Theriogenology xxx (2015) 1–8
Contents lists available at ScienceDirect
Theriogenology journal homepage: www.theriojournal.com
Teaching of diagnostic skills in equine gynecology: Simulator-based training versus schooling on live horses Christina Nagel a, *, Natascha Ille a, Jörg Aurich b, Christine Aurich a a
Centre for Artificial Insemination and Embryo Transfer, Department for Companion Animals and Horses, University of Veterinary Sciences, Vienna, Austria b Section for Obstetrics and Gynaecology, Department for Companion Animals and Horses, University of Veterinary Sciences, Vienna, Austria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 March 2015 Received in revised form 1 June 2015 Accepted 4 June 2015
Transrectal palpation and ultrasonography of the genital tract in mares are first-day skills for equine veterinarians. In this study, the learning outcome in equine gynecology after four times training on horses (group H4, n ¼ 8), training on horses once (group H1, n ¼ 9), and four times simulator-based training (group Sim, n ¼ 8) was assessed in third-year veterinary students with two tests in live mares 14 days apart. The students of group H4 always scored better for transrectal palpation than students of group Sim and H1 (P < 0.05). Overall, the students reached better results for palpating the left versus the right ovary (P < 0.001), but group H1 students were least successful in obtaining correct ovarian findings (P < 0.05 vs. both other groups). Students’ self-assessment reflected test results with palpation of the right ovary experienced as most difficult for group H1 students (P < 0.01 vs. both other groups). Groups did not score differentially for ultrasound examinations. Sim students were nearly as successful in transrectal palpation of the genital tract in mares as H4 students, and for most parameters assessed, they performed better than H1 students. After training four times on horses, students scored best but nevertheless the overall effect of intensive training was limited. Repeated simulator-based training is a useful tool to prepare veterinary students for transrectal palpation of the genital tract in mares and is more effective than one training session on horses. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Equine Gynecologic examination Learning outcome Simulator-based training
1. Introduction Transrectal palpation and transrectal ultrasonography of the genital tract are indispensable diagnostic procedures in equine gynecology and are therefore part of the curriculum at most veterinary schools. However, considerable practice is required to develop the skills needed to locate and describe the uterus and ovaries. Diagnostic procedures in bovine gynecology traditionally are taught in university teaching herds, on cattle before slaughter [1] or on privately owned cattle during farm visits. Training of veterinary students on live cows is often preceded by * Corresponding author. Tel.: þ43 1 25077 6408; fax þ43 1 25077 5490. E-mail address: [email protected] (C. Nagel). 0093-691X/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.theriogenology.2015.06.007
palpation courses with genital organs obtained from a slaughterhouse. With very few exceptions, none of this is an option in equine gynecology. For the year 2011, the European Commission reported less than 200 horses available for educational purposes in European Union countries [2] leading to a high ratio of students to teaching horses. Because of difficulties to obtain consent of the owner and the risk of horse fatalities due to transrectal perforation [3] access of veterinary students to privately owned horses is restricted. Furthermore, animal welfare and ethical considerations increasingly question the use of live animals for teaching purposes irrespective of species. This is particularly true for invasive or potentially stressful procedures [4]. The veterinary profession itself has been pivotal in developing alternatives to skills training on live
2
C. Nagel et al. / Theriogenology xxx (2015) 1–8
animals. Simulation models have become available for a range of procedures in small animal surgery [5,6], dentistry [7], endoscopy [8], emergency resuscitation [9] and for transrectal palpation of the genital tract in cattle [10]. Some simulators use haptic technologies with the construction of virtual objects to reproduce the tactile sensations experienced when performing the procedure [11]. A bovine transrectal palpation simulator taking advantage of haptic technologies has been used in various educational settings [10,12,13], and a horse ovary palpation simulator has been tested [14]. The implementation of alternatives to training on live animals is hindered by a lack of research on the educational value of simulator-based versus established animal-based teaching methods [4]. Therefore, we have compared skills training of veterinary students in equine gynecology on a simulator and on live horses. The learning objective was to enable students to describe the uterus and ovaries after transrectal palpation and transrectal ultrasonography. We hypothesized that although frequent training on live horses may be the most efficient learning method, repeated simulator training is more efficient than less frequent training on live horses.
