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Establishing sub-specialization in obstetrics and gynaecology in
Nigeria: learningfrom the current European models
Leroy Edozien
Outline of presentation
• The rationale for sub-specialization• The range of sub-specialty training programmes in the UK and Europe• The organisation of sub-specialty programmes in the UK• The pros and cons of these programmes• What can we learn from the UK/Europe model? • Some ideas for the way forward
Definition of sub-specialists
‘Obstetricians and gynaecologists who, after undertaking appropriate training in a recognised subspecialty training programme and had acquired special expertise in the relevant field, would devote at least half, and probably more, of their working time in the subspecialty’
RCOG 1982
Why provide sub-specialty training?
‘….it has become impossible for an individual to master in depth all or even most areas of obstetrics and gynaecology’
RCOG 1982
Born in the USA…
In 1982 the Board of the American College of Obstetricians and Gynecologists recognised three subspecialty divisions:
OncologyReproductive endocrinology Maternal-fetal medicine
RCOG Working Party 1982
‘To consider developments in further specialisation within the field of obstetrics and gynaecology, including training implications and to make recommendations’
1984: RCOG Subspecialty Training Committee
Remit to advise and keep under review:• development of subspecialisation, including requirements and
regulations for subspecialist training and accreditation• further development of training for special interest work within
obstetrics and gynaecology• criteria and procedures for approval of subspecialty trainees, training
centres and training programmes and for subspecialist• accreditation upon completion of training
Benefits of sub-specialisation
• Clinical expertise; improved outcomes for patients• Multidisciplinary work• Concentration of cases and skills• Training• Research
Potential disadvantages of sub-specialization
• Elitism• Diminished job satisfaction• Too few generalists• Resources• Workforce planning issues
Impact of sub-specialization
• >90% of respondents agree that subspecialties have helped in the development of O&G.
• The subspecialties have enhanced our image in medical schools (88%) and in the community hospitals (77%).
• The education of medical students (73%) and of residents (86%) has been enhanced by the development of subspecialties.
• The subspecialties have fragmented our specialty (69%), but patient care has not suffered.
• The improved quality of residents was due to the development of subspecialties. • Only 10% of respondents wished subspecialties had never been developed as
contrasted to 82% of all respondents who felt they were commendable
Zuspan FP, Sachs L The impact of subspecialties on obstetrics and gynecology. Am J Obstet Gynecol. 1988;158(4):747-53
O&G structured training programme in the UK
Foundation programme Basic training moduleIntermediate training moduleAdvanced training skills modules (ATSMs)
Duration of training: 7 years
RCOG - setting the structure, curriculum and standards of training All trainees register with the RCOG and are provided with a log book
O&G structured training programme in the UK
Competency based Workplace based assessmentsLog books
RCOG College TutorClinical supervisors Educational Supervisors
Subspecialist training opportunities become available to the trainees in UK after successful completion of their intermediate training modules For candidates wishing to pursue an academic career there is a separate but parallel academic curriculum, ensuring acquisition of clinical and academic skills concurrently
Minimum requirement for a subspecialty training post
• UK National Training Number (NTN)• Completed the fifth Specialist Training year (ST5) • Passed the part 2 MRCOG examination
CCT or CESR holders can also apply.
Sub-specialties, UK
• Maternal and Fetal Medicine • Reproductive Medicine • Gynaecological Oncology • Urogynaecology
• Sexual and Reproductive Health
Each subspecialty programme has a curriculum, logbook and an assessment process.
ModulesGynaecological Oncology sub spec training curriculum
Module 1 General Assessment of a Gynaecological Oncology PatientModule 2 Pre-, Peri- and Postoperative CareModule 3 Generic Surgical Skills in Gynaecological OncologyModule 4 Cancer of the OvaryModule 5 Cancer of the UterusModule 6 Cancer of the CervixModule 7 Cancer of the VulvaModule 8 Cancer of the VaginaModule 9 Medical OncologyModule 10 Clinical OncologyModule 11 Radiology – Investigation and InterventionModule 12 Palliative CareModule 13 Urological SurgeryModule 14 Colorectal SurgeryModule 15 Plastic Surgery and Wound CareModule 16 Gestational Trophoblastic DiseaseModule 17 Cancer Genetics
The modules outline the following:
• Knowledge criteria• Clinical competencies• Professional skills and attitudes• Training support options• Evidence and assessment requirements
Research component
At completion of a 3-year programme, a trainee will have expected to either have undertaken a research or academic programme, leading to an MD or PhD thesis or published two first author papers in citable, referred journals.
Administration of sub-specialty training in the UK
• Postgraduate deanery• RCOG - Subspecialty Training Committee• Specialist societies
Supervision and assessment
The training of each sub-speciality trainee/ fellow is overseen by a Subspecialty Training Programme Supervisor.
