Teaching and Learning Innovations in Obstetrics and Gynecology in The Time of The Pandemic

Teaching and Learning Innovations in Obstetrics and Gynecology in The Time of The Pandemic

August 08, 2022


By Maria Julieta V. Germar, MD,FPOGS, FSGOP, FPSCPC
Professor 4, University of The Philippines College of Medicine
Philippine General Hospital

Excerpts from the Professorial Lecture delivered on June 22, 2022

Dr. Maria Julieta V. Germar, fondly known as Dr. Jayjay, shares her experiences in teaching during the pandemic.

I feel very privileged to be given this honor and opportunity as the mentor who holds this professorial chair is more than just a mentor to me. He has been our source of inspiration through the years and our source of wisdom and strength long after he’s gone.

He taught us not just to be the best gynecologic oncologists, not just to be astute researchers or excellent teachers, but to be good people as well. He played a loving part in our lives, and he will always be our Papang.

In memory of Papang who taught us how, let me share with you what we did in this pandemic to teach our students while learning to be better teachers. We all have a lot of stories to tell, our struggles, our triumphs and how we found our hearts in this pandemic.

My story is the story of a teacher. My very first idol outside the home was my kindergarten teacher. I think I speak for most of you when I say ang unang idol natin ay si ma’am o si sir. Our teachers are like superheroes as we were growing up. They have superpowers, they’re all-knowing, they’re always present, and so we follow everything they say.

When I entered medical school, in my heart, I still wanted to be a teacher. The rockstars for me then were our professors who taught us well whether in the classroom or in the clinics, just like Dr Augusto Manalo. I wanted to be like them.

Dr. Jayjay Germar with her co-interns who faced the full PGH experience together

My first job when I became faculty at the UP College of Medicine, was the OB GYN Academic Coordinator of the Integrated Clinical Clerks and I've held that position for 18 years now. I've always asked to keep the position no matter how toxic, because I like that part of my work.

I am happiest when I teach.

One of the best decisions I’ve ever made was enrolling in NTTC in 2017, I wanted to be a better teacher. As a teacher, I find joy and fulfillment in seeing the students eagerness in learning something new, and the awe they feel in performing a skill for the very first time.

Then, COVID 19 happened. It disrupted our lives in an unprecedented manner we could never have been prepared for. This however became the catalyst for this transformation in health professions education. We need to continue to teach and transform. The pandemic brought clarity and critical urgency to this purpose. It pushed us to find ways. In the clinical sciences, we were hit hard. The pandemic removed our students from the opportunity to talk, examine and interact with a patient. We had to keep our students away from the very place where they would experience learning best.

Let me tell you our story.

When the pandemic hit, it was the second week of my students, and I had to think of teaching learning activities they can do from home. I made them work on infographics on COVID-19 and pregnancy. We met virtually and I gave them whatever guidelines were available. We found refuge in the work we were doing.

We posted their work on Facebook, Twitter, and all Viber groups. They were the FIRST ever infographics on COVID-19 and pregnancy, and in one day, these were shared 331 times in social media platforms. Clinicians from Palawan, Zamboanga and Ilocos asked to create tarpaulins as guidance for their trainees and patients. The Philippine Obstetrical and Gynecological Society President and Vice President acknowledged their work.

A day later, on March 17,2020, I got a call from Dr Pura Rayco-Solon of the World Health Organization. She was calling from Geneva. She asked about the infographic on COVID-19 and breastfeeding and how our students can add the just posted WHO recommendations. She then posted the updated infographic on her social media page. The post was shared 132 times. My students went international.

On January 2021, it was decided that our third year medical students still could not have face to face classes. Third year is when they have their first clinical exposure. In this year level, everything is amazing, everything is wow. How do we now teach them these clinical skills virtually?

We needed to look at each teaching and learning strategies and modify, adapt, and modify again. We had to check our resources, our personal capabilities and we had to inform and prepare our faculty–our greatest resource, a constant resource that COVID cannot change. My greatest weapons through the years are my residents who share the passion and commitment to teach. We were prepared.

