Student numbers

As in the UK where over 8000 doctors are trained each year, Australia and New Zealand have seen a massive expansion in medical school places with the number of graduates expected to increase from 1900 per annum in 2007 to 3700 in 2014. This increase has been accomplished in part by expanding places in existing schools but, in addition, the number of medical schools has increased from 13 to 19 since 2004. In New South Wales, with a population of less than 7 million, eight universities now have medical schools. Approximately 40% of places are in graduate-entry programmes of 4-year duration, with nine schools only accepting graduates. Undergraduate courses are of 5 or 6 years’ duration. The size of medical intake ranges from 80 at the University of Wollongong to more than 400 at the University of Queensland. There is one privately funded school (Bond in Queensland) but the remainder is funded by the federal government. Most schools also attract a significant number of full fee-paying overseas students, especially from South East Asia. The situation differs in the UK where no more than 7.5% of the student intake can be from overseas and also, due to cost constraints with regard to the duration of tertiary education for those pursuing medicine as a 2nd degree, graduate-entry programmes are in a minority. Financial support for fees is available for domestic students. To address specific issues of recruitment and retention of doctors in rural Australia, students can obtain subsidised places in return for undertaking to agree to a period of practice after qualification outside one of the large metropolitan centres. To encourage recruitment from the indigenous population, several schools have separate entry streams for students of indigenous origin and provide additional academic and pastoral support after admission. To date, approximately 150 doctors of aboriginal origin have graduated from Australian medical schools; two are practising in O&G. Despite this, the indigenous population remains substantially underrepresented in the medical workforce. Recruitment into medicine from disadvantaged groups is also a priority in the UK. There are a large number of very successful schemes although, since the numbers admitted from these groups will always be small, the cost-effectiveness of these initiatives is less clear.

Geography

This is particularly important in Australia. Obstetricians and gynaecologists comprise about 2.5% of hospital specialists in Australia with 1270 consultants and just under 400 trainees. These are mainly based in the large cities with much of the provision of obstetrics services in rural and remote areas relying on general practitioners (GPs) and career medical officers. The most noticeable difference in the Australian system is the proportion of consultants who work principally in private practice. Most public hospitals rely on visiting medical officers (private practitioners with part-time public contracts and admitting rights to public hospitals) and more than 20% of deliveries take place in the private sector. As many as 80–90 trainees per year are currently admitted to the college training programme, representing a 37% increase over the last 10 years, with 63% of these now being women.

To encourage interest in the speciality, the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) and the RCOG in the UK provide funding to support an annual prize for excellence in women’s health. In Australia, this is offered for each medical programme for the most outstanding student in the subject, as well as providing support for students undertaking research in an aspect of reproductive health. In the UK, prizes are offered on a regional basis with national travel awards and prizes for presentations at national meetings.

The majority of medical programmes are based in the large metropolitan areas around the coasts where most of the population lives. In a traditional model where clinical experience for undergraduates has been based in tertiary teaching hospitals, this has created increasing competition for clinical placements.

The tyranny of distance

Flinders University’s Northern Territory clinical school is more than 3000 km (1880 miles) from its Adelaide base, taking 36 h to drive. Australian and New Zealand medical schools are located in four different time zones and the two furthest apart (Perth and Otago) take more than 7 h to fly between. The sheer size of Australia presents considerable challenges to providing supervision and support for students at distant sites. Travel by staff across the teaching footprint of many medical schools is time consuming, expensive and sometimes dangerous. This has had two effects. One has been to place greater reliance on information technology (IT) with more online learning materials and greater use of different forms of videoconferencing. Initially, the latter was mainly by dedicated Integrated Services Digital Network (ISDN) connection but broadband wireless is being increasingly used in even the smallest centres to allow students using laptops to take part. The second effect has been to encourage teaching resources to be shared across disciplines. This is perhaps best illustrated by the University Departments of Rural Health (UDRHs). Although aligned with one or more universities, these multiprofessional teaching and research centres (usually based in medium-sized rural centres) have their own funding. The number of medical students may not be large, but these centres can still employ a range of academics and general staff, who support students across several professional groups.

