Abstract
Background/Aim: The Royal College of Obstetricians and Gynaecologists (RCOG) introduced a new curriculum in 2019. Furthermore, the National Health Service was hit by the COVID 19 pandemic in 2020. Our survey aims to find how the new RCOG curriculum and COVID 19 pandemic affected gynaecological training amongst specialist trainees in the UK. Patients and Methods: A cross sectional study was conducted using the University of Leicester online survey platform involving the RCOG trainees in the UK from the 1st of June 2021 to the 1st of October 2021. The survey was divided into two main categories: 1) new RCOG curriculum and gynaecology training, 2) COVID 19 pandemic and gynaecology training. Results: We received replies from 10% of trainees. The quality of gynaecology training under the new RCOG curriculum was described as less than good in 75.6% of respondents. Around one-third (29.2%) of trainees did not have local gynaecology simulation training. The COVID 19 pandemic adversely affected all aspects of gynaecology training. Benign gynaecology, subfertility, urogynaecology, and gynaeoncology modules training were affected in 94.0%, 85.1%, 89.7%, and 83.5% of trainees, respectively. During the pandemic, gynaecology teaching was affected in 84.9% of trainees, redeployment occurred in 11.8% of trainees, and 16% suffered adverse ARCP outcomes. Conclusion: The new RCOG curriculum and COVID 19 pandemic have simultaneously compromised the gynaecology training amongst the UK trainees. RCOG and GMC-led more comprehensive survey would be welcomed to incorporate our findings and take necessary actions.
Obstetrics and Gynaecology specialty is one of the most rewarding and challenging specialties with a wide range of medical and surgical aspects and a high level of personal satisfaction among the United Kingdom (UK) trainees (1). Although it is accompanied by emergencies, long working hours, unexpected twists, most trainees will again choose the same specialty, as revealed in a UK survey (2).
The Royal College of Obstetricians and Gynaecologists (RCOG) established the Obstetrics and Gynaecology training program initially in August 2007. The scheme consisted of a seven-year run-through program including basic, intermediate, and advanced competencies (3). Subsequently, the RCOG established a new curriculum in 2019, where a new portfolio was implemented for all obstetrics and gynaecology trainees across the UK. Four professional identities replaced nineteen modules. In addition, the clinical content was updated, supervising learning events and work-based assessments were changed. The General Medical Council (GMC) gave more weight to general professional skills to meet the generic professional capabilities required for modern training (4).
In December 2019, COVID 19 caused by the coronavirus started spreading in Wuhan City in China and was followed by a viral outbreak (5-7). In 2020, the WHO announced COVID 19 as a pandemic (8). The virus exponentially spread through many countries globally, including the UK (9). Unfortunately, the UK was one of the countries severely affected by the virus across the nation (10). The effect of having a new RCOG curriculum and COVID 19 pandemic simultaneously amongst UK obstetrics and gynaecology trainees and the impact on gynaecology training have not been explored, and no data on this have been published so far. The study’s objective was to explore how the new curriculum and COVID 19 pandemic affected gynaecology training in the UK.
Patients and Methods
A cross sectional study was conducted using the University of Leicester online survey platform involving the RCOG trainees in the United Kingdom. Obstetrics and gynaecology trainees in the UK were asked to express how the new RCOG curriculum and the COVID 19 pandemic affected their gynaecology training.
The survey was composed of fourteen multiple main choices and free text questions. Trainee responses were anonymized to reduce bias. The survey was divided into five parts: demographics, gynaecology skills development under the new curriculum, gynaecology simulation, the impact of COVID-19 pandemic on gynaecology training, and suggestions to improve gynaecology training. All UK obstetrics and gynaecology trainees were invited to participate in the survey.
Ethical approval for the conduct of the survey was gained from the Medicine and Biological Sciences Research Ethics Committee, University of Leicester (Reference Number: 29574-ab1122-ls) on the 17th of May 2021.
The online survey platform was UK GDPR (General Data Protection Regulation) compliant and certified to ISO 27001 standard. The survey was conducted in accordance with the University of Leicester’s policies and procedures, which include the University’s Research Code of Conduct and the University’s Research Ethics Policy.
The Chair of the National Trainees’ Committee of the RCOG was approached, and the survey was sent to the trainees’ representatives across the UK. The representatives circulated the survey among their trainees. The trainee representatives were sent reminders thereafter. A pilot study was performed from the 15th of May 2021 to the 17th of May 2021, involving ten trainees. The survey was then edited and relaunched to all trainees from the 1st of June 2021 to the 1st of October 2021. Data were analysed using descriptive statistics.
Results
Respondent trainees’ characteristics. One hundred and seventy-one responses were obtained. The response rate was 10%. One was excluded as it was not filled. The respondents were mainly females compromising 75.6%, while male trainees were 22.6%. The survey received responses from the different years of training: junior trainees [ST1 (7%) and ST2 (10%)], middle-grade trainees [ST3 (15%), ST4 (12%) and ST5 (16%)] and senior trainees [ST6 (12%), ST7 (17%), trainees in the out of training program (6%) and subspecialty trainees (5%)] (Figure 1). Most of the respondents were in full-time training (73.1%), while 26.9% were in less than full-time training. The majority were from the health education of East Midlands (26%) followed by health education North West deanery (19%) (Figure 2).