2.2. Students A total of 25 students (20 female, five male) with no previous experience in transrectal palpation of horses participated in the study. Students were between 21 and 33 years of age (24.2 0.5 years). Twenty-three students were right handed and two left handed. 2.3. Horses A total of 15 Haflinger and one Warmblood mare aged between 3 and 14 years were available for the study. All horses were used to rectal palpation of the genital tract for at least several months and showed no adverse reactions to this procedure. Before the experiment, they were examined daily or every second day during estrus to assess the exact day of ovulation and maximally every third day during the luteal phase of the estrous cycle. On each occasion, mares were examined by two students. During examinations, horses were placed in stocks. The mares did not receive any medications and were not sedated for transrectal examinations. 2.4. Simulator
2. Materials and methods 2.1. Experimental design A course on gynecologic examination in horses with focus on transrectal palpation and ultrasonography was offered to third-year veterinary students at Vetmeduni Vienna. The course started with 6 hours of lectures on equine gynecology (anatomy, ovarian cycle, gynecologic examination, pregnancy diagnosis), a demonstration of the gynecologic examination, and a case-based e-learning session. Thereafter, students were allocated at random to three different groups for the practical part of the course and received skills training in equine gynecology either four times on live horses (group H4, n ¼ 8), once on live horses (group H1, n ¼ 9), or four times on a training simulator (group Sim, n ¼ 8). One day and 14 days after the last training session, the students’ diagnostic skills were tested on live horses (Table 1). The study was approved by the competent authority for animal experimentation in Austria with regard to the use of horses (Bundesministerium für Wissenschaft und Forschung, license number: BMWF-68.205/0203-II/3b/2013) and by the Ethics Committee of the Medical University of Vienna with regard to studies on human subjects (license number: EK 2131/2013). Students signed an informed consent at the beginning of the study.
A static simulator for transrectal palpation of the genital tract in horses was used for this study (Breed’n Bonny; Brad Pickford, Byaduk, Victoria, Australia). The simulator consists of a metal frame with a latex-made “back end” of a mare through which students may insert a gloved lubricated hand into a rubber tube representing the mare’s rectum. Different nonpregnant and pregnant (Days 14–65) rubber uteri and ovaries of different size were available to simulate findings of different stages during the estrous cycle and pregnancy. The rectum and model genital organs were placed in a water-filled acrylic tube, which recreates an “in-mare” temperature and pressure (water rectum). 2.5. Gynecologic transrectal examination During each training session and in both tests, students examined two horses or two different simulator settings. All students palpated with their dominant hand. For each examination, they were given maximally 5 minutes for transrectal palpation of the uterus and ovaries. Time measurement started after removal of feces from the horse’s rectum. After the examinations, students documented their findings on uterine size, symmetry between uterine horns, uterine consistency/contractility, and size of both ovaries on an examination sheet. During the subsequent 5 minutes,
Table 1 Study schedule for students trained four times on horses (H4), once on horses (H1), or four times on a simulator (Sim). Time Week Week Week Week Week Week Week
Group H4 1 2: 2: 2: 2: 2: 4
Day Day Day Day Day
1 2 3 4 5
Group H1
Lectures, demonstration, case-based e-learning (all groups) Training on 2 horses Training on 2 horses Training on 2 horses d Training on 2 horses d Training on 2 horses d Test with gynecologic examination of 2 horses (all groups) Test with gynecologic examination of 2 horses (all groups)
Group Sim Simulator Simulator Simulator Simulator
training training training training
with with with with
2 2 2 2
settings settings settings settings
C. Nagel et al. / Theriogenology xxx (2015) 1–8
