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Undergraduate obstetrics and gynecology medical education: why are we underrated and underappreciated?
Viewpoint
ajog.org
EDUCATION
Undergraduate obstetrics and gynecology medical education: why are we underrated and underappreciated? Archana Pradhan, MD, MPH; Sarah Page-Ramsey, MD; Samantha D. Buery-Joyner, MD; LaTasha B. Craig, MD; John L. Dalrymple, MD; David A. Forstein, DO; Scott Graziano, MD; Brittany S. Hampton, MD; Laura Hopkins, MD; Margaret McKenzie, MD; Abigail Wolf, MD; Jodi F. Abbott, MD
O
bstetrics and gynecology education is one of the lowestranked medical school experiences by US medical school graduates. The inability to provide students with experiential excellence could be a detriment to our patients. The causes of student dissatisfaction are not unexpected: long work hours, minimal hands-on experience, limited faculty interactions, ineffective teaching by residents/fellows, and mistreatment issues. The purpose of this Viewpoint article is to discuss these clerkship weaknesses identified by national and local survey data. Strategies employed by nationally recognized obstetrics and gynecology educators to develop adaptive behaviors to address these educational shortcomings will be reviewed.
Background After 24 hours of call, delivering 4 babies, saving a woman’s life by surgically removing an ectopic pregnancy, and performing a handful of emergency room and inpatient consults, we are told that we are rated poorly by the medical students. Why? The annual data from the Graduate Questionnaire (GQ) of the Association of American Medical Colleges (AAMC) show 79% of graduating medical students in 2014 rate the overall quality of the obstetrics and gynecology (obgyn) clerkship as good or excellent as compared to 91.6% in internal medicine (P < .002).1 Most core clerkships are rated above ob-gyn, including surgery (Table), which has many similar characteristics to our specialty. A focus group of clerkship directors from the Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics (APGO) reviewed their individual clerkship evaluations and came up with several common themes regarding medical student evaluations of the ob-gyn clerkship. Medical students reported several unappealing elements: long work hours,2 minimal hands-on experience,3 limited faculty interactions,1 ineffective teaching by residents/fellows,1 and mistreatment issues.4,5 The purpose of this Viewpoint article is From the Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics, Crofton, MD. Received Sept. 4, 2015; revised Oct. 21, 2015; accepted Oct. 23, 2015. The authors report no conflict of interest. Corresponding author: Archana Pradhan, MD, MPH. archana.pradhan. [email protected] 0002-9378/$36.00 ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.10.915
to discuss strategies to develop adaptive behaviors to address these educational shortcomings. Best practices described on student surveys and by medical schools with ob-gyn clerkships that perform above the GQ national averages are reviewed.
Long work hours The Liaison Committee on Medical Education requires medical schools to have policies to limit student work hours.6 Most policies follow Accreditation Council for Graduate Medical Education guidelines in which residents are not allowed to work >80 hours per week. Regardless of work hour limits, many medical students comment on the difficulty of overnight calls and long shifts. Several studies have cited income and lifestyle as key elements identified by our current medical students in the decision to pursue a specialty.7 Ob-gyn is perceived as a specialty with an uncontrollable lifestyle.6 Acknowledging the challenging hours as a field-specific characteristic, and one each student should experience, can potentially frame their role on the labor floor as one needed for students to both fully participate in births and to understand the context of obstetric care. Additionally, it is important to educate medical students that the lifestyle of a resident in not necessarily the life of a practicing ob-gyn. Decreased hands-on experience Another factor as to why students rate our specialty lower is that medical students are given less autonomy on the rotation. In a study by Grasby and Quinlivan,8 38% of ob-gyn patients refused involvement of students. Female patients are more likely to refuse involvement of a student in their medical care due to the sensitive nature of the physical examination. Data support “that female supervisory physicians prioritized patients’ autonomy above students’ learning needs.”3 As educators, we must find ways to incorporate innovative techniques to supplement the volume of clinical experiences. Although the sensitive nature of our field will never change, there are several successful ways to increase a student’s comfort and expertise with gynecological exams and basic obstetrical procedures. Utilization of standardized patients and gynecological teaching associates to teach gynecological history taking and pelvic examination skills are keys to a successful ob-gyn clerkship. Low- and high-fidelity simulation drills to train students on spontaneous vaginal deliveries are immersive educational experiences designed to improve both patient safety and quality of medical education. MARCH 2016 American Journal of Obstetrics & Gynecology
345
Viewpoint
Education
ajog.org
TABLE
2014 Graduate Questionnaireequality of educational experience
feeling that a faculty member genuinely cares about the individual student’s development. This is particularly important as we are often switching them from service to service at short intervals to give the students broad exposure to the field.
