Subspeciality training in obstetrics and gynaecology in the United Kingdom was introduced more than 25 years ago following a report published by a working party of the Royal College of Obstetricians and Gynaecologists (RCOG) in 1982. There are now over 400 accredited subspecialists and over 150 approved subspeciality training programmes. It is timely to consider whether there are sufficient or too many subspeciality training programmes and whether some of the training resource should be directed towards delivery of advanced training skills modules (ATSMs). It is 5 years since the establishment of the Postgraduate Medical Education and Training Board (PMETB), which has responsibility for all postgraduate medical education and training, which includes the subspecialities. This has changed the way that new centres are approved and training programmes monitored and assessed. The RCOG has the expertise and experience to ensure that programmes deliver high-quality training to develop doctors for the future who will become leaders in their field. Changes to the curriculum and methods of assessment of trainees need to be integrated into the structures developed by PMETB.
It is more than 40 years ago since the American Board of Obstetrics and Gynaecology recommended the development of three subspecialities, which included gynaecological oncology, foetal maternal medicine and reproductive medicine. In 1980, the Council of the Royal College of Obstetricians and Gynaecologists (RCOG) established a Working Party with the brief to consider developments in further specialisation within the field of obstetrics and gynaecology, including training implications. In 1982, the RCOG published a report of a Working Party which discussed further specialisation within obstetrics and gynaecology. The Working Party noted that the main arguments for the development of further specialisation within obstetrics and gynaecology were as follows:
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The recognition that it has become impossible for an individual to master in depth all or even most areas of obstetrics and gynaecology.
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A high degree of specialisation indicates special training, experience and skills, which will improve knowledge, practice, teaching and research. It was anticipated this would improve recruitment into the speciality.
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The concentration of clinical material, special facilities and diagnostic expertise would be of benefit to patient care.
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The subspecialist would be in a good position to secure good working relationships with other disciplines to support the care of patients with complex conditions.
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Subspecialist teams would allow the coordination of delivery of clinical care within a region, which in turn would support research and higher training.
The Subspecialty Training Committee was formed in 1984.
Subspecialists were defined as obstetricians and gynaecologists who, after undertaking appropriate training in a recognised subspeciality training programme and had acquired special expertise in the relevant field, would devote at least half, and probably more, of their working time in the subspecialty. As subspeciality practice and training have developed, subspecialists are increasingly spending all or most of their time in the relevant area. Consultants in sexual and reproductive health have always spent 100% of their time in that field.
In the United Kingdom (UK), there are 61 specialities and 34 subspecialities recognised by Postgraduate Medical Education Training Board (PMETB) and the trend amongst most specialties is to increase the number of subspecialties. There are concerns in some parts of the service that increasing the availability of subspeciality training could impact on the number of trained doctors who will be working in their Certificate of Completion of Training (CCT) speciality. In obstetrics and gynaecology, this particularly applies to staffing of the labour ward. Increasing consultant presence on the labour wards in the UK remains an important priority to minimise risk and ensure the patients are looked after by trained doctors.
The Working Party report also highlighted the importance of supporting individuals who wish to develop special interests within the field of obstetrics and gynaecology. In 2007, the RCOG introduced advanced training skills modules (ATSMs), which are open to all trainees in ST years 6 and 7 ( Table 1 ). There are currently 20 topics for ATSMs, which include maternal medicine, pelvic surgery and gynaecological oncology. In the near future, the number of ATSMs will be reviewed to address service requirements and ensure that training in ST 6 and 7, whether as a subspecialist or as ATSMs, covers the range of training opportunities, which should be offered to trainees in the UK. The number of these posts and the curriculum should be determined by the needs of the service. The RCOG document on ‘The Future Workforce in Obstetrics and Gynaecology England and Wales’ recommends that there should be flexibility within training programmes to move between subspeciality and ATSM training to ensure that there is an appropriate balance between special interest and subspecialty consultant, which matches the projected needs of the clinical service.
