are common
practice.[8]
In view of the aforementioned reasons, the objective of the present study was to evaluate
the factors associated with anxiety and the effect of SBT on anxiety, self-confidence
and student satisfaction in relation to pelvic and breast examination.
Methods
A longitudinal, observational study was conducted with students enrolled in the 7th semester of medical school at the Universidade José do Rosário Vellano in Alfenas,
Minas Gerais, Brazil. It was during this semester (between March and July 2018) that
the students participated in the Obstetrics and Gynecology (Ob/Gyn) clerkship.
As part of the Ob/Gyn clerkship program, the students attended a theoretical class
on Ob/Gyn anamnesis and watched a video showing, step by step, how to perform pelvic
and breast examinations. The students who agreed to participate in the study then
completed a sociodemographic questionnaire and a form containing questions to be rated
on a 7-point Likert-type scale regarding their self-perceived anxiety in relation
to performing pelvic and breast examinations. This questionnaire was adapted from
the Fear of Pelvic Examination Scale (F-PEXS) proposed by Siwe et al.[12] The F-PEXS was chosen because it has shown outstanding reliability and the right
construct validity scale in a previous study. Although F-PEXS has not yet been validated
for use in Brazilian Portuguese language, the items are quite straightforward, and
a pilot study with a group of 28 medical students was conducted to make semantic adjustments.
After completing these instruments, the students participated in the first SBT session.
During that session, the students were divided into three groups, with each group
being assigned to one mannequin. Two types of mannequins were used to teach the students
how to perform a pelvic examination: a pelvic simulator for gynecological examination
and a pelvic simulator for cervical examination (dilatation). Each student underwent
individual training, supervised by the professor assigned to that particular group.
They were taught how to perform a speculum examination, how to collect cervical cytology
specimens, and how to perform a digital vaginal examination to evaluate cervical dilatation.
The following day, the students participated in the second SBT session, in which they
were taught to perform a clinical breast examination, including palpation for lumps,
evaluation of nipple discharge and palpation of axillary and supraclavicular lymph
nodes on a mannequin. Two types of mannequins were used at the second session, one
representing the female thorax and the other composed of single breasts attached to
a base. A professor assigned to each group also supervised this training. Each session
lasted 2 hours and, after completion, the students answered a second questionnaire
containing questions on anxiety regarding pelvic and breast examination. These questions
were identical to those contained in the form applied at baseline but also included
the questions on the Student Satisfaction and Self-Confidence in Learning Scale validated
by Almeida et al[5] for Brazilian Portuguese.
Statistical Analysis
The scores obtained from the Likert-type scale were calculated by adding the ratings
for each answer within the domain of interest and then dividing the sum by the number
of questions in that domain. Ratings ranged from 1 to 7, in which 1 meant “I completely
disagree” with the statement and 7 meant “I completely agree” with the statement.
Students scoring a mean of 5 or higher in the anxiety domain were considered to be
extremely anxious.
The Student t-test for paired samples was used to compare mean anxiety scores measured prior to
and following SBT. The Pearson correlation coefficient was used to evaluate the association
between pre- and post-SBT anxiety scores and to evaluate the association between satisfaction
and self-confidence, satisfaction and anxiety, and self-confidence and anxiety. The
Student t-test for independent samples was used to evaluate whether the scores assessed for
anxiety, satisfaction and self-confidence differed between female and male students.
Cronbach's α was used to assess the internal consistency of the questions in each
of the three domains evaluated.
Results
A total of 80 students were included in the study. Of these, 62.5% were women and
the mean age of the participants was 24.1 ± 4.2 years. Most stated that they had already
initiated their sexual life and only two of the students reported being homosexual.
Only 12 students reported having had previous experience in women's health, either
as an intern or when they participated in an academic league ([Table 1]).
