Exploring patient involvement in obstetrics and gynaecology medical education: a scoping review

Abstract

Background

The benefit of patient involvement in medical education has been widely described. In particular, patient story-telling and sharing of personal experiences has been shown to increase study empathy and connection to patients. Patient involvement in obstetrics and gynaecology requires particular consideration with regard to patient dignity and autonomy. This scoping review aims to explore the context of patient involvement in medical education of this specialty to date, with a view to identifying gaps in the current provision of training and amplifying the patient voice and perspective in an ethical way.

Methods

A search was carried out across nine databases to identify studies pertaining to patient involvement in medical education in obstetrics and gynaecology. Studies from 1960 to 2025 were included. Patient involvement was categorised according to Towle’s “Spectrum of patient involvement”. Benefits to students from patient involvement were examined. Details regarding patient recruitment, consent, compensation and debriefing were recorded in order to ascertain the ways in which patient safety and wellbeing was cared for in each study.

Results

The search identified fifty-three studies for final analysis. Most studies detailed patient involvement with regard to the demonstration and teaching of pelvic examination (n = 48). Few studies gave details on patient consent for participation (n = 12). The benefits to students from patient contact were clear with the majority of studies showing benefits (n = 51) in terms of either examination skills, empathy levels or interpersonal skills development. Few studies referenced patient training (n = 11) prior to participation or patient debriefing (n = 7).

Conclusion

To date, patient involvement in medical education in this specialty has been largely confined to the demonstration and teaching of pelvic examination skills. Given the rich and diverse experiences of those seeking care in obstetrics and gynaecology, improvements could be made to place more emphasis on personal experiences and education delivered by patients themselves. Patient consent and respect for patient well-being should be of paramount importance in the context of any involvement in medical education. Future initiatives involving patients should ensure to explicitly define and outline how the protection, dignity and well-being of patients is ensured throughout their involvement in educational programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08091-w.

Introduction

The ways in which patients are becoming involved in medical education are continuously evolving and expanding but the benefits of patient involvement to both the patient participant and the student remain clear [1, 2]. This scoping review aimed to explore the involvement patients have had to date within the specialty of obstetrics and gynaecology.

In particular, this review aimed to establish to what degree patients are involved by sharing their personal experiences and stories with students. Patient’s personal stories are a powerful tool that can be used to enhance student understanding and empathy for the lived experience [3]. A brief, preliminary review of the literature on this topic revealed that patient involvement in obstetrics and gynaecology to date seemed largely weighted towards the demonstration and teaching of physical examination, namely the pelvic examination. The practice of utilising gynaecology teaching associates (GTAs), women who are trained to use their own bodies to guide and deliver feedback to students on pelvic examination, has been in widespread use since the late 1960 s [4]. The use of GTAs has shown benefits to students in terms of both competence in performing the pelvic examination and communication skills [5]. By examining the current literature in detail, this scoping review aims to identify gaps in the provision of medical education in this specialty so that future initiatives can be aimed at expanding patient involvement beyond physical examination and introducing the patient voice into the education in this specialty and doing so in the safest and most respectful way possible. Patients have a unique perspective that cannot be emulated or delivered by clinicians who have not lived the real experience [6].

The specialty of obstetrics and gynaecology presents unique challenges in the context of patient involvement. Of course, the practice of active patient involvement in any specialty requires sensitivity and utmost respect for patient consent and autonomy, however it requires special consideration in obstetrics and gynaecology. Firstly, many of the clinical scenarios in this specialty are highly intimate in nature, in particular in relation to physical examination. Secondly, there has been an ongoing discussion in the literature around consent practices and patient autonomy in decision making processes in obstetrics and gynaecology [7, 8], therefore it is imperative that patient involvement is considered and held to the highest standards of ethical practice.

Methods

A protocol was developed for this scoping review according to the Joanna Briggs Institute methodology for scoping reviews [9]. This protocol was published in BMJ Open in October 2024 [10]. Primary and Secondary Research questions were developed including:

1. What published research is available on the extent of patient involvement in undergraduate medical education within the field of obstetrics and gynaecology?

2. Are there benefits to patient contact for the student?

3. What are the ethical issues highlighted in the literature surrounding patient involvement in this specialty, and how is the safety and well-being of the patient educator cared for?

