In 2004, the Royal College of Obstetricians and Gynaecologists (RCOG) established a working group of experienced Fellows, Members, trainees and educationalists, who were responsible for writing and coordinating the development of a new curriculum in obstetrics and gynaecology. The curriculum would underpin the new 7-year speciality training programme. In December 2006, the UK Postgraduate Medical Education and Training Board approved the curriculum. In August 2007, the new Speciality Training and Education programme in Obstetrics and Gynaecology was launched.
The curriculum forms the backbone of the 7-year speciality training programme in obstetrics and gynaecology. The programme is divided into three levels of training: basic, intermediate and advanced. The programme is competency-based rather than being focussed on time periods or the number of hours or number of procedures required to progress through the programme. Successful progress is achieved by meeting the requirements at designated waypoints defined within the programme.
The curriculum outlines not only the knowledge and technical clinical skill requirements, but also the professional skills and attitudes that must consistently be adopted by health-care professionals in a modern health service. The curriculum was originally benchmarked against the General Medical Council’s Good Medical Practice criteria:
- (1)
Good clinical care;
- (2)
Good medical practice;
- (3)
Successful relationships with patients;
- (4)
Working with colleagues;
- (5)
Teaching and training;
- (6)
Probity;
- (7)
Health.
The concept of a curriculum
A curriculum is a constantly ever-evolving reference, which informs users of defined criteria required to meet an overall outcome. In the case of the obstetrics and gynaecology curriculum, the reference aims to produce an individual competent to perform independently to the required standard of a consultant obstetrician and gynaecologist. There are many factors, which determine whether a curriculum is fit for purpose, but an agreed definition of the end point is crucial and is the greatest challenge in an ever-evolving health service. In 2005, the Royal College of Obstetricians and Gynaecologists (RCOG) commissioned a working party to establish the future service requirements of the consultant in obstetrics and gynaecology. In parallel, the new curriculum was developed with an aspiration to produce the future consultants that the UK National Health Service (NHS) requires. The particular challenge of higher training was recognised and the RCOG commissioned a working party to address this phase of training.
The journey through a training programme needs to be standardised, yet be flexible. In an evaluation of different types of curricula known in the educational literature, the Postgraduate Medical Education and Training Board (PMETB) highlighted the following descriptions.
A paper-based version of a curriculum
A statement of purpose that includes the aims, content experiences and materials. This is also known as a ‘planned’ or ‘formal’ curriculum.
A curriculum in action
A curriculum on paper is actually put into real-life practice. This is known as the ‘received’ curriculum.
A curriculum-user’s experience
An outline of what curriculum users do, how they learn and practise in real life and what they interpret to be important for new progress. This is the ‘informal’ curriculum.
A hidden curriculum
An outline of the behaviours, knowledge and performances that learners infer to be important from the formal curriculum: an ‘informal’, ‘unplanned’ and ‘perceived curriculum’.
Interpretation of a curriculum
For the obstetrics and gynaecology curriculum, trainees and trainers will construct their own interpretation of how to deliver a curriculum based on their own experiences. To this end, based on their own requirements, previous experiences and the way they know that opportunities and milestones will be presented throughout a training programme in a particular unit, a programme will be crafted for trainees. All adult learners attain competencies differently and at different rates; hence, although a curriculum is a standardised guide, if all of these factors are taken into consideration, PMETB’s 2006 definition of a curriculum is functional:
“A statement of the intended aims and objectives, content, experiences, outcomes and processes of an educational programme including : • A description of the training structure (entry requirements, length and organisation of the programme including its flexibilities and assessment system) • A description of expected methods of learning, teaching, feedback and supervision”. 5
A curriculum enables future trainees to observe the scope of the profession before application to generalist roles of subspecialist roles. In addition, it develops a professional model that is reflexive, collective, developmental and process-orientated such that it can be followed and referred to by trainees and consultants wishing to continue their professional development. The curriculum also acts as a guide to high-level requirements, which enables the public to see the expertise acquired by practitioners and the level of care that they can expect from the profession.
The introduction of PMETB and MMC
National changes in postgraduate medical education, with the advent of the PMETB and the evolution of NHS Modernising Medical Careers (MMC), were addressed by the RCOG through a number of working parties formed in 2005, and also influenced by the study of a working party tasked with evaluating the core logbook in 2002.
The MMC principles state that speciality training curricula should underpin a programme, which is carefully designed to deliver nationally agreed standards. All speciality curricula should be defined by the domains of General Medical Council (GMC) Good Medical Practice and the management of the content and delivery of the curriculum. The curriculum management and ongoing development of the curriculum is audited annually by the PMETB. The process is managed by ensuring that the PMETB Standards for Curricula and Assessment are adhered to and the appropriate evidence is collected for review.