Table 1
Sociodemographic and behavioral characteristics of the students
|
Frequency
|
Sociodemographic and behavioral characteristics
|
n[*]
|
%
|
Type of secondary education
|
|
|
Public
|
9
|
11.4
|
Private
|
69
|
87.3
|
Public and Private
|
1
|
1.3
|
Does the student perform any paid work?
|
|
|
Yes
|
1
|
1.2
|
No
|
79
|
98.8
|
Monthly family income
|
|
|
≤ R$ 5,000.00
|
6
|
7.7
|
Between R$ 5,001.00 and R$ 12,000.00
|
27
|
34.6
|
> R$ 12,000.00
|
45
|
57.7
|
Is currently participating in or has participated in an extension program or academic
league in gynecology?
|
|
|
Yes
|
5
|
6.2
|
No
|
75
|
93.8
|
Is currently participating or has participated in a practical work experience in gynecology?
|
|
|
Yes
|
7
|
8.8
|
No
|
73
|
91.2
|
Has already initiated his/her sexual life?
|
|
|
Yes
|
77
|
96.3
|
No
|
3
|
3.8
|
At what age did you first have sexual intercourse?
(For the students who have already initiated their sexual life)
|
|
|
13–15 years
|
19
|
26.4
|
16–18 years
|
39
|
54.1
|
> 18 years
|
14
|
19.5
|
Sexual orientation
|
|
|
Heterosexual
|
76
|
97.4
|
Homosexual
|
2
|
2.6
|
Have you ever been submitted to a digital rectal examination?
|
|
|
Yes
|
5
|
6.2
|
No
|
75
|
93.8
|
Have you ever been submitted to a gynecological examination? (Only for female students)
|
|
|
Yes
|
48
|
96.0
|
No
|
2
|
4.0
|
* Although the overall database consisted of 80 students, the number of students does
not always add up to 80 for all the variables analyzed due to missing data in some
cases.
The internal consistency of the questions measured using Cronbach's α showed good
reliability and good internal consistency in the different domains.
Baseline overall anxiety was low (2.04 ± 0.80) and, in general, the students' anxiety
in relation to pelvic examination was found to be greater than their anxiety regarding
breast examination (2.38 ± 0.98 versus 1.70 ± 0.79, respectively; p < 0.001). When anxiety levels were compared between the groups of male and female
students, no significant differences were found, with the following mean baseline
scores being recorded for the two groups, respectively: anxiety regarding pelvic examination
(2.33 ± 1.01 versus 2.44 versus ± 1.00; p = 0.649), anxiety regarding breast examination (1.84 ± 0.88 versus 1.63 ± 0.74; p = 0.317), and anxiety regarding both pelvic and breast examinations (2.11 ± 0.90
versus 2.00 ± 0.75; p = 0.594).
The causes of anxiety in relation to pelvic examination were never having seen a pelvic
examination (24.0%), not knowing how to perform a pelvic examination, fear of hurting
the patient or of being clumsy (44.0%), fear of the patient feeling uncomfortable
(20.0%), and the students themselves feeling uncomfortable with the examination (8.0%).
The causes of anxiety in relation to breast examination were fear of hurting the patient
or of being clumsy (33.3%), fear of making the patient feel uncomfortable (33.3%),
feeling uncomfortable (22.2%) and never having seen the exam performed (11.2%).
When stratified according to gender, the main reason for anxiety reported by the female
students was fear of hurting the patient, both in relation to the pelvic examination
and to the breast examination. The main reason for anxiety reported by the male students
was never having performed the exam previously and fear of making the patient feel
uncomfortable.
The anxiety scores in relation to the overall gynecological examination decreased
significantly from 2.04 ± 0.80 at baseline to 1.46 ± 0.50 following SBT (p < 0.001). Regarding anxiety in relation to pelvic examination specifically, the mean
score of 2.40 ± 1.00 prior to SBT decreased to 1.64 ± 0.68 following the intervention
(p < 0.001), while the mean score of 1.70 ± 0.79 for anxiety regarding breast examination
prior to SBT fell to 1.33 ± 0.46 following SBT (p < 0.001) ([Table 2]).
Table 2
Comparison of scores for anxiety with respect to the gynecological examination between
baseline evaluation and the evaluation performed following simulation-based training
Anxiety Scores
|
Descriptive Measures
|
|
Phase
|
n
|
Minimum
|
Maximum
|
Mean
|
SD
|
p-value
[*]
|
Pelvic examination
|
|
|
|
|
|
|
Baseline
|
80
|
1.00
|
5.17
|
2.40
|
1.00
|
|
Post-SBT
|
80
|
1.00
|
3.33
|
1.64
|
0.68
|
< 0.001
|
Baseline - Post-SBT
|
|
|
|
0.76
|
0.82
|
|
Breast examination
|
|
|
|
|
|
|
Baseline
|
72
|
1.00
|
4.67
|
1.70
|
0.79
|
|
Post-SBT
|
72
|
1.00
|
3.00
|
1.33
|
0.46
|
< 0.001
|
Baseline - Post-SBT
|
|
|
|
0.37
|
0.64
|
|
Pelvic and breast examination
|
|
|
|
|
|
Baseline
|
72
|
1.00
|
4.92
|
2.04
|
0.80
|
|
Post-SBT
|
72
|
1.00
|
3.00
|
1.46
|
0.51
|
p < 0.001
|
Baseline - Post-SBT
|
|
|
|
0.58
|
0.64
|
|
Abbreviations: SBT, simulation-based training; SD, standard deviation.
