Do’s and Don’ts in Obstetrics and Gynecology Practice Tushar Kar, Asaranti Kar
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Making of a Postgraduate1

Tushar Kar
Asaranti Kar
 
INTRODUCTION
The need for reappraisal and a critical evaluation of the postgraduate training program in Obstetrics and Gynecology has been long felt in India. The goal of postgraduate education to produce a competent specialist, medical teacher and research scientist depends much upon the nature and content of training imparted to them during the postgraduate period and also on the teachers and/or trainers. Now the Medical Council of India, which is the regulatory body of medical education provides broad guidelines in postgraduate medical education regulations, 2000.1 According to MCI 2000 regulations, the major components of PG education are:
  • Goals and objectives of PG education
  • PG curriculum
  • Thesis
  • Assessment.
 
GOALS AND OBJECTIVES OF PG EDUCATION
Why there is a need for writing an unusual chapter like “Making of a postgraduate?” Because the postgraduate students after admission into the curriculum, do not know about the exact contents of their training as well as the teachers are ignorant about the teaching module. Many of the teachers/trainers have already felt that even the ongoing teaching methods are inappropriate and inadequate for postgraduates. Therefore, keeping in view of producing the best consultants and medical teachers, it is high time we revamp the postgraduate training program, which we have felt for years together.
 
Goals
The goal of postgraduate education in Obstetrics and Gynecology is to produce a competent specialist for future needs.
  • After completing the course, he must be able to recognize the health needs of the women, which includes adolescents, females in reproductive age group, and postmenopausal females. He must be well versed and abide by the principles of National Health Policies.
  • And always he must follow the professional ethics. For that he must have a thorough knowledge of medical ethics and by no means should disobey them.
  • He should be completely aware of the anatomy, physiology, pathology related to reproductive system of females by which he can completely manage the clinical situations.
  • He should be updated regarding the recent advances and developments in the field of Obstetrics and Gynecology which will enable him to serve the community better.
  • He should be able to demonstrate competence in basic concepts of research methodology and be able to critically analyze the relevant publications and literature.
  • He should develop skills in using educational methods and techniques for teaching of paramedical and medical health professionals.
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Objectives
The learning objectives of postgraduate education of students is to:
  • Cater a quality maternal care in diagnosis and management of normal and abnormal pregnancies during antenatal, natal and postnatal period.
  • Manage skillfully the emergencies during obstetric and early neonatal period.
  • Provide counseling regarding family planning for couples and should efficiently perform the medical termination of pregnancy.
  • Acquire a thorough knowledge on benign and malignant gynecologic disorders, knowledge of interpretation of various laboratory investigations and other diagnostic data to reach at a plausible diagnosis.
  • Should know everything about medical and surgical problems related to Obstetrics and Gynecology.
  • Should practice adequate surgical skills for management of majority of obstetrical and gynecological problems.
  • Organization and supervision of maternal components like National Health Programs, Reproductive and Child Health, Family Welfare, STD, AIDS, Reproductive tract infections as per Government of India perspectives.
  • Demonstrate empathy and humanitarian approach towards patients and their relatives.
  • Should be thorough in writing details of OPD patients and keen in record keeping in bed head tickets and documentation of details in case of morbidity and mortality.
  • Should be aware of medicolegal aspects in obstetrics and gynecology and should know how to record in a medicolegal case.
  • Should be inclined to research methodology and recent advances in the field of obstetrics and gynecology.
  • Should learn leadership qualities to lead health care, teaching activities and obtain skill to teach medical and paramedical health workers as a teacher trainer.
 
PG CURRICULUM
The major focus of MCI regulations is on staffing pattern, their qualification and facilities and recognition of institutions for PG courses rather than regulating a standard curriculum. There should be a defined curriculum for Obstetrics and Gynecology with specified learning experiences and progressive graded responsibilities. It should provide a broad based educational experience. Till date, it is said that the postgraduate has to be a self-directed learner, recognizing continuing educational needs, selecting and using appropriate learning resources such as seminars, journal clubs, symposia, reviews, guest lectures, case presentations, etc.2 Since the postgraduate training program is a self education program, no spoon feeding is to be done. The teachers guide them only.3
The major components of the postgraduate curriculum shall be:
  • Theoretical knowledge
  • Practical and clinical skills
  • Thesis skills
  • Attitude including communication skills
  • Training in research methodology.
 
