The Royal College of Obstetricians and Gynaecologists (RCOG) has developed a curriculum for specialty training in obstetrics and gynaecology in the UK.1 The main aim of this specialty training curriculum for obstetrics and gynaecology is competency instead of considering variable steps or the amount of time spent on the training. As a result, it may take longer time for some trainees to achieve all competencies and their certificate of completion of training (CCT) as compared to others. Candidates who are starting at specialty training year 1 (ST1) level can expect to take 7 years for completing their training, subject to satisfactory assessment of progress. The number of posts available at ST1 to ST3 (specialty training year 3) level varies each year across the UK.
CAREER PATHWAY IN OBSTETRICS AND GYNAECOLOGY
If the aspirants are thinking to pursue a career in obstetrics and gynaecology following their graduation in medicine, they are advised to gain as much experience as possible before applying for the specialty training. Before applying for specialty training in obstetrics and gynaecology, candidates must ensure that they develop appropriate skills required to be a good obstetrician and gynaecologist. Some examples of these skills are as follows: clinical problem solving, good communication skills, decision making, teamwork, empathy, sensitivity, manual dexterity, working under pressure, etc.2 Day-to-day management and quality assurance of training are provided by the postgraduate dean during the period of specialty training. Alternatively, the training programme director supervises the training programme at the local level.
When the candidate enters specialty training programme in obstetrics and gynaecology, they would be provided with an ePortfolio by the RCOG.3 This portfolio shall act as a log for the attainment of competencies in the curriculum. It also records their inductions and appraisals as well as workplace-based assessment. The RCOG and the concerned deanery shall keep in touch with the candidate via the ePortfolio.
Throughout the candidate's training period, the College shall set out the criteria and content for training. They will also provide guidance regarding the educational support material and training courses. Figure 1.1 represents the training programme in obstetrics and gynaecology in the UK and this training programme is also described next in details.
TRAINING PROGRAMME IN OBSTETRICS AND GYNAECOLOGY
The candidates who are considering their career in obstetrics and gynaecology can apply for specialty training, which is a run-through scheme, following the completion of their foundation training (FY1 and FY2). Aspirants apply for training at ST1 level. Advancement to ST2 level, and then to ST3 and beyond (till the ST7 level) occurs; only if candidates are successful at subsequent levels. When the applicant has accomplished all the requirements of the programme, they will be awarded a Certificate of Completion of Training and registered in the specialist register of the General Medical Council.1 They can then practice at the consultant level in the UK.
Application process for specialty training in obstetrics and gynaecology is a competitive process initiated via the Health Education North West website (https://www.nwpgmd.nhs.uk/OG_Recruitment).4 The responsibility for national recruitment to obstetrics and gynaecology at ST1 level has been formally transferred by the Health Education England from the Royal College of Obstetricians and Gynaecologists to Health Education North West with effect from the August 2017 intake. In 2016, the competition ratio of clinical trainee to specialty trainee (CT1:ST1) in Obstetrics and Gynaecology was 2.03.5
Fig. 1.1: Career pathway for obstetrics and gynaecology.1
There were 2,133 consultants and 2,481 medical registrars in England in the year 2016 in the specialty of obstetrics and gynaecology.6
Foundation Training (FY1 and FY2)
A rotation in obstetrics and gynaecology is involved in many posts for foundation year 2 and a few posts for foundation year 1. For the candidates who have just completed their medical graduation and are interested in further pursuing their career in the field of obstetrics and gynaecology, it is a wise decision to spend some time doing an audit, publishing a case report, or conducting teaching sessions in the specialty of obstetrics and gynaecology. Presently, MRCOG part 1 of the examination can be attempted as soon as you have gained your medical degree. Successfully clearing the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Part 1 examination during the foundation training is likely to help you gain an edge over the other candidates while applying for the ST1 post in obstetrics and gynaecology.
