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Review Article

A variety of teaching interventions to improve bovine transrectal palpation training
Annett Annandale,a,b Dietmar Holma

aFaculty of Veterinary Science, University of Pretoria, Pretoria, South Africa
bSchool of Veterinary Medicine, Murdoch University, Perth, Australia

Abstract
Pregnancy diagnosis by transrectal palpation (TRP) is a frequently performed https://www.blisscupcakesallen.com/ 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.

Keywords: Transrectal palpation, bovine pregnancy diagnosis, competency, clinical skills training

Citation line: Clinical Theriogenology 2023, 15, 9591, http://dx.doi.org/10.58292/CT.v15.9591

Copyright: © 2023 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Published: 30 May 2023

CONTACT Annett Annandale, [email protected]

Competing interests and funding: Authors have no conflicts of interest to report.

Introduction
Bovine pregnancy diagnosis (PD) via transrectal palpation (TRP) is a frequently performed procedure in bovine practice,1 of economic importance,2–11 and an important competency for veterinary graduates.12 Training of bovine TRP and PD is challenging, however, as it requires extensive exposure to TRP in live cows to achieve competency.13–16 Veterinarians often refer to the anecdotal ‘magic 10,000,’ that is the number of rectal palpations assumed to be necessary to ensure palpation competence. The origin of this number is unknown but indicates the perceived amount of practice necessary to confidently perform bovine PDs. It is possible that it is a link to Ericsson’s concept of deliberate practice where a practice time of at least 10,000 hours is stipulated to lead to expert status in a specific skill.17 The Australian Veterinary Association also previously recommended a minimum of 2,000 live cow palpations before attempting the competency examination.18,19 Some publications evaluated students’ TRP and PD performance after training and how many palpations are required to ensure competence,13–15,20 and it was suggested that 200 live cow palpations were insufficient to establish TRP competence for all 10 students in the evaluated group.13 Compared to many other skills, TRP and PD training is further complicated by the nature of the procedure; demonstration of the technique by an instructor and observation of a student palpating a live cow are not possible as execution of the procedure cannot be seen.13,16,19,21 In addition to these challenges, veterinary schools are expected to graduate entry-level veterinarians with advanced skills,22,23 while welfare and ethical concerns about the use of live animals for training purposes, large student cohorts, budget constraints, and difficulty sourcing cadaver material limit hands-on experience and training opportunities in general,22,24–35 thus influence PD training for veterinary students at teaching institutions due to a shortage of palpation opportunities.13–16,21 Furthermore, it seems difficult for students to get additional bovine PD and TRP exposure outside the veterinary course.15,36 Described training strategies to overcome some of the challenges listed above are exposure to abattoir-derived organs followed by live cow palpations,19,36 the use of cows at abattoirs prior to slaughter,15 student exposure to bovine TRP and PD during extramural studies,16,21 or ambulatory clinic rotations,15,21 and the use of a computer-assisted learning tool.19 Furthermore, a variety of rectal examination simulators such as the Veterinary Simulator Industries’ bovine theriogenology model,a Minitube’s ’Henryetta’ model,b the Breed’n Betsy® rectal examination simulators,c and the Haptic Cowd are commercially available, and several studies evaluated the use and implementation of rectal examination simulators in veterinary training programs.13,16,36–40

While training of bovine TRP and PD has been identified as challenging,13–16,19 only limited data were available on student performance in bovine TRP and PD.13,14 Recent investigations into TRP and PD training outcomes highlighted that students’ PD accuracy was an area that needed improvement.36,41,42 This led to a series of projects 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 TRP skill learning process.43 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.

Recommended evidence-based teaching approaches
The teaching approaches are listed below. This paper elaborates on the background of those and why implementation is expected to improve student competence for bovine TRP and PD. For the context of this paper, sensitivity of PD is defined as students’ ability to correctly identify pregnant cows, whereas specificity is defined as students’ ability to correctly identify non-pregnant cows.

In summary, we recommend:

