Despite publications presenting MUTA programs [17, 18] being released within years of the report of the first GTA program [19, 20], most articles continue to focus primarily on GTAs. Even the Healthcare Simulation Dictionary [1] incorporates MUTAs as a subset of GTAs, rather than a distinct or analogous role. Is there a reason for this discrepancy? Although the anatomy and relevant examination techniques vary, program descriptions and definitions indicate that the structure and intention of MUTA sessions are otherwise very similar to GTA sessions. This suggests that many implementation and utilization characteristics can likely be applied to both GTA and MUTA programs. Further research is recommended to collect additional evidence regarding MUTA programs and to identify similarities and differences between GTA and MUTA programs.
Program descriptions also indicate that engagement patterns are similar in spite of wide variation in terminology. These variations in terminology challenge research efforts and obscure potentially beneficial publications. Kretzschmar’s [6] landmark publication coined the terms “Gynecology Teaching Associate” and “Professional Patient,” and the official definitions for GTA, MUTA, and GUTA have existed for years. Upholding standardized terminology ensures a shared understanding of the concepts being discussed [21]. It is not uncommon for programs that engage patient models for demonstration to identify themselves as a “GTA/MUTA” program despite the individual receiving the physical assessment being a passive receiver of an examination, as opposed to instructing the examination [22]. This hinders effective communication, reduces the impact of relevant research, and poses a substantial risk for harm if inappropriate methodologies are unknowingly applied due to misunderstandings. Consistent use of terminology in alignment with the Healthcare Simulation Dictionary [1] and application of the ASPE GTA/MUTA SOBP [9] will help support clarity on this methodology while facilitating a safe, effective teaching/learning environment.
Program utilization and engagement
Although much work has been done to assess the learner’s response to the program (which is consistently positive), the characteristics that make GTA/MUTA programs most valuable have yet to be sufficiently identified and articulated. For example, GTA/MUTA preparation, learner objectives, learner preparation, and time allocated to the session will impact learner outcomes, but the importance of these individual variables is not yet known or fully understood. In most studies, these variables were either not explicit or insufficiently specific to evaluate. Many studies report that the GTAs/MUTAs provide “feedback” or “instruction,” yet both of those processes can be undertaken in a variety of methods. Real-time feedback during a session (e.g., confirmation of comfort, technique, and anatomy being palpated) is distinct from completion of a checklist on conclusion of the session. Adhering to the publication recommendations to enhance the quality of Standardized Patient research [23] will enhance the rigor of GTA/MUTA publications.
There is some evidence exploring use of task trainers before and after GTA sessions [24], but there is otherwise very little exploration of GTA/MUTA pedagogy. An instructional session with the objective of developing learner competence in visual identification of the cervix may (or may not) need more time than a session with the objective of placing a speculum. A MUTA program whose central objective is to identify a healthy prostate may (or may not) choose to employ MUTAs with ongoing prostate pathology. A GTA/MUTA who instructs independently may (or may not) support the learner’s belief that the “patient” is in control of their clinical encounter as opposed to the faculty or the examiner. Learners are being allocated between 10 and 75 min for instruction on the pelvic examination, which is most widely reported. These programs are almost exclusively used in graduate-level health professions programs, where effective pedagogy is essential for optimizing learning outcomes and later patient outcomes. While experiential learning [25] is being prioritized, the wide variance described in program utilization illustrates that we have not yet identified ways to optimize learning outcomes using GTA/MUTA methodology. While this may be challenging to explore, enhanced reporting consistent with Howley et al. [23] will facilitate sharing of such data.
Implementation
The ASPE SOBP [7] was the first document to illustrate standards of best practice for Standardized Patient Educators. Some of the Principles and Practices do not translate perfectly to GTA/MUTA programs, so the spirit of the document was used in this study to guide assessment of implementation characteristics. GTAs and MUTAs represent an application of Standardized Patient methodology so while the original ASPE SOBP has been applied in many contexts, the ASPE GTA/MUTA SOBP [9] demonstrates the Principles and Practices specific to offering instructional sessions that engage GTAs/MUTAs. These documents should help researchers better identify program characteristics to implement and report upon thus elevating the rigor of future publications and the field as whole.
