Tag Archives: gynecology procedures

Using simulation to practice vulvar procedure skills

This article provides novice women’s health nurse practitioners (WHNPs) and WHNP students, as well as instructors and preceptors for WHNP students, with detailed information needed to safely, competently, and efficiently perform two vulvar procedures commonly done in outpatient women’s healthcare settings: vulvar biopsy and application of trichloroacetic acid as a treatment for vulvar condylomata acuminata. The author presents two simulation modules that can be used to practice and refine skills for performing these procedures.

Vulvar biopsy and application of trichloroacetic acid (TCA) to treat vulvar condylomata acuminata (genital warts) are two minimally invasive office procedures routinely performed by women’s health nurse practitioners (WHNPs). To ensure patient safety and good outcomes, WHNPs must receive formal education and training prior to performing these procedures. The busy women’s health or primary care clinic is not always an ideal environment for novice WHNPs or WHNP students to practice these types of skills.1

Simulation training offers an opportunity for learners to acquire knowledge, hone skills, and gain confidence. The National League of Nursing promotes simulation training as an effective teaching methodology to prepare nurses for practice.2 The current literature supports simulation-based training with practice as an effective means to achieve patient safety.Simulation provides novice WHNPs and WHNP students with an opportunity to practice office gynecology skills in a safe environment conducive to increasing competency and efficiency.4 This article provides these learners, as well as WHNP faculty and preceptors of WHNP students, with simulation modules that can be used to review, practice, and master the steps needed to perform two specific vulvar procedures.

Vulvar biopsy

Case study presentation

A G2 P2002, 69-year-old postmenopausal woman presents to the clinic with this complaint: “I’ve had persistent itching on the left side of my vulva for 3 months.” She denies having vulvar or vaginal bleeding, discharge, or odor. She has been applying over-thecounter (OTC) cream for yeast vaginitis, 1% hydrocortisone cream, and warm compresses to the affected area, with little relief. The WHNP performs a visual examination of the vulva and observes an irregularly shaped, pigmented lesion approximately 3 cm wide on the left side of the vulva. Given the patient’s presenting complaint and the physical exam findings, the WHNP thinks that a pathology report will confirm the presence of vulvar intraepithelial neoplasia (VIN). Until the pathology report is received, vulvar pruritus is documented as the diagnosis in the patient’s health record.

Indication for procedure

The American College of Obstetricians and Gynecologists recommends performing a biopsy for any pigmented lesion on the vulva or for a case involving vulvar symptoms that persist despite topical therapy.5 The purpose of the biopsy is to determine the cause of the symptoms and to rule out malignancy. Biopsy-proven VIN is a risk factor for vulvar cancer.5

Contraindications

No absolute contraindications for vulvar punch biopsy exist; relative contraindications include coagulation disorder, current infection at the biopsy site, allergy to local anesthetic, and inability to comply with wound care.6 If melanoma is suspected, the WHNP should refer the patient to a dermatologist or gynecologist-oncologist to perform the biopsy.

Diagnosis

The diagnosis in this case is vulvar pruritus; the ICD-10 code is L29.2. The CPT code for a vulvar biopsy is 56605.

Procedure directions

Initial steps include reviewing risks and benefits of the procedure with the patient, obtaining a signature on the consent form, and ruling out any allergies associated with antiseptic solutions used for cleansing the vulva. The patient is draped appropriately, assisted into the reclined position on the exam table with both feet in the stirrups, and asked if she is comfortable. Before performing the procedure, the WHNP ensures that a good light source is available.

After washing the hands and applying clean gloves, the WHNP observes the vulvar lesion to identify where to collect the biopsy; the area with the greatest observed changes in texture and

color is chosen. The WHNP cleans the area with povidone iodine or another appropriate antiseptic solution. Using a 22-gauge needle and a tuberculin syringe, the WHNP injects 1-2 mL of 2% lidocaine with epinephrine at the biopsy site. About 2-3 minutes later, the WHNP confirms with the patient that the site is numb by using a sterile cotton swab to lightly touch the area. Using a 3-mm Keyes biopsy punch, the WHNP applies gentle pressure while slowly and steadily twisting the instrument clockwise and counterclockwise until the punch is fully inserted into the pigmented lesion (Photograph 1). The punch is removed and the location of the tissue sample is identified. Using sterile forceps, the WHNP picks up the tissue sample and removes it using sterile scissors (Photograph 2). The WHNP places the specimen into a pathology container with liquid formalin. If bleeding is observed at the site, the WHNP applies pressure using sterile cotton gauze or a cotton swab. Next, the WHNP applies a small amount of antibacterial ointment to the biopsy site and covers it with a bandage.