We had to learn about our students, our learners. We must create an environment where learners feel supported and psychologically safe especially in this pandemic. I set aside every first Monday of the rotation to get to know them. This pandemic disrupted our social relationships. We all longed for social interaction. The virtual platform actually allowed more intimate interactions. I ask them to introduce themselves and mention a fun fact no one knows. They become excited and creative. I asked what they did in the pandemic—some baked, some have pets, some have art, plants. We had show and tell. It breaks the ice. Then I ask their expectations, their learning needs, their connectivity issues. I got to know each student more now than pre pandemic. We developed friendships.

Access and communication became critical. I had a telegram chat group with them. All 6 blocks, 30 students per block. They have direct access to me, and I have access to them. Access provided us so much comfort during these uncertain times.

I learned to be mindful of their circumstances. I had students who could not join because of internet limitations. One had a brownout at home and tried to join using a streetlight. One had to be in a bus to come to Manila due to an emergency. One had to take care of family with COVID, and one had to work after 5 pm and so had to leave. We have weekly feedback also by Telegram, either in the group chat or direct message. Sometimes I send a summary post session to reinforce key messages, and/or a reflective exercise to help consolidate their learning.

The next step is facilitating active learning. Visual learners prefer material that is delivered through visual media. Auditory learners prefer the spoken word to visual material. We have AVPs prepared for these aspects of learning. Kinesthetic learners learn best when the learning involves them in physical activity. The tactile aspect of learning must be achieved. I had to engage them in these 3 aspects. So we needed to find a way to do this virtually.

This is the conceptual framework of the OB GYN 250 Virtual Learning Simulation Kit. First, I sent them the AVPs for all the clinical skills—Physical Examination in OB GYN. I gave them performance checklists for each skill. Then I sourced the cheapest materials I can find, made a cervix out of clay, found low-cost disposable specula and tested prototypes. I assembled each one and included instructions.

This is the first ever OB GYN 250 Virtual Learning Simulation Kit. For the pelvic exam and pap smear, the kit has a disposable speculum, gloves, spatula, swab and glass slide and the clay cervix to be mounted in a toilet paper core. For episiorrhaphy, the kit contains a needle holder, scissors, tissue forceps, suture, gloves, syringe, and a yellow sponge simulator. I asked the students to prepare toilet paper cores to be vaginal canals, find their old stuffed toys and use their imagination.

I sent them one by one to those in Metro Manila and the regions. Thirty students at a time every 3 weeks, for all 181 students. The Foundation and donors helped augment the cost of the kit. It was a test of patience, but I wanted to make this work.

OB GYN 250 Simulation Kits are assembled by Dr. Jayjay Germar, which are then delivere dto each student’s homes for their best learning during the pandemic

Skills acquisition in clinical teaching involves learning how to perform the skill, the rationale for doing each step, and the interpretation of the findings. Without these three components, the skills merely become a mechanical performance with limited clinical applications. It’s not just knowledge, it’s not just muscle memory, there’s a fourth aspect. How to humanize the learning experience so that it makes a student perform the skill in a gentle manner while interacting with a patient and making sure she is not in pain she is comfortable, and she understands the procedure being done. When we teach our health professionals the skills necessary to make them competent physicians the most important aspect is, how to make sure each step is understood not just in the cognitive aspect, not just in perfect motor synchrony but with empathy as well.

I do a live demonstration for each skill every Thursday of their 3-week rotation. I annotate, explain the rationale for each step. I encourage questions and promote interaction. We must engage the learner; we must compensate for what can’t be done face to face. Particular attention is given to making sure each step is done with care with the patient’s comfort and safety in mind. I asked them to use stuffed toys and regard them as patients as they inform her of every step. I encourage the students to ask questions and clarify what is not clear in the steps. Redirection, refocusing, and increasing critical awareness are important.

For Normal Labor and Delivery, we do the live demo on the cardinal movements of labor and delivery using a pelvic model and a baby. I use three cameras for better views. For the episiorrhaphy workshop using a yellow sponge simulator, I do a live demo again, using all possible angles. I then ask them to mark the muscles in their sponges, so they review the anatomy of the perineum. I sometimes do the demo 2-3x per block before the breakout to make sure they learned. Sometimes some cannot follow so I schedule a separate one on one with that student. Individualized learning and feedback are necessary for some students.

We divide them into breakout groups and do the return demo using the checklist. The tactile component of learning became evident. They annotate as they perform the steps. We then debrief each one. What has been achieved may be conscious competence. We may then aim for unconscious competence by constant practice at home which makes the kits handy.

