Accepted Manuscript Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and evaluation of a simulation curriculum Lauren F. Damle, MD Eshetu Tefera, MS Julie McAfee, Ms. Mary K. Loyd, RN, Ms. Allison M. Jackson, MD MPH Tamika C. Auguste, MD Veronica Gomez-Lobo, MD PII:
S1083-3188(14)00262-9
DOI:
10.1016/j.jpag.2014.07.008
Reference:
PEDADO 1744
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 25 February 2014 Revised Date:
29 June 2014
Accepted Date: 9 July 2014
Please cite this article as: Damle LF, Tefera E, McAfee J, Loyd MK, Jackson AM, Auguste TC, GomezLobo V, Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and evaluation of a simulation curriculum, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and evaluation of a simulation curriculum
RI PT
Lauren F. Damle MDa, Eshetu Tefera MSb, Ms. Julie McAfeec, Ms. Mary K. Loyd RNc, Allison M. Jackson MD MPHd, Tamika C. Auguste MDa, Veronica Gomez-Lobo MDa,e
MedStar Washington Hospital Center, Department of Women and Infant Services, Washington,
DC
c
MedStar Health Research Institute, Hyattsville, MD
M AN U
b
SC
a
Simulation and Training Environment Lab, MedStar Health, Washington, DC
d
Children’s National Medical Center, Child and Adolescent Protection Center, Washington, DC
e
TE D
Children’s National Medical Center, Department of Surgery, Washington, DC
Study was conducted at MedStar Washington Hospital Center in Washington, DC, Department of Women and Infant Services and Simulation and Training Environment Lab (SiTEL) at
EP
MedStar Health, Washington, DC
AC C
The authors report no conflict of interest. There are no disclaimers.
Corresponding author/requests for reprints: Lauren F. Damle, MD
[email protected] MedStar Washington Hospital Center
1
ACCEPTED MANUSCRIPT
110 Irving St. NW 5B-41 Washington, DC 20010 P 202-877-4099
AC C
EP
TE D
M AN U
SC
RI PT
F 202-877-4383
2
ACCEPTED MANUSCRIPT
Structured Abstract: Study Objective: Develop a Pediatric and Adolescent Gynecology (PAG) curriculum,
RI PT
appropriate pelvic model for teaching examination skills, and an objective structured clinical examination (OSCE) for evaluation. Compare OSCE performance between residents with
clinical training in PAG versus those that completed the curriculum versus those without either
SC
experience. Design: Prospective cohort study
Participants: Senior OBGYN residents
M AN U
Setting: Obstetrics and Gynecology (OBGYN) residency program in an urban academic center
Interventions: A simulation-based teaching curriculum was created to teach PAG skills. A pediatric mannequin with anatomic pre-pubertal genitalia was developed for teaching and assessment of skills.
using a 40 point checklist
TE D
Main Outcome Measures: Performance on a PAG based OSCE as assessed by two observers
Results: 17 residents participated in the OSCE; 5 completed the curriculum, 6 completed a
EP
clinical rotation, and 6 were controls. The teaching curriculum group had the highest median
AC C
composite OSCE score (75.0%) compared to the clinical group (73.1%) and control group (55.3%). There was no statistical difference between the scores of the teaching and clinical groups, but the teaching group scored statistically higher than controls (p=.0331). Scores for each OSCE component were compared. The teaching and clinical groups outperformed controls on assessment and procedures. There was no difference in scores on history taking or physical examination.
3
ACCEPTED MANUSCRIPT
Conclusion: An interactive teaching curriculum incorporating simulation and a realistic pediatric pelvic model can be used to teach PAG clinical skills. Using an OSCE to evaluate skills shows that residents completing the curriculum perform as well as those with clinical experience and
SC
RI PT
better than controls.