The WHNP confirms that the patient’s identification information is documented on the outside of the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form includes the patient’s name, a second patient identifier, date and time of the biopsy collection, specimen source, diagnosis, ICD-10 code, and practitioner’s name.

Post-procedure patient education

The WHNP reassures the patient that slight bleeding at the biopsy  site is normal and that minor discomfort may be experienced. The patient is asked to notify the WHNP if she experiences pain unrelieved by use of an OTC nonsteroidal anti-inflammatory drug (NSAID), malodorous or bloody drainage from the biopsy site, or a temperature of 100.5º F or higher.6

Description of the simulation

Supplies (Table 1 ) may be purchased from a medical supplier, a craft store, or a grocery store. Most of the supplies are disposable, but some can be reused. Simulation training is a safe and cost-effective way to practice procedures. This vulvar biopsy simulation can be performed at a cost of about $5.

Step-by-step simulation assembly and video link

The first step is to cut a small piece (3 cm x 3 cm) of raw calf’s liver with the shiny sheath visible on top. A lesion can be drawn on the liver with a red marker if desired. The liver is dried with the disposable underpad before the lesion is drawn. Readers can access a video link for the vulvar biopsy simulation.*

Trichloroacetic acid treatment for vulvar condylomata acuminata

Case study presentation

A G0 20-year-old woman visits the clinic for the first time. She presents with the complaint, “I have vulvar warts—again,” and asks the WHNP for treatment. She denies having vaginal discharge, itching, or odor. She is single and sexually active with one partner. She uses depot medroxyprogesterone acetate for contraception. She denies ever smoking cigarettes. She also denies receiving the HPV vaccination. The WHNP inspects the patient’s vulva and visualizes a small cluster of condylomata acuminata 2 cm in diameter and two individual warts about 1 cm in diameter each on the right side of the vulva at the 4 o’clock position. No discharge or odor is present. Given the patient’s history of condylomata acuminata, the WHNP discusses treatment options with her and recommends topical treatment with TCA. In addition, the patient is advised to receive the first of three doses of the 9-valent HPV vaccine. The first application of TCA and the first dose of the HPV vaccine are administered at this visit. The WHNP asks the patient to return for a follow-up visit in 1 week and educates her about the importance of undergoing cervical cancer screening when she reaches age 21, along with the importance of routine condom use for sexually transmitted infection prevention.

Indication for procedure

Ninety percent of genital warts are caused by HPV type 6 or 11.7 Genital warts can occur as simple lesions or in clusters. Patients describe them as unattractive, irritating, and itchy. Left untreated, genital warts can disappear within 12-24 months, remain unchanged, or multiply.7  Various treatments can relieve the aesthetic concerns and bothersome symptoms, but no therapy can eradicate the HPV infection from the body.7 Treatment of existing genital warts does not prevent future ones from occurring.

Contraindications

The only absolute contraindication for using TCA is the presence of a hypersensitivity or an allergy to it. TCA should not be used to treat genital warts of the urethra, vagina, cervix, or rectum.

Diagnosis

The diagnosis in this case is anogenital warts. The ICD-10 code is A63.0. Application of TCA is considered simple destruction of vulvar lesions and is billed as a CPT code of 56501.

Treatment procedure directions

Prior to the TCA application, the WHNP discusses risks and benefits of the procedure with the patient and obtains her signature on the consent form. The patient is asked if she has any allergies, especially those related to povidone iodine or TCA. The patient is draped appropriately, assisted into the dorsal lithotomy position on the exam table with both feet placed in the stirrups, and asked if she is comfortable.

After washing the hands and applying clean gloves, the WHNP inspects the external genitalia to locate the vulvar warts. The area is cleaned with povidone iodine or another appropriate antiseptic solution. Using a small cotton-tip swab, the WHNP applies petroleum jelly to a thin circular area around each wart to prevent the TCA from spreading when it is applied (Photograph 3). In addition,the WHNP can numb the area surrounding the warts with 2% topical lidocaine gel if this product is available in the clinic. The TCA is then applied to the warts using a small cotton-tip swab (Photograph 4 ). The WHNP touches the swab directly to the wart and holds it there until the area blanches. The TCA is allowed to dry completely. The patient’s discomfort level is assessed. If she is experiencing discomfort, then the WHNP applies baking soda to the treated area to help neutralize the acid.These steps are repeated until the warts have a frost-like appearance (Photograph 5).