Formal annual assessment carried out by two subspecialists nominated by the RCOG Subspecialty Committee. Submission of a written report from both the trainee and the STPS and a formal review of progress towards the required competencies detailed in the logbook. The RCOG Subspecialty Committee makes recommendations regarding progress and expected accreditation date
Advanced Training Skills Modules (ATSMs)
• During the last 2 years of training trainees can undertake 2-3 ATSMs• Designed to follow the same format as the subspecialty training
programmes • Fitted around general training (1–2 sessions per week) • Boundaries of practice are more tightly defined
Advanced Training Skills Modules (ATSMs)
Abortion CareAcute Gynaecology and Early Pregnancy Advanced Antenatal PracticeAdvanced Labour PracticeBenign Abdominal SurgeryAdvanced laparoscopic surgery for the excision of benign disease Benign Gynaecological Surgery: Hysteroscopy, Benign Gynaecological Surgery: Laparoscopy, Benign Vaginal Surgery Colposcopy.
Advanced Training Skills Modules (ATSMs)
• Paediatric and adolescent gynaecology• Urogynaecology and vaginal surgery• Fetal medicine• Medical education• Oncology• Forensic gynaecology• Menopause• Maternal medicine
Advanced Training Skills Modules (ATSMs)
• The RCOG has developed the theoretical course syllabuses in conjunction with either the relevant special societies or the ATSM course lead• The RCOG does not require courses to be submitted for formal
approval• ATSM training is delivered by ATSM Educational Supervisors, ATSM
Preceptors and ATSM Directors
Development of specialist societiesThe development of subspecialties within the field of obstetrics and gynaecology has resulted in the establishment of specialist societies
• British Society for Colposcopy and Cervical Pathology (BSCCP)
• British Society for Gynaecological Endoscopy (BSGE)
• British Society for Gynaecological Imaging (BSGI)• British Society for Paediatric and Adolescent
Gynaecology (BritSPAG)• British Society for the Study of Vulval Disease
(BSSVD)• British Society of Psychosomatic Obstetrics,
Gynaecology and Andrology (BSPOGA)
Association of Early Pregnancy Units (AEPU)British Association of Perinatal Medicine (BAPM)British Fertility Society (BFS)British Gynaecological Cancer Society (BGCS)British Maternal and Fetal Medicine Society (BMFMS)British Menopause Society (BMS)British Society of Urogynaecology (BSUG)
Workforce planning
The RCOG: there is an overproduction of subspecialiststhe number of sub-speciality training units at any one time may need to be limited
A survey of new consultant appointments indicated that less than 50% of those that complete subspecialty training in urogynaecology are appointed as a subspecialist in urogynaecology
UK trainees aiming to be sub-specialists
2002 46.5%
2008 13.7%
Eligibility requirements for EBCOG Sub-specialty Training CentreTertiary centreClose collaboration with related disciplinesAdequate workload providing a full range of experience in the subspecialtyCompetent programme directorAdequate medical staffing to enable trainee……Adequate library, laboratory and other resources to support subspecialty work, training and researchResources for a research programme related to the sub-specialty
EBCOG -ESGO
• The duration of subspecialty training should include a minimum of two years in an approved programme and should cover the clinical and research aspects of the following areas:
• Surgical training in a gynaecological oncology unit• General surgical training• Training in surgery of the breast• Urology• Radiotherapy• Medical oncology• Cytological diagnosis and pathology• Tumour biology
ESGO's collection of educational materials includes
• 200+ Congress Webcasts / Podcasts• 900+ ePosters• 700+ Learning Quizzes • eLectures• CME accredited Courses• Postgraduate Surgical Videos
The Netherlands
Subspecialty board of the Dutch Society of Obstetrics and Gynaecology (NVOG) applies the requirements for all recognized subspecialties
Adhere to those of EBCOG-ESGO.
Two years. Logbook.
Sub-specialties in Canada
Royal College of Physicians and Surgeons of Canada -• Maternal-Fetal Medicine,• Reproductive Endocrinology and Infertility• Gynaecologic Oncology.
Paediatric and Adolescent GynaecologyUrogynaecology Advanced Gynaecologic Endoscopy
Factors to consider……
• Duration of residency training• Size of hospitals• Number of obstetricians and gynaecologists• Relative size of the private sector
What do the UK/European models tell us?
• Structured• Competency-based• Closely supervised • Standardized evaluations• Committed faculty
• Long training• Workforce planning issues• Expensive• Reliance on other
specialties/professionals• Research is an essential
component
Moving forward – baseline assesments
Scoping:Survey of centres that can deliver sub-specialty trainingCensus of ob-gyn consultants with special interests/subspecialists
Setting of standards for accreditationCentresSupervisorsTrainees
Moving forward – working in partnership
• Role of the Colleges – WACS; PMCN• Role of SOGON• Role of NMC• Role, and formation of, specialist societies
……in conceptualising, developing and implementing a model for sub-specialization in O & G in Nigeria
Moving forward – key stakeholders
Role of the private sector?
Role of other specialties and other professionals
Link with other agencies:Internal – e.g. experts in educational theory and curriculum
developmentExternal – e.g. RCOG
Prime candidate?
• Oncology - challenges of multidisciplinary input (radiotherapy, chemotherapy)• Reproductive medicine – equitable use of public funds• Maternal and Fetal medicine – ready access to ultrasound
Moving forward – the challenges
• Funding• Business case• Curriculum development• Faculty development• Teaching and learning aids
Road map
• Set up a Working Party• Scoping exercise and stakeholder engagement• Determine strategy• ? Start with 1-3 ATSMs
• Source funds for pilot• Agree accreditation standards for pilot• Map evaluation criteria for pilot