Simulation Training in Pediatric and Adolescent Gynecology | Article

This chapter should be cited as follows:
Dumont T, Torres A, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.418063

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 2

Adolescent gynecology

Volume Editor: Professor Judith Simms-Cendan, University of Miami, USA

Chapter

Simulation Training in Pediatric and Adolescent Gynecology

First published: November 2022

AUTHORS

Tania Dumont, MD, FRCSC

Pediatric, Adolescent and Adult Gynecologist, Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Department of Surgery, Division of Gynecology, CHEO, Ottawa, Ontario, Canada; Associate Professor, Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada

Anna Torres

Pediatric, Adolescent and Adult Obstetrician and Gynecologist, Pediatric and Adolescent Gynecology Unit, University Children’s Hospital of Lublin, Poland; Full Professor of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Medical University of Lublin, Poland

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BASIS OF SIMULATION-BASED EDUCATION (SBE)

Healthcare simulation plays a critical role in patient safety; therefore it is important to integrate simulation at all levels of education. In Pediatric and Adolescent Gynecology (PAG), prior training in a simulated environment is of special importance, as the encounter with gynecologist is a very stressful experience for most PAG patients and their caregivers.

There are multiple definitions of simulation; however, in this chapter we use the definition from Professor David Gaba, a pioneer in healthcare simulation: Simulation is a technique – not a technology – to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.¹

It is important to acknowledge that the role of simulation in PAG education is broader than technical skill acquisition. Many adverse incidents in medical practice arise from failure in non-technical domains such as communication, teamwork, or situational awareness rather than technical expertise.²^,³ Simulation can be employed to promote learning, practice, and assessment of both technical and non-technical skills in a patient-safe environment. It also allows for specific rehearsal of rare or unique situations.⁴

Similar to other educational strategies, simulation is informed by coherent frameworks of ideas called learning theories. Learning theory can guide the general approach to simulation, the way it is implemented into the curriculum, simulation scenario design, development, and facilitation. It can also inform the approach to feedback and debriefing. In many instances, simulation is guided by more than one learning theory, and different aspects of simulation implementation may benefit from aspects rooted in various learning theories.

It is important for the clinical teachers to be aware of the theoretical background of the tools they choose to use, in order to optimally facilitate learning and make the best of the simulation, taking into consideration that it is a costly, as well as a time- and resource-consuming, teaching method.⁵

There are several theoretical perspectives, which can inform utilization of simulation in medical education. They include behaviorism, Dewey and Kolb’s experiential learning, Bruner’s constructivist theory, Shon’s reflective practice theory, situated learning theory described by Lave and Wenger as well as critical theories and Hamstra’s functional task alignment theory,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹² the extensive discussion of which is beyond the scope of this chapter.

DESIGNING AND FACILITATING SIMULATION EVENTS

From practical point of view simulation activity design consists of five phases: (1) preparation, (2) briefing, (3) simulating, (4) debriefing (5) evaluating. The phases are summarized in Table 1.

Phases of simulation.

Phase	Stages	Actions
Preparation	Alignment with the curriculum	Analyze program needs Determine participants’ prior knowledge and experience Choose learning goals Schedule the events within the curriculum
	Scenario design	Choose the topic Drafting the story Create scenario progress/labs/prompts Determine equipment requirements/information for technical support Deliver information for simulated patients, caregivers, confederates Brief script preparation Plan adequate time for debriefing Debrief script preparation Check-list preparation (optional) Expert evaluation/review
	Faculty recruitment or training	Train the trainers activities in: simulation facilitation debriefing techniques
	Simulated patient training	SP scenario/script design SP training
	Booking resources	Reserve of rooms in simulation center Reserve technicians Reserve standardized patients
	Performing mock simulation	Facilitate scenario evaluation in terms of: logistics and time team preparedness feasibility logical or technical flaws
Briefing	Logistical information about simulation event	Logistics can be provided the day of simulation or in advance in electronic format and should include: Simulator characteristics Dos and don’ts during simulation Fiction contract Safety issues Introduction to simulation environment
Briefing	Case briefing	Provide Information about: Expectations from learners Sharing learning objectives Case information
Simulation		Conduct simulation Make use of checklists in preparation for debriefing If available, provide video-recording with tagging for debriefing.
Debriefing/ feedback	Choosing the strategy for performing debriefing; consider using video-assisted debriefing Make good use of debriefing	3-phase approach most commonly used: Description Analysis Application (or Summary)¹³ Multiple available approaches:¹⁴^,¹⁵^,¹⁶ 3Ds – Defusing, Discovering, Deepening GAS – Gather, Analyze, Summarize PEARLS – Promoting Excellence And Reflective Learning in Simulation
Evaluation	Preparation of evaluation strategy	Use rubric evaluation forms for consistent evaluation Consider timing of evaluation directly after delayed evaluation
Evaluation	Making use of evaluation results	Implement changes into the simulation event, design or facilitation

Various equipment is available to aid in the delivery of SBE activities and can be adapted to what is available in each training center. They are listed in Table 2.

