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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 96-104

Implementing a combined instruction model on pregnancy options counseling for pre-clinical medical students: Expert physician panel, case-based learning, and pre-recorded lectures


Indiana University School of Medicine, Indianapolis, IN, USA

Date of Submission04-Aug-2022
Date of Acceptance24-Aug-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Ms. Lucy D Brown
340 W 10th St, Indianapolis, IN 46202
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EHP.EHP_18_22

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  Abstract 

Introduction: The Association of Professors of Gynecology and Obstetrics (APGO) recommends that pre-clinical medical students learn how to counsel on pregnancy options as a standard learning topic during undergraduate medical curriculum. Materials and Methods: Second-year medical students viewed pre-recorded lectures and attended a panel on pregnancy options counseling covering adoption, abortion, and pregnancy continuation. Students were then surveyed about their experiences. Results: Participants (n = 57) were primarily female (74%), non-Hispanic (89%), and Caucasian (77%). Students determined that most (80–100%) of the APGO Student Learning Objectives were adequately covered by the panel and pre-recorded lectures. Students reported on a 5-point Likert-type scale a statistically significant increase (P < 0.0001) in their perceived preparedness to counsel across each pregnancy option category: abortion (2.17 ± 0.94 before vs. 3.5 ± 0.94 after), adoption (1.81 ± 0.86 before vs. 2.56 ± 1.04 after), and continuation of pregnancy (2.52 ± 1 before vs. 3.38 ± 0.95 after). Eighty-seven percent of the respondents felt that the panel was inclusive of diverse viewpoints. Discussion: Students appreciated the pre-recorded lectures and case-based panel as providing important exposure to pregnancy options counseling. Students noted a significantly increased preparedness to counsel a newly diagnosed pregnant patient on abortion, adoption, and pregnancy continuation, most notably with abortion counseling. The overwhelmingly positive reception of the panel highlights the desire of medical students to learn about these issues. Conclusion: This study demonstrates the efficacy of combined instruction modalities, including traditional didactics, case-based learning, and an expert provider panel, in educating students on pregnancy options counseling.

Keywords: Abortion, adoption, contraception, didactic, medical education


How to cite this article:
Brown LD, Combs S, McKinzie A, Barber M, Komanapalli S, Wu CY, Hardman S, Stout J. Implementing a combined instruction model on pregnancy options counseling for pre-clinical medical students: Expert physician panel, case-based learning, and pre-recorded lectures. Educ Health Prof 2022;5:96-104

How to cite this URL:
Brown LD, Combs S, McKinzie A, Barber M, Komanapalli S, Wu CY, Hardman S, Stout J. Implementing a combined instruction model on pregnancy options counseling for pre-clinical medical students: Expert physician panel, case-based learning, and pre-recorded lectures. Educ Health Prof [serial online] 2022 [cited 2023 Feb 4];5:96-104. Available from: https://www.ehpjournal.com/text.asp?2022/5/3/96/357538




  Introduction Top


The Association of Professors of Gynecology and Obstetrics (APGO) recommends that learning how to counsel on pregnancy options be a standard learning topic during undergraduate medical curriculum.[1] Pregnant patients seeking health care should be counseled on options for their pregnancy, including adoption, abortion, or parenting (continuing the pregnancy). Because physicians in any specialty may encounter pregnant patients seeking care, all healthcare providers should be confident and competent in discussing these options with their patients. Medical aspects of continuing pregnancy are a routine component of medical school curricula; however, gaps exist regarding other options.