Inclusion criteria

The Population, Concept, Context framework was used to define the inclusion criteria and search strategy for this scoping review. The population included medical students only. The Towle Spectrum of Involvement was used to characterise the extent of patient involvement [11]. Only studies above Towle level 2 or above are included. See Table 1 for an outline of the Towle Spectrum of involvement.

Table 1.

Level of patient involvement according to Towle spectrum of involvement

Degree to which the patient is actively involved in the learning encounter
1. Paper-based or electronic scenario
2. Standardised or volunteer patient in a clinical setting
3. Patient shares his or her experience with students in a faculty-directed curriculum
4. Patient-teacher(s) are involved in teaching or evaluating students
5. Patient-teacher(s) are equal partners in student education, evaluation and curriculum development
6. Patient(s) involved at the institutional level in addition to sustained involvement as patient-teacher(s) in education, evaluation and curriculum development for students

Studies were also characterised according to the Kirkpatrick framework which categorises outcomes from training programmes according to four levels [12] reaction, learning, behaviour and results. Only studies within the specialty of obstetrics and gynaecology were included. The full inclusion and exclusion criteria used can be found in the Table 2.

Table 2.

Details of inclusion and exclusion criteria for scoping review articles

Inclusion Criteria	Exclusion Criteria
Must be Published in English Language	Non-English Language Articles
Must involve medical students	Students from other health professions
Articles must be available in full text	Commentary or Review Articles
Must be interventional study design	Systematic Reviews or Descriptive Articles
Must be primary research article	No mention of evaluation of the teaching session
Must include an evaluation of the teaching intervention	Other areas of women’s health e.g. Breast disease/Breast Cancer
Must pertain to specialty of obstetrics and gynaecology	Studies that do not give a description of the methodology of the teaching session

Search strategy

The search strategy for this scoping review was developed by CK, SAlT and MH along with the assistance of the UCD academic librarian DS. The search strategy was developed with the aim of carrying out a comprehensive search of the available literature. A comprehensive search strategy used for Pubmed (Medline) including MeSH terms can be seen in Table 3 below.

Table 3.

Example of medline search strategy including mesh terms

Medline Search Strategy	Mesh Terms
“Patient involvement” [All Fields] OR “patient participation“[All Fields] OR “Service user involvement“[All Fields] OR “service user participation“[All Fields] OR “client involvement“[All Fields] OR “client participation“[All Fields] OR “consumer involvement“[All Fields] OR “consumer participation“[All Fields] OR “teach* associate“[All Fields] OR “professional patient*“[All Fields] OR “patient expert*“[All Fields] OR “user involvement“[All Fields] OR “user participation“[All Fields] OR “patient educator*“[All Fields] OR “patient tutor“[All Fields] OR “future clinician*“[All Fields])	“Patient Participation” [MeSH Terms] OR “Stakeholder Participation” [MeSH Terms]
“Undergraduate Medical education“[All Fields] OR “medical educat*“[All Fields] OR “medical student*“[All Fields] OR “graduate entry med*“[All Fields] OR “graduate entry medical student*“[All Fields] OR “preclinical“[All Fields] OR “clerkship“[All Fields] OR “medical school*“[All Fields]	“education, medical, undergraduate“[MeSH Terms] OR “students, medical“[MeSH Terms] OR “education, medical“[MeSH Terms]
“pbstetric*“[All Fields] OR “gynaecolog*“[All Fields] OR “gynecolog*“[All Fields] OR “gynaecolog* health“[All Fields] OR “gynecolog* health“[All Fields] OR “women s health*“[All Fields] OR “reproductive health“[All Fields] OR “reproductive med*“[All Fields] OR “sexual health*“[All Fields] OR “sexual medicine“[All Fields] OR “matern* health*“[All Fields]	Obstetrics“[MeSH Terms] OR “Gynecology“[MeSH Terms] OR “Women’s Health“[MeSH Terms]

The following databases were searched including: PubMed (Medline), Embase, Google Scholar, CINAHL, ERIC and PsycInfo. Scopus, Cochrane Library and Web of Science. Three academic journals were hand searched for the previous five years of publication including “Medical Education”, “Medical Teacher” and “The Clinical Teacher”. Citation Searching was carried out on included studies to identify any relevant studies not captured in the original search.