Theoretical Knowledge
  • Anatomy, physiology, embryology, genetics concerned to female urogenital system.
  • Pathology and pathophysiology of major obstetric and gynecologic disorders.
  • Forensic aspects and microbiological aspects of Obstetrics and Gynecology.
  • Pharmacology of drugs used in Obstetrics and Gynecology.
  • Management of normal and abnormal pregnancies, labor and puerperium.
  • Management of MTP cases, conduction of family welfare programs and its complications.
  • Knowledge of contraception/family planning/sterilization methods.
  • Management of normal neonates and common problems in neonatal period.
  • Knowledge of emergency obstetric care.
  • Diagnosis and management of all benign and malignant gynecologic disorders.
  • Must have theoretical knowledge on ultrasonography.
  • Must have knowledge of laparoscopy, hysteroscopy and cystoscopy.
  • Evaluation and treatment of infertility.
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  • Knowledge of cervical cytology and its interpretation to facilitate treatment.
 
Practical and Clinical Skills
OPD: History taking and workup including presentation of all cases to the teachers. This also includes all the special clinics like infertility, endocrinology, menopause, and adolescent clinics.
Labor room: History taking, workup and documentation of all cases, sending and filling of all investigations, performing NST and maintaining partogram.
  • IV line insertion, Ryle's tube insertion, catheterization and cerviprime gel introduction.
  • Management of sick patients like eclampsia, abruptio placentae and postpartum hemorrhage.
  • Preparation of weekly, monthly and annual statistics.
 
Indoor
Obstetrics: Care of puerperal cases with regard to nutrition (IV/oral), breastfeeding, immunization of neonates and contraception planning.
Gynecology: History taking and workup of all gynecological cases, preoperative assessment and preparation before surgery, assertive dressing and suture removal.
Operation theater: All must do minor procedures independently and assist in major procedures. In addition to these they should learn the work of family planning, laparoscopy and ultrasonography.
  • In clinical practice, a student should be competent in history taking, physical examination, basic life supports and common procedures like amniotomy, conduct of normal delivery, perineal infiltration, pudendal block, etc. in labor room.
  • He must be able to examine and manage normal antenatal cases, recognize high-risk cases and manage them successfully avoiding morbidity and mortality.
  • He will be able to conduct ANC clinic, high-risk clinic and menopausal clinic, infertility clinic, endocrinology and adolescent clinic.
  • Exploration of cervix, repair of perineal and cervical tear, delivery of breech and twin.
  • Antenatally, he should be competent in cervical encirclage, external cephalic version, extra-amniotic and intra-amniotic drug infusion, amniocentesis and nonstress test.
  • Intranatally, he should know the management of postpartum hemorrhage, shock, amnio-infusion, reposition of inversion of uterus and destructive operations, manual removal of placenta.
  • In addition, he should know suction and evacuation, dilatation and evacuation.
  • Lower segment cesarean section, cesarean hysterectomy, uterine and ovarian artery ligation and internal iliac ligation.
  • In gynecology, all the postgraduates must be competent in certain common procedures like taking of pap smears, postcoital test, endometrial aspiration and biopsy, cervical biopsy, polypectomy, cervical cauterization, hysteron-salpingography, opening and closing of abdomen.
  • Besides he must assist in all the major gynecologic operative procedures.
  • In family planning, he must know the procedure of insertion and removal of IUCD, female sterilization, MTP and male sterilization.
Job responsibility: For a student in obstetrics and gynecology includes all the above maintioned.
Teaching and learning: The key stone of postgraduate medical education is acquisition of practical competencies. Learning in postgraduate program is essentially self education and is mainly based on the experience derived from clinical and academic work. It should be self directed learning with group discussion, case presentation and practical hands on learning. This core effort can be derived from the formal sessions such as:
  • Clinical case discussion (clinical teaching round and bedside teaching)
  • Seminars/journal club /statistical meeting (weekly/ monthly), monthly interdepartmental meetings and others like guest lectures/vertical seminars/ central statistical meets.
 
Teaching Schedule
The departmental teaching schedule for postgraduates in Obstetrics and Gynecology should be:
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  • Once a week–Seminar/symposium, case presentation and journal club with pediatric department—discussing monthly neonatal deaths.
  • Twice a month–Interdepartmental clinical meet and grand round of the words.
  • Once a month–Thesis meet by PG students, parinatology review including CS and maternal deaths and interdepartmental statistical meet.
In addition, the followings may be conducted as and when required:
  • Guest lectures—UG student seminars, sessions on basic sciences, research and teaching methodology.
  • Medical ethics and legal issues.
  • Continued medical education program, workshops and conferences.
 
Clinical Posting
Before posting, at the outset all are oriented about proper history taking, clinical examination and relevant investigations for OPD and indoor patients. An orientation class of postgraduates especially by the professor of the department should be taken. He/she has to delineate all the responsibilities and teaching schedule to the new comers.
In the beginning, they are posted for 6 months in labor room to manage normal and abnormal deliveries and to manage all emergency situations.
After 6 months–They are posted at various units on rotation wise under the supervision of unit heads where they should be distributed equally in obstetrics and gynecology wards.
Last 6 months–They should be posted with the guide and/or the teacher.
In between, they are to manage the emergency duties in the labor room as well as ward with uniform distribution in addition to their regular duty.
During the PG period, they should be posted in allied departments like family planning clinics, neonatology and oncology departments.
 
