A sustainable model for raising colposcopy expertise in low-to-middle-income countries.

OBJECTIVE: The objective of the study was to assess the effectiveness of training low-to-middle-income countries' local healthcare providers using the Train-the-trainers model in basic colposcopy for cervical cancer prevention. METHOD: This project was designed based on a philosophy known as Train-the-trainers which train proficient colposcopists and a cadre of local trainers who can continue to train and maintain their expertise in a self-sustaining system. The Train-the-trainers workshop is a 1-day program that focuses on three domains; knowledge, communication, and practical skills. Trainer candidates were given pre-course reading assignments and presentation decks. The expert trainers provided feedback on their presentations and tips on communication skills. The practical aspects of the training are supported by proficiency at the Loop Electro-excision procedure simulator and their responses to frequently asked questions. RESULTS: Sixteen physicians from Vietnam attended the Colposcopy Workshop in 2018 and are used as controls. Eleven attended a workshop conducted by trainer candidates who went through the training program outlined above in 2019. A Wilcoxon Signed-ranks test indicated that differences between pre- and post-quizzes' scores were statistically significant in both the 2018 (Z=4.21, P=0.003, r=1.26) and 2019 cohorts (Z=3.558, P<0.001, r=0.89) while Mann-Whitney U test did not detect the difference between the 2018 and 2019 cohorts, U=70.0, P=0.359, r=0.176. The subjective feedback scores from Year 2019 were similar to scores to Year 2018. CONCLUSION: Our preliminary data did not highlight any differences between lectures delivered by expert trainers and lectures delivered by trainer candidates trained in the program. Train-the- trainers might be a more sustainable model for organically raising expertise to effectively provide cervical cancer screening and prevention in low-to-middle-income countries.

Interactive Learning Modules With Visual Feedback Improve Resident Learning in Colposcopy.

OBJECTIVE: The Accreditation Council for Graduate Medical Education and the Council on Resident Education in Obstetrics and Gynecology have milestones and/or competencies relating to colposcopy; however, the optimal way to reach these objectives is not proscribed and left to individual programs. Here, we aim to assess resident skill, confidence levels, perceived level of knowledge, and satisfaction with colposcopic training before and after implementation of a new interactive learning module with visual feedback. MATERIALS AND METHODS: A new online educational intervention was developed by the author (E.L.N.) based on adult learning theory and introduced into our obstetrics and gynecology resident colposcopy curriculum in July 2014. We assessed performance on an objective competency examination administered at baseline and repeated after 6 months of our 24 residents.In addition, we assessed resident confidence levels, perceived level of knowledge, and satisfaction with training before and 6 months after intervention. RESULTS: Scores on a national online examination improved after the intervention (p = .014). Significant improvements on the examination were seen in the sections of medical knowledge (p = .031) and management (p = .011). Residents' perceived knowledge increased significantly after the intervention (p = .030). CONCLUSIONS: Learning outcomes improved after introduction of a novel teaching intervention.

Low-Cost Instructional Apparatus to Improve Training for Cervical Cancer Screening and Prevention.

BACKGROUND: Cervical cancer remains one of the leading causes of cancer for women in medically underserved areas. This is in part due to a lack of trained clinicians to provide the necessary diagnosis and treatment of precancerous lesions to prevent cervical cancer. Increasing medical provider knowledge and skills is important for the early detection and prevention of cervical precancer and cancer in medically underserved areas of the United States and globally. METHOD: LUCIA is a low-cost, universal cervical cancer instructional apparatus that can be used to teach and practice a variety of essential skills for cervical cancer screening, diagnosis, and treatment, including: visual inspection with acetic acid, Pap and human papillomavirus DNA specimen collection, colposcopy, endocervical curettage, cervical biopsy, cryotherapy, and loop electrosurgical excision procedure. EXPERIENCE: LUCIA was used to provide hands-on training in six courses held in Texas (n=3), El Salvador (n=1), and Mozambique, Africa (n=2). Standardized provider evaluations were administered at three of these courses and resulted in mean scores of 4.12/5 for usefulness, 4.46/5 for skill improvement, and 4.43/5 for ease of skill evaluation. CONCLUSION: LUCIA provides dynamic, real-time feedback that allows trainees to learn and practice important skills related to cervical cancer prevention while simulating a patient exam.

A Colposcopy Trainer to Simulate Visualization and Biopsy of the Cervix.