The distances in Australia mean the closing of small maternity units which has a major impact on small- to medium-size communities, often resulting in women having to travel hundreds of kilometres to the nearest base hospital. This has meant that many units, which would have been closed or amalgamated in the UK, remain open although they may not be supported by specialist staff. With increasing pressure for clinical placements, medical schools have begun to develop more of these sites for teaching. Apart from opening up new areas of the public hospital system to students, the case mix in such units may be more appropriate to the learning needs of undergraduates than the increasingly specialised referrals seen in the tertiary referral centres. The challenges for such small centres lie in the higher cost per student in providing infrastructure and teaching support and ensuring equity in their learning experience.

Rural and remote communities face a shortage of doctors in O&G and the past decade has seen government-funded schemes to attract more graduates to work in these areas. These have included help for applicants from rural communities to get into medical school and funding incentives for medical schools to have all students spend at least 4 weeks in rural clinical placements and at least 25% of intakes to spend more than 6 months. The aim is both to encourage students to return to work in these areas and to provide them with a knowledge base and skill mix more appropriate for the demands of such practice.

Alongside greater use of local hospitals and small maternity units, the past 15 years have seen increased interest in using primary care settings for teaching O&G. This is helped by the fact that, in Australia, GPs still provide intra-partum care in many communities. The case mix in general practice makes the teaching model of discrete discipline blocks impracticable, therefore, instead students effectively study a number of disciplines simultaneously over a longer period of time.

Perhaps the best-known example of these Parallel Rural Community Curricula (PRCC) is the Riverland’s model introduced by Flinders University in 1997. The Riverland region lies within the central-eastern section of South Australia, approximately ‘3-h’ drive from Adelaide and encompasses an area of 24 090 sq. km.

A selected group of students in the third year of the medical course are attached to a primary health-care centre for 12 months during which they learn about a number of disciplines including O&G while their colleagues rotate through a series of hospital-based attachments in the traditional way. Their clinical learning is prompted by the health needs of the patients who enter the clinic each day. The PRCC students are learning in rural general practice, but are not learning merely about rural general practice.

Local GPs provide face-to-face tuition with support from the university and, in return, the university builds suitable facilities for teaching. Students benefit from higher level of supervision and greater opportunities to learn clinical skills but considerable investment is required to set up such programmes and the cost per student tends to be higher than for those based in large hospitals. The opportunity to undertake such training is only available to a minority of students in each year and does not suit all students. In addition, there is always conflict between the concept of clinical skills being taught by those with expertise in an area in contrast to GPs, who will often have developed their own ‘short cuts’. There are no correct answers to many of these conundrums.

In the UK, undergraduate teaching in medicine is still coordinated through the Universities although it is no longer confined to city ‘teaching hospitals’ as in the past. All hospitals are now considered to be teaching units and will have medical students rotate through them and, in addition, more teaching is conducted in primary care. This means that aims and objectives must be clear and this is likely to be facilitated by a common curriculum such as that described later in this article.

Interprofessional relationships

Poor interprofessional relationships in maternity units mean that some students who have an adverse experience will be less likely to pursue a career in O&G as well as affecting patient care. This can be helped by developing opportunities for interprofessional team working during a student’s attachment, for example, attaching students to midwives so that they can obtain more experience of delivering babies.

In an attempt to address this as well as the learning needs of students in intra-partum care, a number of schools in Australia have employed clinical midwifery educators (CME) for medical students. Midwife supervision has, of course, always been the principal method of skills training in normal birth but the CME role extends this to include orientation at the start of clinical attachments and small-group teaching. CMEs contribute to the evaluations of student performance both as part of their clinical attachments and in more formal summative assessments such as Objective Structured Clinical Examination (OSCE). The CME model supports interprofessional learning and exposes students to the midwifery philosophy of women-centred care. As an integral member of the local maternity unit with responsibilities across both medical and midwifery professions, CMEs can also be powerful advocates for medical student training with their peers.

The environment

In the UK, health care is becoming progressively more target driven. More patients must be seen and treated in less time than in the past and doctors’ contracts are changing. This leads to conflict since teaching takes time and doctors do not always have enough. It is difficult for students to really understand what patient-centred care means and they are annoyed by the inevitable problems that occur in an acute speciality where doctors’ timetables may change at very short notice should an emergency arise. Cancellation of teaching sessions is a source of annoyance for students and, if this is frequent, then it is likely to discourage them from pursuing a career in O&G.

