Annett Annandale

This article describes the implementation of an educational intervention, ‘bovine pregnancy diagnosis challenge’ over an 8-year period, and how evidence-based changes were applied to ensure the best learning outcome for bovine pregnancy diagnosis (PD) via transrectal palpation. With the worldwide shift from mainly knowledge-based to competency-based veterinary courses, many new and innovative teaching interventions have been introduced into veterinary education. These teaching interventions include but are not limited to simulators, models, virtual realities, applications, and computer-assisted learning tools; of which, many have been implemented into various veterinary training programs. While these advances are noteworthy, the question still remains as to whether or not the implementation of these teaching interventions is optimal. Do we know the ‘when,’ ‘who’, and ‘how’ of a specific intervention that will optimize the educational outcome? The described evolution of the bovine PD challenge shows how these questions were investigated for transrectal palpation skills, and how changes were implemented to optimize student training. This is an example of an approach that could be applied widely for validation and skills training investigations within veterinary education to optimize learning outcomes.

Pregnancy diagnosis by transrectal palpation (TRP) is a frequently performed procedure in bovine practice and an important competency for veterinary graduates. Student training for these skills has been identified as challenging, and reported training outcomes highlighted that students’ pregnancy diagnosis accuracy was an area that needed improvement. This led to a series of investigations evaluating specific teaching approaches aimed at optimizing TRP training and improving learning outcomes while decreasing the number of palpations needed to become competent, or in other words to ‘fast-track’ the transrectal palpation skill learning process. Gathered data were used to develop and implement research-based innovative teaching ideas, including optimized simulator training, in-training assessment methods, additional training opportunities linked to or not directly linked to the TRP skill itself, and the use of technology to improve skills training. This paper is a summary of these teaching interventions and elaborates on the background of those and why implementation is expected to improve student competence. Furthermore, even though the investigations described here are specific to bovine TRP and pregnancy diagnosis skills, they highlight an approach that can be applied to other clinical hands-on skills.

Live cow artificial insemination (AI) opportunities are limited at training institutions, and this study explored a novel approach to better prepare students for the task. Since the arm and wrist movement while playing foosball (FB) is like picking up the cervix during AIs, the effect of playing FB on veterinary students’ AI performance was investigated. Objective was to determine if playing FB would improve students bovine AI ability through muscle memory development. Fourth year (of a 5 year course) veterinary students (n = 28) either took part in the FB cohort (n = 17) or the nonFB cohort (n = 11). The FB cohort played 30 minutes of FB 3 times/week for 8 weeks. Both cohorts then participated in AI training using bovine cadaver uteruses before they were assessed on their ability to place an AI pipette into a live cow’s uterus. Although there was no difference between cohorts (p = 0.58) there was a higher proportion of successful students in the FB (0.35) compared to the nonFB cohort (0.18). Small cohort size, the fact that only 11 students completed the allocated FB play time, and participants’ transrectal palpation (TRP) inexperience may have influenced the result. This should, however, not discourage further investigations into alternative teaching approaches. Furthermore, this study highlighted the importance of assessing competence for clinical skills that are required to learn new skills first (TRP in this case) before attempting to teach a new, more advanced skill (AI in this case). This is likely to be applicable for many other clinical skills.

Bovine pregnancy diagnosis (PD) by transrectal palpation (TRP) is an important skill for veterinary graduates. Factors influencing students’ PD accuracy were investigated to optimize bovine PD by TRP training without increasing live animal exposure. The objective was to determine whether arm length and strength, proprioception, and exposure to a 6-week exercise training program were significantly associated with students’ PD accuracy. Veterinary students (n = 128) who had previously received formal theoretical and practical training in bovine TRP and PD (live cows and TRP simulators) were assessed for PD accuracy on live cows. Prior to assessment, arm muscle strength measurement, an exercise program, and additional TRP sessions on Breed’n Betsy® simulators and live cows were offered to the students. Seventy-eight students volunteered to participate in the arm length measurement, muscle strength, and proprioception testing. Of these, 35 randomly allocated students completed a 6-week exercise program, after which muscle strength was reassessed. Each student performed PDs on six cows of which the pregnancy status, ranging from 6 weeks to 9 months pregnant or not pregnant, was predetermined by an experienced veterinarian. PD accuracy was measured as sensitivity and specificity, being defined as the proportion of pregnant or nonpregnant cows, respectively, correctly identified by the student. It is concluded that hand grip strength and participation in an exercise program are significant predictors of veterinary students’ PD accuracy. Implementation of an exercise program aimed at improving grip strength in the veterinary curriculum is a novel approach to improve bovine TRP and PD training.

The unusual and tiring physical activity of bovine transrectal palpation (TRP) requires a novel approach to improve students’ TRP and pregnancy diagnosis (PD) skills. It has been shown that students who participated in an exercise program and students who had a grip strength (GS) of more than 30 kilograms performed better in bovine PDs. Participation in the exercise program increased students’ sensitivity (ability to identify pregnant cows) but did not increase total arm muscle strength. To identify which muscles are used during TRPs and to improve the exercise program, an electromyographic (EMG) analysis was used to identify muscle activation patterns and muscle activity levels during bovine TRPs. Eight subject matter experts (SMEs) each palpated two live cows and one Breed’n Betsy® rectal examination simulator while an EMG Triggered Stimulator recorded muscle activity. Muscle activation was higher for forearm muscles compared with all other examined muscle groups (p < .001); was higher during retraction of the uterus and palpation of left and right uterine horn, compared with palpation of cervix, uterine body, left ovary, and right ovary (p < .001); and showed an endurance pattern. Findings have been used to modify the previously developed exercise program in effort to improve students’ TRP and PD skills. The Bovine PD Improvement Exercise Program is available to students through an online application (http://icarus.up.ac.za/vetmlp/) and aims to not only improve GS and TRP accuracy but also stamina and well-being while adding fun to busy study schedules.