Good to excellent, % Internal medicine
92
Pediatrics
87
Emergency medicine
87
Psychiatry
86
Family medicine
84
Surgery
83
Obstetrics and gynecology
79
Neurology
76
Pradhan. How to improve the obstetrics and gynecology clerkship experience. Am J Obstet Gynecol 2016.
Assigning students specific elements of patient counseling (ie, medication counseling) will include them as team members. Additionally, longitudinal experiences such as weekly clinics with the same preceptor or centering groups with the same patients allow faculty to watch a student’s development and permit the student to learn a particular attending’s practice style. These strategies help students develop a sense of confidence, and faculty members feel more comfortable including medical students in patient care. Consequently, medical students gather more hands-on experience.
Limited faculty observation When students are given opportunities to perform history and physical examinations on the ob-gyn clerkship, they report significantly less direct observation by faculty. In the 2014, AAMC GQ, 92% of students on the internal medicine clerkship strongly agreed or agreed that a faculty member watched them perform a history as compared to only 79% on the ob-gyn clerkship (P < .002).1 Medical students are not observed because of “a lack of faculty time, a lack of faculty skills, a potential stressful effect on the learner, and a perceived lack of validation of the assessment.”9 Although these concerns are valid, a concerted effort to address these issues needs to be made by medical student educators. Medical schools with highly rated ob-gyn clerkships have designed ways to improve faculty engagement with medical students. Improved presence in the preclinical years by allowing clinical faculty to teach reproductive endocrinology allows students to interact with faculty in a classroom setting. Early interaction with ob-gyn student interest groups also allows students increased exposure to the field and to clinicians who are passionate about their life’s work. Including nonphysician faculty in student clinical placements (eg, midwives and nurse practitioners) allows increased opportunities for clinical mentorship and involvement. Implementation of one-on-one mentor experiences while students are on clerkships gives students a sense of continuity and the 346 American Journal of Obstetrics & Gynecology MARCH 2016
Ineffective teaching by residents/fellows Medical students also report significant disappointment with resident/fellow teaching encounters on the ob-gyn clerkship. The AAMC GQ asks students whether resident/fellows provide effective teaching during core clerkships. In the 2014 AAMC GQ, 92% of respondents reported that resident/fellow teaching on the internal medicine clerkship was good or excellent, compared to 75% on the ob-gyn clerkship.1 This is another area that every residency program currently without a resident-as-teachers curriculum can impact. Highly rated ob-gyn clerkships have some best practices in place with regards to resident teaching. A 2004 article by Hammoud and colleagues10 report that teaching residents how to teach can improve the quality of the ob-gyn clerkship. In the study, a 1-day workshop was delivered to 18 of 20 ob-gyn residents. The study was shown to have a positive influence on the student evaluations both at 3 and 9 months postintervention. Residents-as-teachers curricula need to be tailored to the needs of a specific program and should be delivered at regular intervals to have a meaningful impact. Many programs find it difficult to identify on-site resources to deliver such programs. Many best practice clerkship sites send all rising fourth-year residents to a 3-day workshop for residents developed by the Council on Resident Education in Obstetrics and Gynecology (CREOG). This thorough curriculum is delivered by medical education experts in our field with the purpose of training residents to serve as leaders and teachers for junior residents and medical students. Mistreatment Another issue that garners much attention is mistreatment. The AAMC has defined different aspects of mistreatment and asked students to specify which health care professional subjected them to public embarrassment, public humiliation, threat of physical