Key words:
Pediatric and adolescent gynecology Resident education
AC C
EP
TE D
Simulation
M AN U
Objective structured clinical examination
4
ACCEPTED MANUSCRIPT
Main Text
RI PT
Introduction:
Pediatric and Adolescent Gynecology (PAG) is a relatively new subspecialty which encompasses a wide range of gynecologic pathology in young girls and adolescents. A specialist in this area
SC
has knowledge in all aspects of gynecological care for young girls from preventative adolescent care to surgical intervention for genitourinary anomalies. The Council for Resident Education in
M AN U
Obstetrics and Gynecology (CREOG) provides educational objectives for residency training and includes pediatric and adolescent gynecology as a required subject1. Questions pertaining to the unique problems of this patient population frequently show up on CREOG and the American Board of Obstetrics and Gynecology (ABOG) examinations. More importantly, general
TE D
gynecologists may be called upon by community pediatricians, surgeons, and urologists to consult for pediatric patients with gynecological problems. Unfortunately, few OBGYN residency programs provide formal training in this subspecialty either due to lack of qualified
EP
faculty or infrequent encounters with this patient population. A recent survey of OBGYN
rotation2.
AC C
residency programs revealed that 83% of respondents did not have a formal, dedicated PAG
Simulation in medical education is a rapidly growing field. It provides the opportunity for trainees to master basic skills prior to real world application and exposure to management of more rare conditions that may not frequently arise during clinical training. In the field of OBGYN, successful simulation models have been developed to train physicians to handle
5
ACCEPTED MANUSCRIPT
emergencies such as shoulder dystocia, vaginal breech delivery, and postpartum hemorrhage as well as surgical skills such as hysteroscopy and laparoscopy3-7. In the field of PAG, there is only one published study in the literature describing the use of simulation to teach the skills necessary
RI PT
to evaluate and care for pediatric patients with gynecological complaints8. This was a study of 19 resident physician participants that compared performance on an objective structured clinical examination (OSCE) before and after a formal lecture during which examination technique was
SC
taught. The study showed improvement in the OSCE scores after participants attended the
M AN U
lecture and demonstration.
While the aforementioned study showed that participants performed better on an OSCE after a teaching intervention than prior to the intervention, we sought to compare performance on OSCE between OBGYN residents with clinical exposure to pediatric and adolescent gynecology, those
TE D
who completed a simulation teaching curriculum and a control group without either experience. Our goal was to develop an appropriate teaching curriculum which could be implemented in training programs without the ability to establish a formal clinical rotation in PAG and determine
EP
if the curriculum was effective in teaching the necessary skills to properly evaluate and treat
AC C
pediatric gynecology patients.
Materials & Methods:
This study had two objectives. First was to develop a PAG simulation teaching curriculum, appropriate pelvic model for teaching examination skills, and an assessment tool to evaluate participants’ skills. The second was to compare performance on an objective structured clinical
6
ACCEPTED MANUSCRIPT
examination (OSCE) between senior residents with clinical training in PAG versus those that completed the simulation teaching curriculum versus those that had neither experience. This study was approved by the MedStar Health Research Institute’s Institutional Review Board and
RI PT
informed consent was obtained from all participants prior to enrollment.
SC
Development of a teaching curriculum and pelvic model
We designed a teaching curriculum, Pediatric and Adolescent Gynecology Education through
M AN U
Simulation (PAGES), to teach the basic principles of evaluation and management of common gynecological complaints in pre-pubertal girls. The curriculum included two online lectures viewed prior to a live session. One lecture was recorded by the senior author (VGL) and covered common vulvar complaints in prepubertal girls. The second lecture was recorded by one of the
TE D
other authors (AMJ) who is a specialist in child physical and sexual abuse and covered aspects of history taking and examination of children with suspected sexual abuse.
EP
The live portion of the PAGES curriculum was a half day session during resident didactic time in the simulation laboratory led by the study authors: PAG fellow (LFD), PAG faculty (VGL) and
AC C
pediatric physical and sexual abuse specialist (AMJ). The session covered a variety of topics including approach to the pediatric patient, prepubertal female genital anatomy, proper examination techniques and positioning, and procedural skills of culture collection, vaginal irrigation, and vaginoscopy. The session included hands on demonstrations of skills and a simulated patient encounter for each participant.