Background
To improve bovine transrectal palpation (TRP) and pregnancy diagnosis (PD) training, the effect of a high‐intensity one‐week training programme for veterinary elective students (N=59) with an interest in production animal practice was evaluated.

Methods
Training consisted of exposure to rectal examination simulators, abattoir organs, theory materials and live cow PDs supervised by experienced large animal practitioners. Palpation skills were assessed before and after training using a validated TRP Objective Structured Clinical Examination (OSCE) in non‐pregnant cows. Each student then performed PDs (n=12) on cows of known pregnancy status. Students’ PD accuracy was measured as sensitivity and specificity, being respectively defined as the proportion of pregnant and non‐pregnant cows correctly identified.

Results
Students’ scores improved from the first to the second OSCE (P=0.03), mostly as a result of improved ability to identify uterine symmetry/asymmetry and the presence/absence of a corpus luteum on the right ovary (P<0.01 and P=0.03, respectively). Overall student sensitivity and specificity of PD were 89.1 per cent (95 per cent CI 78.1–92.2 per cent) and 67.7 per cent (95 per cent CI 60.1–74.5 per cent), respectively.

Conclusion
This prospective cohort study describes a strategy to improve students’ TRP skills with the potential to reduce training time and animal use at teaching institutions by outsourcing student training to private practitioners.

This study evaluated whether one supervised simulated ovariohysterectomy (OVH) using a locally developed canine OVH model, decreased surgical time for final-year veterinary students' first live-animal OVH. We also investigated student perceptions of the model as a teaching aid. Final-year veterinary students were exposed to an OVH model (Group M, n = 48) and compared to students without the exposure (Group C, n = 58). Both groups were instructed similarly on performing an OVH using a lecture, student notes, a video, and a demonstration OVH performed by a veterinary surgeon. Students in Group M then performed an OVH on the model before performing a live-animal OVH. Students in Group C had no exposure to the OVH model before performing a live-animal OVH. Surgical time data were analyzed using linear regression. Students in Group M completed a questionnaire on the OVH model after performing their first live-animal OVH. The OVH model exposure reduced students' first canine live-animal OVH surgery time (p = .009) for students without prior OVH experience. All students (n = 48) enjoyed performing the procedure on the mode; students practicing an OVH on the model felt more confident (92%) and less stressed (73%) when performing their first live-animal OVH. Results suggest that the canine OVH model may be helpful as a clinical training tool and we concluded that the OVH model was effective at decreasing students' first OVH surgical time.

Bovine pregnancy diagnosis (PD) by transrectal palpation (TRP) is one of the most frequently performed procedures in bovine practice, and an important competency for veterinary graduates. It is currently not known if pre-existing TRP skills on non-pregnant cows can be used to predict students’ future PD accuracy. The study objective was to evaluate if TRP objective structured clinical examination (OSCE) scores can predict students’ future PD accuracy.

Fourth year (of a six-year programme) veterinary students (n=128) received TRP and PD training on Breed’n Betsy (BB) simulators and live cows. Students’ TRP skills were assessed using a live cow TRP OSCE after completion of the fourth year training. The same students received additional TRP (BB and live cows) and PD (BB) training sessions in the first semester of their fifth year. PD accuracy was assessed after the additional TRP and PD training, five months after the TRP OSCE assessment and measured as sensitivity and specificity (the ability to correctly identify the presence and absence of pregnancy, respectively). Each student palpated six cows transrectally to diagnose pregnancy status and stage for the PD assessment. The TRP OSCE results were analysed as predictors for students’ PD accuracy.Students with ‘competent palpation skills’ on the TRP OSCE had higher PD specificity. The individual OSCE components that were predictive of higher PD accuracy were students’ ability to estimate ovarian size, identify uterine position and exclude intrauterine fluid. It was concluded that a TRP OSCE has the ability to predict students’ future PD accuracy.

To optimize bovine pregnancy diagnosis (PD) training, factors influencing student performance were investigated. The objective was to determine whether training method, gender, background (farm, urban, or mixed), previous experience in bovine PD, and current career interest influenced the accuracy of bovine PD by trans-rectal palpation (TRP). Fourth-year (of a 6-year program) veterinary students (n=138) received one PD training session in groups using either simulator training on Breed'n Betsy (BB) or training on live cows (C). Students completed a questionnaire on gender, background, and career interest. Students' PD accuracy (pregnancy status and stage) was determined after training when each student palpated six cows with known pregnancy status. Students' accuracy in determining pregnancy status was measured as sensitivity and specificity (the ability to correctly identify the presence and absence of pregnancy respectively). Factors that influenced overall accuracy with a higher student sensitivity of bovine PD by TRP were training method, farming background, an interest in a mixed animal career, and stage of gestation. Gender of students and previous experience in bovine PD did not have an influence. Training on BB simulators was associated with lower student sensitivity for pregnancy detection in cows <6 months pregnant. Student sensitivity for pregnancy detection in cows >6 months pregnant was similar for training on BB simulators and live cows. No evaluated factors were significantly associated with specificity of PD. Teaching efforts focusing on specificity of PD and repeated simulator-based training in conjunction with live cow exposure are recommended.