harm, actual physical harm, requirements to perform physical services, and offensive sexist remarks, to name a few. In the 2014 AAMC GQ, 39% of respondents reported that they were mistreated (excluding public embarrassment) during 4 years of medical school.1 Most incidents included public humiliation and offensive sexist remarks. The sources of mistreatment incidents have been attributed to mainly clerkship faculty and residents/interns. Although the GQ does not parse out mistreatment data by clerkship, data from clerkship evaluations from medical schools across the country and multiple presentations at annual CREOG-APGO meetings identify ob-gyn as offenders.4,5 Clerkships and institutions that have a lower percentage of students reporting mistreatment tend to have 2 things in common: (1) a culture of mutual respect and open dialogue,
Education
ajog.org and (2) a low tolerance for abusive behaviors and coordinated interventions when such behaviors do occur. Medical schools need to ensure that faculty and students are aware of policies and consequences of poor behavior. Anonymous mechanisms to report mistreatment incidents should be implemented. Every department should gather departmental data from the students and act on the information received. Remediation programs for faculty and residents need to be a part of the learning environment, and if those programs fail, senior administration must not be afraid to remove the offending teacher from a milieu that involves students. Chen and colleagues recently wrote an article on bullying in medical school: “.the culture for all these years has been to just take the mistreatment and not say anything. It wasn’t right back then and it shouldn’t be tolerated anymore.”11
Conclusion The fast-paced and unpredictable nature of ob-gyn is a defining characteristic of our exciting field. However, these same elements can make the ob-gyn clerkship a challenging environment for learners. Medical students recurrently identify issues such as minimal patient experience, limited faculty interactions, ineffective teaching by residents/fellows, and mistreatment as areas for improvement. Our role as women’s health advocates require our commitment to an effective educational environment for all medical school graduates. High-performing ob-gyn programs across the country have identified characteristics and programs that can be implemented with successful results. To provide maximal positive impact toward both women’s health and student education, we have an obligation to work toward
Viewpoint
incorporating these best practices into our educational programs. REFERENCES 1. Association of American Medical Colleges. Graduation Questionnaire. Available at: http://www.aamc.org/data/gq. Accessed October 15, 2015. 2. Dorsey ER, Jarjoura D, Rutecki G. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-8. 3. van den Einden LC, te Kolste MG, Lagro-Jansse AL, Dukel L. Medical students’ perceptions of the physician’s role in not allowing them to perform gynecological examinations. Acad Med 2014;89:77-83. 4. Breed C, Purkiss J, Santen S, et al. Evaluating clerkship-specific medical student mistreatment. Obstet Gynecol 2015;126:48-9S. 5. Baecher-Lind L. Student mistreatment: an exploratory study of students’ perceptions of the learning environment during obstetrics and gynecology clerkships. Poster presented at 2014 CREOG-APGO Meeting, March 2014, Atlanta, Georgia. 6. Friedman E, Karani R, Fallar R. Regulation of medical student work hours: a national survey of deans. Acad Med 2011;86:30-3. 7. Newton D, Grayson M, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998e2004. Acad Med 2005;80:809-14. 8. Grasby D, Quinlivan JA. Attitudes of patients towards the involvement of medical students in their intrapartum care. Aust N Z J Obstet Gynaecol 2001;41:91-6. 9. Fromme HB, Karani R, Downing SM. Direct observation in medical education: a review of the literature and evidence for validity. Mt Sinai J Med 2009;76:365-71. 10. Hammoud MH, Haefner MK, Schigelone A, Gruppen LD. Teaching residents how to teach improves quality of clerkship. Am J Obstet Gynecol 2004;1919:1741-5. 11. Chen P, Kogan JR, Bellini LM, Shea JA. Implementation of the miniCEX to evaluate medical students’ clinical skills. Acad Med 2002;77: 1156-7.