BACKGROUND: Colposcopy is a common office procedure providing a magnified view of the cervix for the evaluation of an abnormal cytology result. Traditionally the procedure has been replicated in simulation training by using a sausage or hotdog to represent the cervix and allow for target biopsy. This is neither reusable nor sustainable. METHOD: We developed a cervix model comprised of food coloring and ballistics gel. After cooling, the surface was dotted with gel that can be activated by a black light to mimic acetowhite changes. The cervix was placed into an existing pelvic trainer and then piloted by attending physicians and resident trainees in obstetrics and gynecology and family practice. EXPERIENCE: Sixteen physicians and residents were surveyed after a simulated colposcopy. Twelve had performed colposcopies and of those, eight stated that the model was very comparable with the real procedure; four stated the model was somewhat comparable. Three had never performed a colposcopy but stated that model was very or somewhat comparable with textbook or journal photographs. CONCLUSION: Our colposcopy trainer represents continued innovation in the field of simulation while being sustainable and economic. We continue to work on enhancing our model to be even more sophisticated and offering additional training options.

Web-based instrument to assess skills in visual inspection of the cervix among healthcare providers.

OBJECTIVE: To validate a web-based instrument for assessing healthcare providers' skills in visual inspection with acetic acid or Lugol iodine (VIA/VILI) for the diagnosis and management of cervical intraepithelial neoplasia. METHODS: An observational cross-sectional study enrolled healthcare providers in a web-based assessment of VIA/VILI skills between August and November 2014. Participants participated in a four-module training course, followed by a multiple-choice test with 70 questions based on cervical photographs of HPV-positive women participating in cervical screening. Logistic regression was used to identify relationships between independent variables and success on the test. RESULTS: Overall, 255 participants completed the test and 99 (38.8%) passed. No correlation was found between age or sex and test performance. Compared with other healthcare workers, physicians (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.01-3.63; P=0.048), and participants with more colposcopy experience (OR 3.62, 95% CI 1.91-6.85; P<0.001) and postgraduate VIA/VILI training (OR 1.95, 95% CI 1.16-3.29; P=0.012) were more likely to pass the test. Participants who repeated the test (31/255 [12.2%]) were five times more likely to succeed on their second repeat (OR 5.89, 95% CI 1.46-23.73; P=0.013). CONCLUSION: Web-based training for VIA/VILI is feasible and can identify healthcare workers who are proficient in this technique.

Impact of laparoscopic sacrocolpopexy learning curve on operative time, perioperative complications and short term results.

OBJECTIVE: Laparoscopic sacrocolpopexy (LSCP) learning is a challenge for unexperienced surgeons, since complications occurrence and anatomical results could depend from surgeon's experience. The aim of this study was to describe LSCP characteristics, perioperative complications and short term anatomical results when LSCP was performed by LSCP-experienced surgeons or trainees. STUDY DESIGN: Patients who underwent LSCP in our surgical unit in the last ten years were included. Patients were excluded if laparotomy was performed without any laparoscopic time. Interventions were divided into LSCP experienced surgeons (who had performed at least 30 procedures) and trainees (residents, fellows, and surgeons with less than 30 procedures). Main outcomes were operative time, peroperative complications (included conversions to open or vaginal surgery, bladder and vaginal perforation, epigastric vessels injury and hemorrhage) early postoperative complications, mesh complications and anatomical results at three months. RESULTS: 492 patients were included, 108 in the trainee group and 384 in the LSCP-experienced group. Groups were comparable for demographics, preoperative clinical examination and surgery characteristics. Average operative time was significantly higher in trainees group than in LSCP-experienced group (251 versus 178 min (p<0.0001)). There was no difference in open surgery conversion rate (5.6% versus 3.9%, p=0.42) or peroperative complication occurrence (4.7% versus 4.6%, p=0.98). Bladder perforations were more frequent in trainee group but difference was not statistically significant (3.7% versus 1.3%, p=0.11). 98% patients were assessed at three months. Overall anatomical success rate was 94.9%. There was no difference in anatomical failure rate between trainee group and LSCP experienced surgeons group (respectively 4.7% versus 5.2%, p=0.82), neither in mesh complication rate (3.9% versus 2.8%, p=0.77). CONCLUSION: LSCP learning in an experimented surgical team induces high operative time, but remains safe for patient.

Colposcopy training and assessment across the member countries of the European Federation for Colposcopy.