In the modern obstetrics and gynaecology programme, educational progression is assessed by an annual review of the documented acquisition of competencies in the curriculum, for both clinical and professional competencies. Competencies are benchmarked and referenced against average time scales within a programme to measure satisfactory progress at designated waypoints.
The RCOG convened two working parties in 2004, the Basic and Advanced Specialist Training Working Parties. The working parties were responsible for reviewing and evaluating the existing core logbook and special skills modules and for planning and conducting the development of the new curriculum, in keeping with NHS MCC principles.
The curriculum structure and proposed content were agreed upon by the Basic and Advanced working parties, the Specialist Training Committee, the Education Board and, finally, by the Council of the RCOG in 2006. The curriculum was implemented in August 2007, following approval by the PMETB.
Following the introduction of the new speciality training and education curricula, the Tooke Report questioned the concept and function of MMC and the structure of medical education. Because of the enquiry, the creation of a new body, NHS Medical Education England (NHS: MEE), was proposed. NHS: MEE would relate to the revised medical workforce advisory machinery and act as the professional interface between policy development and implementation on matters relating to postgraduate medical education and training.
The introduction of PMETB and MMC
National changes in postgraduate medical education, with the advent of the PMETB and the evolution of NHS Modernising Medical Careers (MMC), were addressed by the RCOG through a number of working parties formed in 2005, and also influenced by the study of a working party tasked with evaluating the core logbook in 2002.
The MMC principles state that speciality training curricula should underpin a programme, which is carefully designed to deliver nationally agreed standards. All speciality curricula should be defined by the domains of General Medical Council (GMC) Good Medical Practice and the management of the content and delivery of the curriculum. The curriculum management and ongoing development of the curriculum is audited annually by the PMETB. The process is managed by ensuring that the PMETB Standards for Curricula and Assessment are adhered to and the appropriate evidence is collected for review.
In the modern obstetrics and gynaecology programme, educational progression is assessed by an annual review of the documented acquisition of competencies in the curriculum, for both clinical and professional competencies. Competencies are benchmarked and referenced against average time scales within a programme to measure satisfactory progress at designated waypoints.
The RCOG convened two working parties in 2004, the Basic and Advanced Specialist Training Working Parties. The working parties were responsible for reviewing and evaluating the existing core logbook and special skills modules and for planning and conducting the development of the new curriculum, in keeping with NHS MCC principles.
The curriculum structure and proposed content were agreed upon by the Basic and Advanced working parties, the Specialist Training Committee, the Education Board and, finally, by the Council of the RCOG in 2006. The curriculum was implemented in August 2007, following approval by the PMETB.
Following the introduction of the new speciality training and education curricula, the Tooke Report questioned the concept and function of MMC and the structure of medical education. Because of the enquiry, the creation of a new body, NHS Medical Education England (NHS: MEE), was proposed. NHS: MEE would relate to the revised medical workforce advisory machinery and act as the professional interface between policy development and implementation on matters relating to postgraduate medical education and training.
From a logbook to a curriculum
Review of the core logbook, 2002
The curriculum in obstetrics and gynaecology evolved from the output of the obstetrics and gynaecology Core Logbook Working Party, which produced the first logbook of competencies with a rating against competency levels enabling trainees to demonstrate progress.
The working party identified that postgraduate training needed a reference document, which would provide all trainees with a broad understanding of what the competencies in obstetrics and gynaecology were and which would assure that trainees and their core training competencies could be acquired flexibly. To allow every trainee to have opportunities to access comprehensive training for the acquisition of all skills required and to achieve a level of competency whereby they become equipped for independent professional practice, it was identified that the logbook would evolve from a syllabus into a curriculum. The aim was to integrate the knowledge criteria and to specify the practical skills and attitudes required for professional practice. In addition, it was recognised that systems for assessing these competencies would be required in line with the standards arising from the PMETB.
The ultimate aim was to ensure that trainees would become equipped for independent professional practice following completion of all logbook requirements, and the way progress would be measured would be to create a system to rate the development and the increasing professional responsibility of the trainee. The syllabi for the Part 1 and Part 2 MRCOG examinations were reviewed and clearly defined the core knowledge required for specialist training, and the logbook would provide a comprehensive and mandatory list of the skills to be acquired during core training across the iterative 7-year programme. All skill requirements were reviewed, definitions were updated and advice was provided for trainers assessing the trainees for each module. Skills, that needed to be evaluated repeatedly throughout the programme, were also identified.
A five-point scale was deemed to be fit for purpose to demonstrate progress, as was the modular organisation of relevant clinical skills. It was agreed that certain skills would be best acquired at formal training days or sessions and these were highlighted as compulsory requirements of relevant modules.
- 1.
Observer: Observes the procedure performed by a colleague
- 2.
Assistant: Assists a colleague in performing the procedure
- 3.
Directly supervised: Performs the entire procedure under direct senior supervision
- 4.
Indirectly supervised: Performs the entire procedure with indirect senior supervision
- 5.