Scenes from Dr. Jayjay Germar’s session teaching episiorrhaphy to Integrated Clinical Clerks

This Kolb’s Experiential learning cycle is applied. We start with the concrete experience, then reflective observation in the breakout rooms, conclusions drawn during the debrief and active experimentation starts with skills enhancement before the actual patient encounter.

Motivation is key. The kit was something they appreciated and something they own. It sparked interest as they assembled and found other items from the house to help with their learning. The learning became individualized participative and interesting.

Student’s learning is affected by their motivation. Controlled motivation is brought about by external pressures (other people’s expectations; rewards and punishments) or what they think is expected. This leads to rote-learning with little integration of the material into the student’s long term values. In contrast, autonomous motivation occurs when individuals see the material to be learned as intrinsically interesting or important. This leads to greater understanding, better performance, and greater feelings of competence. This is what we continuously aim for.

Motivation is for both the students and the teacher so we must ourselves be motivated. Like oxygen needed at a time of an emergency, we need to fit our own oxygen masks first before we help others.

Next is the lack of patient exposure. This would have been their first exposure to patients in the ambulatory setting. I can’t make them do telemedicine as a tag along with residents because most patients don’t have gadgets nor access so it’s usually a simple call, no videos. So, we must find ways. We found low-cost gadgets and made telemedicine hubs at the OPD.

They interview and interact with the patient via Zoom. They discuss their findings with preceptor who in turn examines the patient and discusses the findings with the student. They arrive at a diagnosis and plan. The student then discusses the diagnosis and plan with the patient. All competencies except for the actual physical exam were fulfilled. Patients appreciate the attention of the students, and the students get the chance to have a patient encounter even if virtually. There are many skills that cannot be taught even in a face-to-face classroom. The humanistic aspect of medicine requires the presence of a patient, real or simulated.

The next step would be assessments both to assess the students and the course and the teacher. Rubrics are essential. We had to balance accurate evaluations with compassion. We need to grade them, but we need to prioritize learning over grades. I give them personal feedback on their quizzes. I find it therapeutic as I get to know them more and it motivates them to do better.

The last step would be to calibrate the responses based on feedback. We needed to complete the last two steps to complete the experiential learning cycle. So we designed the skills enhancement program. This was formative with feedback and debriefing. We focused on basic physical examination skills. This was our bridging module to close the learning gaps, face to face.

We started hybrid sessions in March 2022. What we continue to provide: a safe learning environment, formative assessments, personalized feedback, and a calibrated response. We’ve resumed doing the lectures that precede the workshops as face to face. We did birth simulation using a high-fidelity simulator, keeping in mind the mindfulness and one on one teaching we learned when it was online. The face to face encounters we do now are much more appreciated. This is something we will never take for granted ever again.

As face to face classes are slowly resuming, skills enhancement sessions are conducted to ensure adequate knowledge and skill of incoming clerks.

The pandemic is not yet over. We must prepare our students to be compassionate, to be brave and to remember the very reason they want to be in this profession. We need to arm them as they play multiple roles in Society. The roles we play go beyond just being educators.

Ang pandemya ang nagturo sa atin na ang mahalaga ay hindi lamang ang utak o galing kundi ang malasakit at ang puso.

Dr. Augusto M. Manalo said the following in a speech he delivered in 1997 addressing his students now educators and he said:

“Kung sa tinagal-tagal ng iyong pagdadalubhasa ay natutunan mong tumangis sa kahirapan at kalungkutan ng iyong mga kababayan,
kung natagpuan mo sa iyong puso na maglingkod sa kanila nang kahit
paminsan-minsan ay walang inisip na katumbas na kabayaran,
ikaw na marahil ang isa sa maitatanghal na tunay na bayani ng ating
pangkasalukuyang lipunan...
Maybe you are the reason why many of us have spent the best years of our lives
being involved with teaching and residency training programs.
Maybe you are the reason why we never stopped to improve these programs…
Maybe you are the reason why we can walk with joy in the twilight of our careers...
...because we know that there will be you to take good care of our people.”

We can only hope our students become the individuals we envisioned them to be, the individuals they themselves aimed to be and the individuals the society, this country deserves to have.