Clinical Teaching Associates (CTAs) are people, not necessarily medically trained, who provide their own bodies as teaching resources for medical education. CTAs can be exposed to physical or psychological examinations as part of the teaching process which are often extremely intimate. It is unclear how useful CTAs are in medical education and there is no region-wide policy on its implementation or efficacy. This review aims to look at different aspects of CTA programs as well as their benefits and difficulties.
Data and studies were sourced using Medline via Ovid as it provided the easiest access to keyword searching. The following keywords were used in the search: Clinical Teaching Associate, effectiveness, ethics, gynecology, patient simulation, physical and simulation examination amongst others. Supplementary searching on google scholar and Pubmed were made whilst searching for particular titles.
Results and Discussion
It is widely acknowledged that medical and nursing students require access to clinical environments where they can practice and hone their examination and practical skills. Where access to appropriate patients or clinical areas is neither appropriate or adequate, simulation can be used as an educational tool. Simulation has been defined as an interactive method of teaching which imitates real scenarios in a guided manner (Gaba, 2004). This could be through the use of actors, mannequins, or CTAs. Mannequins were first introduced into medical education in the mid1950s to simulate airway and lung functionality (Okuda et al. 2009) but it was not until the 1980s that computerized, “realistic” mannequins that could respond to stimuli in a similar way to actual humans were introduced with the goal of improving patient outcomes (Cooper and Taqueti 2008).
Proficiency in pelvic examination is fundamental in women's health but, due to its intimate nature, teaching medical and nursing students adequate technique is often difficult (Kleinman et al. 1996). Often, students learn these skills by practicing on mannequins and or on patients in operating theatres and clinics under supervision. While, anatomically, simple mannequins may provide a basis of physical examination, they have been criticized for not effectively teaching students adequate communication skills. Equally, performing examinations on patients under general anesthetic has similar issues. CTAs are trained specifically to teach students physical examination skills as well as communication and interpersonal skills which might not be available in other forms of simulation (Fairbank et al. 2014). Additionally, many CTA programs incorporate oral or written feedback from practitioners to students which has been shown to further improve student competence in pelvic examinations (Dilaveri et al. 2013).
CTA teaching usually involves two tutors: one simulating the patient and the other guiding and teaching before and during the practical aspect of the lesson. Afterward, both tutors provide constructive feedback to each student.
There are several difficulties with CTA programs both in terms of logistics and for individual women working as CTAs. A study from Melbourne Medical School(Fairbank et al. 2014) identified many of these problems. Spreading awareness of the program for recruitment purposes is difficult due to logistical reasons as recruitment options are often limited to “word of mouth” and posters on clinic walls. Additionally, the study identified public ignorance on the issue and, by extension, the concept that there are few people willing to subject themselves to such intimate procedures especially when the role is not understood or deemed worthy in society.
Many CTAs find that the role is very psychologically and physically demanding due to the invasive and personal nature of examinations performed upon them. Coupled with the relative inexperience of students performing these examinations, stress can mount rapidly if not monitored well. It is for this reason that most CTAs are limited to a specific number of examinations a week. In the case of Melbourne Medical School, that number is four pelvic examinations per week and much of their time is spent preparing student feedback(Fairbank et al. 2014). As it stands, there is little research into the psychological or physical effects of working as a CTA and this area is one which needs to be explored so as to ensure that this teaching resource is safe for the women undertaking it. It could be argued that this lack of research is symptomatic of a historical bias in the medical field away from women's health until relatively recently because research, which was mostly carried out on men, was assumed to be true for women (Holdcroft 2007, Norton et al. 2016).
While most CTAs were found to come from health or teaching backgrounds, many find it difficult to talk about their work with colleagues and family members due to varying degrees of abuse or ignorance (Fairbank et al. 2014). Some of the worst examples of such abuse were people comparing the job to prostitution and not recognizing the relevance of the role within society.