Current state of medical education

While pregnancy continuation is a mainstay of teaching within didactic female reproductive health curriculum, other topics of abortion and adoption are often de-emphasized or neglected completely. Within pregnancy options, abortion counseling is a critical skill which cannot ethically be excluded; however, it remains a contentious topic. A national survey of 78 accredited medical schools across the USA found that 17% of clerkship directors reported no formal education about abortion either in the pre-clinical or clinical years. During third-year obstetrics/gynecology (OBGYN) rotation, 68% of the schools reported no lecture specifically about abortion. A 2021 review summarizing the current literature on pregnancy options counseling in undergraduate medical education in North America found that no standardized curriculum exists, and, thus far, curricular interventions have been uncoordinated and insufficient.[2] Internationally, in Australia, a survey study identified a lack of structured and standardized teaching of abortion,[3] and a systematic review including medical schools in Canada, the UK, and Norway found a low rate of universal abortion training, signifying that the issue of quality abortion training traverses country borders and represents a global challenge.[4]

Interest exists among students to learn about pregnancy options counseling, including abortion. Several studies have exhibited no correlation between students’ attitudes to abortion and teaching rating of abortion curricula. In a survey of students in one medical school in London, students who identified both as “pro-choice” and “pro-life” rated teaching about abortion as important and valued the range of methods used; in fact, students requested more simulated practice speaking to patients seeking an abortion. Another US survey study found that most (96%) students felt that abortion education belonged in the curriculum and over half supported opt-out training.[5] Abortion education is widely accepted by medical students. Furthermore, it is appropriate and necessary to include in curricula of all medical schools.

Regarding adoption, there has been a documented lack of instruction about adoption counseling in medical school curricula. In a randomized trial of 105 third-year students, performance in an objective structured clinical examination (OSCE) before and after participation in a pregnancy options competency workshop was evaluated.[6] Only 48% of the students addressed adoption before workshop participation, which only improved to 63% (P = 0.16) after workshop participation. When caring for patients recently diagnosed with unintended pregnancy, adoption is an important option; therefore, formal integration of adoption into undergraduate medical education curriculum cannot be overlooked.

Henry et al.[7] described an elective training for medical students about how adoption and foster care may affect their future patients. The student attendees rated their knowledge about adoption and foster care as minimal or moderate before taking the course. The authors noted that student comments indicated that many students learned about personal connections to adoption or foster care as part of the course and that they re-evaluated their personal beliefs about the topics. Perry and Henry[8] reinforced that even genetic counselors—health professionals who work with expectant parents requiring informed decision-making about pregnancy options—have an absence of graduate education and professional knowledge about adoption.

A previous survey exploring the need for and student interest in expanding reproductive health topics in a large Midwestern Medical School didactic curriculum revealed that students were not comfortable counseling patients about pregnancy termination.[9] In contrast, students felt more prepared to counsel patients on less controversial healthcare interventions such as diuretics and beta-blockers. This discrepancy demonstrated a deficiency of the medical school’s reproductive health curriculum and served as an impetus for improving pregnancy options counseling education.

Educational design

Several schools have implemented pregnancy options counseling curricula using active learning formats such as problem-based learning (PBL), team-based learning (TBL), and case-based learning (CBL).[10],[11],[12],[13] At the University of Louisville, student perceptions were assessed regarding a case of a pregnant patient diagnosed with Zika virus seeking termination of pregnancy.[14] There was a statistically significant increase from 30% to 58% of students who felt informed about abortion after the PBL (P < 0.001). At Northwestern University, TBL was used to counsel patients on methods of contraception, first-trimester abortions, and sterilization.[15] After the TBL, students cited improved understanding of course material and problem-solving skills (P=0.01). In both formats, students appreciated the opportunity to apply their knowledge of pregnancy options counseling and to clarify their own values surrounding abortion.

Provider panel discussions also represent a viable option for curricular integration, where experts in their field can openly share their real-world experiences on clinical skills, counseling, and shared decision-making. Expert panel sessions provide an opportunity to acquire knowledge and communication skills related to the topic of interests, while enabling students to ask questions as they arise.[16] This format can also be more personalized to the providers. In broader topics with a higher potential for tangential diversions, a moderator can aid in redirecting panelists back to the topic of interest.

As a curricular intervention, the physician panel and surrounding assignments can provide an opportunity for coordination between activities in the clinical skills training course and the medical knowledge-focused basic science course in the second-year medical curriculum.