Independent: Performs the entire activity without the need for supervision
All of the skill targets in the core logbook were to be compulsory and trainees would need to be rated at level 5 in order to achieve the Certificate of Completion of Specialist Training (CCST) at the end of the training programme.
A review of training
Basic and advanced specialist training working parties, 2004–07
All members of the two working parties and the coordinated writing groups were clinical and educational supervisors and included trainee representation. All members of working parties were guided and supported by the Education Development Officer. The Education Development Officer’s role (as a non-clinical educationalist) was to provide educational expertise and to coordinate the groups to develop a realistic, deliverable structure in the clinical setting. The expertise from trainers and senior trainees who were aware of current opportunities and developments in practice (including time constraints) was paramount, in addition to implementing conclusions drawn by the work of ‘ The Future Role of the Consultant ’ Working Group.
The Basic and Advanced Specialist Training Working Parties designed the new curriculum to build on the skill requirements in the logbook but to more comprehensively address required levels of professionalism, attitudes and different types of competencies by introducing a series of workplace-based assessments. It was important that the curriculum would be less of a checklist and list of requirements, and more of an interface between trainees and trainers to inculcate clinical competency, professional skills, attitudes and reflective learning. The potential for workplace-based assessment was to be fed throughout the entire curriculum to coordinate uniform, structured learning sessions and encourage a culture of documenting the acquisition of competencies for clinical, educational and professional competencies, as required by the MMC.
The acquisition of knowledge and skill and the consistent maintenance of performance would be achieved by the incremental acquisition of competencies. The level at which skills should normally be acquired is included in the relevant module (and sub-modules) of the curriculum. This model is based on Miller’s triangle of learning, which runs from “knows”, to “knows how”, to “shows how” and “does” ( Fig. 1 ). Different levels of skills are required by the end of different stages in training. The waypoints are those needed by the end of the first 2 years of training (the end of basic training), those required to be completed before the start of advanced training (by the end of intermediate training) and those skills needed by the completion of training for the award of the certification of completion of training (CCT) following 2 years of advanced training.
The core curriculum
The core curriculum runs through the 7-year training programme; it includes general obstetrics and gynaecology training and it is aimed to be delivered and is designed to be deliverable at District General Hospital level ( Fig. 2 ). College Tutors recruit educational supervisors and the college provides guidance concerning appraisals and assessments to ensure that the responsible individuals have the expertise to coordinate supervision and delivery of training in the deanery for core training. In addition to the clinical knowledge that supervisors have, they also have knowledge and experience of pedagogy from ‘training the trainers’ courses and their own experiences as trainees. Feedback on educational developments from the college is channelled from Heads of Schools/Chairs of Deanery Specialty Training Committees to College Tutors and training programme directors to educational supervisors and clinical trainers.
The core curriculum is divided into 19 modules and each curriculum has a logbook of competencies:
- (1)
Module 1: Basic Clinical Skills.
- (2)
Module 2: Teaching, Appraisal and Assessment.
- (3)
Module 3: Information Technology, Clinical Governance and Research.
- (4)
Module 4: Ethics and Legal Issues.
- (5)
Module 5: Core Surgical Skills.
- (6)
Module 6: Postoperative Care.
- (7)
Module 7: Surgical Procedures.
- (8)
Module 8: Antenatal Care.
- (9)
Module 9: Maternal Medicine.
- (10)
Module 10: Management of Labour.
- (11)
Module 11: Management of Delivery.
- (12)
Module 12: Postpartum Problems (the Puerperium).
- (13)
Module 13: Gynaecological Problems.
- (14)
Module 14: Subfertility.
- (15)
Module 15: Women’s Sexual and Reproductive Health.
- (16)
Module 16: Early Pregnancy Care.
- (17)
Module 17: Gynaecological Oncology.
- (18)
Module 18: Urogynaecology and Pelvic Floor Problems.
- (19)
Module 19: Professional Development.
These modules were selected as representing the core subjects required in the preparation of all trainees for the profession of obstetrics and gynaecology.
To progress through a curriculum module, competencies are gained by the trainees first observing, then performing under supervision and repeating until competent to perform independently.
Each module follows the pattern of curricula developed for the core curriculum, based on the GMC’s Good Medical Practice guidelines. The aims and objectives of each module are defined and the expected skills and expertise will be assessed and documented as evidence for the annual review of competence progression (ARCP).
The sequencing is established by working through the modules, starting from the most basic and progressing to the most complex; however, significant clinical requirements are reiterated in several modules for reinforcement. Within modules, the logbook is structured to indicate the degree of competency expected (e.g., from initial observation, to performing procedures under supervision to independent practice). The logbook colour codes competences so that trainees/trainers can clearly see the expected progression for each skill through the entire programme. Three colours are used to represent competences, which are to be achieved by the end of basic, intermediate or advanced training. Competencies may be acquired before the set level (see Fig. 3 ).