* Student's t-test for paired samples. The number of students differs from the total sample of
80 students due to missing data for some of the variables.
The analysis of the correlation between the anxiety scores evaluated prior to and
following SBT is shown in [Table 3].
Table 3
Analysis of the correlation between the anxiety scores evaluated prior to and following
simulation-based training (n = 80)
Scores
|
r
|
p-value
[*]
|
Anxiety regarding pelvic examination: baseline versus post-SBT
|
0.53
|
< 0.001
|
Anxiety regarding breast examination: baseline versus post-SBT
|
0.60
|
< 0.001
|
Anxiety regarding pelvic and breast examination: baseline versus post-SBT
|
0.61
|
< 0.001
|
Abbreviation: SBT, simulation-based training.
r = Pearson's correlation.
* Student's t-test for paired samples.
The levels of anxiety observed prior to SBT decreased after SBT in both genders. As
at baseline, following SBT there was no difference in the level of anxiety between
genders, either for the overall gynecological examination (mean 1.53 ± 0.62 versus
1.47 ± 0.52 for males and females, respectively; p = 0.67) or for the pelvic examination (1.66 ± 0.74 versus 1.63 ± 0.65, respectively;
p = 0.86) or breast examination (1.41 ± 0.56 versus 1.32 ± 0.47, respectively; p = 0.47).
When the group of students with previous experience in women's health (resulting from
their participation in academic leagues or extension activities) was compared with
the other students. Those with prior experience were found to be less anxious with
respect to the overall clinical examination prior to SBT (1.55 ± 0.45 versus 2.12 ± 0.82,
respectively; p = 0.004), with none of the students being classified as extremely anxious. Following
SBT, the difference between the group with previous experience and the other students
in relation to the overall clinical examination was no longer statistically significant
(1.32 ± 0.27 versus 1.48 ± 0.54, respectively; p = 0.14).
Student satisfaction was very high (mean 6.85 ± 0.39) and there was no statistically
significant difference between the female and male students. Self-confidence was also
high (5.97 ± 0.88) following SBT, with no difference between genders. Satisfaction
with SBT was similar between the group of students with previous experience in women's
healthcare and the remaining students (6.88 ± 0.23 versus 6.86 ± 0.41, respectively;
p = 0.84); however, self-confidence, although high in both groups, was higher in the
group with previous experience (6.41 ± 0.67 versus 5.89 ± 0.89, respectively, p = 0.03).
No statistically significant correlation was found between the degree of student anxiety
and the student's satisfaction with the learning experience (r = -0.04; p = 0.771) or between the degree of student anxiety and his/her self-confidence (r = -0.07;
p = 0.561) ([Table 4]).
Table 4
Analysis of the correlation between anxiety scores prior to simulation-based training
and scores for learning-related satisfaction and self-confidence in learning (n = 80)
Scores
|
Satisfaction (p-value)[*]
|
Self-Confidence (p-value)[*]
|
Anxiety regarding pelvic examination
|
−0.03 (0.799)
|
−0.10 (0.409)
|
Anxiety regarding breast examination
|
−0.04 (0.763)
|
−0.02 (0.867)
|
Anxiety regarding pelvic and breast examination
|
−0.04 (0.771)
|
−0.07 (0.561)
|
Database: 80 students.
* Pearson correlation analysis. Correlation analysis between anxiety regarding pelvic
examination and anxiety regarding breast examination (r = 0.64; p < 0.001).