Post-procedure patient education

The WHNP informs the patient about the pain and burning sensation commonly experienced after application of TCA. The patient is advised to use sitz baths, topical lidocaine, cool compresses, and/or oral NSAIDs to help relieve the discomfort. She is advised to wear a small peri-pad for the remainder of the day to protect the surrounding tissue. Sitz baths are used to cleanse the area. The patient is asked to notify the practitioner if she experiences increased vulvar swelling, malodorous drainage, erythema, bleeding from the procedure site, pain not resolved with NSAIDs, or a temperature of 100.5° F or higher. A follow-up appointment is scheduled for the patient 1 week after the initial TCA application. Depending on their size and shape, many warts fall off after a few applications of TCA.

Description of the simulation

All of the supplies (Table 2) are easily obtained from a convenience store, grocery store, or online store. Supplies for this simulation are disposable and can be purchased at a cost of $2-$3. Liver is preferred; other meat sources will not blanch when TCA is applied. TCA is sold online and by medical supply companies.

Step-by-step simulation assembly and video link

Wearing disposable gloves, the WHNP cuts a small piece (4 cm x 4 cm) of chilled, raw calf’s liver with the shiny sheath visible on top and places it on a disposable underpad. The shiny sheath of the liver will blanch with TCA application. The WHNP cuts a small piece of tissue paper into a ó inch x ó inch square and then molds it into a small ball with the thumb and index finger and secures it on the piece of liver with a straight pin to give the appearance of warts on the vulva (Photograph 6). Readers can access a video link for the TCA application simulation.*

Conclusion

Women’s health NPs need to know how to safely and accurately perform vulvar procedures, including a vulvar biopsy and condylomata acuminata treatment with TCA. The busy clinic setting does not provide novice WHNPs or WHNP students with an environment conducive to master newly learned procedures. Simulation learning can provide educational and clinical benefits to enhance practice.3  In a controlled, simulated envi ronment, learners can focus on achieving accuracy, confidence, and competence when performing vulvar procedures.3, 8

Aimee Chism Holland is Assistant Professor at the University of Alabama at Birmingham School of Nursing. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author heartily thanks Mr. James Clark, Instructional Design Specialist at the UAB School of Nursing, for recording these procedures for her.

References

1. Nakajima AK, Posner GD. Human Simulation for Women’s Health. New York, NY: Springer Publishing Company; 2012.

2. National League of Nursing Board of Governors. A Vision for Teaching with Simulation. April 20, 2015.

3. McGaghie WC, Issenberg SB, Cohen MR, et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706-711.

4. Cooper S, Cant R, Porter J, et al. Simulation based learning in midwifery education: a systematic review. Women Birth. 2012;25(2):64-78.

5. Committee on Gynecologic Practice of American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 509: Management of vulvar intraepithelial neoplasia. Obstet Gynecol. 2011;118(5):1192 1194.

6. Sulik SM, Heath CB. Primary Care Procedures In Women’s Health. New York, NY: Springer Publishing Company; 2010.

7. CDC. Sexually transmitted diseases treatment guidelines. MMWR. Morbid Mortal Wkly Rep. 2015;64(3):84-90.

8. Nitschmann C, Bartz D, Johnson NR. Gynecologic simulation training increases medical student confidence and interest in women’s health. Teach Learn Med. 2014;26(2):160-163.

*These videos are the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Using simulation to practice and perfect gynecologic procedure skills

Minimally invasive office gynecology procedures such as endocervical polypectomy and endometrial biopsy are routinely performed by women’s health nurse practitioners (WHNPs). To ensure patient safety and comfort and to avoid complications, the WHNP must have knowledge of indications and contraindications, as well as skills needed to perform each of these procedurecompetently and efficiently. WHNP programs provide didactic and clinical instruction for these skills, often in a supervised clinical simulation format. However, the fast-paced clinical setting does not necessarily provide novice WHNPs or WHNP students with an environment conducive to feeling confident when they first perform these office gynecology procedures on their own.1

Simulation learning is a valuable strategy for acquiring skill and confidence in performing clinical procedures. The Institute of Medicine report, To Err is Human: Building a Safer Health System, recommends simulation learning as a means to help prevent errors in the clinical setting.2 Simulation learning provides a controlled, risk-free environment for learners that allows time for adequate practice to acquire skills and confidence.