These collective experiences implement the four steps of Kolb’s experiential learning cycle, which include concrete experience, reflective observation, abstract conceptualization, and active experimentation[17] [Figure 1]. For these reasons, we selected a combined traditional lecture/CBL/provider panelist with moderator format for our study.
Figure 1: Kolb’s experiential learning theory[18]

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  Materials and Methods Top


Pre-recorded lectures

Second-year medical students at Indiana University School of Medicine (IUSM) were invited to attend a virtual panel regarding pregnancy options counseling through their pre-clinical, didactic course on Endocrine, Reproductive, Musculoskeletal, Dermatologic Systems (ERMD). Prior to the panel, students were encouraged to access various self-paced, pre-session activities via the ERMD course page on the Canvas (Instructure, Salt Lake City, UT, USA) course website.

These activities consisted of brief 15-min mini-lectures about abortion, adoption, and pregnancy continuation presented by faculty.

Expert panel covering case of unintended pregnancy

The 90-min panel session was conducted through a Zoom (Zoom Video Communications, San Jose, CA, USA) webinar, in which physician panelists, including both abortion providers and non-abortion providers, shared their experiences providing all-options counseling for pregnant patients. To guide panel discussion, the authors created a clinical case and an accompanying PowerPoint about a 25-year-old female presenting with an incidental positive pregnancy test [see Appendix 1]. Questions written in the PowerPoint probed how the physician panelists approach discussions about pregnancy with their patients, including informing patients that they are pregnant, counseling patients on their options, and considering with patients how factors such as their gestational age, past medical history, and socio-economic status influence options for their pregnancy. Students were able to interact with physician panelists through a Q&A chat function on Zoom, which was moderated by a fourth-year medical student.

Survey

Immediately after the panel, the survey was advertised in the Zoom chat and class social media [see Appendix 2]. The survey was delivered using Qualtrics XM software (Qualtrics, Provo, UT, USA) and the survey link remained active for 7 days.

Students were asked to rate whether undergraduate medical Session Learning (SL) Objectives recommended by APGO were appropriately covered by both the pre-recorded lectures available on Canvas and the synchronous Pregnancy Options Panel on Zoom. Only responses from participants who attended the panel and/or watched the pre-recorded lectures were analyzed.

The APGO SL Objectives evaluated by students were as follows[1]:

  1. Describe the physician’s responsibility to provide patient-centered all-options counseling to a patient who is pregnant.


  2. Identify the options available to a pregnant patient including abortion, adoption, and continuing the pregnancy.


  3. List surgical and non-surgical methods of pregnancy termination and the risks and efficacy of these methods.


  4. Describe foundational facts about abortion, adoption, and continuing the pregnancy that can assist the pregnant patient with decision-making.


Students were prompted to self-assess their preparedness to counsel a newly diagnosed pregnant patient before and after the panel on a 5-point Likert-type scale (1=not prepared and 5=very prepared). Students were also asked several optional free response questions and to what extent they agreed or disagreed with several statements.

Statistical analysis

A χ2 test of independence was performed to examine the relationship between learning modality and the proportion of students who indicated that the SL Objectives were met during these experiences. A two-tailed paired t-test was utilized to measure differences in Likert-type scale self-rated preparedness before and after the panel.


  Results Top


  • a The χ2 statistic was used to compare categorical measures across groups


  • b Only sex was statistically different from IUSM demographics data. Significance at P < 0.05


  • c The IUSM demographic fact sheet only reports female percentage. The remaining percent comprised both male and non-binary students.


