A Gynecologic Teaching Associate (GTA) and a Male Urogenital Teaching Associate (MUTA) occupy a unique position in the medical learning process. GTAs and MUTAs provide physically intimate instruction of highly stigmatized and emotionally difficult curricular material. GTAs and MUTAs are fundamentally teachers with a very specialized skill set.
At the same time, GTAs and MUTAs also act as “practice patients” during their instructional sessions to give learners the invaluable opportunity to practice invasive genital examinations on a real person before having to do these difficult exams on an actual patient. In this regard, GTA/MUTA work is related to what is commonly called a standardized patient, simulated patient or, simply, an SP.
As for Standards of Best Practices, GTAs, MUTAs and program directors (a general term which may include administrators, SP coordinators, faculty, professors, medical professionals, or anyone who is overseeing the GTAs/MUTAs while they are working) should always be in line with universally recognized SOBPs for SPs. The Association of Standardized Patient Educators (ASPE) has already done excellent, thorough work on SOBPs. IGMA refers you to the ASPE SOBP (Lewis et al. Advances in Simulation (2017) 2:10DOI 10.1186/s41077-017-0043-4) for a complete review of SOBPs that affect a broad range of best practices when it comes to curriculum development, training, program management and professional development. These ASPE SOBP domains all apply with equal measure to the work that GTAs/MUTAs do, and we support them, stand by them, and will adress them only as they overlap in their applicability to GTA MUTA methdology. Since GTAs and MUTAs are instructors who use their bodies as primary teaching tools, there are certain nuances in GTA/MUTA work that require additional practices that are either not included in the ASPE SOBP, or are worth emphasizing because they are critical to safe, successful, GTA/MUTA programming.
SAFE WORK ENVIRONMENT
- INSTRUCTIONAL METHODS:
a. Independent Instruction: Most GTAs and MUTAs go through an extensive training program to be able to successfully conduct the components of the exam independently. This was the original intent of this methodology when studies were being conducted as far back as the mid 1960s and is the gold standard of this method. In this standard, the GTA or MUTA is the only instructor in the room. Other faculty may be present as observers but should not contradict or override the instruction of the GTA or MUTA. In fact, the vast majority of GTA/MUTA Programs welcome session observation by institutional faculty. However for the physical and emotional safety of the GTA or MUTA instructor and for the best outcomes of program goals and objectives (including, but not limited to, reduction in student anxiety) observing faculty should honor the autonomy of the GTA/MUTA instructor. This ensures program standardization and reduces risks to the GTA or MUTA instructor. Should interaction be warranted, such as questions regarding pathology, mutual respect between the observing faculty and the GTA or MUTA must be maintained. At times, the clinical skills techniques being taught may differ from the ones the observing faculty is accustomed to using. The instruction must be allowed to continue seemlessly in order to maintain program standardization. Any redirection by the faculty to the students should occur subsequent to the session conclusion.
b. Preceptor Involvement: In programs where GTAs and MUTAs receive limited training, they sometimes Team Teach (work in teams) or work with preceptors. In this model the preceptor works in equal partnership with the GTA or MUTA and responds to questions beyond the GTA or MUTA’s scope of practice such as questions about pathology or course curriculum. The faculty preceptor should honor the body autonomy of the GTA or MUTA and never belittle the instructor. When the GTA or MUTA provides feedback to the student, the preceptor should refrain from belittling or contradicting the GTA or MUTA instructor. While this is not the safest method given that the preceptor is not familiar with the GTA or MUTAs anatomy, and in the case of GTAs, her internal structures, it has been effective when the preceptor and GTA or MUTA work together as a team.
a. Room: Instructors must be in a private space with their learners, whether it’s an individual room or curtained area. Instructors will be in various states of genital exposure during their sessions, and maximum privacy should always be provided.
b. Exam tables: GTAs should be provided with exam tables complete with gynecological footrests (*See 3b below), and an adjustable backrest. MUTAs should always have an adjustable backrest. Should these types of tables be unavailable, program directors should always communicate in advance with the GTA/MUTA program director in order to discuss possibilities for safe instruction. Accomodations should be planned for in advance to meet the needs of the GTA or MUTA instructor.
c. Supplies: Specula, lubricant, gloves, latex-free gloves, hand-sanitizer, chux, drapes, a portable light source, mirrors, gowns, paper towels, a waste-basket and condoms are among the supplies that a GTA or MUTA may need during their instruction. These should always be discussed in advance with the GTA/MUTA program director to determine who will provide these items so that the instructor has all the supplies necessary in order to safely and successfully conduct the session.
d. Cameras: Many facilities have camera-monitoring systems in their simulation rooms. This should always be discussed with the GTA/MUTA program director and mutual agreement must be pre-determined as to whether they will be remaining on or turned off during the sessions.
a. Sexually charged language should always be avoided by both institutional representatives and the GTA/MUTA instructors given the sensitive nature of the exam.
b. *The word “Stirrups” should be avoided in this context; it is a word that can be perceived as having sexual connotations.
