Becoming a trainer can be exciting, challenging, and most of all, rewarding. As you help learners to develop and refine important clinical skills, you also have the opportunity to teach about other critical aspects of reproductive health, such as the public health context of unintended pregnancy, the nuances of patient-centered care, word choice, and cultural humility. As a trainer, you will also build relationships within the reproductive health community and help address stigma associated with abortion provision.
VALUES CLARIFICATION AND PROFESSIONAL RESPONSIBILITIES
It is best to introduce the process of values clarification with each learner before, or soon after having begun patient contact in the abortion care setting.
- Have new trainees read Chapters 1 and 2 before training initiation to clarify their personal values about pregnancy options and abortion in the context of professional judgments they will be called upon to make.
- Remind trainees of their professional responsibility to, and opportunity to support patients by, provide appropriate referrals regardless of their own beliefs.
- Relay how literature recognizes the “conscience” in abortion provision, and not just refusal to participate. Teach how provision can address stigma, as well as impact clinical practice, law and bioethics (Harris 2012).
- Offer each trainee to shadow a patient all the way through the counseling and abortion process, to understand a patient’s perspective before getting into the specifics of clinical care.
- Continue to revisit your own values as you work with patients and trainees, as these interactions may shed new light on your experiences.
- Remember that stigma is an important predictor of satisfaction, burnout and compassion fatigue among abortion care providers (Martin 2014). Therefore, strengthening human resources for abortion care requires stigma reduction efforts. Participants in the Provider Share Workshops show reductions in stigma over time.
A thoughtfully implemented opt-out policy is key to the success of an integrated abortion training program. Significantly more trainees receive abortion training when it is incorporated as a routine part of the curriculum with opt-out provisions, compared to when it is elective only. In addition, working with opt-out trainees is likely to help reduce abortion stigma, by providing exposure to the points of view of both patients and providers.
In addition to training future providers, we hope this curriculum broadens the perspective of opt-out trainees to provide unbiased evidence-based care. Gaining skills to provide balanced options counseling, referral and follow-up, miscarriage management, and contraceptive care is critical for all learners. By tailoring the program content to focus on individual interest, trainees ambivalent about abortion still gain critical reproductive health skills.
Studies show that trainees opting-out of some or all abortions valued the ability to partially participate in the family planning training. Many identified specific aspects of their training that impact future patient care, including those addressing core competencies in medical knowledge, exam and procedural skills, counseling skills, appropriate referrals and professionalism. (Steinauer 2014, Freedman 2010, Nothnagle 2008).
For opt-out trainees, we recommend that you:
- Respect varying opinions, which can help defuse polarity.
- Express interest in how a trainee developed their point of view.
- Reinforce that even trainees ambivalent about abortion have important knowledge and patient-care skills to gain from this rotational experience.
- Be explicit about not forcing anyone to perform procedures. There is plenty more to learn.
- Consider sharing part of your own experience, such as the first time you looked at fetal parts or used intra-operative ultrasound.
- Tailor program using the Opt-Out or Partial Participation Curriculum in Chapter 1.
- Refer to online modules like Physicians for Reproductive Health’s LEARN (Lessons to Enhance Awareness of Reproductive Needs) and ARSH (Adolescent Reproductive and Sexual Health).
As learners realize that choices to provide abortion services are not black and white for providers, opt-out trainees often expand their participation through the rotation.
PRACTICE WITH SIMULATION MODELS PRIOR TO PATIENT CARE
A growing body of literature supports the use of simulation models in medical education (Lofaso 2011, Okuda 2009, Ziv 2003). Limited patient encounters, demands on training hours, and heightened focus on safety have all lead to the increasing use of models and simulated complication scenarios. Simulation can help learners with procedural comfort, complication management, and stress-readiness during a crisis.
Existing simulation models for uterine aspiration include low-cost fruit models such as the papaya (Paul 2005) and pitaya (Goodman 2015); both enable trainees to practice cervical anesthesia, aspiration, pelvic exams, or IUD placement. In addition, a number of anatomic models are available to help new learners with pelvic exams and gynecologic procedures.
Programs and trainers should consider require comfort with a model BEFORE a real patient, to set a learner up for success during an actual procedure. The model can be very simple—for example using the trainer’s fisted hand as a pretend cervix if no other model is available—but comfort should be obtained prior to doing the procedure itself.
MODELING HIGH QUALITY PATIENT-CENTERED CARE
Remember that in the role of trainer, our own interactions with patients and staff communicate our underlying philosophy. Given the sensitivity of this work, we encourage you to specifically consider the following resources to:
- Incorporate patient-centered counseling techniques and word choices
- Explore implicit bias
- Promote inclusiveness and cultural humility
It is helpful to differentiate evidence-based recommendations from provider preference or style.
- Stay current with the growing body of abortion and contraceptive literature
- Expose trainees to the styles of various providers
Rather than focus on trainees achieving specific procedural numbers or specialty training, there have been concerted efforts in reproductive health training to help learners attain clinical knowledge and skill-based competencies in line with health professional education standards (e.g. ACGME Family Medicine Milestones, AACN, ACNM, NONPF). Each skill can be delineated into clear steps with observable competencies for learners and for trainers-in-training (Cappiello 2016).
In one clinician training model (Levi 2012), competencies were monitored by both the trainer and the trainee. Both groups used daily and final competency assessments in areas of a) patient comfort, b) procedural completeness, c) speed, and d) ability to identify problems, while review of complications was used to identify concerns about clinician safety.
Abortion safety, efficacy and acceptability are found to be equivalent between most cadres of advanced practice clinicians and physicians (Bernard 2015, Weitz 2013). And the similarity in safety and efficacy is true for both experienced and newly trained providers (Jejeebhoy 2011, Warriner 2006). This supports the adoption of policies allowing more providers to perform early aspiration abortions, and in turn, helps to expand patient access to abortion care.