OBJECTIVES: Colposcopy training and assessment is not uniform across Europe with individual countries determining their own required standards and regulations. In light of the significant changes in colposcopic practice that have occurred over the past decade and the expansion of the European Federation for Colposcopy (EFC) membership, a study was conducted firstly, to assess the current requirements for training in each of the member countries and secondly, to review an EFC-approved core training curriculum for colposcopy. STUDY DESIGN: A questionnaire survey of the EFC representatives from all member countries investigating their country's current practices/requirements with regard to training, assessment and accreditation for colposcopy. A two-round Delphi consultation with representation from the full, associate and three potential member countries was conducted using a 5-point Likert scale for scoring opinions. The results were analysed with respect to each country's population size and World Bank economic classification. RESULTS: For the questionnaire survey, responses were received from 31/34 countries invited to participate. Training programmes were reported to be in place in 21 of the 31 countries but only 17 of the 21 countries had a committee overseeing the training programme. An assessment was part of the training programme in 20 countries with multiple choice questions and portfolios the most common assessment tools. Countries with a population size less than 2 million have a statistically significant lower probability of having a structured training/assessment programme, 1/5 compared to 20/26 for a populations greater than 2 million, p=0.013. For the Delphi study, responses were received from 34/39 countries invited to participate. Of the 51 competencies previously identified only 2 did not receive full support: 'perform bacterial swabs' and 'provide data to national body'. There was no significant difference in the responses given by member, associate member or potential member countries. CONCLUSIONS: There is considerable variation in colposcopy training and assessment across Europe. This study has enabled consensus opinion with the EFC on the contents of an EFC core curriculum. The revised curriculum has a mandate from the EFC member countries to be implemented across Europe as the standard for colposcopic training.

Providing a genitourinary medicine colposcopy service.

Between 15 and 30 years ago, the management of women with abnormal cervical cytology fell within the remit of GU Medicine. This involved performing colposcopy. With the introduction of certification for colposcopists in 1998, most GU Medicine clinicians stopped providing a colposcopy service. As certification is not required for using the colposcope to diagnose and manage other ano-genital conditions, a GU Medicine-based colposcopy service was introduced at Addenbrooke's Hospital, Cambridge, UK, to assess young women with post-coital bleeding (PCB). One of the objectives of this study was to review this service. In 2011, local guidelines were implemented advising referral to the department of GU Medicine for women under the age of 40 years presenting with PCB with or without inter-menstrual bleeding (IMB) and with no history of previous cervical pathology. A case note review was undertaken for 357 consecutive patients to document clinical findings and management and to determine whether this was an appropriate route of referral. Cervical pathology was found to be uncommon and easily treated within the GU Medicine setting. The provision of a colposcopy service by GU Medicine nurse practitioners or doctors is achievable but requires appropriate training. Importantly, once obtained, these skills can be easily and usefully transferred to examining the vulva, penis, anus and anal canal.

Examiners' perceptions of the objective structured clinical examination in colposcopy.

Certification in Colposcopy by the British Society for Colposcopy and Cervical Pathology (BSCCP) and the Royal College of Obstetricians and Gynaecologists is a formal pre- requisite to the practice of colposcopy within the UK. This certification is awarded after passing an Objective Structured Clinical Examination (OSCE). The aim of the project is to explore examiners' perceptions of the OSCE examination in colposcopy and consider whether it is the right tool to differentiate between safe and unsafe practice in colposcopy. A case study research methodology was employed for the project, and questionnaires were sent to 30 examiners for OSCE in Colposcopy. The project also included conducting semi-structured interviews with two examiners, two trainees and a senior manager of the BSCCP. The questionnaire had a response rate of 28 (94%). The satisfaction rate among the examiners about the standard of questions in OSCE in Colposcopy was 93%, and 89% of the examiners would allow a candidate passing the examination to carry out a clinic in their absence. A total of 26 (94%) examiners thought that the examination was fit for purpose. It was suggested that testing of practical skills should also be made part of the examination. It seems OSCE in Colposcopy is perceived well both by the examiners and the candidates.

Current situation: lower genital tract pathology and colposcopy training in spanish gynecology and obstetrics residents.