Work–life balance

Work–life balance has become an important topic in recent years. A survey of specialist trainees in the UK demonstrated it to be an important topic with men finding a satisfactory balance easier to achieve. Most trainees find O&G stressful although it is not clear if this is a higher proportion than for trainees in other specialities. More attention needs to be given to this although the European Working Time Directive that limits the hours of work in the UK to 48 h per week should help facilitate this.

Teaching in O&G

Curriculum and approaches to undergraduate teaching in women’s health are changing in Australia. The traditional model of teaching in discipline-based silos under the auspices of a teaching/research department is gradually being replaced by a more integrated approach. This is partly a response to the problem-based learning (PBL) approach that most medical schools have adopted with its focus on problems rather than subjects. In most medical schools, the traditional research role of the department has been replaced by research centres with a common interest drawn from a range of disciplines. Although obstetrician–gynaecologists generally remain responsible for teaching in reproductive health, it is in the role as course co-ordinators rather than department heads. Most medical schools now run integrated preclinical courses with teaching from a number of disciplines, and this pattern is now beginning to be adopted in the more clinical parts of their programmes. Several schools run combined teaching blocks that include aspects of obstetrics, gynaecology and neonatology or children’s health. The newer medical schools have taken this further. Notre Dame University in Sydney has adopted a mentoring model where students are attached to an individual clinician for 5 weeks, eight times a year. During these attachments, they spend four to five sessions with the mentor and undertake one ‘learning activity’ in each session. This is supported by a central curriculum of case-base learning, lectures and tutorials that take place once a week during a back-to-base day. The tutors have a single student each 5 weeks, are remunerated as 0.1EFT senior lecturer and supported by a full-time clinical academic hospital coordinator. This model is readily adapted to teaching at a wide range of clinical settings, in particular allowing students better access to the large private sector in Australia and to non-tertiary teaching hospitals. The model also means that the traditional model of teaching being delivered by departments with relatively large numbers of full-time academic staff in partnership with unpaid conjoint (honorary) clinical staff is replaced by almost all teaching being delivered by paid clinicians with only a small core of academics responsible for curriculum oversight and quality control. This type of model is being considered in parts of the UK because the numbers of clinical academics in O&G has decreased and many of those remaining tend to be research orientated.

The spectrum of O&G practical experience that UK medical schools include in their curricula was determined by sending out a questionnaire to all medical schools seeking information concerning their individual courses. The results of this survey provided background information on what was happening throughout the UK in relation to teaching of undergraduate O&G and was included in the report of NUCOG published for fellows and members of the RCOG in January 2009.

A brief survey was sent to curriculum leads for O&G in Medical Schools in all UK medical schools: all but four responded, although information from a further one was obtained at a later date by informal discussion. In two schools, the lead was not a specialist in O&G because increasingly, O&G is being taught with other subjects such as primary care, genitourinary medicine or child health, as they are in Australia.

Labour-suite experience

Studies suggest that all medical schools should endeavour to preserve ‘hands on’ experience, particularly on labour wards, because this often sparks an interest in O&G as a career as well as teaching important skills in regard to patient-centred care. In 20% of UK medical schools, it is no longer compulsory to observe a delivery and, where one has to be observed, it was not necessarily a vaginal delivery. A minority (36%) now stipulate that actually delivering a baby is a requirement.

However, as in the UK, in Australia the expansion in medical student numbers has challenged traditional teaching models. Experience of intra-partum care still forms part of the curriculum for all medical courses but the approach to ensuring adequate clinical experience varies. In a survey of 20 medical schools in Australia and New Zealand, four indicated that they had no mandatory requirement for the number of deliveries students needed to attend and three of the new schools had not yet decided what approach to take. Of the 13 schools that did have some requirement, nine specified a minimum number of normal deliveries that the student had to take an active role in, with a median of three deliveries specified (range 1–5). As in the UK, there is competition from midwifery students. Caesarean sections rates have increased to more than 30% and a survey in 2001 found that only 62% of women would agree to have a medical student present at delivery (43% if the student were male) even though 84% agreed it was an important part of student education. All of these factors mean there are fewer opportunities for students to participate and to reach a specified number of deliveries. Those schools that have abandoned attempts to prescribe minimum requirements point out that the aim of undergraduate teaching is to produce functional interns where the ability to deliver a baby is not a requirement and that in any case even five deliveries would not be sufficient to obtain basic competence.