MEETING INDIVIDUALIZED NEEDS OF YOUR LEARNER
Use a step-wise approach to involving new trainees
- Start slowly on earlier cases, and build involvement with each case. Trainees may progress at differing paces. For some trainees, they may build up to doing most steps of a case in the first session or so. For faster learners, the trainee can do the pelvic exam and observe the first procedure, help aspirate the uterus with the second, help dilate and place the cannula on the third, and be involved in the entire abortion on the fourth. .
- To best support learning, stay aware of the trainee’s skill advancement. At first, stand behind a trainee, so you can assist with your hands, and see what they are seeing. As the learner gains competence, move back or to the side.
- Consider agreeing ahead of time on a time limit after which the trainer intervenes (for example, if cases go on longer than 5 minutes). This helps depersonalize the need for the trainer to intervene, and ensures patient comfort and flow maintenance.
- With time, trainees should also take command of communication with the patient.
- Consider having a trainee work independently at the end of the rotation, especially for earlier gestational ages, while you stay within earshot if they need your assistance.
TEACHING DURING THE PROCEDURE
Prioritize patient safety
At the beginning of the training session, ask the trainee what their priorities are for the day, and review plans for communicating during procedures so it is patient-centered. For example:
- Introduce yourselves as a team, and initially lead the patient conversation, allowing a trainee to focus on new procedural skills.
- Don’t hesitate to step in when you are concerned about patient comfort or safety.
- Consider having a signal for “trading places” such as a tap on the shoulder if the situation becomes challenging.
- Encourage trainees to stop for assistance if the procedure does not feel right (i.e. they feel resistance with dilation or instruments pass further than usual).
Play an active role in clinic flow (particularly in a high-volume clinic)
- Set reasonable goals for procedure times with trainees. Emphasize that longer procedures may be uncomfortable for patients and increase waiting for other patients. A first trimester abortion should rarely take longer than 5-10 minutes of speculum time.
- Prior to seeing the first patient, review critical steps of the procedure, such as accurate bimanual exam, efficient speculum placement, the first dilator pass, and the final check for completion.
- Plan special needs for a case before entering the procedure room to minimize trips out.
- Review tray set-up to adhere to the no-touch technique.
- Tell trainees that part of your communication with them will be through speaking with the patient. For example, you may prompt a new learner to inject anesthetic by saying to the patient, “Next is numbing medicine; you may feel a cramp or nothing at all.”
- Rely on a medical assistant or doula to support the patient to distract from the teaching process.
- If a trainee is taking a long time for any one step (e.g.: speculum placement or dilation), assist with your hands or step in, and offer helpful tips before the next patient, when the trainee can try again.
- Communicate early and often with the clinic or flow manager.
- Provide most teaching and feedback between cases, or bookmark them for the end of the day.
- For additional ideas, see Clinic flow strategies.
GIVING EFFECTIVE FEEDBACK
Feedback helps keep an individual on target to achieve learning goals. Data show that learners appreciate feedback early and often (Cantillon 2008). Providing this information can increase a learner’s rate of improvement, and inspire higher levels of performance.
- Provide feedback in private.
- Invite a trainee to take the first shot at self-evaluation. Ask, “How do you think that case went?” or “What else might you try in this situation?”
- Give better feedback using a simple five step model captured in the acronym SMART: giving feedback that is Specific, Measurable, Achievable, Relevant and Time-based.
- Offer feedback that reinforces good clinical skills before constructive criticism, to soften the delivery and avoid discouragement.
- Share observations about non-verbal communication, wording, and tone.
- Give feedback that includes an action plan for what to try next.
Remember that all learners benefit from constructive feedback, even experienced providers.
Consider varying the types of feedback you provide.
- Share your observation: “You used a number of open-ended questions with that client.” “Your pelvic assessment was accurate, as we see from the angle the dilator entered.”
- React at a personal level: “I liked your reassuring tone; it really seemed to calm her down.” “I appreciate how you asked for help with cannula placement.”
- Predict the outcome of a situation and emphasizing the consequences of an incorrect practice: “One risk of continuing to push against resistance is creating a false tract or perforation. You avoided that by stopping to confirm the patient’s uterine position.”
MASTERING AND TEACHING ULTRASOUND (US)
As you become more proficient as a provider and trainer, continue to master your own US skills for dating and intra-operative guidance. Where available, try to provide your trainees with US experience at multiple gestational ages. In addition to reviewing basic US principles from Chapter 3, encourage learners to take advantage of interactive online curriculum that may be available in your setting. If you have other staff members proctoring trainees, consider observing a trainee sonogram yourself to assess skill level. Resources include:
- Ultrasound in Abortion Care (Interactive Online Curriculum), ARMS 2007
- Ultrasound Lecture Series – Obstetrics and Gynecology, AUIM
- Early Pregnancy Ultrasound Skills Evaluation (see below)
HELPING TO PREPARE FOR TRANSITIONS TO PRACTICE
It is valuable to ask trainees how they might integrate this material into their future careers, Reinforce the stories and benefits of being able to offer services in one’s own practice.
- Compare a primary care office to a high-volume setting, which has more ancillary staff to provide counseling, lab work, ultrasound, or recovery support.
- Point out areas where different practice standards exist (i.e. routine vs. selective US).
- Encourage trainees to consider how they will adapt to these differences.
Reinforce the expectation that the trainee should be able to provide multiple aspects of care by the end of their training. On the last day of training, consider completing all steps (US, counseling, pre-medication, procedure, recovery) in one room, to simulate a primary care practice experience.