4. TRAINING AND CURRICULUM:
a. Ensure the method and extent of training of the GTA or MUTA instructor meets the needs for the required instruction. Ie. An instructor with a single day of training is ill equipped to teach independently.
b. Ensure content of GTA/MUTA instruction meets needs of instiutional curriculum and protocol.
c. Ensure the time available for the session is adequate so that intructors are not rushing through session techniques creating undue risk.
d. Curriculum needs and expectations must be discussed and agreed upon prior to session commencement.
e. GTAs/MUTAs must receive specialized training and be monitored by their trainer during the training process to ensure they are psychologically and physically capable of conducting the GTA/MUTA work safely with inexperienced learners.
5. INCIDENT REPORTING:
a. Program directors should communicate the process for reporting an unexpected incident or issue that may occur during the session, such as but not limited to, learner illness, nausea or fainting, learners who do not follow instruction or protocol, are difficult, or fail to achieve competency during the session.
b. Program directors should provide a process to report any emotional or physical harm that happens to a GTA/MUTA as a result of a learner’s behavior during the session.
6. ON SITE ACCESSIBILITY TO PROGRAM DIRECTORS:
a. Program directors should always be available during the sessions in case a learner requires emotional attention during these stigmatized examinations. It is impossible to know what will trigger someone, and learners sometimes unexpectantly need emotional support in the middle of a session and the GTA/MUTA may need assistance dealing with such a learner.
b. For the physical safety of the learner, program directors should always be available during the session should a learner injury occur. For example, if a learner faints, a GTA or MUTA will need the program director’s help immediately. Handling a physical crisis is beyond the GTA or MUTA’s scope of practice.
ADHERENCE TO EMPOWERMENT MODEL OBJECTIVES
GTA/MUTA methodology has several pertinent program goals and objectives. This methodology is based on patient empowerment models focused on patient centered care. To that end, several crucial elements must be maintained by GTA/MUTA instructors and institutional program directors must permit discussion and adherence to these elements during the GTA or MUTA session.
Safe effective invasive clinical exam technique instruction: GTAs and MUTAs should receive sufficient training in order to meet this requirement. GTA/MUTA programs should provide training in clinical skills techniques that provide opportunities for GTA MUTA trainees to:
a. Learn about personal anatomy so that they can guide students in recognition and assessment of structures
b. Practice both as a student and a GTA or MUTA instructor in the training experience. This provides opportunity to experience the techniques from a learner’s perspective and to instruct the techniques to other trainees. This ensures appropriate identification of anatomical structures and ability to distinguish them for learners.
c. Learn clear concise methods to instruct a learner in the use of medical supplies and equipment during well-patient examinations. This will reduce risk of injury with anatomy or implements that must be inserted inside a person’s body in order to appropriately conduct the technique.
2. Patient Empowerment techniques designed to create more equal partnerships between patient and practitioner: GTA and MUTAs have individual approaches to meet this objective. It is crucial to include in GTA and MUTA protocol, techniques, which may be for the benefit of the instructor, student, future patient, or all three, that ensure better communication and more respectful discourse between future doctors and their future patients. To that end, the following techniques should be included:
i. Use of mirror
ii. Back table up to 90 degrees for teaching with explanation of 45 degree table back height for patient examinations
iii. Proper draping sufficient to provide view of vulva while protecting patient modesty
iv. Appropriate language: in such a sensitive exam, language that is unprofessional or sexualized in nature should NOT be used.
v. Back of hand for non examination physical contact
vi. Pre physical contact techniques:
- Thigh contact: Contact must be made with the thigh prior to physical contact with the genitals to reduce spasmodic muscle reaction. Contact after the examination technique completes should also end at the thigh.