During the foundation programme, the candidates who are wishing to pursue their specialty training in the field of obstetrics and gynaecology are expected to complete the Women's Health Module available on the RCOG website. Prior to the submission of an application for specialty training, it is essential for the candidate in the previous 1 year to undertake a formal hands-on training on basic life support. This may be undertaken in a hospital posting or on a recognised course. Other desirable courses which can be attempted by the candidates prior to the application for ST1 post include various courses such as:
- The basic practical skills in obstetrics and gynaecology course: The content of this course is designed to complement the RCOG Training Portfolio Logbook and is linked to OSATs or Objective Structured Assessment of Technical skills.
- The Advanced Life Support in Obstetrics (ALSO) course: This is an evidence-based, interprofessional, and multidisciplinary training programme. This training programme equips the entire maternity team to effectively manage various obstetric emergencies.
- The European Paediatric Advanced Life Support (EPALS) course: It is a collaborative course between the European Resuscitation Council and the Resuscitation Council (UK). The aim of EPALS is to train the doctors and nurses in the efficient and prompt management of the children showing early signs of respiratory or circulatory failure.
Years 1 and 2 (ST1 and ST2): Basic Specialty Training
Aspirants are likely to gain knowledge and skills in several areas of obstetrics and gynaecology at ST1 and ST2 level, while working together with other trainees at the similar level as well as those at advanced levels. Though the candidate is likely to work with several consultants across a range of specialties, there would be one consultant who would act as their educational supervisor. After satisfactory completion of the required assessments, the candidate is likely to progress to ST2. Within a minimum span of 2 years at the level of ST1-2, the candidate is likely to achieve all the required competencies.
The candidate is expected to see the patients in antenatal and gynaecology clinics during the basic specialty training. An opportunity to do caesarean sections and conduct instrumental deliveries in the delivery suite will also be provided to them. There are many other competencies required for the candidate at ST1 and ST2 level besides conducting uncomplicated elective caesarean sections and non-rotational instrumental deliveries and those include opening and closing the abdomen during various surgeries, perineal repair, and uncomplicated surgical uterine evacuation.7 The training achievements of all individuals will be recorded in their training logbook and ePortfolio.3
With the advancement of candidate's training, they will start to possess the various competencies in their logbook signed off. After the candidates attain set competencies and are successful in their annual review of competence progression, they are able to reach to the next level of their specialty training.
Progression from ST2 to ST3 Level
One of the important assessment steps of progression from ST2 to ST3 level (i.e. from basic to intermediate training) for a candidate is to pass the first part of the RCOG membership examination (Part 1 MRCOG). They should have completed the RCOG basic practical skills in obstetrics and gynaecology course, and should have attained the relevant competencies for independent practice as highlighted in the trainee logbook. This includes modules in basic clinical and surgical skills, teaching appraisal and assessment, ethical and legal issues, and maternal medicine. At this stage, the candidate is likely to take increased clinical responsibility and progresses from first on call to second on call. At this level, the candidates become competent to handle the delivery suite independently. At the same time, they must be aware of their limitations and should know when to seek senior assistance.
Years 3–5 (ST3–ST5): Intermediate Training
Once the candidates have progressed to ST3 level, they will have to spend the next 3 years obtaining further experience in all areas in the specialty of obstetrics and gynaecology. By the time, the candidates reach ST4 to ST5 level, they have become capable to carry out almost all the obstetric and gynaecological procedures with indirect supervision (with a consultant available nearby). By the time candidates reach ST5 level, they have acquired a broad base of knowledge and expertise on which to develop advanced skills and make future career plans. During this time, trainees get the opportunity to follow their subspecialty interests. They get a chance to work closely with a consultant in a specific subspecialty. Satisfactory completion of ST5 marks the completion of intermediate training.
To progress through training during ST3 to ST5 levels, the candidates need to achieve set competencies as mentioned in their ePortfolios and logbooks. They also need to have regular assessments. In order to progress towards advanced training (ST6 level) following the completion of intermediate training, the candidate needs to complete all the intermediate competencies and pass the second part of the membership examination (Part 2 and Part 3 MRCOG examination). Once the candidate has completed all intermediate requirements, they move to ST6 level. Here they have the option to complete advanced training skills modules (ATSMs) or do subspecialty training.
