COMPETENCY-BASED SKILLS

Rather than focus on trainees achieving specific procedural numbers, specialty, or fellowship training, we believe that abortion provision should be based on learners attaining the clinical knowledge and skill-based competencies necessary to provide comprehensive care. Each skill should be delineated into clear steps with observable competencies (Cappiello, 2016).  And these should be in line with health professional education standards (e.g. ACGME Family Medicine Milestones, AACN, ACNM, NONPF).

Compared with obstetrician-gynecologists, primary care trained physicians and advanced practice clinicians are more likely to provide care in underserved and rural communities (Ruddy 2005). Evidence suggests that abortion safety, success rates, and acceptability to patients are found to be equivalent between most cadres of physicians and advanced practice clinicians (Levi 2012, Barnard 2015; Weitz 2013). And the similarity in safety and success rate is true for both experienced and newly trained providers (Jejeebhoy 2011, Warriner 2006). This supports the adoption of policies allowing various providers to perform aspiration abortions, and in turn, helps to expand patient access to abortion care.

GUIDING TRAINEE PARTICIPATION IN CARE

Meet your learner where they are

• Start each day by checking-in with your trainee. “What is your previous experience with gynecologic exams? How comfortable do you feel with a trauma-informed pelvic exam and speculum placement?”
• Set achievable goals for the day and / or rotation.
• Use a step-wise approach to involving new trainees as described below.
• Consider the power dynamic between trainer and trainee as well as between providers and patient. What can you do to minimize the risk of confirming negative stereotypes about an individual’s racial, ethnic, gender, or cultural group? (Strategies; Stanford).

Prioritize patient safety & communication 

After checking-in with your trainee, review plans for communicating during procedures in a person-centered way.

• Informed consent is a crucial part of respecting patient autonomy & safety. Understanding elements of verbal and / or written consent for the abortion procedure should be incorporated into training.
• Introduce yourselves as a team, and initially lead the patient conversation, allowing a trainee to focus on new procedural skills.
• Encourage trainees to recognize their limits; stopping for assistance if the procedure does not feel right (i.e. they feel resistance with dilation).
• Let trainees know that you may occasionally place “hand on hand”, for example, to demonstrate the right pressure, but it doesn’t always mean you are stepping in to take over. If you are concerned about patient safety or comfort, however, don’t hesitate to step in. A tap on the shoulder or another cue can be a signal to indicate “let’s trade places” if the trainee seems to need assistance.
• Consider setting an agreed upon time limit after which the trainer intervenes (e.g. if case lasts over 8-10 minutes). This practice is patient-centered, and helps depersonalize the need for intervention. Emphasize that longer procedures are uncomfortable and increase overall waiting time. A first trimester abortion procedure should rarely take longer than 5-10 minutes of speculum time.

Step-wise approach to hands-on involvement 

• Carefully consider both patient & trainee comfort levels. Start new trainees with observation, gradually building hands-on involvement with each case.
• Before engaging in hands-on procedural work with patients, the trainee should be experienced with a simulated procedure and / or be able to verbally detail / talk-through the procedure and feel comfortable handling an MVA.
• Trainees progress at differing paces. Be aware of each trainee’s skill advancement and customize their progression. On the first day, consider the following potential progress for a trainee:
  • 1st procedure: observes counseling sessions and observes in entirety
  • 2nd procedure: completes pelvic exam, speculum placement, and paracervical block, then observes dilation. The trainer may do “hand-on-hand” with cannula placement & uterine aspiration.
  • 3rd procedure: assists with dilation and aspiration.
  • Remaining procedures: completes the entire procedure with trainer hand-on-hand guidance as needed.
• Stand behind new trainees so you can assist with your hands and see what they see. As trainees gain competence, you can move to the side.
• With time, trainees should begin to lead verbal dialogue with patients.
• As trainees reach higher levels of comfort and competency, consider having them work without direct supervision, especially for cases at early gestational ages, while you stay immediately available. It is reassuring that in one training program study, trainees initially reported less confidence in their own ability than the trainers’ reported confidence in the trainee. But by the end of the training period, these ratings were in alignment, suggesting congruence in external and internal assessment (Levi 2018).
• Encourage trainees to track their procedures and include all procedures in which they gain observational and / or hands-on experience.

Teaching while considering patient & clinic flow    

• To model patient-centered care, provide most teaching and feedback between cases, or bookmark for later in the day. Avoid teaching the procedure aloud, which a patient might not want to hear.
• Review more challenging steps ahead of time, such as the first dilator pass.
• Plan items needed before entering the procedure room to minimize interruptions.
• 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, prompt a learner to inject anesthetic by saying to the patient, “Next we’ll be giving some numbing medicine.”
• Encourage an assistant to talk with the patient to distract from the teaching process.
• Communicate early and often with the clinic or flow manager.
• For additional ideas, see Clinic flow strategies (Stanford).