Demographics

Of the 206 attendees, 57 (28%) started the optional survey. Four participants only filled out the background portions of the survey without answering questions about the panel; therefore, only the 53 (26% of attendees) completed survey responses were included to avoid demographic bias. Most participants were non-Hispanic (89%), Caucasian (77%), and female (74%). Compared with IUSM students overall, only sex demographics significantly differed from the survey participants, where only 23% of the respondents were male, representing less than the expected student body (P < 0.0001) [Table 1]. Students were interested in a wide variety of specialties [Figure 2].
Table 1: Our study participants compared to available IUSM 2020–2021 demographic data[19]

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Figure 2: Specialty interests of all attendees

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Coverage of APGO’s SL Objectives

Each learning modality (i.e., pregnancy options panel, pre-recorded lectures) was assessed. Forty-seven percent (25/53) of the participants indicated that they had viewed the pre-recorded lectures, all of whom had also attended the panel. Students agreed that 80–100% of APGO SL Objectives were adequately covered by the panel and 81–95% were adequately covered by the pre-recorded lectures [Figure 3]. There was no significant difference (P = 0.55) in the SL Objectives met between learning experiences.
Figure 3: Students indicated whether SL Objectives were covered by the expert panel and/or the pre-recorded lectures

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Options counseling preparedness: Before and after

Compared with their comfort level counseling about pregnancy options before the panel, following the panel, students reported a statistically significant increase in their perceived preparedness to counsel across each pregnancy option category: abortion (2.17 ± 0.94 before vs. 3.5 ± 0.94 after) (P < 0.0001), adoption (1.81 ± 0.86 before vs. 2.56 ± 1.04 after) (P < 0.0001), and continuation of pregnancy (2.52 ± 1 before vs. 3.38 ± 0.95 after) (P < 0.0001) [Figure 4].
Figure 4: Assessment of self-rated preparedness before and after the panel lectures

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Written responses

Students were asked a series of four free response questions after attending the panel. Students were first asked why they decided to attend the optional panel. Eighty-nine percent (47/53) of the students responded to this question, with many answering that the topic was important for taking care of future patients, regardless of specialty and personal beliefs [Table 2]. Some responses indicated personal interest in or passion about the topic, as well as desire to be more informed and learn more about pregnancy options. Several respondents indicated that the panel offered an opportunity to learn about topics otherwise not taught in the medical school curriculum.
Table 2: Representative free responses to, “Why did you decide to attend this optional panel?”

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Students were then asked if they felt the panel was inclusive of representative and diverse viewpoints. Eighty-five percent (45/53) of the students responded to this question. The majority of the respondents (87%, 39/45) answered, “Yes.” Several students commented on the fact that they appreciated hearing the viewpoint of one panelist who did not himself provide abortions but who continued to empower patients to make their own choice regardless of the provider’s own personal beliefs, and, importantly, referred patients to the appropriate provider who can perform this procedure. Students also appreciated the perspective of a pediatrician and her/his approach to pregnancy options counseling for adolescent patients.

Students were asked whether the panel was well-organized or whether they would have preferred a different format for presenting the information. Eighty percent (44/53) of the respondents answered this question. Most students (86%, 38/44) responded that the case-based panel was an effective, well-organized format for learning key information. In fact, some (9%, 4/44) students believed the panel discussion was so effective that it should be required. The most frequent (9%, 4/44) criticism of the panel was that the students would have liked more engagement strategies during the discussion, such as multiple-choice questions presented and answered by the class and/or a pre-quiz online prior to the panel to self-test knowledge of these topics. Some (5%, 2/44) students responded that their specific questions were not answered fully or logically by the panelists, but this did not appear to be a theme or overwhelming sentiment from the majority of respondents.

Finally, students were asked whether there were additional topics they would have liked to learn more about, after attending the panel [Table 3]. Seventy percent (37/53) of the students responded. Ten students (27%) specifically responded that they would have liked increased focus on adoption as an option. Seven students (19%) wanted specific information about current laws and rules regarding pregnancy options in the state, as well as information on how to connect patients to timely resources. Five students (14%) desired discussion of the procedures/methods of pregnancy termination. Three students (7%) asked about sharing resources and improving access for patients.
Table 3: Representative free responses to, “After attending the panel, what other topics regarding pregnancy options counseling would you have liked to learn more about?”