Discussion
Simulation-based training effectively reduced anxiety in medical students of both
genders, both in relation to pelvic and breast examinations. Furthermore, after training,
scores for satisfaction and self-confidence were high. Therefore, in the present study,
the effect of SBT in reducing anxiety in relation to pelvic and breast examination
is in agreement with reports from earlier studies.[7]
[8]
[9]
[11]
The present study showed, however, that insofar as the effects of SBT were concerned,
there was no statistically significant difference between male and female students,
with a decrease in anxiety in both genders. Nevertheless, no statistically significant
correlation was found between anxiety level and learning-related satisfaction or between
anxiety level and self-confidence.
At the baseline evaluation, the students experienced less anxiety in relation to breast
examination than in relation to pelvic examination. Hugon-Rodin et al[8] suggested that the finding of less discomfort with breast examination compared with
pelvic examination could be explained by the less intimate and more discrete nature
of that examination. Those authors did not mention any differences between genders.
In the present study, the main cause of student anxiety with respect to pelvic examination
was fear of hurting the patient (44%), followed by never having seen a pelvic examination
performed (24%). When the replies were analyzed according to gender, it was found
that the female students mentioned fear of hurting the patient as the principal cause
of their anxiety, whereas the men emphasized never having performed the exam. Pugh
et al[9] investigated the main source of student anxiety when learning to perform a clinical
pelvic examination on women and found that fear of causing harm or pain was the most
common answer given by medical students (49.7%). This was followed by the intimate/personal
nature of the exam (25.7%). Conversely, a study conducted in France, in agreement
with a study conducted in Australia, showed that the majority of students (62%) felt
embarrassed because they had never performed a gynecological examination.[8]
[13] The Australian study also identified embarrassment as the main cause (42%) followed
by insecurity at performing a pelvic examination.
In relation to the breast examination, fear of hurting the patient and fear of the
patient feeling uncomfortable were the main causes of anxiety prior to SBT. Conversely,
according to a study conducted by Pugh et al[11] in a university in the USA, fear of missing a breast lesion and the intimate/personal
nature of the exam were responsible for 73.8% of the anxiety experienced prior to
training.
In the present study, the students' satisfaction and self-confidence were high following
SBT, with no statistically significant differences between genders. These results
are consistent with other studies published in the literature in relation to SBT in
gynecology, in which satisfaction rates for students are reported as being > 90% following
training.[8]
Students who had participated in gynecology leagues or who had extracurricular practical
experience in gynecology had less overall anxiety prior to SBT in relation to the
group with no previous experience. It is interesting to note, however, that there
was no statistically significant difference in overall anxiety between these two groups
following SBT. To the best of our knowledge, there are no studies in the literature
that have specifically evaluated this subgroup of students with greater prior exposure
to the subject matter.
The limitations of the present study include the fact that measures of anxiety and
confidence were based on students' self-perception. According to Deladisma et al,[14] since measures of anxiety and confidence are subjective and self-reported, they
may not correlate with actual levels. In addition, the F-PEXS has not yet been validated
for use in Brazil. However, the questions contained in this scale are straightforward
and easily understandable, and the authors performed rigorous adaptation procedures
in a group of students with similar characteristics to those of the study participants
until the final version was considered adequate, that is, until the participants reported
no more doubts or difficulties in answering the questions. Another limitation refers
to the fact that the study was conducted in a single institution; therefore, the results
cannot be extrapolated to other settings. In addition, the sample size was small and
predominantly female. Although this sample size was sufficient to allow a reduction
in anxiety following SBT to be detected, it may have been insufficient to detect differences
between genders. The finding of low overall anxiety at baseline may also have limited
the capacity of the study to detect certain differences in the subanalyses. This low
baseline level of anxiety could be related to the fact that the students had already
watched an educational video and a lecture on how to perform a gynecological examination.
Nevertheless, statistically significant differences were found between the analyses
conducted prior to and following SBT, highlighting the importance of this strategy.
Conclusion
The main cause of anxiety in relation to pelvic and breast examination was the fear
of hurting the patient. In our opinion, it is vital to deal with student anxiety in
the initial phases of learning, since this could affect their performance in clinical
practice. Therefore, knowledge on the factors associated with anxiety is important
to improve the way in which they are managed. The use of SBT in a group of 7th semester medical students showed a reduction in the anxiety scores with respect to
pelvic and breast examinations, with a high rate of satisfaction and self-confidence
in relation to their ability to perform a gynecological examination. Future studies
with larger sample sizes and conducted in different medical schools will provide more
data with which to extend the present analysis.