The purpose of this article is to provide examples of simulation modules that can be used to review and practice the required steps previously learned to promote confidence prior to performing endocervical polypectomy or endometrial biopsy on a patient. The materials used in these simulation modules are readily available outside the clinical learning lab. Novice WHNPs who have not yet performed endocervical polypectomy or endometrial biopsy in clinical practice, WHNPstudents, and even instructors and preceptors for WHNP students, may find these simulation modules helpful. The photographs in this article are screen shots from the simulation modules.

Endocervical polypectomy

Case study presentation

A G4 P2204, 29-year-old female presents to the clinic with this complaint: “I’ve been spotting after sex for the past 2 months.” She denies vaginal discharge or odor. Her last menstrual period occurred 1 week ago and was described as heavy without visible clots. She is married and sexually active with one partner. The vaginal ring is used for contraception. The WHNP performs a speculum examination, which shows a thin, 2-cm-long, red, pedunculated growth protruding from the cervical os. Given the patient’s presenting complaint and physical exam findings, the WHNP thinks that a pathology report will confirm a diagnosis of endocervical polyp.

Indications for procedure

The purpose of an endocervical polypectomy is to remove the pedunculated growth from the cervix and rule out malignancy of the tissue. Although fewer than 5% of all endocervical polyps are malignant, all of them should undergo biopsy.3 Removal is indicated to stop intermittent spotting and bleeding symptoms related to the polyp.4

Diagnosis

The diagnosis in this case is endocervical polyp. The ICD-10 code for endocervical polyp is N84.1. The current procedural terminology (CPT) code for an endocervical polypectomy is 58999.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endocervical polypectomy is contraindicated during pregnancy because increased blood flow to the cervix may result in substantial bleeding. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP inserts an appropriate-size speculum into the vagina and visualizes the cervix with the polyp protruding from the endocervical canal (Photograph 1). A benign endocervical polyp is thin, red, and smooth in appearance.5 Caution to proceed is exercised if the endocervical mass appears thick. Cervical cancer, an endometrial polyp, and uterine fibroids may resemble an endocervical polyp.5

The WHNP cleans the cervix with povidone iodine or other appropriate antiseptic solution. The WHNP then inserts a small sterile cotton swab just inside the endocervical canal and moves it in a clockwise direction completely around the inside of the canal to confirm the location of the polyp base. If the WHNP cannot locate the polyp base or freely move the swab in the cervical canal, the procedure is halted and the patient is referred to a gynecologist for further evaluation of the endocervix and endometrial cavity with a hysteroscope.

Otherwise, the next step is to securely close a ring forceps around the endocervical polyp as close to the base as possible and twist the polyp in a clockwise direction, applying gentle tension. The WHNP continues twisting the polyp until the base is no longer attached to the cervix. The specimen is then placed in a container of liquid formalin (Photograph 2). If bleeding is observed at the site, the WHNP applies pressure using a large cotton swab. If necessary, a silver nitrate stick or Monsel’s solution can be applied to manage bleeding. The speculum is then gently removed, and the patient is slowly assisted into an upright sitting position, with her stability assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient that vaginal spotting/bleeding is not uncommon a few hours after the procedure. A peri-pad is offered to the patient, who is advised to avoid placing anything into the vagina for a few days post-procedure. The patient is asked to notify the WHNP if any of these situations occur: pelvic pain not relieved with a non-steroidal anti-inflammatory drug (NSAID), malodorous vaginal discharge, continuous bright red vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 1) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost-effective way to practice procedures. This endocervical polypectomy

simulation can be performed at a cost of about $6.

Step-by-step simulation assembly and video link

Cut off a 5-cm piece of red chenille pipe cleaner. Insert the pipe cleaner into the center of a hot dog, leaving approximately 2-3 cm of it on the outside of the hot dog. Readers can access a video link for the endocervical polypectomy simulation.  This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Endometrial biopsy

Case study presentation

A 55-year-old menopausal patient presents to the clinic with this complaint: “My period has come back on. I’ve been spotting and bleeding from my vagina intermittently for the past 3 months.” The woman’s last menstrual period took place when she was 52 years old. The patient, a widow, has not had sexual intercourse in the past 2 years.