Years 6 and 7 (ST6 and ST7): Advanced Training
During ST6 and ST7 level, the candidates continue to expand and improve their general skills in obstetrics and gynaecology. Besides consolidating the clinical skills they have already learned during specialty training, they are likely to expand their knowledge in topics such as medical management and clinical governance. This would ensure that they are properly prepared for the non-clinical aspects of working as a consultant in the National Health Service (NHS).
During this period, the candidates also get a chance to gain more knowledge and experience in their area of special interest. They have the option to do ATSM or the subspecialty training.8 Following these two final 2 years of training, the candidate can apply for their final qualification, the Certificate of Completion of Training.
Advanced training skills modules: The candidate can choose from 20 ATSMs, based on the skills suitable for future career progress as a consultant. Some of the advanced training modules include, maternal medicine, oncology, forensic gynaecology, vulval disease, medical education, and menopause.9
Subspecialty training: Subspecialists are obstetricians and gynaecologists who are recognized to have subspecialty expertise in their field. They have undertaken appropriate additional higher training beyond that which can be achieved in normal advanced training. There are four subspecialties in obstetrics and gynaecology: gynaecological oncology, maternal and foetal medicine, reproductive medicine, urogynaecology and sexual and reproductive healthcare. The training programme is set out by the relevant subspecialty. The candidate would, however, continue to undertake on call work in general obstetrics and gynaecology during their subspecialty training. The subspecialty training lasts for 3 years: 2 years of clinical training and 1 year of research. If the candidate has already published appropriate publications, it may count towards the research component.
CERTIFICATION OF TRAINING AND SPECIALIST REGISTRATION
For the candidates to be able to practice as a consultant in the NHS, they need to be entered on the Specialist Register. On successful completion of their advanced training, they would be conferred certificate of completion of training. The RCOG would then recommend them to the General Medical Council for inclusion on the Specialist Register. This would enable the candidate to independently practice as a consultant in obstetrics and gynaecology in the UK.
NATIONAL HEALTH SERVICES
While attempting the MRCOG Part 2 or 3 examination, it is especially important for the overseas candidates to be familiar with the working of healthcare system in the UK. NHS or the National Health Service is a publicly funded national healthcare system for England. The four national health services in the United Kingdom include NHS (England), NHS (Scotland), NHS (Northern Ireland), and NHS (Wales).10 It is the largest and oldest single-payer healthcare system in the world and covers all healthcare services including the antenatal care, screenings, maternity services, long-term healthcare, and end of life care. Three core principles of NHS are as follows:
- Based on clinical needs and not on the ability to pay
- Meeting the requirements of everyone
- Free at the point of delivery.
Funding for NHS directly comes from taxation. Various levels of healthcare in the NHS include primary level, secondary level, and tertiary level. As per data of March 2017, there are 233 NHS providers of secondary and tertiary care. Of these 233 NHS providers, there are 152 foundation trusts and 81 aspirant trusts.11 Additional non-NHS organisations also provide secondary and tertiary care services.
Primary Level Healthcare
Primary care acts as the first point of contact for someone and covers everyday health services. It can be regarded as the ‘gateway’ to receiving more specialist care. It is usually delivered by primary care trusts such as GPs (general practitioners), dentists or opticians. NHS provides funds to the GP surgeries that are responsible for delivering primary care to the patients. There is a clinic called GP surgery in every community, which covers the population in their catchment area. People living in that area can get themselves registered with that GP surgery. The medical records of a person are usually held by the GP. The GP also knows the patient's complete medical history. Patients usually cannot refer themselves to a specialist except in two conditions:
- Referral to A&E
- Referral to sexual health clinics or genitourinary medicine (GUM clinics).
