Establishing sub-specialization in obstetrics and gynaecology in Nigeria: learning from 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: Oncology Reproductive 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 module Intermediate training module Advanced 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 assessments Log books RCOG College Tutor Clinical 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.

Modules Gynaecological Oncology sub spec training curriculum Module 1 General Assessment of a Gynaecological Oncology Patient Module 2 Pre-, Peri- and Postoperative Care Module 3 Generic Surgical Skills in Gynaecological Oncology Module 4 Cancer of the Ovary Module 5 Cancer of the Uterus Module 6 Cancer of the Cervix Module 7 Cancer of the Vulva Module 8 Cancer of the Vagina Module 9 Medical Oncology Module 10 Clinical Oncology Module 11 Radiology – Investigation and Intervention Module 12 Palliative Care Module 13 Urological Surgery Module 14 Colorectal Surgery Module 15 Plastic Surgery and Wound Care Module 16 Gestational Trophoblastic Disease Module 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 Care Acute Gynaecology and Early Pregnancy Advanced Antenatal Practice Advanced Labour Practice Benign Abdominal Surgery Advanced 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 societies The 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 subspecialists the 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 % %

Eligibility requirements for EBCOG Sub- specialty Training Centre Tertiary centre Close collaboration with related disciplines Adequate workload providing a full range of experience in the subspecialty Competent programme director Adequate medical staffing to enable trainee…… Adequate library, laboratory and other resources to support subspecialty work, training and research Resources 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 Gynaecology Urogynaecology 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 training Census of ob-gyn consultants with special interests/subspecialists Setting of standards for accreditation Centres Supervisors Trainees

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 development External – 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