Training levels of respondents.
UK training regions of respondents.
The effect of COVID 19 on gynaecological training. COVID 19 pandemic had adversely affected all aspects of gynaecology training of the UK trainees. The pandemic affected the benign gynaecology module training, subfertility module training, urogynaecology module training, gynaeoncology module training, hysteroscopy training, and colposcopy training. These training modules training was compromised in 92%, 85.1%, 89.7%, 83.5%, 85.4% and 87.6% of the trainees respectively (Table I).
The impact of COVID 19 pandemic on gynaecology training of respondents.
The survey showed that COVID 19 pandemic had adversely affected the regional and deanery gynaecology teaching in 84.9% of the trainees, as demonstrated in Figure 3. Redeployment of the obstetrics and gynaecology trainees occurred in 11.8% of the respondents. More than three-quarters (77.8%) of the redeployed trainees said they felt uncomfortable or stressed by this issue (Figure 4).
The impact of COVID 19 pandemic on gynaecology regional and deanery teaching amongst respondents.
Redeployment due to COVID 19 pandemic and its effect on respondents.
Adverse annual review of competency progression (ARCP) outcome was reported in 16% of respondent trainees (Figure 5). They advised that their gynaecology training needs were not met due to the COVID 19 pandemic. Respondents were given the opportunity to explain the rationale of poor ARCP outcomes. They expressed it was mainly due to lack of gynaecology theatre sessions, lack of specific skills like endometrial ablation, and inability to complete their educational needs due to the pandemic.
Adverse ARCP outcome due to the lack of gynaecology training opportunities amongst respondents.
Most of the respondents had facilities for gynaecology simulation at their training-based hospital (70.8%). Trainees rated the simulation as excellent, good, and fair in 43.8% of respondents (Figure 6). However, 56% of trainees indicated that simulation was poor and very poor due to lack of equipment, lack of time, no appointed sessions, difficulty to fit around working hours, unable to utilize the facility, shortage of staff, and supervision. Moreover, several respondents could not make use of the gynaecology simulation due to the social distancing policy applied during the pandemic.
Availability and quality of gynaecology simulation training.
The effect of new RCOG 2019 curriculum on gynaecological training. The quality of gynaecology training in the new curriculum was described as less than good in 72% of respondents (Figure 7). However, it was observed that the subspecialty trainees were the most satisfied trainees, with 66.7% describing training as good to excellent.
Quality of gynaecology training amongst respondents.
The trainees were asked to describe their level of competency in various gynaecology procedures and skills (Table II). Regarding simple abdominal hysterectomy, 57.1%, 10%, and 26.2% of senior trainees claimed they were able to perform it under direct supervision, indirect supervision, and independently. Furthermore, 88.9% of subspecialty trainees were able to perform it independently.
Level of competencies of gynaecological procedures as described by respondents.
Around two-thirds (65.6%) of senior trainees could perform simple operative laparoscopy independently, while 23.9% of senior trainees could perform it under direct supervision. However, middle-grade trainees described their ability to perform simple operative laparoscopy independently, under indirect supervision, and under direct supervision in 12.4%, 5.5%, and 57%, respectively.
Three-quarters (75%) of senior trainees could perform diagnostic laparoscopies independently, and 16.3% were able to perform it under direct supervision. Middle-grade trainees expressed their ability to perform diagnostic laparoscopy independently, under indirect supervision, and under direct supervision in 22.2%, 7%, and 64%, respectively. Laparoscopic management of ectopic pregnancy was performed independently, under indirect supervision, and under direct supervision in 50%, 20%, and 26% of senior trainees.
Regarding ovarian cystectomy (open or laparoscopic), 49.2% of senior trainees were able to perform it independently, and another 29.8% of senior trainees were able to perform it under direct supervision. Vaginal hysterectomy was performed independently and under direct supervision in 20.8% and 38.8% of senior trainees. Pelvic floor repair surgery was performed independently in 22.4% of senior trainees and under direct supervision in 47.7% of senior trainees.
Endometrial ablation was performed independently, under indirect supervision, and under direct supervision in 56.7%, 10.4%, and 25.3% of senior trainees. It was noted that 9.5%, 9.7%, and 36% of middle-grade trainees were able to perform endometrial ablation independently, under indirect supervision, and under direct supervision. The procedure was observed or never seen by 2% of senior trainees and 44% of middle-grade trainees.
Senior trainees were able to perform diagnostic hysteroscopy independently in 82.0%, under indirect supervision in 12.2%, and under direct supervision in 4%. Moreover, diagnostic hysteroscopy was performed independently in 36%, under indirect supervision in 26.4%, and under direct supervision in 34.7% of middle-grade trainees.