Repeated rectal examination simulator-based training in conjunction with live cow exposure early in the curriculum.
Teaching efforts focusing on specificity of PD.
Teaching efforts focusing on stage corrected sensitivity and early pregnancy stages.
Encouraging students to use an exercise program like the ‘bovine pregnancy diagnosis improvement exercise program’ (http://icarus.up.ac.za/vetmlp/) to improve grip strength and indirectly palpation abilities.
Use of the ‘mini-cow palpation box’ to develop coordination and fine motor skills to estimate object sizes without visualization.
Introduction of a TRP objective structured clinical examination (OSCE) (on simulator and/or non-pregnant live cows, depending on availability) as a compulsory formative in-training assessment (‘rite of passage’ examination) before advancing to PD training on live cows.
Use of the validated TRP OSCE on non-pregnant live cows as well as a validated PD assessment on live cows to ensure training outcomes and track student progress during advanced TRP and PD training sessions.
Implementing focused access to live cow palpations for students with an interest in production animal practice during later stages of the curriculum.
Ensuring supervision and quality feedback during palpation sessions.
Repeated rectal examination simulator-based training in conjunction with live cow exposure early in the curriculum
The first recommendation is based on a validation study comparing rectal examination simulator versus live animal PD training.36 It revealed that students’ ability to detect pregnancy in cows > 6 months pregnant was similar for training on simulators and live cows. However, PD training on simulators, compared to training on live cows, was associated with lower student PD sensitivity for cows < 6 months pregnant. This was an interesting outcome since the Breed’n Betsy® simulators are specifically designed for early pregnancy detection and also because the live cows used for training purposes in that study were all > 6 months pregnant.36 A potential reason for this paradox was thought to be that overcoming the unusual experience of TRP may be more difficult than the actual ability to palpate.36 Absence of rectal peristalsis, anal sphincter tone, and other internal organs (e.g., urinary bladder and rumen) make reproductive tract palpation easier on a simulator than in the live animal, and the simulator experience may not impart the feeling of palpating a live cow. Also, simulator palpations were suspected to require various arm movements and muscle activations than the same procedure on live animals. While a follow-up investigation to elaborate on this hypothesis concluded that there is no difference in muscle activation for simulator and live cow palpations, it revealed that muscle relaxation between individual TRP steps for simulator palpations was more distinct for simulator compared to live cow palpations. This was thought to be due to the absence of rectal peristalsis in simulators, and a potential reason for a difference in simulator and live cow training outcome. While it was demonstrated that rectal examination simulators cannot replace live animal training, implementation of simulators into veterinary teaching programs offers remarkable additional training opportunities beyond live cow training that can help reduce the requirements of live animal training. These findings were in accordance with other studies evaluating the use and implementation of rectal examination simulators in veterinary training programs.13,16,37–40 In the case of TRP and PD, simulator training was superior to theoretical instruction only,39 and additional simulator training substantially improved students’ performance after live cow palpations.16 Therefore, repeated simulator-based training in conjunction with live cow exposure is recommended to optimize learning outcomes.13,16,36,39 Another finding related to the use of simulators is that timing of simulator training in relation to student experience within the veterinary course is important.20,36 The proposal of simulator training early in the curriculum stems from student feedback where 4th year students (of a 6 year course) without any prior live cow PD experience were exclusively positive about their simulator experience, whereas students with previous live cow PD experience made negative remarks about the simulator exposure.36 This finding was endorsed by final-year student questionnaire feedback showing that refresher rectal examination simulator training at these later stages in a student’s career was not perceived as beneficial by the majority of students.20 It has previously been described that satisfaction data should be considered, as student perceptions of a model will affect their motivation to use it.44,45 Since students felt the model was useful at a specific point in their veterinary education, they will likely be motivated to practice on it.44 Enjoying a procedure enhances positive emotions that have been reported to facilitate successful learning.46 Therefore, rectal examination simulator training should be implemented early in the curriculum before but in conjunction with live cow exposure.

Teaching efforts focusing on specificity of PD
PD specificity is defined as the students’ ability to correctly identify non-pregnant cows. Correctly and reliably identifying non-pregnant cows is especially important for farmers due to the economic implications of a false positive PD. While students are not expected to be at the same competence level as experienced practitioners, a specificity of 41 and 42% reported for 4th and 5th year students, respectively, had been identified as a problem area,36,41,42 and teaching efforts focusing on specificity of PD are recommended. Strategies to accommodate this part of the training are repeated simulator training exposure before live cow access, assessment of basic palpation skills before advancing to live cows, and demonstrating competence in non-pregnant cow palpations before advancing to PDs. This approach increased student specificity to 67%.20

Teaching efforts focusing on stage corrected sensitivity and early pregnancy stages
The stage of pregnancy is one of the factors associated with students’ bovine PD accuracy. While overall PD sensitivity can be defined as correctly identifying pregnancy, stage corrected sensitivity takes the pregnancy stage into consideration. This has been defined as correctly identifying the stage of pregnancy within 1 month of the actual stage of pregnancy for all pregnancy stages up to 4 months, and within 2 months of the actual stage of pregnancy for pregnancy stages beyond 4 months.

While the mean overall reported student PD sensitivity was 61 and 82%, stage corrected sensitivity was only 31 and 43%, respectively (in the same cohort of students).36,42 Furthermore, students’ sensitivity of pregnancy detection was repeatedly higher for cows more than 6 months pregnant.36,42 This confirms the need to concentrate training efforts on palpations during early pregnancy stages.

Encouraging students to use an exercise program like the ‘bovine pregnancy diagnosis improvement exercise program’ to improve grip strength and indirectly palpation abilities
The fairly unusual and tiring physical activity of bovine TRP sparked an idea for a novel approach to improve students’ TRP and PD skills. The effect of a physiotherapy exercise program on students’ TRP and PD skills was evaluated.42 The 2 main findings were that students who participated in the exercise program and students who had a grip strength of more than 30 kg performed better in PDs. Results from this investigation initiated a subsequent electromyography (EMG) study taking these findings a step further and led to the development of the ‘bovine PD improvement exercise program.’47 The EMG study suggested that hand muscles, extensors and flexors of the forearms, shoulder stabilizers, back muscles, and core muscles are strongly activated during TRPs, confirming the role that forearm muscles, and therefore grip strength, play during TRP.42,47 It was also apparent that muscle endurance is more important than total muscle strength. Based on these findings, a 3-month exercise program targeting exactly those muscle groups was developed with the help of an experienced biokineticist.47 The program is divided into 3 levels starting with easier entry level exercises and building up to more advanced exercises. It is available to students via the following link: http://icarus.up.ac.za/vetmlp/. The program uses readily available exercise equipment and is suitable to any exercise level, and instructions are given through narrated video clips (Figure 1). This online program enables students to choose when and where they would like to exercise and only requires the participant to exercise for 30 minutes, 3 times a week. It can be done in conjunction with any other fitness or exercise activity. The program not only increases grip strength and therefore indirectly improves TRP accuracy but also increases stamina and wellbeing, shapes arms nicely, and adds some fun to busy study schedules.