All the preliminary work-up of the patients before referring them to the secondary care (hospitals) is usually done at the GP surgery. When the patient is referred to secondary or tertiary care, the GP surgery pays the hospital for that visit. Therefore, hospitals earn money through these referrals. No payment is done for any further follow-up. As a result, the patients are usually followed up in the GP surgeries based on the recommendations made by the specialists. The specialist may call the patient for further follow-up based on their discretion depending upon the patient's clinical condition.
Secondary Level Healthcare
Secondary level healthcare includes hospital-based as well as community-based care. It can either be planned (elective) care such as a cataract operation, or urgent and emergency care such as treatment for a fracture. Hospital-based care is usually provided by the specialists. A patient is referred to a secondary care professional from primary care. A specialist in secondary or tertiary care will see only those patients who have a referral letter from GP, which outlines the patient's background, the treatments initiated so far, and the patient's response to treatment. Once the specialists have seen the patient, they would write back to the GP their recommendations and observations. Based on the results of the observations or investigations, the specialist may decide to call the patient back to the hospital or refer them back to the GP for further follow-up. In either case, a letter is issued to the GP updating regarding what was done. For example, if the specialist discovers a microbial growth on high vaginal swab (HVS), they can refer the patient back to the GP who would then prescribe appropriate antibiotics to the patient. On the other hand, if the investigation reveals CIN, the patient would be referred to the hospital's colposcopy clinic.
Tertiary Level Healthcare
Tertiary level of healthcare is known as specialized consultative healthcare. This type of healthcare service is usually for inpatients and on referral from primary and secondary healthcare for advanced medical investigation and treatment.
ANTENATAL CARE (MIDWIFERY SYSTEM) IN THE UK
Midwifery system prevails in UK for the care of pregnant women. Midwives act as lead professionals for providing maternity care to all healthy pregnant women. They deliver all aspects of pregnant woman's physical, psychological, and social care. They also act as the first point of contact for the women who want to access maternity services. In case of complicated pregnancies, midwives act as the prime co-ordinators of care within the multidisciplinary team, where they closely work with the obstetricians, GP, specialist services, social services, breast feeding services, etc.
Midwives can conduct a normal vaginal delivery, suture episiotomies, and repair first and second degree tears. In the maternity triage and antenatal day care assessment, midwives can check a patient's presentation and treat the patient on their own unless they encounter a problem and feel the requirement to involve a doctor. In the NHS, following grades of midwives are available: student midwives, middle grade midwives, senior midwives, and specialist midwives. In the UK, midwives can work in the following sectors as discussed next.
Community level midwives provide home visits to the patients, antenatal care, postnatal assessments, assessment of the patient's social support needs, etc.
- Midwife led unit (MLU): These are separate birth centres other than the labour room where the midwives conduct delivery themselves without using any medical intervention. These units are usually next to the main hospital's maternity unit. Facilities for water birth are also here. In case any complication is anticipated during labour, the midwife would advise the patient to change her plan and deliver in the obstetric unit.
In the NHS, the obstetricians or doctors are involved in antenatal care or delivery of patients only when the midwife encounters a complication or feel the requirement for their involvement.
Obstetrics and gynaecology is a unique specialty which is a combination of both medicine and surgery. This specialty is not only concerned with the care of pregnant woman and her unborn child, but also the management of diseases specific to women. A career in obstetrics and gynaecology is likely to be both thrilling and rewarding due to the broad range of subspecialties it offers. It presents countless opportunities, enabling the budding obstetrician and gynaecologist to practise high-quality medicine in an atmosphere of multidisciplinary team. A career in obstetrics and gynaecology in the UK warrants an understanding regarding the working of NHS as well as the role of midwives in imparting care to the pregnant women.
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- NHS specialty training. (2016). 2016 – CT1/ST1 Competition Ratios. [online] Available from https://specialtytraining.hee.nhs.uk/Portals/1/Competition%20Ratios%202016%20ST1_1.pdf [Accessed July 2017].
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- Oxford deanery. (2017). Obstetrics and Gynaecology - ST1 - person specification-2017. [online] Available from http://www.oxforddeanery.nhs.uk/pdf/OG-PS-ST1-1232017-1.pdf [Accessed July 2017].
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