The relative effectiveness of CTAs in improving student competence in women's health conflicts in places. A randomized control study carried out amongst nursing students in the United States looked at the relative grade point average (GPA) of two cohorts of nurses; one using the CTA program and the other using traditional clinical teaching as a control. The study found that there was little difference between GPA scores between the two cohorts. In fact, the GPA was on average 1.6 points lower in the CTA group. Conversely, a similar randomised control study in Iran(Rahnavard et al. 2013) found that usage of CTAs did improve the clinical attainment of nursing students. There are, however, documented differences in the nursing student satisfaction in Iran, and other developing countries, with a wider “gap” between theoretical knowledge and clinical skills amongst nursing students (Rahnavard et al. 2013) with experienced and senior nurses being unwilling to teach students (Ghiasvandiyan 2004). Additionally, 63% of nursing students reported being treated poorly in the workplace(Ghiasvandiyan 2004). The increased performance in the CTA group in the study in Iran(Rahnavard et al. 2013) could be attributed to a more structured educational system with specific learning objectives relating to women's health. With a lower baseline student satisfaction and attainment, introduction of a program with focused learning objectives within a safe environment, such as the CTA, would logically ameliorate scores and competence. More randomized control studies need to be conducted to ascertain the relative effectiveness of CTA programs as opposed to traditional clinical placements.
Both the above studies rely heavily on assessment of clinical knowledge as the main parameter for whether or not CTA is an effective model of clinical teaching. While this is useful information when it comes to analyzing attainment, this is not the sole factor of what constitutes clinical competence in the field of women's health, and more specifically, pelvic examination. Clinical communication and technique are not specifically addressed by either study.
In some cultures around the world, the use of CTAs is considered controversial or even taboo. The idea of practicing examinations on a healthy person, i.e. not a patient, and or examining female genitalia outside of the clinical setting are not considered proper(Sarmasoglu et al. 2016). In Turkey, a pilot program was carried out(Sarmasoglu et al. 2016) which saw dramatic qualitative improvements in students' confidence and proficiency in intimate examinations despite extra cultural hurdles not commonly seen in the west. It was hailed as successful as it managed to break away from cultural paradigms in order to improve student confidence and patient outcomes.
Historically, individuals within medicine, most notably surgery, have gained notoriety for cases of blasé attitudes to gaining consent for procedures under general anesthetic (Irabor 2006) and there have reportedly been numerous cases of surgeons allowing medical students to practice intimate examinations on unconsenting patients while in theatre(Adashi 2020) even when they are not relevant to surgery itself. Even if consent was gained, this would still present many ethical dilemmas(Hammoud et al. 2019) Providing a safe clinical environment for all medical students to practice these examinations in the form of CTA programs could mean that there is less of a need for students to resort to practicing on patients, not only in surgery but in general as well. This is especially relevant today when patients feel increasing like they are tools for students to practice on(Okuda et al. 2009).
In an increasingly overburdened and resource-starved health system, cost-effectiveness should be considered when assessing CTA necessity. A BMJ study(Janjua et al. 2018) carried out an economic evaluation of CTA program compared to mannequin as well as a randomized control study where two cohorts of medical students’ gynecological proficiencies were assessed where one group used a mannequin and the other used CTA teaching. The study concluded that CTA was more effective as a teaching tool but significantly more expensive than the cost of mannequin teaching. The average cost of CTA teaching per student was £45.06 as opposed to £7.40 for a mannequin with extra costs of up to £37.66 per student. The study did conclude that the cost is likely to be considered worthwhile as a degree of competency was seen with CTAs and there were fewer unanticipated costs.
CTA programs certainly give students a safe and focused environment to develop physical and communication skills and are unquestionably excellent teaching tools. Students are ensured access to a part of the medical field which is the cause of anxiety for many students without prior experience(Sarmasoglu et al. 2016). CTAs themselves have an admirable willingness to sacrifice their personal privacy in the name of medical education that is unseen elsewhere in the profession. This is not to neglect the significant but manageable stresses the role can put upon CTAs and their personal lives. Regulation and monitoring of CTAs must be robust to protect workers in this field. There are questions of whether CTAs are more effective than traditional clinical placement or mannequin training. Most studies, however, have limitations whether it be definitions of success or what factors constitute a more useful teaching method. Further, it has been postulated that most would view the CTA programs cost-effective despite the higher cost due to prioritization of higher standard of care. Studies in this review have mostly compared CTAs to other traditional teaching methods but none have explored the possibility of combining CTA programs with more traditional methods. The outcomes of such a program could be useful to study in future.