All searches were downloaded to ENDNOTE citation manager software and transferred from here to Rayyan, an online citation manager. De-duplication was carried out on Rayyan [13]. Each title and abstract was reviewed to determine its suitability for inclusion based on the aforementioned inclusion criteria. Full-text review was carried out on remaining articles. Four full-text studies were obtained through UCD inter-library loan and one article was purchased directly from the publishers. The review process is detailed in the PRISMA flow diagram in Fig. 1 below.

Fig. 1.

Prisma P Flow Diagram 2020 adapted for: Exploring patient involvement in obstetrics and gynaecology medical education - a scoping review

Data extraction

Demographic data was included for both medical students and patients involved including year of medical school training and any personal patient characteristics mentioned. Details were also gathered on the structure of the educational session and details the number of students involved, the categorisation according to Towle’s taxonomy, the method of data collection and the overall outcomes. Data extraction also included details on patient consent, methods through which consent was obtained, patient recruitment and the opportunity for patient debriefing.

Results

In total, 53 studies were included in this scoping review. A summary of the included studies can be found in the supplementary material.

Geographic distribution of the included studies

Most (n = 26) were carried out in the United States of America (USA) with the next most common location for studies to be carried out being Australia (n = 7) and the United Kingdom (n = 6) (See Fig. 2 Below).

Fig. 2.

Geographic Distribution of Scoping Review Articles

Figure created with Datawrapper GmbH [14]. DPR = Democratic Peoples Republic.

Year of publication of included articles

The earliest published article fitting the inclusion criteria was published in 1974 [15]. There was a relative decline in article publication with regard to patient involvement in medical education in obstetrics and gynaecology in the 1990 s with a rise in the number of publications in recent years (See Fig. 3 below).

Fig. 3.

Distribution of scoping review studies based on year of publication from 1974 to 2024

Most studies were quantitative in design (n = 39) with ten studies following a mixed-methods approach and four studies were qualitative in their approach.

The focus of patient involvement in included studies

Of the fifty-three studies identified concerning patient involvement in this specialty, most educational initiatives described have their primary focus on physical examination (n = 45), in particular the demonstration and teaching of pelvic examination skills. Many of the studies combined pelvic examination with teaching on interpersonal skills (n = 8), communication skills (n = 14) and history taking (n = 3). In addition, some of the remaining eight studies, while not focussed on pelvic examination skills entirely, still involve intimate examination as part of the educational session for example by providing training in transvaginal ultrasonography [16, 17].

The remaining included studies have their focus in history taking, empathy and communication skills. Three of these papers, specifically addressed transgender care, with a focus on the individual experiences of those seeking care in the transgender and gender diverse population [18–20]. Two studies were focused on sexual history-taking [21, 22]. The remaining studies covered areas including patient feedback [23], patient storytelling and empathy development in the care of a patient with heavy menstrual bleeding [24] and transvaginal ultrasound scanning [16].

Student participants

The student population involved in the included studies were mostly second (n = 19) and third (n = 13) year medical students. One study included first year students. Fourteen studies referenced fourth (n = 7) and fifth year students (n = 7). In some cases, the year of medical school was not mentioned (n = 2) and four studies references students in final year or year seven. In terms of numbers of medical students involved in each article, the median was 160 students (range 9–606 students).

Patient characteristics

The terminology used to describe patients involved in the education of students was varied, with patients referred to most commonly as “gynaecology teaching associates” (GTAs; n = 20) reflecting the fact that most studies included involved education specific to physical examination. The next most common term was “professional patient” (n = 9) which would suggest patient renumeration, though there was some inconsistency in this regard. Terminology used to describe patients involved in educational initiatives not related to intimate examination included “patient educators” (n = 2), “clinical teaching associate” (n = 3), “standardised patients “(n = 4), “simulated patients” (n = 1) “patient instructors” (n = 2), “teaching associates” (n = 3), “volunteer patients” (n = 1), “professional simulated patients” (n = 1), “professional standardised patients” (n = 1), “intimate examination assistants” (n = 1), “patient actress” (n = 1), “programmed patients” (n = 1) and “clinic patients” (n = 2) or “patients” (n = 1). For the sake of continuity all patients involved in training of pelvic examination as GTAs throughout this paper.

