In this study, we found that initial simulation training for TVS permitted to improve the quality of images produced by GP residents in gynecology units after 2 months compared to clinical training alone.
Simulation is one of the options offered by the university for invasive procedures training [14]. The main goal of simulation in obstetrics and gynecology is to train students to procedures involving the genital sphere without mobilizing volunteers [15]. Most women consider TVS to be at least uncomfortable [16]. Task trainers for teaching vaginal digital examinations already exist. TVS simulators recently appeared and represent a revolution for the residency curriculum [17].
A metanalysis by Cook et al. compared the effectiveness of technology-enhanced simulation versus traditional training. Simulation training was effective for student satisfaction, knowledge, and skills [18]. Skill improvement on simulators was therefore expected. However, transfer of skills to clinical practice and patient effects after simulation training are not well known [19]. The Kirkpatrick pyramid can be used to rank medical education studies depending on the main outcome in four levels: 1—student satisfaction; 2—progress in theoretical and practical knowledge outside the clinic; 3—impact on clinical skills; and 4—impact or benefit for the patient [20]. As our primary outcome is image quality when performed on real patients, our study can be ranked as level 3.
To justify the costs that are invested in this type of training [9, 18, 21], it is necessary to know whether simulation training has a sustained impact on trainees’ skills [22]. Although an immediate effect of simulation is well known, only a few studies have assessed the long-term retention of the skills [23]. In a randomized prospective study, Tolsgaard et al. assessed the sustained effect of TVS simulation training using the Objective Structured Assessment of Ultrasound Skills (OSAUS). Ultrasound competence can be assessed using this valid score. The pass/fail scores may be used to help determine whether trainees are qualified for independent practice [24]. In this study, Tolsgaard et al. Demonstrated that simulation allowed significantly better image optimization, better approach systematization, better image interpretation, and a better decision-taking process with a sustained effect at 2 months. Participants reached the expert level on the simulator in a mean time of 3 h 16 min [13].
Other researchers have reported positive impacts of ultrasound simulation in residency curricula in other areas [25]. In traumatology, for instance, the ultrasound skills of GP residents trained by simulation were similar to those who trained on real patients [26].
In our study, we focused on GP residents. Their training field in gynecology is short, but the flow of patients is huge. They have to become autonomous very quickly. They are not familiar with TVS. The number of US scans necessary to acquire competency in first-line TVS is not known [11, 27]. It is definitely not necessary to teach GP residents expert TVS. However, some diagnosis in gynecology (pregnancy localization, hemoperitoneum) are easily identifiable thanks to a few standardized planes [3]. The four planes that are required are the sagittal view of the uterus, longitudinal views of both ovaries, and the Morrison space [28].
Another advantage of simulation training is that students face many conditions in a very short time. The models showed various situations: intrauterine pregnancy with the possibility of determining gestational age, myoma, ectopic pregnancy, and hemoperitoneum.
Our study had methodological weaknesses, mostly because the number of participants was small. There was no sample size calculation. Another bias was the absence of randomization of the groups. Residents who volunteered for the study were recruited after they did or did not show up to the courses. Our selection was therefore prone to bias. Plus, selection of patients to collect images from for assessment was not standardized. Despite those bias, it was noteworthy that the residents in the simulation group had a significantly better systematic approach and more respect for the standardized quality criteria.
Patient benefits of ultrasound simulation in the area of gynecology, in terms of morbidity or mortality, have not yet been demonstrated. Further research in this area is needed. However, one can assume that better systematization of TVS may avoid misdiagnosis (cysts complications, ectopic pregnancies).
Other benefits for patients were demonstrated in a previous study by Tolsgaard et al. During TVS, patients felt less discomfort and more confidence during TVS when the operator was trained by simulation [29].
Finally, in the area of education, Chalouhi et al. suggested that the use of ultrasound simulators was possible for the National Examination. Indeed, images obtained by residents on simulators were correlated to those obtained on real patients [30]. This implies that volunteers for National examination are no longer necessary.
Simulation has its place in the initial training of GP residents in gynecology. Studies have shown benefits in gynecology and in obstetrics for fetal defect screening. The benefits in terms of public health and impact on the detection of pathologies are, however, difficult to evaluate.
