Objective
We sought to determine the effect of a pregnancy options counseling workshop focusing on communication skills and ethics on medical student competency.
Study Design
This educational trial randomized 105 third-year students to performance of an objective structured clinical examination before or after participation in the workshop assessed by a blinded reviewer. The primary outcome variable was student-level global competency in options counseling; secondary outcomes included competency components of general communication.
Results
Global competency was achieved by 36% of students in the preworkshop group and 50% in the postworkshop group ( P = .16). Students who participated in the workshop demonstrated higher communication skills. Student ratings of objective structured clinical examination quality were 96-100% positive, with 80% reporting an increase in comfort with options counseling and 88% reporting increased comfort with communication skills.
Conclusion
Participation in a workshop focusing on conscientious refusal positively improved communication skills, but did not significantly impact students’ competency in pregnancy options counseling.
The Association of Professors of Gynecology and Obstetrics (APGO) has designated the highest required competency, “does,” to the third-year medical student skill of nondirective counseling of patients facing unintended pregnancy. APGO, however, does not offer a definition or description of the components of the competency. Besides the communication challenges of dealing with patients who may respond with silence, ambivalence, and/or negative extreme emotion in response to the news of unplanned pregnancy, nondirective options counseling may pose ethical difficulty for physicians and trainees morally opposed to ≥1 of the patient’s options.
Surveys of medical students over recent years demonstrate that while the majority supports abortion in most legal circumstances, sizable minorities remain opposed to abortion and/or to nondirective pregnancy options counseling. Many US medical schools do not integrate exposure to abortion and family planning services, which prevents many students from observing or participating in pregnancy options counseling. Only 30% of US schools include pregnancy options counseling in the preclinical curriculum. To provide students the opportunity to discuss and practice options counseling, and to learn a systematic approach to the related ethical issue of conscientious refusal, we developed an ethics and communication skills workshop at the Miller School of Medicine, University of Miami (MSMUM). Student-reported data on the value and impact of the workshop have been previously published, and the complete instructional module has been separately published. To evaluate the effect of the workshop, we randomized students to participation before or after an objective structured clinical examination (OSCE).
Materials and Methods
During academic year 2009 through 2010, the workshop was conducted as a mandatory didactic exercise on all clerkship blocks during the third or fourth week of the 6-week obstetrics and gynecology clerkship. The workshop, described in greater detail in a previous publication, consisted of 3 parts designed to first illustrate the connection between ethical lapses and communication skills, then facilitate private values clarification, and finally provide opportunity for practice of communication skills. The learning objectives for the ethics section were drawn from the American College of Obstetricians and Gynecologists Ethics Committee opinion on conscientious refusal in reproductive medicine.
As no previously published or otherwise available standardized patient exercise to test nondirective options counseling could be located, we wrote 2 patient scenarios in a previously published format. The scenarios and checklists were reviewed by 2 national experts, one in family planning and the other in standardized patient development in obstetrics and gynecology. A third consultant, the communication skills director at the University of Miami, reviewed the communication skills items on the checklist.
Performance of specific elements of checklist were deemed necessary for achievement of third-year medical student competence, while performance of the other items were judged at expert or faculty/resident level, based on the communication skills curriculum at MSMUM and on input from national family planning experts. Three actors were trained as standardized patients, practicing first with 5 student volunteers and then with 2 experienced pregnancy options counselors who performed the exercise to “expert” counseling standards. These practice sessions allowed the researchers to test the instrument for content validity.
MSMUM institutional review board approval was obtained. The last rotation block of academic year 2008 through 2009 was considered the trial run, allowing for further training of the actors and resulting in minor revisions to the checklist for which institutional review board approval was subsequently obtained. Data points were not submitted from this set of exercises.
During academic year 2009 through 2010, all students on 6 of 8 rotation blocks of the core clerkship in obstetrics and gynecology were randomized 1:1 by a course administrator otherwise uninvolved with the study using a published computer-generated random number table to participate in the standardized patient exercise the morning before the workshop, or 1 week after the workshop. The same administrator also carried out the assignment at the time of randomization. The original intent was to conduct the trial over all clerkship blocks during that academic year rather than work with a number based on a prespecified power calculation, as effects on the typical number of students over an academic year in a required course is of most interest to educators. Owing to unforeseen unavailability of key study personnel during 2 blocks, this goal was not realized.
The exercise was explained on the first day of the clerkship as a required but ungraded course element. Students were told that they could elect to have deidentified data from their performance contribute to an educational research project. If so, they would complete a short questionnaire before and after the exercise, and their interaction would be videotaped. They were informed that no person involved in their grading or other course evaluation would be present at the exercise or review their performance over the next year. Upon arrival to the simulation center, students were again provided this information in written format restating that completion of the preexercise questionnaire would constitute their consent to videotaping and use of their performance data in the research project.
In the standardized patient exercise, the student is given an end-of-shift “sign-out” in an urgent care center consisting of a focused history and physical examination for a patient with vague gastrointestinal complaints, fatigue, a slightly enlarged uterus, and a positive pregnancy test. The student is charged with obtaining any additional relevant information, communicating the pregnancy test result, and completing the encounter. The 2 patients were portrayed by actors representing healthy women: one in her early 20s and married, and the other in her late 30s, with a casual partner. The scenario used was determined by the availability of the actor that scheduled day.
In both scenarios, the patient does not “expect” the positive pregnancy test result. She challenges the student first with emotional silence and then deep uncertainty at the news of the pregnancy, and finally with 2 ethical challenges: “What would you do if it were you/your girlfriend or loved one?” and “What should I do?”