7
ACCEPTED MANUSCRIPT
To create a pelvic model, a life size toddler doll was purchased from a commercial retailer (Figure 1a). The hip joints of the doll were modified to allow for better external rotation and leg positioning. The vaginal canal and cervix were created from recycled components of a
RI PT
hysteroscopy model. A latex mold was used to create external genitalia including the labia majora, labia minora, clitoral hood, urethral opening, and hymen (Figure 1b). The latex mold was draped over the perineum of the doll and attached anteriorly and posteriorly above the hips
SC
to hold the external anatomy in place (Figure 1c). The mold was created in this manner to allow for replacement if the latex hymen or other structures become damaged. Costume makeup was
M AN U
used to create erythema of the labia as needed. The model was used during the teaching session for demonstrating positioning, examination techniques, and procedural skills.
TE D
Objective structured clinical examination
An OSCE was created to evaluate participants’ skills in history taking, clinical examination, differential diagnosis, and procedures in relation to a common PAG clinical scenario. The OSCE
EP
was staged in our simulation laboratory in a mock Emergency Room patient bay (Figure 2a). The bay was wired with visual and audio monitors for outside observers to watch and listen
AC C
while participants completed the simulation. Each OSCE was viewed and graded by two independent observers; the PAG fellow (LFD) and PAG faculty member (VGL). Each observer watched and listened on her own screen with her own headphones and the graders did not communicate with each other during or after the OSCE (Figure 2b).
8
ACCEPTED MANUSCRIPT
For the OSCE scenario, participants were instructed to evaluate a 4 year old girl, Paige, with vaginal bleeding in the emergency room by performing a focused history and examination and then reporting their findings and recommendations to their attending. Inside the bay, the model
RI PT
“Paige” was dressed in a hospital gown and positioned sitting on a hospital stretcher. A
professional standardized patient played the role of Paige’s mother. The participant had 10 minutes to interview the mother and examine the patient. The participant was provided with a
SC
variety of examination tools including examination gloves, a pediatric speculum, lubricant, calgi swab and culturette, 10cc syringes, a Toomey syringe, angiocatheters, saline, and pediatric and
M AN U
adult foley catheters. Following the initial evaluation, the participant was asked to describe the examination findings, list the differential diagnosis and suggest the next steps in evaluation and management. The participant was expected to suggest vaginal irrigation followed by a vaginoscopy if no source of vaginal bleeding is found. During the vaginoscopy, the participant
TE D
should identify the foreign object (small bead) and remove it using an appropriate instrument (Figure 2c). Following completion of this final task, the evaluators met with the participant to
EP
provide feedback on performance.
The OSCE was graded using the check list shown in table 1. Participants earned points for
AC C
appropriate history taking questions, examination skills, differential diagnosis and plan, and performing each step of the two procedures. Points were lost for performing speculum or vaginal digital examinations at any time.
Study:
9
ACCEPTED MANUSCRIPT
All senior residents in our OBGYN residency program were invited to take part in the study. Fourth year residents were invited to participate at the beginning of the academic year and third year residents were invited to participate at the end of the academic year. This schedule was
RI PT
designed to capture residents from two different training years at points of time when their general clinical experience was similar (approximately 3 completed years of training). The OBGYN residency program at our institution is the product of a merger of the MedStar
SC
Washington Hospital Center (MWHC) program and the MedStar Georgetown University
Hospital (MGUH) program. The MWHC residency program includes a required one month
M AN U
clinical rotation in PAG during the third year. The MGUH program does not have this clinical opportunity. This created two study groups based on exposure to clinical teaching in PAG. The fourth year residents were divided into two groups, those who were originally with the MGUH program who had not completed a PAG clinical rotation and those from the MWHC program
TE D
who had completed the PAG clinical rotation. Fourth year residents from MGUH, those without a PAG rotation, were invited to participate in the teaching curriculum as previously described. Third year residents from both MGUH and MWHC, who had either no opportunity for a PAG
EP
clinical rotation or had not yet started their planned rotation, were invited to participate in the study as control subjects. All three groups, the fourth year MWHC residents (clinical rotation
AC C
group), the fourth year MGUH residents (teaching group) and third year residents without prior clinical rotation or teaching (control group) participated in the OSCE and were evaluated by two evaluators. Scores from the examiners were averaged for a final score for each participant.