OBJECTIVE: This study aimed to evaluate the impact of an educational intervention in lower genital tract pathology (LGTP) on the knowledge and skills acquired by the Spanish specialist residents. This didactic change was carried out under the auspices of the Asociación Española de Patología Cervical y Colposcopia and the Sociedad Española Ginecología y Obstetricia and its Resident Section. STUDY DESIGN: This is an observational, descriptive, and cross-sectional study. The survey was composed of 15 questions voluntarily answered by Spanish gynecology and obstetrics trainees. RESULTS: Compared with a previous survey, a substantial increase in the proportion of Spanish teaching hospitals with an LGTP unit (9/42 vs 47/59) has been detected while doubling the percentage of residents who acknowledge medium to high knowledge on this pathology. The same cannot be said about the handling capacity of vulvodynia registering a great improvement. CONCLUSIONS: Spanish scientific societies, concerned in the quality of LGTP training gained by their residents, have focused on the necessity of LGTP units. Our study confirms the usefulness of this performance in the new continued LGTP education.

Computer-assisted diagnosis (CAD) in colposcopy: evaluation of a pilot study.

BACKGROUND: A prototype system for computer-assisted colposcopic diagnosis (CAD) currently achieves a high level of accuracy of 80% (sensitivity 85%, specificity 75%) for the automatic assessment of colposcopic images. This pilot study investigated whether this type of CAD system is, in principle, capable of influencing the quality of the examiner's assessment. MATERIALS AND METHODS: In this observer study, 24 digitized colposcopic images from patients attending a dysplasia clinic were assessed by 90 participants. All participants had attended a colposcopy training workshop so that they acquired the same basic information and skills. RESULTS: Wide variation was seen among the non-experts, in contrast to the experts. An overall improvement in diagnostic accuracy was noted when the CAD system was used (non-experts: sensitivity 78%, specificity 70%; experts: sensitivity 74%, specificity 70%). CONCLUSION: The CAD system may serve as an aid in the further diagnosis of cervical intraepithelial neoplasia, and has the potential to improve the diagnostic process.

The influence of ASCCP guideline changes on family medicine residency colposcopy training.

BACKGROUND AND OBJECTIVES: The study objective was to determine the influence of the 2001 and 2006 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines changes on colposcopy training at one family medicine residency. METHODS: We conducted a retrospective chart review from January 1, 2000 to October 31, 2009. The 2001 ASCCP guidelines were fully implemented into our practice in June 2002 and the 2006 guidelines in June 2008. Data were extracted from our electronic medical records and delineated into three groups: 2000-2002 (pre-2001 guideline changes), 2003-2007 (post-2001 and pre-2006 update), and 2008-2009 (post 2006 changes) for total female patient visits aged 18-75 years, pap smears, and colposcopies. An ANOVA post-hoc comparison test was performed on the three data groups to test significance. RESULTS: After the 2001 guidelines, there was a 28.6% significant decrease in colposcopies (CI=0.20-0.37). An additional, 16.5% significant decrease occurred after the 2006 revisions (CI=0.06-0.28). Consequently, residents performed 45.1% fewer colposcopies. The total number of pap smears remained relatively unchanged. CONCLUSIONS: Implementation of the 2001 and 2006 ASCCP guidelines significantly reduced the number colposcopies performed, resulting in greater difficulty training competent family medicine residents in colposcopy.

A questionnaire survey to study the effect of colposcopy training in Europe.

The objective of the study was to see if colposcopy training can provide a measurable effect. A questionnaire containing 10 clinical scenarios requiring colposcopy was completed by delegates attending three colposcopy training courses in Europe. A total of 128 and 132 questionnaires were returned pre- and post-training, respectively. The means and standard deviations for the number of correctly assessed scenarios were M = 4.21, SD = 1.71 at pre-training and M = 5.05, SD = 1.82 at post-training. The χ(2)-test showed a statistically significant difference in the proportions of correct answers at pre- and post-training for five questions. The two factor ANOVA showed that there is a statistically significant difference between the pre- and post-training measures (F((2,124)) = 17.13, p < 0.001) although the effect of training is not the same for all three locations. Trainees' results show that there is a positive effect of training. The questionnaire may be used as a quality tool for measuring the effectiveness of training for colposcopy.

Misconceptions about routine colposcopy.