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Overall student perceptions

Students indicated how strongly they agreed or disagreed with various statements about the panel. Eighty-three percent (45/53) agreed or strongly agreed that the panel changed the way in which they would counsel patients on their pregnancy options. All students (53/53) agreed or strongly agreed that the knowledge and skills acquired from this panel would be useful and relevant for their future career as a doctor in any specialty. Ninety-eight percent (52/53) agreed or strongly agreed that the panel addressed topics that were not represented elsewhere in the didactic medical curriculum.


  Discussion Top


Demographically, respondents were generally representative of the IUSM student body. Significantly more women completed the survey than men. This may be explained by the fact that women are more personally affected by the quality and content of pregnancy options counseling. The most selected specialty was “undecided,” while less than a quarter of total students were interested in the specialties OBGYN and Family Medicine that are typically considered relevant for pregnant patients.

APGO Learning Objectives

Most students reported the physician panel, and its associated lectures met the APGO SL Objectives. These responses further demonstrate the efficacy of this learning modality. Not only did students feel more comfortable providing directed counseling, but they also perceived that they were effectively learning standardized themes outlined by APGO. Failure to master these SL Objectives has been shown to correlate with failing scores on associated NBME, USMLE, and COMLEX exams, demonstrating the importance of these topics in successful medical education.[20] Pre-recorded lectures and panel formats did not differ significantly in their coverage, indicating that these instructional modalities are comparably and complementarily helpful in covering all pregnancy options counseling topics.

Preparedness to counsel

Prior to the panel, students felt most prepared to counsel on pregnancy continuation and least prepared to counsel on abortion. Although the panel was guided by CBL questions, students also dictated the course of the discussion via the anonymous Zoom chat. The vast majority of the chat questions were inquired about logistics and patient care for pregnancy termination; therefore, the attendees tended to have higher interest in and more exposure to abortion than any other counseling topic.

After attending this panel, students noted significantly increased preparedness to counsel a newly diagnosed pregnant patient on abortion, adoption, and pregnancy continuation. This finding demonstrates that the panel effectively accomplished its goal of making students feel more comfortable and confident in their future interactions with pregnant patients. The greatest increase in and highest self-reported level of preparedness to counsel was seen on the topic of abortion. Not all students viewed the pre-recorded lectures covering other topics (i.e., adoption) more thoroughly, and likely there was a skewed focus of the panel on abortion counseling education.

Written response

Students were very thoughtful in the written portion of the survey; many cited themes of respect, patient welfare, and autonomy in caring for pregnant patients, regardless of personal opinion.

Students with diverse viewpoints and specialty interests felt that pregnancy options counseling was an important component of comprehensive reproductive care, as indicated by the following participant quotes:

I strongly support all-options birth control counseling and abortion access. I wanted to further educate myself in these areas since IUSM’s curriculum doesn’t formally include these topics.”—Caucasian female, Pediatrics

I do not agree with abortion but know that it is something I need to have a better understanding of so that my personal beliefs do not interfere with my ability to care for my patients.”—Caucasian female, IM

These quotes were representative of many of the written responses. Students recognized that many of their patients are capable of becoming pregnant, and pregnancy decisions vary for each individual person. Having exposure to counseling for all options is valuable to all students, regardless of intended specialty.

Although students requested more information regarding specific abortion surgical methods and adoption, these learning objectives were extensively covered in pre-recorded videos, and many of the students who wrote these responses did not complete the optional pre-work. In fact, one student who watched the videos prior to the panel responded:

I think you all covered everything with your prework videos and the panel itself. I DON’T think you need to cover adoption in the panel because the prework covers it, and it would take time talking about stuff that’s not our immediate medical care...”—Caucasian female, Psychiatry

Many students also indicated that they would have liked more inclusion of reproductive health policy, as evidenced by the following quote:

I would’ve appreciated more specific education on what Indiana law currently says. We don’t have any other place to learn that, and it feels like it fits here. It will be vital knowledge when we hit our clerkships.”—Caucasian female, Surgery

As abortion laws differ from state to state, this panel was also an opportunity to learn about pregnancy care and abortion care in Indiana where many students are from and may practice in the future.

