No difference was found between the gynecologist and the other specialties (51.3 vs 49.6, P=.09). Urogynecologists similarly scored in a statistically insignificant manner (34.3 vs 31.2, P=.08). Subgroup analysis of urogynecologists revealed a significant increase in their test results after our workshop (mean increase: 18.5, 95% CI 17.1–20.0, P<.001). Urogynecologists had significantly better test scores after the workshop compared with general gynecologists and other specialties (95% CI 51.2–54.4 vs 45.7–51.8, P=.006). There were no statistically significant differences in preworkshop test results of participants who previously had training in urethral, endoanal, or levator ani ultrasonography.
The three-dimensional endoluminal ultrasound technology has rapidly evolved and is increasingly utilized by specialists who perform pelvic floor imaging.2,10 We recommend incorporating pelvic floor phantoms in residency programs to teach pelvic floor ultrasonography to obstetrics–gynecologic residents and especially those interested in urogynecology fellowship training. At INOVA Hospital, we have instituted the new American Institute of Ultrasound in Medicine guidelines for the resident teaching and the resident ultrasound modules are incorporated in the INOVA Center for Advanced Medical Simulation.21
Our course was taught repeatedly with the same structure over a long period of time, which allowed us to evaluate knowledge retention using a 60-question preworkshop and postworkshop test. Our workshop was effective in teaching three-dimensional ultrasound techniques to a large number of participants. The learners took both tests in a group setting in the auditorium provided by the conference organizers. There was no way to separate the learners from each other, but they did not communicate; therefore, we believe the test scores validly represent individual diagnostic skills. Comparison of participants' scores clearly shows improvement in diagnostic skills after the workshop. McNemar analysis of individual questions allows us to scrutinize our workshop on a nuanced subcategory level. Diagnostic skills did not increase in 8 of 24 questions in the endoanal category after our workshop; this informs us that teaching the endoanal category possibly needs improvement.
Possible alternatives to the use of pelvic floor phantoms are live models, fresh-frozen cadavers, and computer simulation. We used human models in a few workshops in which transport of the phantoms was not feasible or in one case, the airport security dug into the pelvic floor phantom gel and rendered it unusable. The workshops not using pelvic floor phantoms were excluded from analysis because of the limited number of participants and heterogeneity of the workshops. Although the use of a human model may have inherent limitations, including cost and the need for privacy while performing endovaginal and endoanal examinations, it is expected that participant diagnostic skills would increase similar to a pelvic floor phantom workshop. Fresh-frozen or minimally embalmed human cadavers do not have the echogenic characteristics of living tissue and they are not good substitutes to be used for ultrasound teaching. Computer software, on the other hand, may realistically simulate performing ultrasonography; in 2004, Heer et al22 created software to teach endovaginal ultrasonography using ultrasound records of real patients. They incorporated a sensor on a pelvic model to stimulate holding the transducer and the images shown on a computer monitor were based on the location of the sensor in the pelvic model. The trainees were medical students and were taught ultrasonography of the basic uterus and appendices. Complex structures of the pelvic floor were not taught in Heer et al's22 study and it is unclear how feasible and costly it would be to include them in the software. Our phantoms simulated important details of the pelvic floor while eliminating the need for privacy. Pelvic floor phantoms provided hands-on experience to novice trainees, allowing them to focus their entire attention on operating the keyboard and orienting the transducer by eliminating the trainees' hesitation of hurting the patient or making mistakes.
As a limitation to our study and a possible focus of our future workshops, we could study the effects of varying our intervention arrangements; ie, didactics, followed by pelvic floor phantom practice compared with providing self-practice with the pelvic floor phantoms outside the workshops. Another limitation to our study is the inability to calculate the effect of preworkshop testing on participants’ diagnostic skills improvement. Indeed, in our workshops, the learners were prompted to use the pretest questions as learning points and these learning points were reinforced throughout the course of the workshops. One robust study design to eliminate these biases is the Solomon Four-Group study design; however, in a workshop setting, it was not possible.
As pelvic floor specialists, the learners have used abdominal probes to perform abdominal or perineal ultrasonography at some point in their careers. Because this study focused on endoluminal imaging, we believe that our study group was predominantly naïve to the workshop material. The pelvic floor phantoms created for this study were prototypes simulating some of the important structures in each compartment. Improvement in the quality of phantoms is an ongoing process. Further investigation is in progress to create more realistic and more detailed pelvic floor phantoms.
In summary, a structured pelvic floor ultrasound workshop utilizing pelvic floor phantoms increased participants' diagnostic skills in the setting of various national and international congresses.
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