MARCH 2016 American Journal of Obstetrics & Gynecology
347
ajog.org
EDUCATION
Undergraduate obstetrics and gynecology medical education: why are we underrated and underappreciated? Archana Pradhan, MD, MPH; Sarah Page-Ramsey, MD; Samantha D. Buery-Joyner, MD; LaTasha B. Craig, MD; John L. Dalrymple, MD; David A. Forstein, DO; Scott Graziano, MD; Brittany S. Hampton, MD; Laura Hopkins, MD; Margaret McKenzie, MD; Abigail Wolf, MD; Jodi F. Abbott, MD
O
bstetrics and gynecology education is one of the lowestranked medical school experiences by US medical school graduates. The inability to provide students with experiential excellence could be a detriment to our patients. The causes of student dissatisfaction are not unexpected: long work hours, minimal hands-on experience, limited faculty interactions, ineffective teaching by residents/fellows, and mistreatment issues. The purpose of this Viewpoint article is to discuss these clerkship weaknesses identified by national and local survey data. Strategies employed by nationally recognized obstetrics and gynecology educators to develop adaptive behaviors to address these educational shortcomings will be reviewed.
Background After 24 hours of call, delivering 4 babies, saving a woman’s life by surgically removing an ectopic pregnancy, and performing a handful of emergency room and inpatient consults, we are told that we are rated poorly by the medical students. Why? The annual data from the Graduate Questionnaire (GQ) of the Association of American Medical Colleges (AAMC) show 79% of graduating medical students in 2014 rate the overall quality of the obstetrics and gynecology (obgyn) clerkship as good or excellent as compared to 91.6% in internal medicine (P < .002).1 Most core clerkships are rated above ob-gyn, including surgery (Table), which has many similar characteristics to our specialty. A focus group of clerkship directors from the Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics (APGO) reviewed their individual clerkship evaluations and came up with several common themes regarding medical student evaluations of the ob-gyn clerkship. Medical students reported several unappealing elements: long work hours,2 minimal hands-on experience,3 limited faculty interactions,1 ineffective teaching by residents/fellows,1 and mistreatment issues.4,5 The purpose of this Viewpoint article is From the Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics, Crofton, MD. Received Sept. 4, 2015; revised Oct. 21, 2015; accepted Oct. 23, 2015. The authors report no conflict of interest. Corresponding author: Archana Pradhan, MD, MPH. archana.pradhan. [email protected] 0002-9378/$36.00 ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.10.915
to discuss strategies to develop adaptive behaviors to address these educational shortcomings. Best practices described on student surveys and by medical schools with ob-gyn clerkships that perform above the GQ national averages are reviewed.
Long work hours The Liaison Committee on Medical Education requires medical schools to have policies to limit student work hours.6 Most policies follow Accreditation Council for Graduate Medical Education guidelines in which residents are not allowed to work >80 hours per week. Regardless of work hour limits, many medical students comment on the difficulty of overnight calls and long shifts. Several studies have cited income and lifestyle as key elements identified by our current medical students in the decision to pursue a specialty.7 Ob-gyn is perceived as a specialty with an uncontrollable lifestyle.6 Acknowledging the challenging hours as a field-specific characteristic, and one each student should experience, can potentially frame their role on the labor floor as one needed for students to both fully participate in births and to understand the context of obstetric care. Additionally, it is important to educate medical students that the lifestyle of a resident in not necessarily the life of a practicing ob-gyn. Decreased hands-on experience Another factor as to why students rate our specialty lower is that medical students are given less autonomy on the rotation. In a study by Grasby and Quinlivan,8 38% of ob-gyn patients refused involvement of students. Female patients are more likely to refuse involvement of a student in their medical care due to the sensitive nature of the physical examination. Data support “that female supervisory physicians prioritized patients’ autonomy above students’ learning needs.”3 As educators, we must find ways to incorporate innovative techniques to supplement the volume of clinical experiences. Although the sensitive nature of our field will never change, there are several successful ways to increase a student’s comfort and expertise with gynecological exams and basic obstetrical procedures. Utilization of standardized patients and gynecological teaching associates to teach gynecological history taking and pelvic examination skills are keys to a successful ob-gyn clerkship. Low- and high-fidelity simulation drills to train students on spontaneous vaginal deliveries are immersive educational experiences designed to improve both patient safety and quality of medical education. MARCH 2016 American Journal of Obstetrics & Gynecology
345
Viewpoint
Education
ajog.org
TABLE
2014 Graduate Questionnaireequality of educational experience
feeling that a faculty member genuinely cares about the individual student’s development. This is particularly important as we are often switching them from service to service at short intervals to give the students broad exposure to the field.