students performed a transrectal ultrasonographic examination followed by documentation of uterine texture and ovarian structures (follicles or CL). After gynecologic examination in the two tests on horses, students answered a self-assessment questionnaire. During the learning period, students received as much assistance by the supervisors as they requested. During the tests, no assistance was given. The occurrence of various reproductive stages on the simulator and in horses during the training and test sessions is summarized in Table 2. 2.6. Test evaluation Before both tests, correct findings and diagnosis in the test horses were obtained by two experienced veterinarians and at no time differed between these examiners. The time needed for examination by the students was recorded. Students received one point each for locating the uterus, left and right ovary and another point if the finding on uterine size, symmetry consistency/contractility, and ovarian size was correctly recorded. On the basis of their findings, students had to formulate a diagnosis (luteal phase, estrus, early pregnancy). 2.7. Statistical analysis The SPSS statistics program (Version 20; IBM, Armonk, NY, USA) was used. Before statistical analysis, for each student, data from examination of the two horses per test were combined. Scores obtained by students were compared with nonparametric tests (between groups: Kruskal–Wallis H test followed by a pairwise Mann–Whitney U test in case of overall significant differences; between tests 1 and 2: Wilcoxon test). Identification, correct description of all genital organs, and correct diagnosis, respectively, versus time needed for the examination were compared by
3
Kaplan–Meier analysis with group as a factor followed by a generalized Wilcoxon test for pairwise comparison between groups. Results for the individual organs (uterus and both ovaries) on transrectal palpation and ultrasonography were analyzed by c2 test (no finding, identification only, identification and correct description by group). For all statistical comparisons, P < 0.05 was considered significant. 3. Results 3.1. Examination When examining mares by transrectal palpation in the first test, the students trained on horses four times (group H4) scored better than the students trained on horses once (group H1) or the students trained four times on a simulator (group Sim; P < 0.05). In test 2, the score in group H4 but not groups H1 and Sim had decreased (P < 0.05), but groups H4 and Sim still scored better than group H1 (P < 0.05; Fig. 1A). For the score on ultrasound examinations, significant differences existed neither between groups nor between tests (Fig. 1B). Kaplan–Meier analysis revealed significant differences between groups with regard to location of the genital organs on transrectal palpation. The students of group H4 were always able to locate the uterus and ovaries in both tests (P < 0.05 vs. H1 and Sim). Group Sim was better than group H1 in test 2 (P < 0.05; Fig. 2A, B). In test 1, maximum points for transrectal palpation were obtained in 50% of examinations in group H4. In groups Sim and H1, only 18% and 6% of transrectal palpations scored maximal points (P < 0.001 vs. H4; Fig. 2C). In group H4, the number of correct findings was higher in test 1 compared to test 2 (P < 0.05). No significant differences between groups existed in test 2 (Fig. 2D). For ultrasonographic examination, an overall mean score of 3.9 0.2 out of six was reached with no differences between groups and tests
Table 2 Occurrence of various gynecologic findings on the rectal palpation simulator and in horses during training and test sessions (for more details see Supplementary Material). Diagnosis
Findings simulator
Frequency simulator
Nonpregnant
Symmetry of uterine horns, firm consistency of the uterus, ovaries of same size Symmetry of uterine horns, firm consistency of the uterus, left ovary larger than the right ovary Symmetry of uterine horns, firm consistency of the uterus, right ovary larger than the left ovary Days 30–65 of gestation, marked asymmetry of the uterine horns, ovaries of different size
3 3 3 3
Pregnant
Estrus
Diestrus
Anestrus
4
Findings horse
Frequency training (H1 and H4)
Frequency test 1 and 2 (all groups)
Symmetry of uterine horns, relaxed consistency of the uterus and moderate uterine edema, follicle of >3.5 cm diameter on left ovary Symmetry of uterine horns, relaxed consistency of the uterus and moderate uterine edema, follicle of >3.5 cm diameter on right ovary Symmetry of uterine horns, firm consistency of the uterus and homogeneous uterine echogenicity, CL on the left ovary Symmetry of uterine horns, firm consistency of the uterus and homogeneous uterine echogenicity, CL on the right ovary Symmetry of uterine horns, relaxed consistency of the uterus and homogeneous uterine echogenicity, absence of a CL and follicles of
Contents lists available at ScienceDirect
Theriogenology journal homepage: www.theriojournal.com
Teaching of diagnostic skills in equine gynecology: Simulator-based training versus schooling on live horses Christina Nagel a, *, Natascha Ille a, Jörg Aurich b, Christine Aurich a a