Results were analyzed by comparing overall OSCE scores for all three groups as well scores for each section: history taking, physical examination, assessment, and procedures (vaginal
10
ACCEPTED MANUSCRIPT
irrigation and vaginoscopy). Groups were compared pair-wisely using non-parametric Wilcoxon rank sum test. A p-value of
S1083-3188(14)00262-9
DOI:
10.1016/j.jpag.2014.07.008
Reference:
PEDADO 1744
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 25 February 2014 Revised Date:
29 June 2014
Accepted Date: 9 July 2014
Please cite this article as: Damle LF, Tefera E, McAfee J, Loyd MK, Jackson AM, Auguste TC, GomezLobo V, Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and evaluation of a simulation curriculum, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and evaluation of a simulation curriculum
RI PT
Lauren F. Damle MDa, Eshetu Tefera MSb, Ms. Julie McAfeec, Ms. Mary K. Loyd RNc, Allison M. Jackson MD MPHd, Tamika C. Auguste MDa, Veronica Gomez-Lobo MDa,e
MedStar Washington Hospital Center, Department of Women and Infant Services, Washington,
DC
c
MedStar Health Research Institute, Hyattsville, MD
M AN U
b
SC
a
Simulation and Training Environment Lab, MedStar Health, Washington, DC
d
Children’s National Medical Center, Child and Adolescent Protection Center, Washington, DC
e
TE D
Children’s National Medical Center, Department of Surgery, Washington, DC
Study was conducted at MedStar Washington Hospital Center in Washington, DC, Department of Women and Infant Services and Simulation and Training Environment Lab (SiTEL) at
EP
MedStar Health, Washington, DC
AC C
The authors report no conflict of interest. There are no disclaimers.
Corresponding author/requests for reprints: Lauren F. Damle, MD
[email protected] MedStar Washington Hospital Center
1
ACCEPTED MANUSCRIPT
110 Irving St. NW 5B-41 Washington, DC 20010 P 202-877-4099
AC C
EP
TE D
M AN U
SC
RI PT
F 202-877-4383
2
ACCEPTED MANUSCRIPT
Structured Abstract: Study Objective: Develop a Pediatric and Adolescent Gynecology (PAG) curriculum,
RI PT
appropriate pelvic model for teaching examination skills, and an objective structured clinical examination (OSCE) for evaluation. Compare OSCE performance between residents with
clinical training in PAG versus those that completed the curriculum versus those without either
SC
experience. Design: Prospective cohort study
Participants: Senior OBGYN residents
M AN U
Setting: Obstetrics and Gynecology (OBGYN) residency program in an urban academic center
Interventions: A simulation-based teaching curriculum was created to teach PAG skills. A pediatric mannequin with anatomic pre-pubertal genitalia was developed for teaching and assessment of skills.
using a 40 point checklist
TE D
Main Outcome Measures: Performance on a PAG based OSCE as assessed by two observers
Results: 17 residents participated in the OSCE; 5 completed the curriculum, 6 completed a
EP
clinical rotation, and 6 were controls. The teaching curriculum group had the highest median
AC C
composite OSCE score (75.0%) compared to the clinical group (73.1%) and control group (55.3%). There was no statistical difference between the scores of the teaching and clinical groups, but the teaching group scored statistically higher than controls (p=.0331). Scores for each OSCE component were compared. The teaching and clinical groups outperformed controls on assessment and procedures. There was no difference in scores on history taking or physical examination.
3
ACCEPTED MANUSCRIPT
Conclusion: An interactive teaching curriculum incorporating simulation and a realistic pediatric pelvic model can be used to teach PAG clinical skills. Using an OSCE to evaluate skills shows that residents completing the curriculum perform as well as those with clinical experience and
SC
RI PT
better than controls.
