The printed model of the pelvis can support health care professionals and patients to better comprehend important anatomical structures of the female pelvis. When combining it with models for pure palpation, its educational potential can be increased. The emphasis on those aspects, which are crucial for rectovaginal palpation, facilitates understanding and keeping an overview. In addition, the active involvement of the students by assembling the model themselves, enables further improved learning results.
Evaluation of the 3D printed model
The model’s potential is shown firstly by the subjective assessment of the skills training. Question 1 was rated by Group A with a mean of 6.7 and by Group B with 8.2 points (p < 0.001). Question 3 scored 8.1 points in Group A and 8.9 points in Group B (p < 0.009). Adding to this, the mean of all points scored from Question 1 to 5 also favored Group B (Group B: 8.4 points, Group A: 7.8 points, p < 0.001). This highlights, that those students, who were able to learn with the 3D printed model, felt better educated about female pelvic anatomy and examination than those without the model.
Secondly, this subjective opinion of the students is affirmed, when viewing Question 6 to 8. These multiple-choice questions aimed at objectively testing the students’ knowledge and understanding of the anatomic coherences they just learned about. Group B answered all three multiple-choice questions more often correctly than Group A with statistical significance concerning this difference (p < 0.001 for Question 6, p < 0.008 for Question 7 and p < 0.001 for Question 8). This can be seen as evidence, that the 3D printed model indeed increases the learning results of medical students.
Thirdly, by asking the students of Group B about the 3D printed model and novel approaches towards teaching, interesting findings could be made. When being asked how helpful the model itself and its differently colored parts were for their understanding of the concerning anatomy (Question 9 and 10), the students rated these two questions with a mean of each 9.0 points, emphasizing their support of the 3D printed model. This fact fits well to the answers of Group B to Question 1 (How well informed do you feel about the overall anatomy of the female pelvis) and Question 3 (Did you understand the anatomical structures and relationships crucial for gynecological examination?), which both favored teaching with the 3D printed model. The interactive aspects of Pelvisio® were also appreciated by the students: Question 11 (How helpful was the possibility to remove single parts of the 3D model for your understanding?) and Question 12 (Was the possibility to use the 3D model in two different positions (standing upright and tilted to 90 degrees) useful?) both scored above 8 points, indicating, that activating the students and giving them the possibility of participating in hands-on learning was perceived positively. Hence, it appears congruent, that Question 13 (Did the model altogether improve the quality of the skills training?) scored a mean of 8.9 points and Question 14 (Would you recommend the use of plastic 3D models, such as the one you experienced today, for medical students’ education?) was rated with a mean of 9.7 points. This underlines the 3D printed model’s potential and showcases the importance of practical learning and participation, especially, when taking into account the students’ rather divided opinion towards the use of solely virtual 3D models for medical students’ education (Question 15, rated with a mean of 5.5 points). Yet, when combined with hands-on-aspects, again allowing activation during education, such as with augmented reality, the idea receives the students’ appreciation, as can been seen with Question 16 (Would you recommend the use of augmented reality for medical students’ education?) scoring a mean of 8.2 points.
When discussing possible future aims, the students of Group B showed, that they were interested in further projects beyond the 3D printed model, such as phantoms showing certain medical conditions or illnesses, e.g. cervical or ovarian cancer, myoma or endometriosis, by rating Question 17 with a mean of 9.6 points. In addition, taking the idea of realistic simulation in medical education one step further, the students clearly approved of the idea of models, which could be used for simulating gynecological operations (mean of 9.3 point for Question 18). Thus, the demand for future projects for high quality model-based simulation is highlighted.
Existing data and limitations
There have been studies emphasizing the potential of simulation with models for gynecological education. Yet, they are often relatively outdated, such as the work of Takestraw et. al. from 1985 [14], Johnson et. al. from 1975 [15], Nelson et. al. from 1978 [16] and Holzmann et. al. from 1977 [17]. It is to be assumed that technical possibilities were different than today, making a direct comparison to current studies difficult.
Many of the promising modern studies, such as from Wånggren et. al. rely on so called Gynaecology Teaching Associates (GTAs) [7, 18–20]. These are professionally prepared patients, who interact with the examiner during the examination, providing him or her with feedback. Although this undoubtedly is a valuable addition to the teaching of practical skills, GTAs are expensive. Additionally, the organization of a GTA-based training is more difficult and the cooperation with such trained patients is only common in selected countries. Effective teaching relies on methods, which are swiftly implemented and not too resource-intensive. Consequently, this leads to GTAs being difficult to introduce in many healthcare systems.
The data of Pugh et. al. indicates, that models of the female pelvis, equipped with pressure sensors, could be a valuable alternative. They were superior to pure lectures and to training with regular models [7, 21, 22]. Nevertheless, only little data is available and, here as well, potentially higher costs must be noticed together with a more resource intensive production.
There are no studies, which focus on the evaluation of models constructed for primary visualization in addition to using them together with models for palpation, in order to teach pelvic examination. Moreover, we could find no study examining the use of a 3D printed female pelvic model, which was to be assembled by the students as part of the teaching process.
A more detailed comparison to the current scientific work, together with a display of the expenses for equipping an institution with the described 3D printed model and an overlook about the increased accessibility as well as the logistical and financial advantages of 3D printing in the context of teaching medical staff is described in our previous work {DOI 10.1186/s41205-022-00139-7, manuscript TDPM-D-21-00013R2 accepted in 3D printing in medicine}.
Limitations to this study must be stated concerning the evaluation-form of Question 4 (How insecure do you feel about performing a gynecological examination of a real patient in the future?). Whereas all questions were to be rated according to the Likert scale 1–10 (1 = “very little” or “very poor”, 10 equals “very much” or “very good”), a high score in Question 4 is to be seen as negative. This inconsistency reduced the quality of our methods and should be corrected in future studies. Moreover, three multiple-choice questions must be criticized as too few, in order to adequately compare the gained knowledge and comprehension between the two groups. The organization of the entire training was planned in order to compare Group A to Group B. Consequently, we could provide the identical settings for both groups, with the same physician for teaching and the same time-frame and content for the lecture as well as the practical training part. Nevertheless, using these settings to perform a direct comparison between two models could have produced more valuable data than the simple comparison of a group being taught with the 3D printed model and a group without any additional input for visualization. Although case numbers in this work are higher than in most previous studies, further projects with more participants, possibly organized as multi-center studies, should be carried out.