THESIS
The objective of thesis writing in PG period is to carry out research project and presenting this work in the form of a thesis. There by, the student will be able to identify a relevant research question, conduct a critical review of literature, formulate a proper hypothesis, determine a study design, the study protocol and state the objective of a study. He can analyze and interpret the data obtained from research work and draw unbiased conclusion. Lastly, he must write the research paper.
 
Guideline for Thesis
The following points should be followed while selecting thesis topic:
  • The resources and time available should be kept in mind.
  • Procedure of research should be emphasized than the result of research.
  • The research work must be ethically approved.
  • Only one student should be allowed per one teacher.
  • The study protocol, interim program as well as the final result should be presented openly in the department.
Periodic departmental review of thesis work should be done as per schedule like:
  • Submission of protocol in the end of 1st year, midterm presentation during 2nd year and final presentation 6 months prior to final examination.
  • Students have to submit five copies of thesis to the university 6 months before the date for final examination and are allowed to appear in examination only after acceptance of thesis.
  • The students should submit the synopsis within 3 months of joining.
  • The thesis should be sent to at least two reviewers and can be rejected only if both reject it. The candidate should be communicated about acceptance within 2 months of submission.4
 
ASSESSMENT
The assessment of postgraduate students should be daily and periodical.
General principles of assessment are:
Validity: The extent to which a test serves the purpose for which it has been prepared.
Objectivity: Consistency in scoring by different scorers or examiners, i.e. uniformity in scoring and reliability.
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It is the degree of concordance between the judgments of independent and competent examiners as to what constitutes a “good” answer for each question.
Reliability: It is the extent to which results obtained through a test remains constant over a period of time or in different situations for the same sample. The methods of evaluation should cover three educational domains of students like cognitive, psychomotor and affective.5,6
Cognitive domain (Thinking): This includes written test, viva-oral test, thesis writing, etc.
Psychomotor domain (Acting or skills): Under this domain come practical and clinical skills, simulated patients and patient interviews, etc.
Affective domain (Feeling): Situational assessment, feeling of students and their communication abilities with the patients are considered in this domain. Each postgraduate must be well trained to communicate with patients and their attendants as and when required. This is very much important for the present time.
Formative, continuing and summative assessments should be done separately.
 
Formative Assessment
The components of formative assessment are continuous and periodical. This does not count towards pass/fail of the student, but, will provide important feedback to the candidate. The feedback for continuous assessment is obtained from senior residents, assistant professors and unit heads.
There must be internal assessment for each candidate. This procedure is not being followed at present in all medical colleges of India, but today we strongly feel that due weightage should be given for formative assessment in view of pass/fail of the candidate.
 
Internal Assessment
It is the most important component of assessing a postgraduate student. The internal assessment should be done as follows:
Items
Marks
1. Personal attributes
20
2. Clinical skills and performance
20
3. Academic activities
20
4. End of term theory examination (1 year, 2 years, 2 years and 9 months)
20
5. End of term practical exam/oral
20
The record of internal assessment must be presented to the board of examiners for consideration at the time of final assessment. Though this is the standard instruction, it is rarely followed up. At this juncture, we feel that some percentage of marks (around 30%) should be weighed for internal assessment.
 
Personal Attributes
Availability: The PG student must be punctual, continuously available on duty, responds promptly to calls and takes proper permission for leave.
Sincerity and motivation: He should be dependable, honest, admits mistakes, does not manipulate information, exhibits good moral values, loyal to institution, initiative, takes responsibilities and exhibits keen desire to learn.
  • He should be fully communicative to patients particularly patients, attendants, staff, fellow doctors and teachers.
  • Communication is most desired need of the day for postgraduation as well as for future profession.
  • Diligence and performance: He should have sound knowledge, participate in academic activities, performs well in oral presentations and above all should be intelligent.
  • Interpersonal skills: He must have compassionate attitude towards patients. Get on well with colleagues and paramedical staffs, must show respect to seniors.
 
Summative Assessment
Principles of summative assessment are:
  • Weightage towards practical and theory examination should be equal.
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  • Obtaining a minimum of 50 percent in theory and practical examination should be mandatory.
 
DO'S AND DONT'S IN OBSTETRICS AND GYNECOLOGY
It is known that obstetrics and gynecology discipline is a combination of art, science and commerce. One must be aware of the fact that it is a sensitive subject. Therefore, before selecting the stream, one must have 100 percent mental make-up. Why this is important ? Because it is observed that after a few months of postgraduation in Obstetrics and Gynecology, few are in conflict of mind to change the subject. This is true in other disciplines also. Therefore, the student should consider all the aspects before counseling for the subject.
 