Centre for Artificial Insemination and Embryo Transfer, Department for Companion Animals and Horses, University of Veterinary Sciences, Vienna, Austria b Section for Obstetrics and Gynaecology, Department for Companion Animals and Horses, University of Veterinary Sciences, Vienna, Austria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 March 2015 Received in revised form 1 June 2015 Accepted 4 June 2015
Transrectal palpation and ultrasonography of the genital tract in mares are first-day skills for equine veterinarians. In this study, the learning outcome in equine gynecology after four times training on horses (group H4, n ¼ 8), training on horses once (group H1, n ¼ 9), and four times simulator-based training (group Sim, n ¼ 8) was assessed in third-year veterinary students with two tests in live mares 14 days apart. The students of group H4 always scored better for transrectal palpation than students of group Sim and H1 (P < 0.05). Overall, the students reached better results for palpating the left versus the right ovary (P < 0.001), but group H1 students were least successful in obtaining correct ovarian findings (P < 0.05 vs. both other groups). Students’ self-assessment reflected test results with palpation of the right ovary experienced as most difficult for group H1 students (P < 0.01 vs. both other groups). Groups did not score differentially for ultrasound examinations. Sim students were nearly as successful in transrectal palpation of the genital tract in mares as H4 students, and for most parameters assessed, they performed better than H1 students. After training four times on horses, students scored best but nevertheless the overall effect of intensive training was limited. Repeated simulator-based training is a useful tool to prepare veterinary students for transrectal palpation of the genital tract in mares and is more effective than one training session on horses. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Equine Gynecologic examination Learning outcome Simulator-based training
1. Introduction Transrectal palpation and transrectal ultrasonography of the genital tract are indispensable diagnostic procedures in equine gynecology and are therefore part of the curriculum at most veterinary schools. However, considerable practice is required to develop the skills needed to locate and describe the uterus and ovaries. Diagnostic procedures in bovine gynecology traditionally are taught in university teaching herds, on cattle before slaughter [1] or on privately owned cattle during farm visits. Training of veterinary students on live cows is often preceded by * Corresponding author. Tel.: þ43 1 25077 6408; fax þ43 1 25077 5490. E-mail address: [email protected] (C. Nagel). 0093-691X/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.theriogenology.2015.06.007
palpation courses with genital organs obtained from a slaughterhouse. With very few exceptions, none of this is an option in equine gynecology. For the year 2011, the European Commission reported less than 200 horses available for educational purposes in European Union countries [2] leading to a high ratio of students to teaching horses. Because of difficulties to obtain consent of the owner and the risk of horse fatalities due to transrectal perforation [3] access of veterinary students to privately owned horses is restricted. Furthermore, animal welfare and ethical considerations increasingly question the use of live animals for teaching purposes irrespective of species. This is particularly true for invasive or potentially stressful procedures [4]. The veterinary profession itself has been pivotal in developing alternatives to skills training on live
2
C. Nagel et al. / Theriogenology xxx (2015) 1–8
animals. Simulation models have become available for a range of procedures in small animal surgery [5,6], dentistry [7], endoscopy [8], emergency resuscitation [9] and for transrectal palpation of the genital tract in cattle [10]. Some simulators use haptic technologies with the construction of virtual objects to reproduce the tactile sensations experienced when performing the procedure [11]. A bovine transrectal palpation simulator taking advantage of haptic technologies has been used in various educational settings [10,12,13], and a horse ovary palpation simulator has been tested [14]. The implementation of alternatives to training on live animals is hindered by a lack of research on the educational value of simulator-based versus established animal-based teaching methods [4]. Therefore, we have compared skills training of veterinary students in equine gynecology on a simulator and on live horses. The learning objective was to enable students to describe the uterus and ovaries after transrectal palpation and transrectal ultrasonography. We hypothesized that although frequent training on live horses may be the most efficient learning method, repeated simulator training is more efficient than less frequent training on live horses.