Pregnancy options counseling represents an opportunity to emphasize non-judgmental, humanistic care. In a qualitative study of 74 US medical students applying to OBGYN, discussion of abortion was assessed as a reflection of their professionalism.[21] In this study, most students, including those with a moral opposition to the procedure, believed that abortion management should be required training in OBGYN residency. Even students who did not personally agree with abortion or plan to provide abortion care in their career expressed that education about abortion and pregnancy options is necessary in order to provide full-spectrum care for patients.

Overall student perceptions

A high percentage of students agreed or strongly agreed that the panel successfully addressed topics traditionally excluded in didactic medical curriculum. The panel provided students the knowledge and skills to counsel pregnant patients appropriately, and the vast majority acknowledged the relevance and usefulness of the panel for any medical specialty. The overwhelming positive attitude toward the case-based panel highlights the desire of medical students to learn about these topics not traditionally covered in medical education.

Integration of learning theories

The model implemented in this study served as the “concrete experience” of Kolb’s theory; however, there are opportunities to encourage more self-reflection and values clarification through the other tenets of experiential learning. The complete learning cycle surrounding pregnancy options counseling could be envisioned as follows:

  1. Concrete experience—viewing pre-work videos and attending the panel


  2. Reflective observation—writing a post-event reflection


  3. Abstract conceptualization—discussing the written reflection with a peer


  4. Active experimentation—practicing communication skills and medical professionalism tenets (i.e., humility, withholding personal judgment, and maintaining curiosity and compassion) with standardized patients and peer-to-peer practice


Similar learning strategies based on Kolb’s theory have proven effective in other health professions education as well as interprofessional education settings.[18],[22],[23]

Study limitations

While abortion was covered extensively and thoroughly, pregnancy continuation and adoption were discussed less during the panel. It is important to note that the pre-clinical reproductive health curriculum already includes pregnancy continuation risks and potential complications. During the panel, the conversation was largely led by student questions, which focussed more heavily on abortion. In order to stimulate a more balanced discussion, techniques could be employed such as reinforcing the learning objectives during the session and encouraging panelists to address all the options.

In terms of survey limitations, only a quarter of student attendees completed the optional survey. About two-thirds of the class attended the panel. Because the panel was not mandatory, the people who participated likely had some interest in the topic. This finding may explain the skew of the survey demographics toward women.

Future directions

Sustainable curricular integration of pregnancy options counseling necessitates that student attendance be mandatory. Otherwise, students with lower interest may not be exposed to these topics. Therefore, the faculty team plans to make this a required activity with a post-session written reflection. Future case-based panels should also include perspectives from those in the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community and other minoritized populations who experience health disparities.


  Conclusion Top


Our study demonstrated that a combination of instructional modalities, including traditional didactics, CBL, and an expert provider panel, can effectively teach all-options pregnancy counseling. Following the pre-recorded lectures and the panel, self-rated preparedness to counsel on the options of abortion, adoption, and pregnancy continuation among students showed a statistically significant increase across all option categories.

Students in our study valued the opportunity to ask questions of experienced physicians about how to best provide non-judgmental, humanistic care. The panel successfully addressed topics that were not represented elsewhere in the didactic medical curriculum. A high percentage of students agreed that the panel changed the way they will counsel pregnant patients in their future practices and that the knowledge and skills acquired would be useful and relevant for their future career as a doctor in any specialty. While students expressed satisfaction with the panel overall, they requested more discussion on adoption in conjunction with abortion and pregnancy continuation.

Acknowledgments

We would like to thank Dr. Caitlin Bernard, Dr. Tracey Wilkinson, Dr. Hua Meng, and Dr. Jon Hathaway for serving as experts on the provider panel. We would also like to thank Dr. Joseph Harmon, Dr. Hua Meng, and Dr. Karen Foli for their contributions to the pre-recorded lectures. We would lastly like to thank the entire ERMD course team for allowing us to implement our curricular model as part of their course.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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