Vaginal examination

The teaching of intimate examinations to students has received much attention in recent years largely because of the issues of ethics and consent. Male students are disadvantaged in terms of acquiring this skill, which could lead to inadequate training. This may be due in part to altered patient attitudes to students, although there could be other contributing factors such as cultural background as well as training support and provision. Acquisition of skills is likely to be helped by having a minimum number of examinations that must be achieved.

Pelvic examination is still mandatory in a majority of UK medical schools (80%) but is assessed using a model or a surrogate patient in over 50%. The role of patients in teaching intimate examinations has been recently reviewed. Studies were included that involved patients as teachers (known as simulated patients/patient–instructors/surrogate patients) and also in formative and summative assessment. Issues of ethics, sexuality and anxiety are covered to a limited extent in the discussion. However, how these programmes can be incorporated into the undergraduate curriculum in the long term is unclear.

In gynaecology, the increasing number of students and the abandonment of the practice of routine examination by students in theatre have also reduced opportunities for students to learn pelvic examination skills. The response to this has been to increase reliance on simulation using training manikins and the development of Clinical Teaching Associates (CTAs). These were introduced in the 1990s in Newcastle and University of Queensland and have since been incorporated in programmes in Melbourne, Northern Queensland, Sydney and New Zealand. The exact model used varies between centres but typically involves students observing a demonstration by two GTAs, observing a peer performing the consultation and undertaking the examination themselves with the GTA acting as both model and instructor. This has the advantage over traditional teaching using patients in that the examination can be interrupted and specific areas repeated or rehearsed until the student is confident and is superior to pelvic models in that the students obtain feedback from the GTA being examined. The major drawbacks are problems in recruiting enough GTAs and the costs of their continued employment.

Examining the pregnant uterus

Examining a pregnant uterus was a component of all the UK curricula but, in the vast majority, the assessment was by course work rather than in final examinations.

Attitudes

Results were very variable. Most UK medical schools discussed topics such as congenital abnormality, contraception and infertility treatment but were less likely to explore issues surrounding termination of pregnancy or care of the very pre-term infant. This is unfortunate as it misses the opportunity for students to consider difficult ethical and legal issues and the importance of respecting the views of others even when they differ fundamentally from one’s own.

Teaching in O&G

Curriculum and approaches to undergraduate teaching in women’s health are changing in Australia. The traditional model of teaching in discipline-based silos under the auspices of a teaching/research department is gradually being replaced by a more integrated approach. This is partly a response to the problem-based learning (PBL) approach that most medical schools have adopted with its focus on problems rather than subjects. In most medical schools, the traditional research role of the department has been replaced by research centres with a common interest drawn from a range of disciplines. Although obstetrician–gynaecologists generally remain responsible for teaching in reproductive health, it is in the role as course co-ordinators rather than department heads. Most medical schools now run integrated preclinical courses with teaching from a number of disciplines, and this pattern is now beginning to be adopted in the more clinical parts of their programmes. Several schools run combined teaching blocks that include aspects of obstetrics, gynaecology and neonatology or children’s health. The newer medical schools have taken this further. Notre Dame University in Sydney has adopted a mentoring model where students are attached to an individual clinician for 5 weeks, eight times a year. During these attachments, they spend four to five sessions with the mentor and undertake one ‘learning activity’ in each session. This is supported by a central curriculum of case-base learning, lectures and tutorials that take place once a week during a back-to-base day. The tutors have a single student each 5 weeks, are remunerated as 0.1EFT senior lecturer and supported by a full-time clinical academic hospital coordinator. This model is readily adapted to teaching at a wide range of clinical settings, in particular allowing students better access to the large private sector in Australia and to non-tertiary teaching hospitals. The model also means that the traditional model of teaching being delivered by departments with relatively large numbers of full-time academic staff in partnership with unpaid conjoint (honorary) clinical staff is replaced by almost all teaching being delivered by paid clinicians with only a small core of academics responsible for curriculum oversight and quality control. This type of model is being considered in parts of the UK because the numbers of clinical academics in O&G has decreased and many of those remaining tend to be research orientated.