2.2. Students A total of 25 students (20 female, five male) with no previous experience in transrectal palpation of horses participated in the study. Students were between 21 and 33 years of age (24.2 0.5 years). Twenty-three students were right handed and two left handed. 2.3. Horses A total of 15 Haflinger and one Warmblood mare aged between 3 and 14 years were available for the study. All horses were used to rectal palpation of the genital tract for at least several months and showed no adverse reactions to this procedure. Before the experiment, they were examined daily or every second day during estrus to assess the exact day of ovulation and maximally every third day during the luteal phase of the estrous cycle. On each occasion, mares were examined by two students. During examinations, horses were placed in stocks. The mares did not receive any medications and were not sedated for transrectal examinations. 2.4. Simulator
2. Materials and methods 2.1. Experimental design A course on gynecologic examination in horses with focus on transrectal palpation and ultrasonography was offered to third-year veterinary students at Vetmeduni Vienna. The course started with 6 hours of lectures on equine gynecology (anatomy, ovarian cycle, gynecologic examination, pregnancy diagnosis), a demonstration of the gynecologic examination, and a case-based e-learning session. Thereafter, students were allocated at random to three different groups for the practical part of the course and received skills training in equine gynecology either four times on live horses (group H4, n ¼ 8), once on live horses (group H1, n ¼ 9), or four times on a training simulator (group Sim, n ¼ 8). One day and 14 days after the last training session, the students’ diagnostic skills were tested on live horses (Table 1). The study was approved by the competent authority for animal experimentation in Austria with regard to the use of horses (Bundesministerium für Wissenschaft und Forschung, license number: BMWF-68.205/0203-II/3b/2013) and by the Ethics Committee of the Medical University of Vienna with regard to studies on human subjects (license number: EK 2131/2013). Students signed an informed consent at the beginning of the study.
A static simulator for transrectal palpation of the genital tract in horses was used for this study (Breed’n Bonny; Brad Pickford, Byaduk, Victoria, Australia). The simulator consists of a metal frame with a latex-made “back end” of a mare through which students may insert a gloved lubricated hand into a rubber tube representing the mare’s rectum. Different nonpregnant and pregnant (Days 14–65) rubber uteri and ovaries of different size were available to simulate findings of different stages during the estrous cycle and pregnancy. The rectum and model genital organs were placed in a water-filled acrylic tube, which recreates an “in-mare” temperature and pressure (water rectum). 2.5. Gynecologic transrectal examination During each training session and in both tests, students examined two horses or two different simulator settings. All students palpated with their dominant hand. For each examination, they were given maximally 5 minutes for transrectal palpation of the uterus and ovaries. Time measurement started after removal of feces from the horse’s rectum. After the examinations, students documented their findings on uterine size, symmetry between uterine horns, uterine consistency/contractility, and size of both ovaries on an examination sheet. During the subsequent 5 minutes,
Table 1 Study schedule for students trained four times on horses (H4), once on horses (H1), or four times on a simulator (Sim). Time Week Week Week Week Week Week Week
Group H4 1 2: 2: 2: 2: 2: 4
Day Day Day Day Day
1 2 3 4 5
Group H1
Lectures, demonstration, case-based e-learning (all groups) Training on 2 horses Training on 2 horses Training on 2 horses d Training on 2 horses d Training on 2 horses d Test with gynecologic examination of 2 horses (all groups) Test with gynecologic examination of 2 horses (all groups)
Group Sim Simulator Simulator Simulator Simulator
training training training training
with with with with
2 2 2 2
settings settings settings settings
C. Nagel et al. / Theriogenology xxx (2015) 1–8
