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The Value of Experiential Sexually Transmitted Disease Clinical Training in the Digital Age

Wangu, Zoon MD*†; Gray, Barbara*; Dyer, Janine MPH*; Chow, Wendy MPH; Calise, Tamara DrPH, MEd; Hsu, Katherine K. MD, MPH

doi: 10.1097/OLQ.0000000000000398
The Real World of STD Prevention

Background The translation of evidence-based guidelines for sexually transmitted disease (STD) care into clinical practice is crucial for the prevention and control of STDs.

Methods Participants in a hands-on, multifaceted, small-group STD Clinical Intensive Course from 2006 to 2013 were asked to complete a survey regarding course content and value compared with other continuing education courses. Survey respondents with demographic and professional information were compared with all other course participants. χ2 Statistics were used to test for differences in proportions; the Cochran-Armitage trend test was used to evaluate for trends in response rate by year of training.

Results Of 113 respondents (35.9% response rate), 92.9% felt that clinical knowledge stayed longer, 84.1% changed clinical practice more, and 90.3% recommended the course more, compared with other continuing education programs in which they had participated previously. Respondents' average suggested registration fee should the course no longer be free was $188.90. Physician assistants and advanced practice nurses were overrepresented among respondents (69.4% vs. 58.1%, P = 0.04); more recent course participants were more likely to respond (P < 0.01).

Conclusions These findings suggest that this STD experiential clinical training program is still relevant to participants in the digital age and is valued more highly than other continuing education experiences. A significant disconnect was identified between what participants are willing/able to pay versus actual course costs, indicating that cost is likely to become a barrier to participation should the course no longer be free.

A survey of participants in a hands-on STD Clinical Intensive Course found that experiential training is still relevant and valuable in the digital age.

From the *Ratelle STD/HIV Prevention Training Center, Massachusetts Department of Public Health, Jamaica Plain, MA; †Division of Pediatric Infectious Diseases & Immunology, UMass Memorial Children's Medical Center, Worcester, MA; ‡JSI Research and Training Institute, Inc, Boston, MA; and §Section of Pediatric Infectious Diseases, Boston University Medical Center, Boston, MA

Acknowledgments: The authors thank Rebecca Millock, BA, of JSI Research & Training Institute, Inc, for her assistance with data analysis; Kevin Cranston, MDiv, and Alfred DeMaria, Jr, MD, of the Massachusetts Department of Public Health and Edward W. Hook III, MD, of the University of Alabama at Birmingham, Alabama, for critical review of the manuscript.

Conflicts of Interest and Source of Funding: W. Chow and T. Calise receive ongoing funding via their institution (JSI Research and Training Institute, Inc.) to serve as external evaluators for the STD Clinical Intensive Course; no additional funds were received for the present manuscript. This work was supported by the Massachusetts Department of Public Health through CDC-RFA-PS09-902.

Correspondence to: Zoon Wangu, MD, Ratelle STD/HIV Prevention Training Center, Massachusetts Department of Public Health, 305 South St, Stables Floor 2, Jamaica Plain, MA 02130. E-mail:

Received for publication August 6, 2015, and accepted November 4, 2015.

Sexually transmitted disease (STD) prevention training centers (PTCs) are Centers for Disease Control and Prevention (CDC) funded to provide 2 to 3 days of intensive in-person training, 4 to 8 participants at a time, at designated STD clinical centers of excellence. Training includes a live model STD examination, video sessions on motivational patient interviewing1 and examination of vaginal wet preps,2 small group discussions on STD syndromes and behavioral counseling, microscope sessions precepted by expert clinicians and laboratorians, and at least ½ day shadowing an STD clinician preceptor. We surveyed course participants to determine what role this in-person training plays in the digital age.

From 2006 to 2013, the Ratelle PTC presented 97 STD intensive courses to 421 participants, all of whom completed Participant Information Forms (PIFs) about themselves. In March 2014, we attempted to contact all participants from 2006 to 2013 via e-mail to complete a SurveyMonkey survey. Reminder e-mails were sent twice; those without valid e-mail addresses were contacted by telephone. We compared respondents with PIF data to all others using the χ2 test. The Cochran-Armitage test was used to evaluate trends in response rate by year of training. Results were considered statistically significant at P < 0.05. If a respondent was still in clinical practice, he/she was asked whether the course (1) resulted in longer knowledge retention, (2) changed clinical practice more, and (3) would be more highly recommended, compared with other continuing education (CE) courses taken. Respondents were also asked whether course length was appropriate. Likert scales were used for responses and free-text fields were provided for comments. Finally, respondents were asked to indicate a price they would be willing to pay to participate, should the course no longer be free. Analyses were conducted using SAS 9.4 (SAS Institute, Inc, Cary, NC).

