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Implementation of a New Gynecology Curriculum in the University of Toronto Obstetrics and Gynecology Residency Program
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Implementation of a New Gynecology Curriculum in the University of Toronto Obstetrics and Gynecology Residency Program

Aisha A Yousuf, MD FACOG1, Eliane M Shore1MD FRCSC MSc, Katie N Dainty2,3,PhD MSc, and Sari Kives1MD FRCSC MSc

1Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Department of Obstetrics and Gynecology St Michael’s Hospital, Toronto, ON; 2 Li Ka Shing Knowledge Institute of St. Michaels Hospital Toronto; 3Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON

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Background

The Royal College of Physicians and Surgeons of Canada is moving toward competency-based medical education (CBME). CBME is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program. This model aims to provide more personalized learning experience, frequent formative assessment and feedback from supervisors,and advance trainees more rapidly to obtain additional skills and knowledge in comparison to current educational models.1

Challenges in the current 12 week St Michaels Hospital (University of Toronto) Obstetrics and Gynecologic (OBGYN) rotation currently exist and would make the implementation of Competency by Design (CBD) difficult. These deficiencies include:
1. Lack of consistency in surgical experience due to varied coverage requirements.
2. Minimal concurrent exposure to office based gynecology.
3. LackofobjectiveassessmenttoolsforsurgicalskillsintheOR.
4. Lack of surgical simulation labs usage for training outside the OR.
5. Inconsistent and multiple preceptors.

A new reimagined gynecologic curriculum was proposed to address these deficiencies, prepare for implementation of CBD expectation and enhance residents’ satisfaction and surgical learning experience.

During a new 6-week gynecology curriculum, post-graduate year 2 residents were assigned to 3 to 4 specific mentors/preceptors for both their gynecologic surgery operating room (OR) and ambulatory clinic experience. The residents were also assigned to simulation sessions with one to one training 1-2 times throughout the curriculum (Figure 1).

Results

A total of 4 residents have participated in the pilot study. Qualitative analysis of the interviews revealed 3 key themes:

Context:

+ Less distractions and more focused OR experience.

  • -  Logistic and scheduling challenges impact learning (summer OR closure).

  • -  High number of trainees lead to dilution of learning experience.

  • -  Educational conflicts between traditional and new curriculum participants when

    creating the daily OR schedule.

    Preceptors:

    + Opportunity to work with consistent preceptors supported the development of surgical skills.

    + Focused mentorship.
    - Value of limiting/restricting number of preceptors.
    - Internal conflicts between participants of the new and traditional curriculum over

    preceptors.

    Educational impact:

    + Enhanced development of surgical skills and confidence in the OR. + Daily continuous reinforcement supported learning.
    + Simulation lab and one-to-one teaching seen as valuable.

  • -  Loss of acquired surgical skills and/or delay in acquiring surgical skills compared to

    their peers in the traditional curriculum due to extended time away from gynecological

    surgeries.

  • -  Six weeks of continuous obstetrics very exhausting.

    Other results are represented in Figures 3 & 4.

Methods

Traditional Curriculum

Mon

Tue

Wed

Thur

Fri

AM

Obstetrics (Labor & Delivery)

Gyn 1 (priority Gyn OR)

Gyn 2 (priority Inpatient care/Consults)

Obstetrics (Labor & Delivery)

Night Coverage

PM

Obstetrics (Labor & Delivery)

Gyn 1

Gyn 2

Obstetrics (Labor & Delivery)

Night Coverage

New Curriculum

Mon

Tue

Wed

Thur

Fri

AM

Preceptor 1 Gyn OR

Preceptor 2 Gyn OR

Preceptor 1 Gyn Clinic

Simulation Lab Practice

Preceptor 3 Gyn OR

PM

Preceptor 1 Gyn OR

Preceptor 2 Gyn OR

Inpatient Care/Consults

Preceptor 2 Gyn Clinic

Preceptor 3 Gyn OR

Figure 1. A sample of a typical week in the traditional 12 weeks traditional curriculum versus the 6-weeks new gyn curriculum

  • Post-graduate year 2 residents were invited to participate in the new gyn curriculum (Figure 1).

  • A modified version of the Objective Structured Assessment of Technical Skills (OSATS) tool2 was used to evaluate the participants’ surgical skills in performing a laparoscopic tubal ligation at commencement of the rotation and again at completion (Figure 2).

  • Semi-structured qualitative interviews intended to elicit resident satisfaction with, and perceived benefits and challenges of the new curriculum were conducted mid-way and at the end of the rotation.

  • A brief survey evaluating resident satisfaction and scored with a 5 point Likert scale was completed by all participants at end of the rotation.

  • REB was obtained from the ethics board at St Michael's Hospital.

  • Descriptive statistics were used for the resident satisfaction survey and the OSATS scores and the transcripts of the analysis were coded by 2 investigators using thematic analysis.

Figure 2. Intraperitoneal view of laparoscopic tubal ligation

Primary Objective

To assess resident satisfaction, experience and surgical evaluation before and after implementation of a new gynecological curriculum by qualitative and quantitative measures.

Curriculum

Figure 4. Average Objective Structured Assessment of

Figure 4. Average Objective Structured Assessment of Technical

Technical Skills (OSATS) Scores in Pre- and Post- New

Skills (OSATS) Scores in Pre- and Post- New Curriculum

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Figure 3. Resident Satisfaction Survey Comparing New Curriculum to Traditional Curriculum (N=4)

Addition of specific mentors is useful Addition of ambulatory gyn clinic is useful Addition of surgical skills lab is useful More constructive assessment for learner More comprehensive surgical foundation More surgical opportunities for learner

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Discussion

  • The participants felt the introduction of a new curriculum provided the opportunity for more constructive assessment for the learner but unexpectedly no additional experience and/or an improved surgical foundation.

  • The pre/post OSATS scores demonstrated an upward trend toward better surgical skills.

  • During the structured interviews some common elements that were identified to contribute to the educational success of this 6 week curriculum included a more focused OR experience, mentorship and intensive opportunity to build surgical skills.

  • Providing reasonable expectations might eliminate some of the anxiety associated with either the delay or retention of gynecological skills as well as the concern about fatigue.

  • Abolishing the parallel traditional obstetrics and gynecology curriculum may also eliminate the conflict over preceptors and OR experience.

  • The parallel traditional curriculum running simultaneously may have resulted in significant bias in the reports of our participants.

Future Directions

  • More participants are needed to draw further conclusions.

  • Surgical case logs of participants in both the new and traditional curriculum need to be collected and compared.

  • Emphasis on a single curriculum with no specific preceptors but rather 6 continuous weeks of gynecology (or two continuous 3-week blocks) may be be more readily accepted and liked.

Reference

1. Royal College of Physicians and Surgeons of Canada. Competence by Design (CBD). 2014. Web. http://www.royalcollege.ca/portal/page/portal/rc/resources/cbme
2. Grantcharov TP, Schulze S, Kristiansen VB. The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room. Surg Endosc 2007;21:2240-3.

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