- Thumb Tuck: Tucking of the thumb is imperative in order to prevent the thumb from making contact with the anus and possibility introducing harmful bacteria into the vaginal canal or making contact with the clitoris and creating an uncomfortable and/or unsafe environment for the patient
- Verbal prompts before physical contact must be expressed
i. Positioning of patient: Back of table at 45 degrees for teaching with explanation of why 45 degree table back height for patient examinations promotes good eye contact throughout the exam. If other positioning is used at any point during the exam, explain rationale from the standpoint of how this will provide comfort for the patient or lower the patient’s anxiety during this part of the exam.
ii. Proper draping sufficient to provide visual inspection and palpation of structures while protecting patient modesty.
iii. Appropriate language: language that is unprofessional, vulgar, or sexualized in nature should NOT be used. Likewise, sophisticated “medical jargon” can be intimidating and should not be used unless a common definition of that term is offered immediately.
iv. Verbal prompts must be expressed before undraping the patient and before any physical contact.
3. Communication skills:
It has been recognized for decades that learners must obtain skills for effective interaction with their future patients. It is the responsibility of the GTA/MUTA program to include communication skills training information in GTA and MUTA training curriculum
a. GTAs and MUTAs must have excellent communication skills and be comfortable speaking to groups of people.
b. GTAs and MUTAs must learn communication objectives, anatomy and information on what segments learners must be able to communicate to their patients.
c. GTAs and MUTAs must be able to effectively communicate patient skills and content so learners can successfully involve patients in the exam experience as equal partners.
4. Reduce learner anxiety:
An objective of GTA/MUTA programming is to create methodology that succeeds in reducing learner anxiety in an otherwise stressful and sometimes embarrassing exam. This carries over to learner interaction with patients and succeeds in reducing patient anxiety.
a. The GTA or MUTA must be provided with anxiety reduction techniques.
b. The GTA and MUTA must be provided autonomy over their own bodies so as to effectively provide step by step instruction with immediate feedback.
c. The GTA or MUTA should create a supportive and nurturing environment, where learners are free to ask questions, try techniques more than once and are involved experientially in the process.
INSTRUCTOR TRAINING CURRICULUM AND PROTOCOL
The training curriculum for the GTA and MUTA must include the following components:
Training Time: Sufficient time must be allotted for the level of instruction to be provided by the GTA or MUTA instructor; little to no verbiage or non independent instruction requires less time than independent instructors. Independent instructors can require up to 8 weeks of training depending on size of curriculum and specialized technique assignment.
Independent Instruction Guidelines: GTAs or MUTAs who are learning to be independent instructors, the safest, highest quality instruction available in this methodology must have access to the following information in their training curricula:
a. 3 tiered learning methodology
i. Curriculum in entirety including verbiage, patient eduation and communication, personal anatomy, learner instruction
ii. Components to instruct learners
iii. Components to teach learners to communicate to patients
b. Personal anatomy training; instructors must know how to guide learners to palpate all structures, internal and external.
c. Patient education and communication; GTA and MUTA instructors must know how to provide this information to learners.
d. Empowerment techniques; Techniques should be utilized in the GTA or MUTA session and explained to learners
e. Variations in instructional techniques vs. live patient interaction; GTA and MUTA instructors must be able to explain why techniques might be different in the lab and how they will be executed in an actual exam; ie. The back of the table for a GTA is at 90 degrees for instructional purposes, however, with a patient it will be at 45 degrees
f. Sufficient time MUST be allotted to practice and observation sessions provided
g. Program goals and objectives, and expectations provided at beginning of training session.
h. GTAs and MUTAs must know the procedure to follow should there be an injury, illness or student disruption during the lab.
i. GTAs and MUTAs must have autonomy and control over their bodies and must be given the authority to make decisions about who and how a learner is making physical contact and the authority to forbid a learner to practice a technique if that learner is non compliant; ie. A learner who refuses to cut their fingernails (if asked) should be refused participation in exam techniques. That decision must be up to the individual GTA or MUTA.
Learning Environment: While a GTA or MUTA is in training, the following should be provided:
a. Space sufficient for training
b. All necessary supplies
c. A written curriculum
e. Any necessary lectures for training needs that may be outside of well-patient
f. Supportive training environment
g. Ample study opportunity and training time
h. Expectations clearly expressed
i. Any agreements signed
j. A Trainer who is familiar with anatomy and structure location and can show the trainee how to identify and locate their own structures
k. Ample breaks
NUMBER OF LEARNERS PER SESSION:
a. GTA/MUTA instruction takes a physical toll on the body. Every body is unique and has different limitations. Many highly trained GTAs/MUTAs with extensive experience can conduct four sessions in a day with four to five learners in each session. Other GTAs/MUTAs will only be comfortable conducting two sessions in a day with two or three learners in each session. There can never be a “standard” number, so deciding how many learners in a session and the number of sessions in a day must be predetermined between the institutional program director and the GTA/MUTA program director in order to arrive at the number that is safe and comfortable for those individual instructors.
b. Needs of the institution must be clearly communicated and instructors chosen who want to conduct the session under the needed parameters and who are comfortable and capable of doing so. In this way, steps can be taken to ensure institutional needs are successfully met without placing the GTA or MUTA instructor under duress.
c. Program directors should never push GTAs/MUTAs to instruct more leareners than the GTA/MUTA is comfortable with at the time
d. Learners should be organized into groups prior to the start of the sessions to avoid over-filling rooms at the last minute.