The preexercise student questionnaire consisted of 6 questions regarding basic demographics and religiosity. The postexercise student questionnaire assessed student ratings of the believability and clarity of the standardized patient and instructions; self-ratings of changes in skills and moral comfort after participation; and amount of clinical experience with disclosure of pregnancy test results and/or options counseling. The actor, not blinded to the student’s preworkshop or postworkshop status, completed the checklist immediately after the exercise. A professional psychologist experienced in options counseling and blinded to group assignment independently reviewed the videotapes and completed the same checklist for each student group.
Descriptive statistics reported as proportions or means were analyzed using χ 2 or t tests, respectively. Data analysis was carried out using STATA-IC 12 (Stata Corp, College Station, TX). Data from the performance of the student who did not participate as randomized were eliminated. The primary outcome was the proportion of participants achieving competency at the third-year medical student level. Secondary outcomes included overall ratings of communication skills, the contributions of clinical exposure and measures of religiosity to achievement of competency, and student ratings of the standardized patient exercise. Individual elements of competency include potential conversation items the student might have discussed with the patient, such as “related news of pregnancy test results in a neutral fashion” and “asked how patient felt about pregnancy.” The exhaustive list of items and 2 definitions of global competency, as assessed by the blinded observer, are depicted in Table 1 . The data analyst was blinded to group assignment.
| Competency items | Preexercise group, n = 45 n (%) | Postexercise group, n = 50 n (%) | P value |
|---|---|---|---|
| Introduced him/herself to patient | 44 (100) | 50 (100) | na |
| Asked about use of contraception | 36 (86) | 35 (78) | .34 |
| Related news of pregnancy test results in neutral fashion | 43 (98) | 50 (100) | .28 |
| Asked how patient felt about pregnancy | 40 (91) | 46 (92) | .85 |
| Acknowledged pregnancy continuation as an option | 41 (93) | 48 (96) | .54 |
| Acknowledged abortion as an option | 39 (89) | 47 (94) | .35 |
| Acknowledged adoption as an option | 21 (48) | 31 (63) | .13 |
| Responded to “What should I do?” without interjecting his/her perspective or values | 40 (91) | 46 (96) | .34 |
| Responded to “What would you do?” without interjecting his/her own perspective or values in a way that felt judgmental | 40 (93) | 47 (96) | .54 |
| Communicated well without judgment | 38 (88) | 48 (96) | .16 |
| Respectfully closed encounter | 37 (88) | 48 (96) | .15 |
| Global competency 1: all 11 items above included | 14 (31) | 17 (34) | .76 |
| Global competency 2: 10 items included (all above items with exception of contraception inquiry) | 16 (36) | 25 (50) | .16 |
Results
The flow of participants throughout the study is depicted in the Figure . In all, 108 students were enrolled in the 6 clerkship blocks. Two were not eligible owing to their participation in the pilot phase of the project. All students participated in their OSCE as randomized except 1 who did not attend either session owing to personal emergency, and another who participated after rather than before the workshop. All 105 students who attended the exercise agreed to participate as research subjects. On the last rotation block, the videotapes of all 10 students in the presession group were damaged, and audio was inadvertently lost or deleted, leaving a total of 44 students in that group with completed data.
Demographic and other baseline characteristics are reported in Table 2 . Included are validated measures of religiosity and student reports of directly relevant clinical experience. Participants were generally well matched on all variables between the 2 groups. Compared with US medical school graduates in 2007, this sample had 6% fewer non-Hispanic whites, 3% more Asians, 4% more Hispanics, 3% fewer blacks, and 5% fewer women. A separate analysis, omitting the 10 students in the preworkshop OSCE group whose data from the blinded observer were lost, revealed no significant baseline differences between the 2 groups.
| Characteristic | Preexercise group, n = 55 n (%) or mean (SD) | Postexercise group, n = 50 n (%) or mean (SD) | P value |
|---|---|---|---|
| Sex | |||
| Female | 23 (42) | 20 (40) | .85 |
| Male | 32 (58) | 30 (60) | |
| Race/ethnicity | |||
| White | 34 (63) | 26 (52) | .69 |
| Hispanic | 5 (9) | 5 (10) | |
| Asian | 10 (19) | 15 (30) | |
| Black | 2 (4) | 1 (2) | |
| Other | 3 (6) | 3 (6) | |
| Religious affiliation | |||
| Buddhist | 2 (4) | 0 (0) | .62 |
| Hindu | 4 (7) | 1 (2) | |
| Muslim | 1 (2) | 1 (2) | |
| Catholic | 13 (24) | 14 (29) | |
| Jewish | 13 (24) | 8 (16) | |
| Protestant | 6 (11) | 8 (16) | |
| None | 11 (20) | 10 (20) | |
| Other | 5 (9) | 7 (14) | |
| Religiosity items | |||
| “I try hard to carry my religious beliefs through all aspects of my life.” | |||
| True | 12 (22) | 14 (28) | .46 |
| False | 43 (78) | 36 (72) | |
| “My approach to life is entirely based on my religion.” | |||
| True | 6 (11) | 3 (6) | .37 |
| False | 49 (89) | 47 (94) | |
| “It doesn’t matter so much what I believe as long as I lead a moral life.” | |||
| True | 44 (80) | 42 (84) | .60 |
| False | 11 (20) | 8 (16) | |
| Frequency of religious service attendance | |||
| Never | 22 (40) | 17 (34) | .71 |
| ≤Once/mo | 24 (44) | 22 (44) | |
| >Twice/mo | 9 (16) | 11 (22) | |
| No. of times delivered news of unplanned pregnancy (means reported) | 0.08 (0.33) | 0.06 (0.24) | .81 |
| No. of times observed or participated in pregnancy options counseling (means reported) | 1.04 (1.62) | 1.46 (2.68) | .33 |
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