Of 421 individuals who attended the course and completed a PIF form, we were unable to contact 106. Of 315 valid e-mails, 3 (1.0%) responded but were no longer in clinical practice; 113 (35.9%) were still in clinical practice and completed the survey; 111 of them could be matched to PIF data and were compared with all other participants with PIF data (n = 310). Physician assistants/advanced practice nurses were overrepresented among respondents with PIF data versus all others (69.4% vs. 58.1%, respectively; P = 0.04); no other significant demographic differences were identified (Table 1). Course participants in more recent years were more likely to complete the survey than participants in earlier years (P < 0.01). Course enrollment declined in 2011 to 2013 as 3 of our STD teaching clinics closed (Manchester, NH; Providence, RI; and 1 site in Boston, MA) (Fig. 1).



Figure 1

Figure 1

One hundred five (92.9%) respondents strongly agreed/agreed they retained clinical knowledge acquired in the STD course longer; 95 (84.1%) strongly agreed/agreed the course changed their clinical practices more; and 102 (90.3%) recommended the course to colleagues more, compared with other CE programs in which they had participated (Table 2). Ninety-two (81.4%) respondents felt the length of the course was appropriate.



Fifty-nine (52.2%) respondents cited the hands-on experience, and 34 (30.1%) mentioned working with preceptors in the STD clinic as the most useful course elements. Participants also mentioned that knowledge retention was specifically due to small group sessions (6, 5.3%). Comments included as follows: “It was the most useful course that I took following graduation from my NP program … I think it should be required for anyone doing adolescent and young adult practice,” and “it's an excellent course with a unique teaching format … most courses are lecture only, but there is great benefit in the lab and clinic observation portions of the course.”

In response to the question about a reasonable registration fee, 111 participants responded; average suggested fee was $188.90 (range, $0–$1500). However, multiple comments emphasized that the course should remain free, including “Free is best for this nonprofit agency,” and “it needs to remain free if the CDC is committed to the treatment of STIs as a public health issue.” One respondent felt “no matter the price … [the course] was well worth it.”

Our findings extend those of our colleagues at the Denver PTC, who previously found that trainees between 2001 and 2004 self-reported gains in knowledge, clinical skills, and implementation of recommended practices 6 months after STD intensive course training.3 Because we lacked a control group (e.g., one exposed to a nonexperiential training format), we elected to ask participants directly about how the STD intensive course compared with other CE experiences to which they were exposed. This “meta-level” approach yielded consistently positive findings across questions asked, despite varied professions and employment settings of our participants and despite being unable to control for variable CE experiences. If anything, variation in prior CE experiences should have biased our study in favor of not identifying consistent findings. Our results are consistent with prior studies of continuing medical education interventions showing that a multifaceted approach utilizing hands-on approaches and small group learning is the most effective methodology.4–8

From 2011 to 2013, despite increasing participant enrollment slots at 2 remaining clinical training sites, Ratelle PTC could not compensate completely for lost local training capacity due to closure of STD clinics in the region. Our findings lend additional support to the critical importance of STD specialty clinics as teaching centers of excellence.9,10

The suggested course fee of $188.90 would fall far short of the estimated per-person cost of $1200 for this 2- to 3-day course (based on calculated costs of supplies and required staff). This disconnect implies that cost could become a significant barrier to clinician participation, because several respondents noted how little they are given for continuing medical education support.

One limitation to our study was that we received responses from only 35.9% of trainees with valid e-mail addresses from between 2006 and 2013. Our survey response rate is typical for an unremunerated Web-based survey with no follow-up assessment11,12 and response rate becomes important primarily when it affects representativeness11 To address this issue, we used PIF data and were able to determine only that respondents were more likely to be physician assistants/advanced practice nurses. Two respondents were categorized as others because we were unable to link them back to PIF data, but misclassification of 2 individuals would not have affected statistical testing applied to the 2 groups. Although this assessment is imperfect, it offers some degree of reassurance that respondents did not differ much from others. Overall responses, however, may have been biased toward those with a positive impression of the course; that remains a limitation of self-reported surveys which do not have 100% response rates.

The STD intensive course at Ratelle PTC continues to be viewed as a more highly effective hands-on clinical CE program, although CE is easily and often freely available on the Web.13–15 Despite the cost of delivery, this course should be continued to support clinicians in their care of patients with STDs and increase compliance with CDC strategies for STD prevention and control.

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