Available equipment in the delivery of pediatric and adolescent gynecology simulation-based education activities.

Type of equipment	Goal of equipment	Examples of equipment
Part-task trainers (PTTs)	Teaching psychomotor, procedural and technical skills	Low-fidelity plastic trainers Advanced trainers Equipped with sensors, enabling self-directed learning
Whole- or part-body manikins	Teaching complex tasks such has fetal resuscitation	Computer that controls the model’s physiology with monitors showing graphic displays of physiological responses
Virtual reality and haptic systems	Teaching simple and complex surgical procedures	Endoscopy trainers Ultrasound trainers
High-fidelity simulations	Teaching complex tasks as well as non-technical skills such as team communication, situational awareness	May comprise the various combinations of the above listed equipment placed in simulated environments participation of simulated patients
Screen-based simulations (SBS)¹⁷^,¹⁸	Teaching cognitive and psychomotor skills including critical thinking skills and crisis management	Online use with software employing standard cloud-based platforms presents hypothetical patient scenarios in the form of dynamic graphical images and supplemental text users interact with these scenarios via keyboards, touchpads, or mouse controls and choose actions from pre-determined selection menus options exist for asynchronous and synchronous teaching at a distance
3-dimensional virtual reality (3D VR)¹⁹^,²⁰	Teaching decision making, critical thinking and clinical reasoning through making users believe they are in a different environment	Interactive VR uses a totally immersive, dynamic, adaptive, interactive world Involves a software to create an immersive simulated environment head-mounted display

BRIEF REVIEW OF SIMULATION IN OBSTETRICS AND GYNECOLOGY

Specific literature in SBE relating to obstetrics and gynecology was first published in 2005. The first studies looked at medical students practicing their gynecological exam on “professional patients”²¹^,²²^,²³ and have progressed to more complex simulations including additional pre-rotation SBE curriculum involving vaginal deliveries, intra-partum cervical exams, suturing, knot tying, speculum and bimanual exams.²⁴^,²⁵^,²⁶^,²⁷

Randomized controlled trials specific to obstetrics and gynecology residents began in 2013 and have shown positive benefits of simulation on resident skills and competence in both the simulated and clinical environments. In 2018, Nippita et al. demonstrated that both low- and high-fidelity models, to teach intrauterine contraception placement, were comparable when comparing placement skills and self-perceived competence and comfort.²⁸ This is of utmost importance in low- and middle-income countries (LMIC) where simulation resources may be sparse.

PEDIATRIC AND ADOLESCENT GYNECOLOGY (PAG) EDUCATION AROUND THE WORLD

PAG is a budding sub-speciality of gynecology and fellowship programs are growing across North America and around the world. To access the most updated list of available fellowships in North America, one can access the North American Society of Pediatric and Adolescent Gynecology (NASPAG) website.²⁹ At the time of publishing this chapter, 16 official PAG fellowship were available across Canada and the United States of America (USA). Additionally, PAG is a recognized specialty by some European Universities in the Czech Republic, Hungary, Greece and France, as well as in Argentina, Venezuela and Chile in Latin America.³⁰ Other universities offer courses without specific fellowships in PAG: almost all the European countries, Hong Kong in China, Australia and New Zealand, India, Philippines and Malaysia. In addition to training PAG fellows, multiple efforts are being made to expose and train gynecology residents in PAG as studies have demonstrated a lack of training and/or inconsistencies amongst residency programs.

Since 1996, researchers in PAG education from around the world have demonstrated a lack of access to PAG training (rotations, clinics, didactics, curriculums) for medical students and residents (in obstetrics and gynecology, pediatric medicine, pediatric surgery and general medicine) and that well designed curriculums as well as better dissemination of available tools can improve the experience and learning³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹ for our trainees.