Discussion
This is the first nationwide survey to review the obstetrics and gynaecology trainees’ views on gynaecology training after the new curriculum has been launched and after the COVID 19 pandemic. We believe that trainees across the UK have been in a stressful situation dealing with the pandemic; however, gynaecology trainees were unfortunate to have faced two significant changes simultaneously. The gynaecology skills amongst UK trainees were markedly affected by the new curriculum and the COVID 19 pandemic.
According to the RCOG, a new change to the curriculum was inevitable. The new GMC guidance development and the RCOG’s evaluations revealed the need for a newly updated curriculum that will lead doctors with more professional skills to meet the demand of the patients. The RCOG had divided the curriculum into four identities. Each professional identity contains capabilities in practice (CIPs) where the trainee should demonstrate competency. The four professional identities were healthcare professional, researcher, scholar and education, clinical expert, and champion for women’s health. The RCOG had proposed that the new curriculum would lead to a more patient-centred approach, build a stronger rapport, and improve interpersonal skills.
Although any new curriculum and approach would be initially challenging, the RCOG believed that the curriculum was modified to align with the latest professional identities formulated by the GMC. Moreover, this approach had shown success in the Royal College of Physicians (RCP); and seemed promising in the RCOG (11). Furthermore, a new curriculum is likely to be developed across all the different medical royal colleges in the UK to ensure the new professional identities are implemented.
The RCOG introduced a new initiative called the e-Portfolio Champions to facilitate the change. The aim was to guide and support the trainees with inquiries regarding the new e-Portfolio. In addition, the RCOG launched an online teaching session on its e-learning platform titled “Curriculum 2019 training resource” to enable the trainees to understand the rationale for changing the curriculum, outline the developments, how the conversion would occur and how it would be evaluated (12).
A study conducted by the RCOG in 2019 revealed that 43% of the UK obstetrics and gynaecology trainees had already felt burnout either through anxiety, depression, or suicidal thoughts (13). This indicated that trainees suffered burnout even before the RCOG curriculum changes were implemented and before the COVID 19 pandemic. Currently, our survey shows that around one-half of the obstetrics and gynaecology UK trainees were dissatisfied with the new curriculum.
A cross-sectional explorative survey involving 25 European countries and 105 trainees observed that gynaecology training has been dramatically affected in regards learning opportunities, teaching, and surgical training (14). A study conducted in Kent, Surrey and Sussex has shown that the gynaecology training was adversely impacted mainly by the temporary delay in gynaecology elective surgeries (15).
Our survey revealed that the COVID 19 pandemic had severely compromised the gynaecological training needs of the trainees. Gynaecology teaching was compromised, simulation training was restricted, some trainees were redeployed, and others had adverse ARCP outcomes. Respondents suggest that gynaecological simulation training can be improved by providing simulators in all hospital settings, arranging regular simulation sessions, and having mentors for supervising the trainees.
We asked the respondents about recommendations to improve gynaecology training. The following were suggested: more gynaecology theatre sessions, more gynaecology operative teaching sessions, more gynaecology simulation sessions, less emphasis on obstetrics training, and a more surgically orientated curriculum. A sample of the trainees’ recommendations is provided in Table III.
Sample of suggestions that can improve gynaecology training as stated by trainees.
This study is the first nationwide survey to assess the trainees’ views on the new RCOG curriculum and COVID 19 and its effect on gynaecology training. The participant trainees were a representative sample of all grades of training. The respondents proposed many suggestions that can be taken into consideration to improve gynaecology training and standard of care.
We believe that there are limitations in this survey. The response rate was low; however, our sample is representative to the obstetrics and gynaecology trainees. According to the RCOG 2019 training data analysis, 79% of the trainees were females (16). Likewise, 75.6% of the survey respondents were females. Our study obtained responses from all the different training grades. RCOG trainees’ representatives were sent regular reminders to maximize the response rate. They expressed that the trainees were fatigued from the large number of surveys circulated, exhausted from the recent changes in training, and felt burnt-out. Another limitation of the survey is that the RCOG curriculum was introduced in 2019, which indicates that new trainees over the last two years will not be able to make comparisons between old and new curricula. Surveys over a broader scale are recommended to see the effect of the new RCOG curriculum on gynaecology training and the long-term effects of the ongoing COVID 19 pandemic.
Our survey reveals that the new RCOG curriculum and COVID 19 pandemic have simultaneously compromised the gynaecology training amongst the UK trainees. RCOG and GMC-led more exhaustive survey would be welcomed to incorporate our findings and take necessary actions. Gynaecology training amongst current trainees should be of the highest quality to optimize patient care in line with the professional skills recommended by the GMC.
Acknowledgements
We want to thank all the UK obstetrics and gynaecology trainees for taking the time to complete the survey.
Footnotes
Authors’ Contributions
AB was involved in conceptualization, validation, formal analysis, investigation, data curation and writing the manuscript. AI edited the manuscript. SC was involved in conceptualisation, reviewing, and editing the manuscript. All Authors read and approved the final manuscript.
Conflicts of Interest
The Authors declare that they have no competing interests.
- Received March 7, 2022.
- Revision received April 1, 2022.
- Accepted April 6, 2022.
- Copyright © 2022, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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