Most included studies did not give details on the personal characteristics or demographic information of involved participants (n = 28). Of the five studies that detailed the ages of patients involved this ranged from 21 to 72 years. A small number of studies did refer to specific participant populations involved in teaching programmes. For example, one study included women involved in oocyte donor programmes who took part in the role of a gynaecology teaching associates, guided students through pelvic examination technique [25]. Individuals from the transgender community were mentioned in three studies [18–20]. Some studies referred to the educational or professional backgrounds of patients involved, including graduate students or health care personnel [26] or those with a professional background in health or education [27]. Another study highlights the fact that the patient participants were graduates of either sociology, psychology, nursing or midwifery [28]. The relationship status of patients were mentioned in a small number of studies, such as one study which commented on the fact that the teaching associates involved were either married, cohabiting or strangers to one another [29]. Another study published in 1975 which compared teaching approaches to pelvic examination using a manikin versus a ‘programmed patient’ commented on individual patient participants as “single and sexually active, but not professional prostitutes” [15]. Lastly, some studies made reference to the included patient’s physical characteristics, commenting on multiparity and the anatomical variants of pelvic structure referring to “anteflexed uteri & palpable adnexae” of female participants [30].

Patient motivations

Most of the included studies do not give any specific detail on patient motivations for participation in medical education. For those studies that do, the most common reason given is to help students improve their skills and to help doctors in training get a better understanding of the care of a female patient. Three studies detail “previous healthcare experiences” as reasons for becoming involved in medical education [18, 31, 32].

Towle level of patient involvement

As detailed in the methods section, Towle’s Taxonomy, which details the degree to which the patient is actively involved with the learner, was used to characterise patient participation in the included medical education initiatives [11]. E-learning or virtual patients were excluded from the review.

The majority of included studies (n = 48) detailed patient involvement at Towle level 4 or above. Two studies detailed patient involvement at Towle level 3. In one of those studies, the focus was on patients sharing their experience with students and participating in a history-taking role play [18]. In the second, the focus was on patient storytelling. Three further studies were categorised as Towle level 2.

Kirkpatrick levels of evaluation

Forty of the fifty-three (40/53) included studies were evaluated student outcomes from the educational session at Kirkpatrick level 2, pertaining to acquisition of knowledge or skills. Ten studies evaluated student outcomes at Kirkpatrick level 1 which measures student’s responses or feelings towards an educational intervention. For a study to be deemed to fit the criteria for Kirkpatrick level 3, it would be required for it to demonstrate a change in behaviour and transfer of the acquired skills or information to the clinical setting. By virtue of the fact that one of my inclusion criteria was that participants must be medical students and not-yet qualified clinicians, there were just three included studies that demonstrated an impact at Kirkpatrick level 3. None of the included studies met the criteria for Kirkpatrick level 4.

Outcomes of patient involvement

Most (51/53) included studies showed a clear benefit to students from patient involvement in their education. Two studies that I identified showed no benefits to patient involvement.

Impact on examination skills

Most included studies showed an improvement in student examination skills when students had patient contact during the teaching session. Sixteen of the fifty-three studies were comparative in nature, ten of those defined as randomised-controlled trials. Some of these randomised controlled trial (RCTs) demonstrate significant improvement in student examination skills through instruction and demonstration from patients. Other studies comparing teaching methods using manikin with educational initiatives involving patients trained to instruct and give feedback on pelvic examination showed similar results demonstrating improved examination skills in those students taught by GTAs. This improvement in examination skills was demonstrated in student’s improve ability to recognise and identify pelvic structures with superior accuracy than those trained on manikin.

Impact on communication and interpersonal skills

Included studies demonstrated a consistent positive impact in interpersonal and communication skills for students who experienced direct patient contact.

As mentioned already, the majority of studies related to pelvic examination and gynaecology teaching assistants as the principal educators. The GTA studies that examined the impact on students’ communication skills showed significant improvement in those trained by GTAs compared to those trained by traditional or manikin based approaches.

Included studies outside of pelvic examination instruction demonstrated similar positive findings in terms of benefits to student communication and interpersonal skills.