Good to excellent, % Internal medicine
92
Pediatrics
87
Emergency medicine
87
Psychiatry
86
Family medicine
84
Surgery
83
Obstetrics and gynecology
79
Neurology
76
Pradhan. How to improve the obstetrics and gynecology clerkship experience. Am J Obstet Gynecol 2016.
Assigning students specific elements of patient counseling (ie, medication counseling) will include them as team members. Additionally, longitudinal experiences such as weekly clinics with the same preceptor or centering groups with the same patients allow faculty to watch a student’s development and permit the student to learn a particular attending’s practice style. These strategies help students develop a sense of confidence, and faculty members feel more comfortable including medical students in patient care. Consequently, medical students gather more hands-on experience.
Limited faculty observation When students are given opportunities to perform history and physical examinations on the ob-gyn clerkship, they report significantly less direct observation by faculty. In the 2014, AAMC GQ, 92% of students on the internal medicine clerkship strongly agreed or agreed that a faculty member watched them perform a history as compared to only 79% on the ob-gyn clerkship (P < .002).1 Medical students are not observed because of “a lack of faculty time, a lack of faculty skills, a potential stressful effect on the learner, and a perceived lack of validation of the assessment.”9 Although these concerns are valid, a concerted effort to address these issues needs to be made by medical student educators. Medical schools with highly rated ob-gyn clerkships have designed ways to improve faculty engagement with medical students. Improved presence in the preclinical years by allowing clinical faculty to teach reproductive endocrinology allows students to interact with faculty in a classroom setting. Early interaction with ob-gyn student interest groups also allows students increased exposure to the field and to clinicians who are passionate about their life’s work. Including nonphysician faculty in student clinical placements (eg, midwives and nurse practitioners) allows increased opportunities for clinical mentorship and involvement. Implementation of one-on-one mentor experiences while students are on clerkships gives students a sense of continuity and the 346 American Journal of Obstetrics & Gynecology MARCH 2016
Ineffective teaching by residents/fellows Medical students also report significant disappointment with resident/fellow teaching encounters on the ob-gyn clerkship. The AAMC GQ asks students whether resident/fellows provide effective teaching during core clerkships. In the 2014 AAMC GQ, 92% of respondents reported that resident/fellow teaching on the internal medicine clerkship was good or excellent, compared to 75% on the ob-gyn clerkship.1 This is another area that every residency program currently without a resident-as-teachers curriculum can impact. Highly rated ob-gyn clerkships have some best practices in place with regards to resident teaching. A 2004 article by Hammoud and colleagues10 report that teaching residents how to teach can improve the quality of the ob-gyn clerkship. In the study, a 1-day workshop was delivered to 18 of 20 ob-gyn residents. The study was shown to have a positive influence on the student evaluations both at 3 and 9 months postintervention. Residents-as-teachers curricula need to be tailored to the needs of a specific program and should be delivered at regular intervals to have a meaningful impact. Many programs find it difficult to identify on-site resources to deliver such programs. Many best practice clerkship sites send all rising fourth-year residents to a 3-day workshop for residents developed by the Council on Resident Education in Obstetrics and Gynecology (CREOG). This thorough curriculum is delivered by medical education experts in our field with the purpose of training residents to serve as leaders and teachers for junior residents and medical students. Mistreatment Another issue that garners much attention is mistreatment. The AAMC has defined different aspects of mistreatment and asked students to specify which health care professional subjected them to public embarrassment, public humiliation, threat of physical harm, actual physical