Key words:
Pediatric and adolescent gynecology Resident education
AC C
EP
TE D
Simulation
M AN U
Objective structured clinical examination
4
ACCEPTED MANUSCRIPT
Main Text
RI PT
Introduction:
Pediatric and Adolescent Gynecology (PAG) is a relatively new subspecialty which encompasses a wide range of gynecologic pathology in young girls and adolescents. A specialist in this area
SC
has knowledge in all aspects of gynecological care for young girls from preventative adolescent care to surgical intervention for genitourinary anomalies. The Council for Resident Education in
M AN U
Obstetrics and Gynecology (CREOG) provides educational objectives for residency training and includes pediatric and adolescent gynecology as a required subject1. Questions pertaining to the unique problems of this patient population frequently show up on CREOG and the American Board of Obstetrics and Gynecology (ABOG) examinations. More importantly, general
TE D
gynecologists may be called upon by community pediatricians, surgeons, and urologists to consult for pediatric patients with gynecological problems. Unfortunately, few OBGYN residency programs provide formal training in this subspecialty either due to lack of qualified
EP
faculty or infrequent encounters with this patient population. A recent survey of OBGYN
rotation2.
AC C
residency programs revealed that 83% of respondents did not have a formal, dedicated PAG
Simulation in medical education is a rapidly growing field. It provides the opportunity for trainees to master basic skills prior to real world application and exposure to management of more rare conditions that may not frequently arise during clinical training. In the field of OBGYN, successful simulation models have been developed to train physicians to handle
5
ACCEPTED MANUSCRIPT
emergencies such as shoulder dystocia, vaginal breech delivery, and postpartum hemorrhage as well as surgical skills such as hysteroscopy and laparoscopy3-7. In the field of PAG, there is only one published study in the literature describing the use of simulation to teach the skills necessary
RI PT
to evaluate and care for pediatric patients with gynecological complaints8. This was a study of 19 resident physician participants that compared performance on an objective structured clinical examination (OSCE) before and after a formal lecture during which examination technique was
SC
taught. The study showed improvement in the OSCE scores after participants attended the
M AN U
lecture and demonstration.
While the aforementioned study showed that participants performed better on an OSCE after a teaching intervention than prior to the intervention, we sought to compare performance on OSCE between OBGYN residents with clinical exposure to pediatric and adolescent gynecology, those
TE D
who completed a simulation teaching curriculum and a control group without either experience. Our goal was to develop an appropriate teaching curriculum which could be implemented in training programs without the ability to establish a formal clinical rotation in PAG and determine
EP
if the curriculum was effective in teaching the necessary skills to properly evaluate and treat
AC C
pediatric gynecology patients.
Materials & Methods:
This study had two objectives. First was to develop a PAG simulation teaching curriculum, appropriate pelvic model for teaching examination skills, and an assessment tool to evaluate participants’ skills. The second was to compare performance on an objective structured clinical
6
ACCEPTED MANUSCRIPT
examination (OSCE) between senior residents with clinical training in PAG versus those that completed the simulation teaching curriculum versus those that had neither experience. This study was approved by the MedStar Health Research Institute’s Institutional Review Board and
RI PT
informed consent was obtained from all participants prior to enrollment.
SC
Development of a teaching curriculum and pelvic model
We designed a teaching curriculum, Pediatric and Adolescent Gynecology Education through
M AN U
Simulation (PAGES), to teach the basic principles of evaluation and management of common gynecological complaints in pre-pubertal girls. The curriculum included two online lectures viewed prior to a live session. One lecture was recorded by the senior author (VGL) and covered common vulvar complaints in prepubertal girls. The second lecture was recorded by one of the
TE D
other authors (AMJ) who is a specialist in child physical and sexual abuse and covered aspects of history taking and examination of children with suspected sexual abuse.
EP
The live portion of the PAGES curriculum was a half day session during resident didactic time in the simulation laboratory led by the study authors: PAG fellow (LFD), PAG faculty (VGL) and
AC C
pediatric physical and sexual abuse specialist (AMJ). The session covered a variety of topics including approach to the pediatric patient, prepubertal female genital anatomy, proper examination techniques and positioning, and procedural skills of culture collection, vaginal irrigation, and vaginoscopy. The session included hands on demonstrations of skills and a simulated patient encounter for each participant.
7
ACCEPTED MANUSCRIPT
To create a pelvic model, a life size toddler doll was purchased from a commercial retailer (Figure 1a). The hip joints of the doll were modified to allow for better external rotation and leg positioning. The vaginal canal and cervix were created from recycled components of a
RI PT
hysteroscopy model. A latex mold was used to create external genitalia including the labia majora, labia minora, clitoral hood, urethral opening, and hymen (Figure 1b). The latex mold was draped over the perineum of the doll and attached anteriorly and posteriorly above the hips
SC
to hold the external anatomy in place (Figure 1c). The mold was created in this manner to allow for replacement if the latex hymen or other structures become damaged. Costume makeup was
M AN U
used to create erythema of the labia as needed. The model was used during the teaching session for demonstrating positioning, examination techniques, and procedural skills.
