Medical education is changing. Physicians have less time for teaching clinical skills and for direct observation of medical students, due to sicker patients in the hospital, shorter hospital stays, competing demands of research and patient care, and implementation of the eighty hour work week for residents. The consumer movement increased awareness of medical errors, patient safety and quality of healthcare. Teaching the pelvic examination is ethically complex. Questions have arisen about medical students learning to conduct the pelvic examination on actual patients. This study utilizes the pelvic examination simulator and genital teaching associates (GTAs) to teach pelvic exam skills to optimize limited resources, as well as address safety and ethical concerns. The purpose of the study was to provide medical students with more practice in pelvic examination skills, to test a pelvic examination simulator, and to explore a new model for teaching pelvic examination skills to second year medical students. After IRB approval, one hundred sixty eight second year medical students at Virginia Commonwealth University School of Medicine participated in the study. A two-armed trial design provided all medical students with pelvic exam training on the pelvic exam simulator and genital teaching associate. Data were gathered via an experience and demographic questionnaire, blood pressure readings, the Fear of Pelvic Examination Scale scores and performance scores after the training. Data analysis consisted of descriptive statistics, paired and independent sample t-tests and the linear mixed model. Statistical tests determined the relationship between fear, blood pressure and performance. The findings revealed that the GTA training group had significantly more fear than the pelvic exam simulator group and significantly higher performance scores than the simulator group. The gender analysis indicated that males had significantly more fear than females. Prior experience with pelvic exam simulators did not appear to reduce anxiety among medical students when first conducting pelvic exams with humans. Completion of pelvic exam training with a GTA may reduce fear substantially and make later training with the pelvic exam simulator the optimal first experience. Use of simulation in medical education reduces ethical concerns, optimizes limited resources and reduces patient safety issues.

The inspiration for the present studies was the learning concept that used professional patients (PP) as instructors for medical students in learning how to perfom the pelvic examination (PE). Interviews performed with women who were PPs showed that they experienced a continuous beneficial increase in knowledge. This promoted personal development related to bodily awareness and affirmed their femininity, making them less vulnerable and reversing their approach to their own body of being an object to becoming a subject. The growing ability to contribute to students’ learning and the feeling of being valuable enhanced the PPs self-esteem and well-being and promoted independence in the learning situation. Being a PP was rewarding and contributed to the feeling of being empowered and growing as a woman in the examination chair. Two models of teaching the PE to medical students were compared: with PPs or with clinical patients (CP). The outcome showed that the PP students were more skilful in palpating the terus and ovaries and performed more PEs during the clinical clerkship than did CP students. Female and male medical students were interviewed after they had performed their first PE with PPs as instructors. The female students’ most obvious concern was about looking and touching another women’s vulva whereas male students were concerned about how to establish rapport with the PP. The interactive and supportive feedback from the PPs enabled the students to overcome their hesitation and encouraged creative learning of interpersonal and palpation skills. The LS positively enhanced the female students’ awareness of own bodies and promoted a deeper interest in PEs, both as an examiner and as patients. The male students became aware of the importance of creating a beneficial interaction with the woman and gained an insight into a previously “unknown” female world that deepened their understanding of women’s possible vulnerability during a PE. Women at an outpatient clinic participated in individual LSs about the female anatomy and the PE, and performed a PE on a mannequin prior to visiting the gynaecologist. Following the visit interviews were performed to gain a deeper understanding of the impact of the LS. The womens’ active participation during the LS generated increased self-confidence and knowledge, triggered emowerment and promoted a creative ability to interact subsequently during their own PE. Part of the studies involved developing a questionnaire to measure the fear of performing the pelvic examination, the Fear of Pelvic Examination Scale (F-PEXS). The questionnaire was shown to have a very good reliability (e.g. Cronbach alpha is .96) and good construct validity. Engaging voluntary, healthy and knowledgeable women as instructors in the PE situation creates a safe and ethical learning environment and promotes interaction with students. Immediate constructive feedback enables students to integrate communication and behavioural skills in a professional manner whilst learning to palpate the uterus, facilitating an inner security as a future examiner. The learning sessions were of benefit to the PPs, the female students in the PP model, and the women in the clinical study. The acquired knowledge started something positive within the women; a will to act and find out more about themselves. The LSs initiated empowerment in the sense that an empowered person has increased capacity to act in goal-directed ways.

Bakgrund: När en kvinna genomgår en graviditet och förlossning innebär det stora påfrestningar för hennes kropp. Vid en förlossning kan bristningar uppstå, vilket kan medföra besvär för kvinnan i olika utsträckning. Genom eftervårdsbesöket har barnmorskorna en möjlighet att identifiera problem som kan ha uppstått och upptäcka odiagnostiserade förlossningsskador. Syfte: Syftet var att beskriva barnmorskans erfarenheter av gynekologisk undersökning och att bedöma bäckenbottens strukturer vid eftervårdsbesök inom mödrahälsovården. Metod: Semistrukturerade intervjuer genomfördes med elva barnmorskor yrkesverksamma inom mödrahälsovården. Tematisk analys användes för att analysera materialet. Resultat: Ett huvudtema, tre organiserande teman samt tio basteman identifierades. Huvudtemat var: kvinnans behov i centrum. Organiserande teman var: att stödja genom sitt förhållningssätt; att verka hälsofrämjande och förbättringsområden. Basteman var: att vara lyhörd; att bekräfta; att se individuella behov; att motivera till undersökning; att motivera till egenvård; utbildning; struktur; dokumentation; tidsaspekten och uppföljning. Slutsats: Barnmorskor inom mödrahälsovården fyller en viktig funktion i att arbeta hälsofrämjande och arbetar med kvinnans behov i centrum. De försöker individanpassa varje besök och den information som ges ut men upplever att det kan finnas svårigheter att motivera kvinnor till gynekologisk undersökning. Mer utbildning, bättre och tydligare struktur för bedömning av bäckenbotten samt en förbättrad samtalsmetodik kring besvär som kan kvarstå efter förlossningen kan bidra till att kvinnor får den hjälp och vård de behöver. Klinisk tillämpbarhet: Studiens resultat belyser behov av mer kunskap, utbildning och struktur. Att detta uppmärksammas i denna studie kan leda till diskussion om vidareutveckling och att ämnet lyfts i den kliniska verksamheten. / Background: Undergoing pregnancy and childbirth, entails great strain on a woman’s body. When giving birth vaginally, tears may occur, which may cause problems for the woman to a different extent. Through the postpartum check-up, midwives have an opportunity to identify problems that may have occurred and detect undiagnosed perineal injuries. Aim: The aim was to describe the midwife’s experiences of pelvic examination and to assess pelvic floor structures at the postpartum check-up. Method: Semi-structured interviews were conducted with eleven midwives working in maternal health care. Thematic analysis was used to analyze the material. Results: One global theme, three organizing themes and ten basic themes were identified. The global theme was: the woman´s needs. The organizing themes were: to support through the approach; to promote health and areas for improvement. The basic themes were: to be responsive; to confirm; to see individual needs; to motivate for examination; to motivate selfcare; education; structure; documentation; time aspect and follow-up. Conclusion: Midwives in maternal health care play an important role in health promotion and working with women's needs. They try to personalize each visit and adapt the information given, but their experience is that there are difficulties in motivating women to undergo a pelvic examination. More education, a better and clearer structure for assessing the pelvic floor and an improved way of addressing problems that may persist after childbirth may enable women getting the help and care they need. Clinical application: The study results highlight an existing need for more knowledge, education and structure. Attention to this can lead to discussion of further development and the subject can also be raised among other healthcare providers.