Given that NASPAG has a mission to “Conduct and encourage multidisciplinary and inter-professional programs of medical education” they developed both short and long curriculums for disciplines that care for the PAG population such as gynecology, pediatric and general practice residents.⁴²^,⁴³ A pan-European PAG post-specialty training curriculum with 17 chapters including medical, surgical and baseline skills sections was recently published.⁴⁴ Small studies have attempted to evaluate the impact of implementing a PAG curriculum in a gynecology residency. All these studies demonstrated an increased comfort in managing PAG patients and some also demonstrated an increase and/or retention in knowledge.⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸

There are many reasons why PAG is undertaught in residency programs including lack of PAG patients in smaller centers, lack of PAG pathology due to small catchment areas or patients who declined to be examined by trainees, lack of PAG trained-providers to offer educational experiences, lack of PAG surgical exposure, etc. Since identifying this issue, PAG-related educational publications have focused on different educational modalities to palliate the paucity of PAG educational opportunities in residency programs. These modalities include videoconferencing, web-based computerized case series, case-based learning, eLearning modules and PAG simulation.⁴⁹^,⁵⁰^,⁵¹^,⁵²

ALIGNING SIMULATION-BASED EDUCATION WITH PAG CURRICULA

In order to bring the expected learning benefit, the PAG SBE needs to be carefully aligned and positioned within the overall PAG curriculum. It has been suggested that learners and faculty are more likely to take simulation experiences more seriously, if they are well integrated into the curriculum, the evaluation process, and everyday educational activities.⁵³ In the case of PAG curricula, simulation can be especially valuable to facilitate teaching about rare or sensitive conditions with limited access to real-life patient situations. Using simulators and simulation experiences to address such problems can strengthen the overall curriculum and educational program.

Implementation of simulation activities into the curriculum should be preceded by careful analysis of the learning objectives and content, which are best delivered with this technique, timing of simulation event within the curriculum, academic hours dedicated to SBE, availability of faculty and equipment. It should also be decided a priori if the simulation session will be used solely for teaching and/or for performance assessment.⁵⁴ Collaboration with the simulation specialist should be considered from the very beginning of curriculum design. The literature suggests that simulation brings best results if it is introduced at different time points and levels of expertise within the curriculum, and that scaffolding the level of challenge motivates and sustains learner engagement.⁵³

The ADDIE model was proposed as an effective framework for developing and maintaining sustainable SBE activity within any curriculum. It consists of five steps that occur iteratively: assess/analyze, design, develop, implement/deliver, evaluate. The detailed description of this models is beyond the scope of this chapter, further readings are available in the reference section.⁵⁵

SIMULATION-BASED EDUCATION IN PAG

Simulation has been developed in many fields to palliate the paucity of resident access to certain types of patient encounters, exams, procedures and surgery. The same holds true of PAG. Various simulation models and curriculums have been developed over the past decade by passionate PAG providers and educators. In Table 3, the available literature on SBE in PAG in summarized.

Summary of current literature of simulation-based education in pediatric and adolescent gynecology (PAG).

Year, location and first author	Competency evaluated	Type of trainer used	Outcomes of the study
2009, Israel, Beyth⁵⁶	Communication with adolescents	Simulated patients	Satisfaction rate of the participants was so high that they recommended this program be expanded to all gynecologists and residents in gynecology.
2011, USA, Loveless⁵⁷	PAG gynecological exam, collection of microbial cultures, vaginal lavage, vaginoscopy	Simulated pelvis	Significant improvement in scores pre- and post-training and this improvement in knowledge and scores was found to be consistent amongst all years of residency.
2014 and 2016, Canada, Dumont⁵⁸^,⁵⁹	PAG history taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion	Part-task trainers: breasts, pelvis, abdomen	All residents agreed that they gained self-perceived knowledge and that the simulation curriculum should be implemented as a recurrent part of their curriculum; all resident agreed that a simulation scenario focussed on child/adolescent communication should be included in the curriculum; mean OSCE score increased from 54.6% to 78.1% thus concluding the positive impact of this simulation curriculum on resident history taking, examination skills, operative techniques and approach to the PAG population
2015, USA, Damle⁶⁰		Pediatric mannequin with anatomic pre-pubertal genitalia	Residents who were in the simulation group did as well as those on rotation and better than the controls. This reinforces the need to implement PAG simulation curriculums into all residency training programs as simulation can palliate the lack of PAG clinics, OR exposure and clinical rotations.
2019 and 2020 Poland, Torres⁶¹^,⁶²	Self-assessed skills in PAG examination	High-fidelity hybrid model (pelvic trainer + simulated patient + simulation gynecology office	All participants recommended the hybrid model; residents valued the hybrid model in all three components that were assessed (cognitive, affective and behavioral). This was a mixed-methods study the qualitative assessment of which from interviews uncovered six themes that affect the PAG simulation learning environment: physical realism and perceived difficulty, emotional realism of the patient, emotional states, comparison of difficulty between the two simulation types, engagement with the patient and perception of higher fidelity with the hybrid model. This led to the development of a conceptual model influencing learning with high-fidelity hybrid models in PAG simulation (Figure 1).