TE D
Objective structured clinical examination
An OSCE was created to evaluate participants’ skills in history taking, clinical examination, differential diagnosis, and procedures in relation to a common PAG clinical scenario. The OSCE
EP
was staged in our simulation laboratory in a mock Emergency Room patient bay (Figure 2a). The bay was wired with visual and audio monitors for outside observers to watch and listen
AC C
while participants completed the simulation. Each OSCE was viewed and graded by two independent observers; the PAG fellow (LFD) and PAG faculty member (VGL). Each observer watched and listened on her own screen with her own headphones and the graders did not communicate with each other during or after the OSCE (Figure 2b).
8
ACCEPTED MANUSCRIPT
For the OSCE scenario, participants were instructed to evaluate a 4 year old girl, Paige, with vaginal bleeding in the emergency room by performing a focused history and examination and then reporting their findings and recommendations to their attending. Inside the bay, the model
RI PT
“Paige” was dressed in a hospital gown and positioned sitting on a hospital stretcher. A
professional standardized patient played the role of Paige’s mother. The participant had 10 minutes to interview the mother and examine the patient. The participant was provided with a
SC
variety of examination tools including examination gloves, a pediatric speculum, lubricant, calgi swab and culturette, 10cc syringes, a Toomey syringe, angiocatheters, saline, and pediatric and
M AN U
adult foley catheters. Following the initial evaluation, the participant was asked to describe the examination findings, list the differential diagnosis and suggest the next steps in evaluation and management. The participant was expected to suggest vaginal irrigation followed by a vaginoscopy if no source of vaginal bleeding is found. During the vaginoscopy, the participant
TE D
should identify the foreign object (small bead) and remove it using an appropriate instrument (Figure 2c). Following completion of this final task, the evaluators met with the participant to
EP
provide feedback on performance.
The OSCE was graded using the check list shown in table 1. Participants earned points for
AC C
appropriate history taking questions, examination skills, differential diagnosis and plan, and performing each step of the two procedures. Points were lost for performing speculum or vaginal digital examinations at any time.
Study:
9
ACCEPTED MANUSCRIPT
All senior residents in our OBGYN residency program were invited to take part in the study. Fourth year residents were invited to participate at the beginning of the academic year and third year residents were invited to participate at the end of the academic year. This schedule was
RI PT
designed to capture residents from two different training years at points of time when their general clinical experience was similar (approximately 3 completed years of training). The OBGYN residency program at our institution is the product of a merger of the MedStar
SC
Washington Hospital Center (MWHC) program and the MedStar Georgetown University
Hospital (MGUH) program. The MWHC residency program includes a required one month
M AN U
clinical rotation in PAG during the third year. The MGUH program does not have this clinical opportunity. This created two study groups based on exposure to clinical teaching in PAG. The fourth year residents were divided into two groups, those who were originally with the MGUH program who had not completed a PAG clinical rotation and those from the MWHC program
TE D
who had completed the PAG clinical rotation. Fourth year residents from MGUH, those without a PAG rotation, were invited to participate in the teaching curriculum as previously described. Third year residents from both MGUH and MWHC, who had either no opportunity for a PAG
EP
clinical rotation or had not yet started their planned rotation, were invited to participate in the study as control subjects. All three groups, the fourth year MWHC residents (clinical rotation
AC C
group), the fourth year MGUH residents (teaching group) and third year residents without prior clinical rotation or teaching (control group) participated in the OSCE and were evaluated by two evaluators. Scores from the examiners were averaged for a final score for each participant.
Results were analyzed by comparing overall OSCE scores for all three groups as well scores for each section: history taking, physical examination, assessment, and procedures (vaginal
10
ACCEPTED MANUSCRIPT
irrigation and vaginoscopy). Groups were compared pair-wisely using non-parametric Wilcoxon rank sum test. A p-value of