The Survey of Training carried out by the RCOG Trainees’ Committee showed that demand for subspeciality training posts has dropped between the 2002 and 2008 surveys. Only 13.7% of trainees aim to become subspecialists compared with 46.5% of junior specialist registrars in 2002. It was suggested that this was due to an awareness amongst trainees that demand for subspecialty-trained consultants had declined in recent years.
There are now four recognised subspeciality areas related to obstetrics and gynaecology. These are maternal and foetal medicine (MFM), reproductive medicine (RM), gynaecological oncology (GO) and urogynaecology (UG). In 2009, sexual and reproductive health (SRH) was recognised as a separate speciality and will no longer be recognised as a subspeciality area.
The development of subspecialities within the field of obstetrics and gynaecology has resulted in the establishment of specialist societies such as the British Gynaecological Cancer Society (BGCS), British Society of Fetal Maternal Medicine, British Fertility Society and British Society for Urogynaecology, which will improve and support training and research activities. For example, the BGCS was established in 1985 and the composition of the BGCS Council reflects the broad membership including a gynaecologist, a clinical/medical oncologist, a pathologist, a scientist and a nurse specialist. Two scientific meetings are held each year and it collaborates closely with the RCOG and through the Gynaecology Network Site Specific Group (NSSG) to the Department of Health.
Access to Subspeciality Training
There are three approaches to the organisation of training: Subspeciality training in parallel with general training, in the final 2 or 3 years of speciality training or as post-CCT training. In obstetrics and gynaecology, usually trainees enter subspeciality training after successful completion of specialist training to year 5. The work-based assessments and Part 2 Membership Exam of Royal College of Obstetricians and Gynaecologists (MRCOG) must be satisfactorily completed and an Annual Review of Competence Progression (ARCP) achieved before entering a subspeciality training programme. Subspeciality training can be undertaken after obtaining a CCT in general obstetrics and gynaecology. In 2009, 10 out of the 90 subspeciality trainees were undertaking their training post-CCT. From 1997, it has been a legal requirement in the UK that to take up a consultant post in the National Health Service (NHS), a doctor’s specialist qualification must be included on the Specialist Register. Following completion of general or subspeciality training, a trainee will be awarded a CCT in Obstetrics and Gynaecology although a doctor has the legal right to have the appropriate subspeciality training recognised and associated with his/her entry on the Specialist Register. A trainee’s individual entry in the Specialist Register will list their subspeciality alongside the main speciality.
Following advertisement, selection of the successful candidate for subspeciality training should be by open competition involving a structured interview process. The current (2010) RCOG entry criteria, which are regularly reviewed, are as follows:
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Holder of a UK national training number (NTN) with successful completion of clinical training to ST5 (SpR 3) level confirmed by Regional In Training Assessment (RITA) C or ARCP evidence and passed Part 2 MRCOG.
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Holder of a UK CCT or Certificate of Eligibility of Specialist Registration (CESR), who is formally entered on the UK Specialist Registrar in Obstetrics and Gynaecology or in possession of a CCT or CESR that will, in due course, entitle the applicant to enter the Specialist Register.
Formal entry to the programme can only be confirmed once formally entered on the UK Specialist Register.
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European Economic Area (EEA) and overseas applicants who are listed on the UK Specialist Register in Obstetrics and Gynaecology.
Trainees are appointed to a training programme which is a minimum of 3 years (or pro rata for less than full-time trainees) incorporating 12 months of dedicated research. At completion of a 3-year programme, a trainee will have expected to either have undertaken a research or academic programme, leading to an MD or PhD thesis or published two first author papers in citable, referred journals. It is critical that the research component is planned and timetabled at the outset of the training programme. The research year should not be in the final year. Trainees who have already completed 12 months in research and been awarded either an MD or PhD or published two first author papers, as outlined above, can apply for research exemption and undertake a 2-year clinical training programme. Trainees who have fulfilled the research criteria prior to entry will be expected to undertake further research during the programme. Subspeciality trainees will have a major responsibility for National Health Service (NHS) research and development, particularly if they take up a regional responsibility for a service. The importance of understanding the principles of research and adequate exposure to academic training will be essential to allow these individuals to become effective leaders in their field. Trainees are expected to meet internationally recognised standards of research excellence such as those published in the Medical Research Council (MRC) ‘Good Research Practice’ (updated September 2005). Inevitably, many of the subspeciality training programmes are in the larger hospitals with academic centres and in some situations, the funding of lecturer posts that will be involved in subspeciality training will be an important route to develop the clinical leaders of the future.