harm, requirements to perform physical services, and offensive sexist remarks, to name a few. In the 2014 AAMC GQ, 39% of respondents reported that they were mistreated (excluding public embarrassment) during 4 years of medical school.1 Most incidents included public humiliation and offensive sexist remarks. The sources of mistreatment incidents have been attributed to mainly clerkship faculty and residents/interns. Although the GQ does not parse out mistreatment data by clerkship, data from clerkship evaluations from medical schools across the country and multiple presentations at annual CREOG-APGO meetings identify ob-gyn as offenders.4,5 Clerkships and institutions that have a lower percentage of students reporting mistreatment tend to have 2 things in common: (1) a culture of mutual respect and open dialogue,
Education
ajog.org and (2) a low tolerance for abusive behaviors and coordinated interventions when such behaviors do occur. Medical schools need to ensure that faculty and students are aware of policies and consequences of poor behavior. Anonymous mechanisms to report mistreatment incidents should be implemented. Every department should gather departmental data from the students and act on the information received. Remediation programs for faculty and residents need to be a part of the learning environment, and if those programs fail, senior administration must not be afraid to remove the offending teacher from a milieu that involves students. Chen and colleagues recently wrote an article on bullying in medical school: “.the culture for all these years has been to just take the mistreatment and not say anything. It wasn’t right back then and it shouldn’t be tolerated anymore.”11
Conclusion The fast-paced and unpredictable nature of ob-gyn is a defining characteristic of our exciting field. However, these same elements can make the ob-gyn clerkship a challenging environment for learners. Medical students recurrently identify issues such as minimal patient experience, limited faculty interactions, ineffective teaching by residents/fellows, and mistreatment as areas for improvement. Our role as women’s health advocates require our commitment to an effective educational environment for all medical school graduates. High-performing ob-gyn programs across the country have identified characteristics and programs that can be implemented with successful results. To provide maximal positive impact toward both women’s health and student education, we have an obligation to work toward
Viewpoint
incorporating these best practices into our educational programs. REFERENCES 1. Association of American Medical Colleges. Graduation Questionnaire. Available at: http://www.aamc.org/data/gq. Accessed October 15, 2015. 2. Dorsey ER, Jarjoura D, Rutecki G. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-8. 3. van den Einden LC, te Kolste MG, Lagro-Jansse AL, Dukel L. Medical students’ perceptions of the physician’s role in not allowing them to perform gynecological examinations. Acad Med 2014;89:77-83. 4. Breed C, Purkiss J, Santen S, et al. Evaluating clerkship-specific medical student mistreatment. Obstet Gynecol 2015;126:48-9S. 5. Baecher-Lind L. Student mistreatment: an exploratory study of students’ perceptions of the learning environment during obstetrics and gynecology clerkships. Poster presented at 2014 CREOG-APGO Meeting, March 2014, Atlanta, Georgia. 6. Friedman E, Karani R, Fallar R. Regulation of medical student work hours: a national survey of deans. Acad Med 2011;86:30-3. 7. Newton D, Grayson M, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998e2004. Acad Med 2005;80:809-14. 8. Grasby D, Quinlivan JA. Attitudes of patients towards the involvement of medical students in their intrapartum care. Aust N Z J Obstet Gynaecol 2001;41:91-6. 9. Fromme HB, Karani R, Downing SM. Direct observation in medical education: a review of the literature and evidence for validity. Mt Sinai J Med 2009;76:365-71. 10. Hammoud MH, Haefner MK, Schigelone A, Gruppen LD. Teaching residents how to teach improves quality of clerkship. Am J Obstet Gynecol 2004;1919:1741-5. 11. Chen P, Kogan JR, Bellini LM, Shea JA. Implementation of the miniCEX to evaluate medical students’ clinical skills. Acad Med 2002;77: 1156-7.
MARCH 2016 American Journal of Obstetrics & Gynecology
347