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