The conceptual model illustrating factors influencing learning in hybrid model high-fidelity simulation environment.⁶²

To help the reader understand the different models used to date in SBE in PAG, we have taken samples from the current literature as well as personal collection and explained them in Table 4.

Available models in simulation-based education in pediatric and adolescent gynecology.

What to simulate	How to simulate	Picture
Pediatric perineum (Loveless et al.⁵⁷)	Cellophane tapped over the perineum to create a “hymen” tension adjusted so the “hymen” is fully visualized only id proper anterior and lateral traction is applied to labia but otherwise obscured as encountered in the pediatric patient
Pediatric pelvic exam in the lab	Undersized pelvic trainer on the lab bench (low fidelity)
Tanner breast staging (Personal collection, Dumont)	Tanner stages of breast development from 1 to 5 using silicone molding
Tanner breast and pubic hair staging (personal collection share by Nichole Tyson)	Tanner stages of breast development from 1 to 5 using knitted models
Collection of microbial cultures (Torres et al.)⁶¹	Catheterization trainer with vaginal opening and soft labia minora (e.g. Laerdal, often available in Simulation Centers)
Pediatric pelvic exam: demonstrating positioning, examination techniques, and procedural skills (Damle et al.⁶⁰)	Life-size toddler doll purchased from a commercial retailer Doll’s hip joints modified to allow for better external rotation and leg positioning
	Vaginal canal and cervix created from recycled components of a hysteroscopy model Latex mold used to create external genitalia
	Latex mold draped over doll’s perineum and attached anteriorly and posteriorly above the hips to hold the external anatomy in place (replaceable in case of damage) Costume makeup used to create labial erythema
Pediatric vulva and hymen (Dumont, personal communication)	Hybrid model with life-sized doll with phone on speaker-mode placed under the gown (in order to make the doll respond to the exam by trainee), wire coat hanger placed into the legs in order to be able to place in frog-leg position and a pediatric vulva and vagina (silicone gel (Dragon skin) molded over a syringe)
Hybrid model of pelvic exam (Torres et al.⁶²)	Pelvic trainer positioned on the gynecological bed with the SP’s voice and SP caregiver present in the simulated exam room (middle fidelity)
Hybrid model of pelvic exam (Torres et al.⁶²)	Pelvic trainer connected to SP with the SP caregiver present in the simulated exam room (high fidelity)
Imperforate hymen (Dumont et al.⁵⁸)	Two oval shaped silicone skin flaps between which a balloon containing red liquid was placed to mimic an imperforate hymen
Vaginoscopy (Dumont et al.⁵⁹)	“Retired” cystoscope or hysteroscope
Hybrid model for cystoscopy/ vaginoscopy (Ngyuen et al.⁶³)	A bladder model using core-out papaya presented by Nguyen et al. (2015)⁶³ can serve as vagina model for vaginoscopy, it can be placed inside a rubber pelvic model and for higher fidelity it can be connected to the simulated patient
Adnexal torsion (Dumont et al.⁵⁹)	View of inside the laparoscopic model of the adnexal torsion

THE FUTURE OF PEDIATRIC AND ADOLESCENT GYNECOLOGY SIMULATION-BASED EDUCATION

There are many areas of PAG SBE that require more studies. To date, there are no studies looking at knowledge retention and transferability of PAG acquired skills during simulation training and/or implementation of simulation curriculums to either the clinical setting or high-stakes evaluations. This will be an important area of PAG simulation education to explore in future studies.

Studies are needed to explore the role of simulated patients including the possibility of the use of minors as simulated patients. Additionally, interprofessionalism in SBE in PAG could be introduced and its role explored. PAG SBE should not only be considered for learners but also for the professional development and appraisal of PAG specialist.

Finally, the role of screen-based simulators (SBS) and 3-dimensional virtual reality (3D VR) is a new avenue of SBE and its merits in PAG need to be explored.

PRACTICE RECOMMENDATIONS

Educational theory should guide practice in simulation-based teaching in PAG.
SBE should be considered a method of teaching and assessment for both technical and non-technical PAG skills.
Functional fidelity with excellent instructional design confers to successful learning in simulation environment.
Program directors, gynecologists and residents should familiarize themselves with the available and published PAG simulation curriculums.
PAG Simulation curriculums should be implemented into all gynecology residency training programs.
PAG Simulation curriculums should be tailored to each training center, their available resources and their patient population and should be integrated with the core PAG curriculum.

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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