Management and assessment of subspeciality training
Since subspeciality training was introduced in 1984, there have been significant changes in the way that medical education is managed. The PMETB began operations on 30 September 2005 and is responsible for postgraduate medical education and training. It took over the responsibilities of the medical royal colleges. The Postgraduate Deans are accountable for the educational governance of postgraduate training to standards required by PMETB and the General Medical Council (GMC). The principles outlined in ‘A Reference Guide for Postgraduate Specialty Training in the UK’ (The Gold Guide) also apply to trainees undergoing subspeciality training. The RCOG is responsible for the development of the specialty curricula in accordance with the principles of training and curriculum development published by PMETB. The new PMETB-approved subspeciality training curriculum is now well established and the RCOG, with support from the specialist societies, has an important role in supporting the Deaneries to deliver the curriculum to ensure that it addresses the needs of the future role of the consultant. All subspecialty trainees have a mid- and final review by appointed RCOG subspecialists who provide advice to the Deaneries on a trainee’s progress.
Structured postgraduate medical training is dependent on having curricula, which clearly sets out the standards and competencies of practice, an assessment strategy to know whether those standards have been achieved and an infrastructure, which supports a training environment within the context of service delivery. It is expected that all trainees, in addition to a mid- and final-term review organised by the RCOG, will undergo an ARCP taking into account the three key elements of appraisal, assessment and annual planning. The RCOG Subspecialty Assessors compile a written report of progress of the trainee, which is reviewed by the RCOG Subspecialty Training Committee that makes recommendations regarding progress to or attainment of accreditation. These are circulated to the trainee, the subspeciality training programme supervisor and the Deanery Specialty Training Committee (STC) chairs. It is expected that subspecialty trainees submit the same number of team observations (TO assessments) as trainees undertaking advanced training (ST6 and 7). These should be made available to the subspecialty assessors at the time of the mid- and final-term review and the ARCP.
The clinical component of subspecialty training is competency based and the length of the programme will depend on the opportunities to complete the curriculum. It is a minimum of 2 years. The RCOG Subspecialty Curricula have been approved by PMETB and all the modules are presented with the same format. The modules outline the following:
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knowledge criteria;
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clinical competencies;
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professional skills and attitudes;
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training support options; and
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evidence and assessment requirements.
Within some of the subspeciality programmes, there are a small number of procedures, which are so fundamental to the practice of that subspeciality that an objective assessment tool has been developed to aid the assessment process. Objective structured assessment of technical skill (OSATS) is a validated assessment tool to assess a trainee’s clinical competency. The curriculum indicates those skills, which require to be assessed by an OSATS. For example, in gynaecological oncology, OSATS are required for pelvic lymph node dissection and ureteric dissection. In maternal foetal medicine, trainees will be expected to have undergone OSATS in chorionic villus sampling and external cephalic version.
The mini-clinical evaluation (mini-CEX) tests can be used to assess a number of different competencies, which are outlined in each of the subspeciality curricula. This tool allows the trainer to observe and assess a subspeciality trainee in the process of history taking, clinical examination, formulating management plans and communications with the patient.
Case-based discussions (CbDs) are used to assess clinical decision making, knowledge and application of that knowledge. The curriculum indicates the competencies, which can be assessed, using this technique.
It is a PMETB requirement that the RCOG ensures that trainees can demonstrate achievement of both the outcome set in the approved speciality curriculum and those set out in the approved subspecialty curriculum. In some situations, assessment for achievement of both curricula may be difficult. For example, a subspeciality trainee in gynaecological oncology may do little or no obstetric on call for the 2 years of the clinical programme and yet will achieve a CCT in obstetrics and gynaecology.
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