The spectrum of O&G practical experience that UK medical schools include in their curricula was determined by sending out a questionnaire to all medical schools seeking information concerning their individual courses. The results of this survey provided background information on what was happening throughout the UK in relation to teaching of undergraduate O&G and was included in the report of NUCOG published for fellows and members of the RCOG in January 2009.

A brief survey was sent to curriculum leads for O&G in Medical Schools in all UK medical schools: all but four responded, although information from a further one was obtained at a later date by informal discussion. In two schools, the lead was not a specialist in O&G because increasingly, O&G is being taught with other subjects such as primary care, genitourinary medicine or child health, as they are in Australia.

Labour-suite experience

Studies suggest that all medical schools should endeavour to preserve ‘hands on’ experience, particularly on labour wards, because this often sparks an interest in O&G as a career as well as teaching important skills in regard to patient-centred care. In 20% of UK medical schools, it is no longer compulsory to observe a delivery and, where one has to be observed, it was not necessarily a vaginal delivery. A minority (36%) now stipulate that actually delivering a baby is a requirement.

However, as in the UK, in Australia the expansion in medical student numbers has challenged traditional teaching models. Experience of intra-partum care still forms part of the curriculum for all medical courses but the approach to ensuring adequate clinical experience varies. In a survey of 20 medical schools in Australia and New Zealand, four indicated that they had no mandatory requirement for the number of deliveries students needed to attend and three of the new schools had not yet decided what approach to take. Of the 13 schools that did have some requirement, nine specified a minimum number of normal deliveries that the student had to take an active role in, with a median of three deliveries specified (range 1–5). As in the UK, there is competition from midwifery students. Caesarean sections rates have increased to more than 30% and a survey in 2001 found that only 62% of women would agree to have a medical student present at delivery (43% if the student were male) even though 84% agreed it was an important part of student education. All of these factors mean there are fewer opportunities for students to participate and to reach a specified number of deliveries. Those schools that have abandoned attempts to prescribe minimum requirements point out that the aim of undergraduate teaching is to produce functional interns where the ability to deliver a baby is not a requirement and that in any case even five deliveries would not be sufficient to obtain basic competence.

Vaginal examination

The teaching of intimate examinations to students has received much attention in recent years largely because of the issues of ethics and consent. Male students are disadvantaged in terms of acquiring this skill, which could lead to inadequate training. This may be due in part to altered patient attitudes to students, although there could be other contributing factors such as cultural background as well as training support and provision. Acquisition of skills is likely to be helped by having a minimum number of examinations that must be achieved.

Pelvic examination is still mandatory in a majority of UK medical schools (80%) but is assessed using a model or a surrogate patient in over 50%. The role of patients in teaching intimate examinations has been recently reviewed. Studies were included that involved patients as teachers (known as simulated patients/patient–instructors/surrogate patients) and also in formative and summative assessment. Issues of ethics, sexuality and anxiety are covered to a limited extent in the discussion. However, how these programmes can be incorporated into the undergraduate curriculum in the long term is unclear.

In gynaecology, the increasing number of students and the abandonment of the practice of routine examination by students in theatre have also reduced opportunities for students to learn pelvic examination skills. The response to this has been to increase reliance on simulation using training manikins and the development of Clinical Teaching Associates (CTAs). These were introduced in the 1990s in Newcastle and University of Queensland and have since been incorporated in programmes in Melbourne, Northern Queensland, Sydney and New Zealand. The exact model used varies between centres but typically involves students observing a demonstration by two GTAs, observing a peer performing the consultation and undertaking the examination themselves with the GTA acting as both model and instructor. This has the advantage over traditional teaching using patients in that the examination can be interrupted and specific areas repeated or rehearsed until the student is confident and is superior to pelvic models in that the students obtain feedback from the GTA being examined. The major drawbacks are problems in recruiting enough GTAs and the costs of their continued employment.

Examining the pregnant uterus

Examining a pregnant uterus was a component of all the UK curricula but, in the vast majority, the assessment was by course work rather than in final examinations.

Attitudes

Results were very variable. Most UK medical schools discussed topics such as congenital abnormality, contraception and infertility treatment but were less likely to explore issues surrounding termination of pregnancy or care of the very pre-term infant. This is unfortunate as it misses the opportunity for students to consider difficult ethical and legal issues and the importance of respecting the views of others even when they differ fundamentally from one’s own.