Do's
  • Stick to the basics.
  • Immediately after admission into postgraduation, all the students must learn how to write OPD tickets, indoor tickets, OT note, filling of investigation forms and how to write the medicolegal reports from the concerned teachers.
  • Read the undergraduate textbooks first.
  • Basing on these books, in OPD write history in short in relevance to diagnosis, where as in indoor you must write history and examination findings in detail.
  • Learn the clinical examination methods and do it yourself in front a teacher.
  • Think about the line of management independently for each and every case. Have a detail workup individually and compare it with the unit's decision.
  • Before clinical round, you must compile individual case presentation.
  • Give more importance to critically ill patients and try to present the same case.
  • The concerned PG student of the ward must be thorough in presenting the case.
  • All the PGs must participate in the clinical discussion in daily rounds. The postgraduates are stimulated regarding individual case discussion in the rounds and they should read the related chapters in the evening.
  • Ideally they should note down these clinical situations in the rounds for further detailed study.
  • Be practical in day-to-day clinical practice.
  • Do the minor procedures independently.
  • Assist the major operative procedures when ever possible.
  • Write the operative procedures yourself.
  • The labor room is really the learning field for any postgraduate in Obstetrics and Gynecology. As because, in a standard medical college, variety of obstetric cases are seen. The PG must individually assess the cases in labor room. Independently, he must learn how to manage a critically ill patient.
  • He must practically perform the life-saving procedures.
  • He must attend the seminars regularly and must read and participate actively.
  • Everyday, he should at least try to read for sometime in spite of the busy schedule.
  • In all the seminars, try to actively participate.
  • Be well read before seminars.
  • Note down any addition or subtraction relevant to the seminar topic and present during discussion.
  • He must be regular in doing thesis work and should present at definite interval to the concerned guide.
  • The postgraduate must be sympathetic to and communicative with the patients.
  • He must be fully communicative to the patients, attendants, staff, colleagues and teachers. This is very much required at present.
  • He should be cordial to the staff, juniors, seniors and teachers.
  • Lastly in difficult situations, he should not hesitate to consult the teachers for taking decisions.
 
Dont's
  • Don't behave like a consultant from the beginning.
  • Don't treat the patients independently.
  • Don't write unnecessary investigations.
  • Don't be in a haste while taking decisions in labor room.
  • Don't do unnecessary cesarean sections.
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  • Don't apply forceps or vacuum without indications.
  • Don't prescribe unnecessary or costly medicines
  • Don't interfere while others are presenting in seminars.
  • Don't be impatient for assisting or doing any operative procedures.
  • Don't misbehave with patients, patients' attendants, seniors or teachers.
 
FEW SUGGESTIONS FROM AUTHORS
It is high time that there must be revamping of medical education, i.e. both undergraduate and postgraduate not only in India but also across the world. In view of that the following suggestions are put forth:
There should be internal assessment for all the postgraduates. This comprises of day-to-day clinical work, sincerity, understanding and application in patient care as well as academics.
The periodic assessment will be done by all the unit faculties where they are posted on rotation. The weightage for internal assessment may be from 50 to 60 percent.
There should be rotation of examiners for postgraduate examination in all medical college universities.
For a long time, there is no change in methodology of teaching, curriculum and courses for medical education, especially regarding long period of 9 to 10 years to become a specialist. For which we feel that there should be only three years basic medical course for undergraduate after which anybody can opt for any specialization or superspecialization according to choice. This specialization may be family practice or any other subject depending upon the choice of the student. This period may be for 3 to 4 years for specialization after 3 years of basic medical education. The intention of this revamping is to reduce conventional 9 to 10 years of long period taken for specialization, at the same time to refine more in the concerned discipline.
REFERENCES
  1. Medical council of India. Postgraduate Medical Education Regulations; 2000. Medical Council of India. Aiwan-E-Galib Marg, Kotla Road, New Delhi.
  1. www.dypatil.in/picrepimage/Syllabus for Post-Graduate of OBGY. pdf Srivastab RN, Mittal SK.
  1. Sur AM. Postgraduate medical education in India revamp and re-establish cg Pedicon 2006, 7–8th Oct, Rajnandgaon, Chattisgarh.
  1. Paul VK, Ramji S. IAP Guidelines for postgraduate education in Pediatrics. Indian Pediatrics. 2001;38:847–62.
  1. Educational handbook for health personnel. J J Guilbert. WHO; 1987.
  1. Handbook on Education Technology, Henry Ellington. Fred Percival and Phil Race, Kogan Page Publication;  1993.