NUMBER OF SESSIONS PER DAY:
a. GTAs/MUTAs must be clear about their limitations in terms of number of sessions per day they can safely conduct
b. Program directors should schedule no more sessions in a day than the GTAs/MUTAs are comfortable doing, and should avoid adding additional sessions at the last minute.
c. Nor should institutions limit session totals for other institutions without direct consultation with the expressed limits of the GTAs and MUTAs working those sessions. As previously mentioned, highly trained GTAs and MUTAs with extensive experience can safely conduct multiple sessions per day.
d. When possible, short breaks for GTAs/MUTAs should be scheduled between multiple sessions.
a. Learners must wear gloves whenever their hands come in contact with a GTA/MUTA’s physical body.
b. Program directors should ensure that all learners arrive on time for sessions. Because of the nature of this instruction, learners should not enter the session late.
c. Learners should be in professional, comfortable attire at all times. Sometimes small, clinical exam rooms can get hot. GTAs and MUTAs may invite learners to remove their jackets, coats or sweaters if this is the case. This courtesy should be left up to the discretion of the GTA/MUTA.
d. At times during the male exam, the patient will be standing and the practitioner will be seated on a stool. It is necessary for learners to wear professional attire so that the possibility of creating an unintended sexualized or uncomfortable situation in the exam room.
e. Learners should be reminded by their program directors and the GTA or MUTA instructor by their program director to ensure they:
i. Bathe before the session to minimize body odor in small, closed exam rooms for the hour to two hour session
ii. Brush teeth and carry mints
iii. DO NOT WEAR cologne or perfume as many people have allergies
iv. Do not take cell phones out during the session. An exception can be made if the learner or instructor is experiencing a crisis with a family member and must be available. Communication must be made prior to session commencement
f. Certain fingernails may need to be trimmed or filed for the safety of the instructor. Learners should anticipate having to trim/file their nails if they wear them long. It is up to the discretion of the instructor, but in most cases, if students refuse to cut their nails, due to high risk of injury to the instructor, the learner will not be able to conduct the exam techniques.
a. Last minute adjustments to the curriculum should be avoided.
b. GTA or MUTA who does not feel comfortable accommodating requests for last minute changes should be respected.
a. GTAs/MUTAs should know the amount of compensation for each session they agree to work.
b. GTAs/MUTAs should be made aware of length of time between session and payment arrival.
c. Potential compensation or lack thereof, for travel, parking, food, etc. should be discussed prior to the session.
a. GTAs/MUTAs should always leave their clinical spaces as they found them, unless otherwise directed, and ask program directors how they would like trash to be disposed of (e.g. Are bio-hazard trash-bags available? Should drapes be put in a special laundry bin?).
b. GTAs/MUTAs should never move task trainers or medical equipment in the rooms without first asking permission from the program director.
i. must have palpable breast tissue in at least one breast
ii. Have one palpable overy
iii. Uterus and cervix must be palpable
iv. External genitalia anatomy should be within average range and have all visible structures, introitus, urethra, cliteris and anus
v. Menstrual flow: Menstruation is a natural part of the reproductive process, and GTAs may be experiencing this during their instruction. This is an exceptional educational opportunity for learners. Program directors should make their learners aware that this is always a possibility, and explain that it is not pathology and does not need to be avoided
i. Must have one palpable testicle; implants are acceptable.
ii. Must have a palpable penis.
iii. Must have a palpable prostate; enlargement is acceptable if determined to be within the safe range for the MUTA.
iv. Anatomy should be within average range of size and the external genitalia should have all visible structures.
a. All GTAs, MUTAs, Program Directors and learners must understand the principles of confidentiality which must be observed during the sessions.
b. Privacy of personal information must be protected at all times. No learner should record these sessions either with video or audio recording devices unless expressly permitted by the GTA/MUTA or if the session was previously set up for video conferencing or video recording for training purposes, and communication regarding the special event was communicated prior to the event commencement.
c. GTAs/MUTAs must maintain the privacy of any personal information learners reveal during their instruction.
a. There should be mutual respect between the institution and the GTA/MUTA program and instructors.