Colposcopy is practised in two ways: (1) to assess women with abnormal screening findings and/or clinically suspicious cervix (called referral colposcopy), and (2) as part of a routine gynaecological examination (referred to as routine colposcopy). There are several misconceptions about routine colposcopy probably reflecting the lack of experience in using routine colposcopy. Misconceptions include: routine colposcopy is screening colposcopy, it is time-consuming, expensive, a waste of time, and the training and maintaining of colposcopic expertise is probably not sufficient in this setting. Routine colposcopy, however, is not a screening tool, it is not screening colposcopy, but capable of identifying cervical precursors and cancer, and thereby reducing the false rates of cervical cancer screening (mainly cytology). Unlike referral colposcopy, routine colposcopy is an inexpensive and rapid procedure conducted as a part of a pelvic examination and has no, or minimal, discomfort that certainly does not exceed that of smear taking, neither is it associated with any psychological burden. Routine colposcopy allows gynaecologists to be convincingly sure in their findings; ensure women having normal epithelium; evaluate abnormalities in details (without biopsy) and counsel patients immediately to alleviate the psychological effects and prepare them for a possible abnormal smear; as well as help make a diagnosis of obscure lesions.

Teaching techniques in the operating room: the importance of perceptual motor teaching.

PURPOSE: To identify sucessful teaching techniques in the operating room environment through examining the teaching of the midurethral sling (MUS) surgery. METHOD: The authors distributed questionnaires with open-ended questions about teaching and learning MUS to 5 urogynecology attendings and 16 obstetrics-gynecology residents in spring 2010. In an effort to identify qualities of an effective sling teacher, the authors used grounded theory to determine common themes and to code participant responses for examples. RESULTS: Of 21 potential respondents, 14 (67%) returned questionnaires. The authors analyzed these and identified seven commonalities among effective sling teachers: they (1) emphasize anatomical landmarks (as determined by 64 total comments); (2) use perceptual-motor teaching (PMT; 38 comments); (3) encourage repetition (28); (4) promote early independence (34); (5) demonstrate confident competence (23); (6) maintain a calm demeanor in the operating room (20); and (7) exhibit a willingness to accept responsibility for mistakes and consequences (9). The second-most common attribute, using PMT, requires the teaching attending to emphasize the motor and tactile aspects of operating and involves incorporating not only what learners see but also what they feel. CONCLUSIONS: The authors report seven qualities or techniques fundamental to good teaching practice in a high-stress, high-technology surgical environment, and they have identified the use of PMT, which to their knowledge has not been previously described. Teachers and learners in this study characterized PMT, which is likely generalizable to surgical procedures other than the MUS, as important. Future research should focus on exploring this technique in other surgeries.

A novel training model for the loop electrosurgical excision procedure: an innovative replica helped workshop participants improve their LEEP.

We wanted to evaluate the feasibility and effect of a hands-on loop electrosurgical excision procedure (LEEP) 2.5-day intensive surgical skills workshop, using a novel training model on porcine tissue. Hands-on simulation-based training was conducted to emphasize colposcopy, local anesthesia, uterine cervix and vulva punch biopsy, LEEP, and complication management. Performance of 51 participants' technical skills was assessed before and after training completion. LEEP performance was significantly better after completion of the training (P < .001). Before and after training mean scores (SD) of 18.0 (3.5) and 23.4 (2.1) were assessed. Multivariate analysis revealed that the training effects were independent of previous surgical expertise. The LEEP workshop was feasible and effective and we recommend implementing hands-on LEEP training into gynecology training programs.

New technologies and advances in colposcopic assessment.

To have a good grasp of clinical colposcopy, it is necessary to understand the histopathologic structure of the normal and dysplastic cervical epithelium. Previous meta-analyses had indicated high overall sensitivity of colposcopy in detecting dysplastic lesions, but recent studies have suggested that the technique has much lower sensitivity in detecting high-grade intraepithelial neoplasia. The best practice in colposcopy relies on accurately taking a biopsy from the correct (i.e. most morphological abnormal) site, and by taking more than one biopsy, the sensitivity for detection of high-grade cervical intraepithelial neoplasia can be increased. Cytological screening programmes of proven and maintained high quality will enhance the predictive colposcopic accuracy for high-grade cervical intraepithelial neoplasia after referral. With the advent of computerised colposcopy and the Internet, digital imaging can be transmitted in real-time for instant viewing, facilitating distant consultation and education. This form of 'telemedicine' will allow family practice and remote areas to have access to colposcopy expertise. Of all the currently available technological adjuncts to colposcopy, spectroscopy devices have demonstrated relatively high sensitivities, and seem to have the best potential to become the technique of choice in future routine clinical practice in developed countries following the human papillomavirus vaccination. Other alternatives may need to be used in parts of the globe with high disease incidence and without organised screening or vaccination programmes. Opportunities remain for global collaboration in research, education and training to promote more effective and affordable cervical screening, and to enhance the skills of colposcopists worldwide.