Ethical considerations and humanization
This instructional methodology grew out of significant ethical concerns regarding the common practice of incorporating sex workers and/or unconsented anesthetized clients into instructional settings [26,27,28,29]. GTAs/MUTAs generally consent to their work; nevertheless, opportunities for coercion and harm remain [30]. For example, testimony in 2019 alleged misconduct including coercion and sexual harassment by administrators against clinical models for breast, pelvic, and rectal examinations [31]; this lawsuit was filed in the wake of the investigations into the even more egregious conduct of Dr. Larry Nassar. While this is an extreme circumstance involving patient models as opposed to GTAs, it suggests that administrative structures and mechanisms that can foster or enable coercive or other unethical behaviors may still be a serious issue in GTA/MUTA programs.
These practices highlight the critical importance of robust administrative processes including recruitment, hiring, and provision of rigorous training to support GTAs/MUTAs becoming effective instructors. Poor practices may increase the risk of harm to GTAs/MUTAs such as having poorly defined expectations; having poorly prepared or unprofessional learners; and placing the GTA/MUTA in a position where another individual in the instructional session holds greater power than they do, or a position where they are/perceived to be unable to decline work (in part or in whole).
Sexual harassment is common within medical schools [32,33,34,35] and healthcare facilities both in the USA [36] and abroad [37]. In the USA, the broader population reports 44% of women and 25% of men experiencing some form of sexual violence in their life, often before age 25 [36]. Worldwide, sexual and/or intimate partner violence impacts 35% of women [37]. In some studies within healthcare settings, faculty and healthcare professionals are more commonly reported to be perpetrators, compared to patients and their families [32, 33]. Instructional sessions therefore have high potential to include both survivors and perpetrators of sexual harassment, sexual violence, and other forms of violence. Although this risk, along with steps to address it, may be made explicit in some training programs, it is not well-addressed in the literature. Many opportunities exist to promote safety in these unique instructional settings, such as effective preparation of learners and GTAs/MUTAs with clear guidelines; inclusion of a chaperone (often additional learner(s)); provision of secure learning environments; and connection to relevant resources on campus.
One survey asked GTAs if they “felt ‘used’”; fortunately they did not, but this is a legitimate concern [38] that requires continued vigilance. Research and oversight should be conducted to ensure that GTA/MUTA programs maintain high ethical standards, and guard against the ethical issues similar to those that brought forth this methodology. The ASPE SOBP [7] and ASPE GTA/MUTA SOBP [9] provide effective frameworks to aid in prevention of such issues, particularly within the Domain addressing Safe Work Environment. This is essential for programs to address, yet is not frequently explored within the included studies.
By addressing these concerns, we can emphasize the safe practice of these skills as they relate to the learner’s future patients. While GTAs/MUTAs are not typically portraying a patient role during their instructional session, they are human and so experience the same sensations, and potentially harms, as a patient may when receiving care. Making the transition from seeing the GTA/MUTA as an educational tool and focusing more on their experience as humans who instruct with their body may help facilitate a shift in the ethical or moral perspectives used to guide this work [30, 39]. Safe work practices that maintain GTA/MUTA safety are, in many ways, consistent with patient safety recommendations. Protecting GTAs/MUTAs demonstrates not only respect regarding their human experience of instructing but also demonstrates the importance of patient safety for the learners they instruct. This may include empowering the GTA/MUTA to pause a session at any time for any reason or may be as complex as considering the maximum number of examinations a GTA/MUTA can instruct or receive in any timeframe. The latter represents a critical question that is commonly discussed within GTA/MUTA programs and organizations [22]—there are challenges in balancing efficiency and the human experience that must be navigated. For example, with repeated palpation of the same structure, the sensation of that exam and/or the anatomy itself may change. Additional research is recommended to evaluate the number of exams that a GTA/MUTA may safely experience in a given timeframe and to identify techniques that may be incorporated to enhance both physical and psychological safety for the GTA/MUTA.
Several studies address, at least in part, the learner experience within a GTA/MUTA session, yet few address the characteristics of GTAs/MUTAs and how they are individually impacted by their work (e.g., [40,41,42,43,44]). Additional research is indicated to explore motivations and experiences of GTAs/MUTAs.
Limitations
It is possible that publications have been omitted due to variations in terminology and/or indexing. GTA/MUTA methodology has been reported in several textbooks [8, 45] and books [27], which were not included in this review due to logistical constraints. Researchers charting data in tandem (two at the same time) may enhance reporting; however, consensus was reached quickly and this is not believed to be a significant challenge. Reporting of various details of GTA/MUTA program utilization and implementation may be incomplete and does not necessarily reflect the breadth of GTA/MUTA programs that exist globally.