students performed a transrectal ultrasonographic examination followed by documentation of uterine texture and ovarian structures (follicles or CL). After gynecologic examination in the two tests on horses, students answered a self-assessment questionnaire. During the learning period, students received as much assistance by the supervisors as they requested. During the tests, no assistance was given. The occurrence of various reproductive stages on the simulator and in horses during the training and test sessions is summarized in Table 2. 2.6. Test evaluation Before both tests, correct findings and diagnosis in the test horses were obtained by two experienced veterinarians and at no time differed between these examiners. The time needed for examination by the students was recorded. Students received one point each for locating the uterus, left and right ovary and another point if the finding on uterine size, symmetry consistency/contractility, and ovarian size was correctly recorded. On the basis of their findings, students had to formulate a diagnosis (luteal phase, estrus, early pregnancy). 2.7. Statistical analysis The SPSS statistics program (Version 20; IBM, Armonk, NY, USA) was used. Before statistical analysis, for each student, data from examination of the two horses per test were combined. Scores obtained by students were compared with nonparametric tests (between groups: Kruskal–Wallis H test followed by a pairwise Mann–Whitney U test in case of overall significant differences; between tests 1 and 2: Wilcoxon test). Identification, correct description of all genital organs, and correct diagnosis, respectively, versus time needed for the examination were compared by
3
Kaplan–Meier analysis with group as a factor followed by a generalized Wilcoxon test for pairwise comparison between groups. Results for the individual organs (uterus and both ovaries) on transrectal palpation and ultrasonography were analyzed by c2 test (no finding, identification only, identification and correct description by group). For all statistical comparisons, P < 0.05 was considered significant. 3. Results 3.1. Examination When examining mares by transrectal palpation in the first test, the students trained on horses four times (group H4) scored better than the students trained on horses once (group H1) or the students trained four times on a simulator (group Sim; P < 0.05). In test 2, the score in group H4 but not groups H1 and Sim had decreased (P < 0.05), but groups H4 and Sim still scored better than group H1 (P < 0.05; Fig. 1A). For the score on ultrasound examinations, significant differences existed neither between groups nor between tests (Fig. 1B). Kaplan–Meier analysis revealed significant differences between groups with regard to location of the genital organs on transrectal palpation. The students of group H4 were always able to locate the uterus and ovaries in both tests (P < 0.05 vs. H1 and Sim). Group Sim was better than group H1 in test 2 (P < 0.05; Fig. 2A, B). In test 1, maximum points for transrectal palpation were obtained in 50% of examinations in group H4. In groups Sim and H1, only 18% and 6% of transrectal palpations scored maximal points (P < 0.001 vs. H4; Fig. 2C). In group H4, the number of correct findings was higher in test 1 compared to test 2 (P < 0.05). No significant differences between groups existed in test 2 (Fig. 2D). For ultrasonographic examination, an overall mean score of 3.9 0.2 out of six was reached with no differences between groups and tests
Table 2 Occurrence of various gynecologic findings on the rectal palpation simulator and in horses during training and test sessions (for more details see Supplementary Material). Diagnosis
Findings simulator
Frequency simulator
Nonpregnant
Symmetry of uterine horns, firm consistency of the uterus, ovaries of same size Symmetry of uterine horns, firm consistency of the uterus, left ovary larger than the right ovary Symmetry of uterine horns, firm consistency of the uterus, right ovary larger than the left ovary Days 30–65 of gestation, marked asymmetry of the uterine horns, ovaries of different size
3 3 3 3
Pregnant
Estrus
Diestrus
Anestrus
4
Findings horse
Frequency training (H1 and H4)
Frequency test 1 and 2 (all groups)
Symmetry of uterine horns, relaxed consistency of the uterus and moderate uterine edema, follicle of >3.5 cm diameter on left ovary Symmetry of uterine horns, relaxed consistency of the uterus and moderate uterine edema, follicle of >3.5 cm diameter on right ovary Symmetry of uterine horns, firm consistency of the uterus and homogeneous uterine echogenicity, CL on the left ovary Symmetry of uterine horns, firm consistency of the uterus and homogeneous uterine echogenicity, CL on the right ovary Symmetry of uterine horns, relaxed consistency of the uterus and homogeneous uterine echogenicity, absence of a CL and follicles of