Patient recruitment

Thirty-two of the fifty-three included studies did not mention any specific methods for recruiting patients in their publications. Of those studies that did detail their recruitment process, some patients were recruited through direct contact either through a health clinic [26, 33, 34], colleagues [35], hospital waiting rooms [24] or community health centres [36]. Recruitment for patient educator programmes was also carried out through flyers placed in hospitals [24, 31, 37] and community health centres [38–40] and advertisements in newspapers [32]. Some patients were recruited through already-established women’s health groups including the “Wellington Sexual Health Service” [41], the “Life Model’s association” [15] and “Women’s Health educational consultants” [42]. In addition, some studies detail patient recruitment through word of mouth [18, 25, 39].

Patient training and compensation

Of the total 53 studies included, 42 studies reported on patient training and 11 studies did not mention any training of patients. Of the 42 studies that provided some form of training, most studies did not specify the training duration provided and for those that did, there was large variation noted in terms of the time dedicated to training. Nine studies specified the number of hours, with a median of 11.2 h (range 1–30 h) provided. One study reported a training duration of three months [28] while another study reported “extensive” training but did not specify a duration [40].Compensation was provided to patients in eighteen out of the fifty-three studies. Comparisons were not made between the amount patients were compensated as large variation exists between currencies. In addition, the wide timeline of included studies made comparisons between compensation amounts challenging.

Patient consent & debriefing

Twelve of the fifty-three included studies specified that patient consent had been taken for their participation in the education session. Of those twelve studies, most (n = 8) did not specify how consent was obtained. Three studies detailed written consent for patients [31, 32, 43]. and one study obtained consent through written clinic letters [17].

Regarding debriefing of patients following, 46 studies did not provide any form of debriefing to patients following their involvement in the educational session. In one of the studies which did provide debriefing [18], the potential harms of patient involvement in medical education were acknowledged. In this study, members of the transgender and gender diverse community were involved in educating students on gender diversity teaching and in recognition of the potentially challenging nature of this participation, those participants were offered formal peer support following the educational session.

Discussion

This scoping review provides a comprehensive map of the current existing literature relating to patient involvement in medical education within a focus on the specialty of obstetrics and gynaecology. It has demonstrated that while patient involvement within obstetrics and gynaecology education exists, it is mostly restricted to the demonstration and teaching of the pelvic examination. The review demonstrates that there are clear benefits to students from patient contact in this specialty, acknowledging that their involvement is mostly restricted to education around physical examination. It is clear from this review that most studies did not explicitly state whether consent was obtained, very few gave details on how consent was obtained or gave details on other important factors such as patient recruitment, renumeration or debriefing. This raises a question about the emphasis placed on patient safety. Perhaps more attention needs to be given to detailing patient consent and the processes in place to ensure the physical and psychological safety of patient educators is cared for.

Towle’s taxonomy – is patient participation meaningful at all levels?

Most studies in our scoping review (48/53) were rated as Towle’s taxonomy level 4 in which reflects patient-teacher(s) who are involved in teaching and evaluating students. This is due to the fact that most of the included studies involve gynaecology teaching associates and so by design, they involve instruction and feedback on the part of the patient. Towle level 3 is defined as patients being invited to share their experiences with students, without being involved in giving feedback or making an assessment of the student’s performance. This contribution has the potential to be deeply personal and insightful. In contrast, the involvement of teaching associates in medical education while purely instructional and focussed on skills acquisition automatically rates ‘higher’ on the taxonomy at level 4. Perhaps this calls into question the way in which Towle’s taxonomy is applied to research on patient involvement in medical education. It was not developed to act as a hierarchical framework. In fact the authors have referred to the taxonomy as a “spectrum of involvement” highlighting the diversity of patient involvement rather than assigning importance to any particular level. There appears to be a suggestion from some authors that patient engagement at the highest level of Towle’s taxonomy is the ultimate goal and is a something medical educators and stakeholders should be striving for. For example, in a systematic review exploring patient involvement in digital undergraduate medical education, the authors reported no involvement of patients above Towle’s level 2 and describe the fact that “patients and carers have not been meaningfully involved in medical education when digital technologies have been used in teaching” perhaps suggesting that engagement at levels lower down in the taxonomy are less worthwhile and that a greater efforts need to be made to involve patients as equal partners [44].