Indications for procedure

The purpose of an endometrial biopsy is to rule out endometrial cancer. Based on the American Congress of Obstetricians and Gynecologists’ Committee Opinion Number 557, an endometrial biopsy should be performed for  women older than 45 years as a first-line screen for abnormal uterine bleeding (AUB).7 Another indication for an endometrial biopsy is exposure to unopposed estrogen in a woman younger than 45 who experiences persistent AUB after failed medical management.7

Diagnosis

The diagnosis in this case is postmenopausal bleeding. The ICD-10 code for postmenopausal bleeding is N95.0. The CPT code for an endometrial biopsy without cervical dilation is 58100.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endometrial biopsy is contraindicated during pregnancy. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP performs a bimanual exam to determine the position of the uterus and cervix and the presence of any tenderness or masses in the pelvis. The WHNP inserts an appropriate-size speculum into the vagina to visualize the cervix, which is then cleaned with povidone iodine or other appropriate antiseptic solution (Photograph 3). After confirming patency of the cervical os and measuring the depth of the uterus with a uterine sound (i.e., sounding the uterus), the WHNP obtains a sterile endometrial pipelle and inserts it into the cervix and uterus.

Difficulty inserting the pipelle may be due to a natural curvature in the cervix or uterus. Depending on this curvature, the WHNP may need to use a sterile method to slightly bend the tip of the pipelle in order for it to slide completely into the uterine cavity. The WHNP may need to apply an instrument, such as a tenaculum, a ring forceps, or a long hemostat to the cervix to help straighten the natural curvature of the cervix and uterus, ensuring that the patient is prepared for the use of an additional instrument (Photograph 4).

Once the pipelle is inserted to the top of the uterine fundus, the WHNP pulls back rapidly on the piston as far as it will go to create suction. The WHNP passes the pipelle in and out between the fundus and internal cervical os 3 or 4 times while continuously turning it a full 360°, rolling it between the thumb and index finger. Endometrial tissue will begin to collect inside the pipelle. Once an acceptable amount of tissue is visualized, the pipelle is removed from the uterus. The WHNP carefully expels the tissue from the pipelle by pushing the piston forward into a plastic container of formalin, and confirms that a sufficient amount of tissue has been collected (Photograph 5). The vaginal speculum is then gently removed. The patient is slowly assisted to an upright sitting position and her stability is assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient about the most common symptoms experienced with an endometrial biopsy, which include pelvic pain, vaginal bleeding, and fainting.8 The patient is advised to notify the WHNP if she experiences

uterine cramping lasting longer than 48 hours or not resolved with an NSAID, malodorous vaginal discharge, heavy vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 2) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost effective way to practice procedures. This simulation endometrial biopsy can be performed at a cost of about $5. Readers can access a video link of the endometrial biopsy simulation. This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Conclusion

Women’s health nurse practitioners are important performers of minimally invasive gynecology procedures such as endocervical poly pectomy and endometrial biopsy. However, the fast-paced clinical setting may not provide the novice WHNP or WHNP student with an environment conducive to mastering newly learned skills. Simulation learning has educational and clinical benefits to enhance practice.9 In a controlled, simulated environment, individuals can focus on achieving competency, efficiency, and confidence when performing these procedures.9, 10

Aimee Chism Holland is Assistant Professor at the University of Alabama at Birmingham School of Nursing. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.  The author heartily thanks Mr. James Clark, Instructional Design Specialist at the UAB School of Nursing, for recording these procedures for her.

References

1. Nakajima AK, Posner GD. Human Simulation for Women’s Health. New York, NY: Springer Publishing Company; 2012.

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in American, Institute of Medicine; 2000.

3. Beckmann C, Ling F, Herbert W, et al. Obstetrics and Gynecology. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

4. Stewart EA. Endometrial polypsUpToDate. October 21, 2013.

5. Hoffman BH, Schorge J, Schaffer J, et al. Williams Gynecology. 2nd ed. New York, NY: McGraw Hill; 2012.

6. Sulik S, Heath C. Primary Care Procedures In Women’s Health. New York, NY: Springer Publishing Company; 2010.

7. American Congress of Obstetricians and Gynecologists. ACOG committee opinion no. 557. Management of acute abnormal uterine bleeding in non-pregnant reproductive aged women. Obstet Gynecol. 2013;121(4): 891-896.

8. Blumenthal PD, Berek JS. A Practical Guide to Office Gynecologic Procedures. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

9. Cooper S, Cant R, Porter J, et al. Simulation based learning in midwifery education: a systematic review. Women Birth. 2012;25(2):64-78.

10. Nitschmann C, Bartz D, Johnson NR. Gynecologic simulation training increases medical student confidence and interest in women’s health. Teach Learn Med. 2014;26(2):160-163.