The expectation that patients “should” be involved as equal partners (Towle level 5 and above) is challenged in a recently published study which follows a qualitative case study approach to examining key stakeholder’s (patients, educators and students’) perspectives on patient involvement in medical education [45]. One of their key themes generated describes how “equal partnerships are neither feasible nor desirable”, with some key stakeholders even expressing concerns about patients sharing equal responsibility for medical education curricula and advocating that the responsibility for decisions made at an institutional level involving curriculum design and delivery should lie with those healthcare professionals, trained in medical education. The authors of this paper argue that true partnerships are formed through valuing patients for their contributions. They challenge the concept that patient partnership is only considered significant at higher levels of the spectrum of involvement. They suggest a framework for measuring patient involvement, the “wheel of patient partnership” which is designed to reflect a layered approach to patient involvement encompassing all of the necessary requirements to establishing meaningful partnerships with patients. While this new framework may be useful at the early planning and design stages of educational programmes involving patients, it does not easily allow for retrospective classification of patient involvement. Therefore, it may be seen as complementary to the Towle framework but the existing framework used in this scoping review allows for a clear and pragmatic way of classifying patient involvement.

As mentioned, in this scoping review, I have found the large majority of included studies to involve patients at Towle level 4. These studies, while focussed on physical examination have demonstrated clear benefits to students therefore no more or less meaningful than the included studies at ‘lower’ levels on the scale. One could argue that all patient involvement is worthwhile, but perhaps more of balance needs to be achieved in obstetrics and gynaecology education so that the patient story and patient experience is equally highlighted.

A focus on physical examination

While the importance of acquiring the technical and communication skills required to carry out a pelvic examination cannot be understated, perhaps the disproportionate focus on physical examination for patients involved in obstetrics and gynaecology education, risks overlooking the many ways patients in women’s health can be a valuable addition to the medical curriculum in other ways. Patients may impart valuable knowledge and lessons through recounting of their own experiences and their personal story. When one reflects on the wide and varied reasons someone might consult an obstetrician or a gynaecologist, a women’s health specialist or a general practitioner we consider key moments in the lifecycle of a female patient. All provide care in a multitude of scenarios, each of which carries a rich personal narrative.

Conclusion and future research

The findings from this scoping review highlight some important considerations for incorporating patient involvement into medical education in this specialty. There is a need for standardised approaches to recruitment, training, consent, compensation and debriefing/feedback. Future research in this area should aim to highlight the patient voice if we are to be truly patient-centred as medical educators.

Abbreviations

BMJ

British Medical Journal

GTA

Gynaecology Teaching Associate

MeSH

Medical Subject Headings

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta–Analyses

RCT

Randomised Controlled Trial

UCD

University College Dublin

USA

United States of America

Authors’ contributions

Clare Kennedy made a substantial contribution by assisting in conception and design of the research and collection of data and data analysis and interpretation AND drafted the manuscript AND gave final approval of the manuscript AND agrees to be held accountable for the work. Karima Abubakr made a substantial contribution by data analysis and interpretation AND co-drafted the manuscript AND gave final approval of the manuscript AND agrees to be held accountable for the work. Shahad Al-Tikriti made a substantial contribution by data analysis and interpretation AND co-drafted the manuscript AND gave final approval of the manuscript AND agrees to be held accountable for the work. Amy O’Higgins made a substantial contributions to data interpretation AND made intellectual contributions on revisions AND gives final approval of the manuscript AND agrees to be held accountable for the work. Jonathan McNulty made a substantial contributions to data interpretation AND made intellectual contributions on revisions AND gives final approval of the manuscript AND agrees to be held accountable for the work. Naomi Cooney made a substantial contributions to data interpretation AND made intellectual contributions on revisions AND gives final approval of the manuscript AND agrees to be held accountable for the work. Mary Higgins made a substantial contributions to the conception and design of the research and data analysis and interpretation) AND made intellectual contributions on text/revisions AND gives approval of the manuscript AND agrees to be held accountable for the work.

Funding

Unfunded.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

As this was a scoping review of published research, ethics committee approval does not apply.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.