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Essay Title - Teaching Skills: Gynaecology Obstetrics

Introduction

Assessment and teaching of professional skills, values and attitudes in Obstetrics and Gynaecology is crucial to sustaining the public’s trust in the specialists in this field. In this area of clinical work, we require intensive training and acquisition of specialised knowledge, skills and attitudes. Work is pursued primarily for women. Success is measured by more than financial return. Clinical Negligence Scheme for the Trust’ (CNST), ‘National Institute for Clinical Excellence’ (NICE), RCOG, General Medical Council (GMC) and national, regional and local guidelines regulate these fundamental aspects of professionalism of a doctor or medical student working in this field. The ‘Mission Statement’ of RCOG - “Setting standards to improve women’s health” implies that we, as doctors working in this speciality, with appropriate professional behaviour and integrity are continuously aiming to provide highest standards of care including teaching and training,. The main concerns of our care are patient choice, patient welfare and social justice.

History of professionalism

Professionalism in medicine is not a new phenomenon. It existed in ancient medicine. “In western culture the traditions go back to Hippocrates, and for centuries the Hippocratic Oath served as the foundation of the morality of medicine. There were 14 content items in the original oath, a covenant with the deity, a covenant with teachers, a commitment to students, 10 items regarding patients, and an agreement to be responsible for one’s actions” (Sohl et al 1980). “Professionalism arose in middle ages, but it remained ill defined and touched only a small percentage of the population until the industrial revolution made it possible for the public to pay for the services” (Elliot,1972). “Early work was largely favourable to the concept of professionalism, and it was felt that the service orientation of the professionals would benefit society” (Cruess, 1997). Over the last few years, there has been overwhelming emphasis on medical professionalism. “This is because, more complaints filed against physicians relate to unprofessional conduct rather than lack of knowledge or poor technical skills” (Ginsburg et al 2000).

Moreover, we, as obstetricians, work in a litigious and increasingly regulated speciality. Hence, we need to address the issue of professionalism in Obstetrics and Gynaecology quite seriously.

Definition of professionalism in Obstetrics & Gynaecology (O & G)

Swick (2000) defines professionalism as subordination of own interest to interest of patients, adherence to high ethical and moral standards, respond to social needs, core humanistic values, accountability, excellence, commitment to scholarship and reflection. Van Der Weyden (2003) defines “professionalism is the basis of medicine’s contract with society. It demands placing the interest of patients above those of the physician, setting and maintaining standards of competence and integrity and providing expert advice to society on matters of health.” Some of the concepts in both of these definitions are subjective and hence Baldwin and Bunch (2000) feel that there is still difficulty with defining and measuring professionalism. For example, neither RCOG nor GMC has given any clear definition of compassion. There is no reliable and objective means to measure compassion. Probity, another attribute of professionalism is poorly defined by GMC and there is no objective tool currently being used in our speciality for assessing this.

Why is assessment of professionalism in O & G important?

Assessment of professional values and attributes is an important aspect of training and delivering health care services to women. Establishing and practising fair assessment procedures establishes value and expectations, provides the motivation to learn and provides motivation to change professional behaviour. For example, RCOG logbook for trainees emphasises in module 1 (Basic clinical skills) the following professional skill and attitudes- ‘Show empathy and develop rapport with patients’, ‘Acknowledge and respect cultural diversity’. Similarly, in module 4 of the logbook, it mentions- ‘Act with compassion at all times’ and ‘Respect the right to confidentiality’ (RCOG curriculum and log book). However, the assessment tool to measure empathy and compassion is either direct observation by trainer or patient feedback questionnaire. RCOG logbook does not mention of any specific structured questionnaire to assess these attributes. I feel there is a scope for research to develop a valid structured tool to assess these professional attributes. “Professional status is not an inherent right, but is granted by the society. Its maintenance depends on the public’s belief that professionals are trustworthy. To remain trustworthy, professionals must meet the obligations expected by the society” (Cruess et al, 1997).

In the past, doctor’s main role was healer. However, tomorrow’s doctor will have more of a management role. To manage more efficiently, we have to be professional. In this millennium, neither patients nor any regulatory body will accept the unprofessional doctor.

Core values of professionalism in O & G

To work in this speciality, doctors must meet the professional standards of competence, care and conduct set by the GMC and RCOG. Both these regulatory bodies have specified the essential attributes of professionalism, which include

honesty/integrity, reliability/responsibility/accountability, respect for others, compassion/empathy, self-improvement, reflection/self-awareness/knowledge of limitations, competence/commitment/caring, confidentiality/compassion, communication/collaboration, and altruism/advocacy. These attributes are similar to the attributes described by the American Academy of Paediatrics (Kline, 2000) and British Medical Association (BMA). Very little empirical research on altruistic attitudes in medicine exists. Coulter (2007) compared the altruistic attitudes of medical students with those of law and business students. It showed that “female students and minority member students have more altruistic attitudes than law students but do not differ from business students.”

Assessment and regulation of professionalism in O & G

Assessment of professionalism is a complex phenomenon. A system, although not robust, does exist in our speciality to assess professionalism. It is usually carried out by staff appraisal (360-degree appraisal, patient satisfaction questionnaire [PSQ], thank you cards, and complaints) and trainee competency assessments (Case-based assessment, Mini clinical evaluation exercise [CEX], direct observation of procedures [DOPs]). (Norcini, 2003) The speciality is regulated by various regulatory bodies and procedures, which include GMC, RCOG, Clinical Negligence Scheme for Trusts (CNST), Healthcare Commission, Research Ethics Committee, Caldicott Guardian, Patients’ Advisory and Liaison Service (PALS), complaints procedures and a whistle-blowing mechanism.

The GMC assesses doctor’s attributes of professionalism in the form of structured references from six consultants with whom the doctor has worked. The references comment on the doctor’s concern for welfare of patients, teamwork and professional demeanour, commitment to learning, accountability and initiative, responsibility and sense of duty, compassion and respect for others, and honesty and integrity. RCOG assesses, in addition to all these, the doctor’s personal and professional development at all levels. However, a consistency in the assessment of professionalism throughout the medical education system should exist to encompass undergraduate students, postgraduate residents, members and fellows of the speciality. The speciality should agree on the characteristics and definitions of the various attributes of professionalism to be assessed. In addition, there should be a mechanism to address significant breaches of professionalism in a supporting manner.

In Obstetrics and Gynaecology, we see teenage girls, young and geriatric women of various culture, religion and ethnicity. Some women (because of cultural or religious reason) prefer a female gynaecologist for their care and we respect their wishes. Again, when we see a 13-year old pregnant girl attending the clinic with a request for termination of pregnancy and she does not want her parents or GP to be informed, we maintain confidentiality and respect her wishes. We try to keep it confidential if she is Fraser competent (less than 16 years old but can fully understand the implications of her medical problem). If not, we try to persuade the girl to inform her parents or any of her friends or relatives. Thus, just by direct observation, patients, nurses, midwives, and colleagues assess our professionalism day in and day out.

What values and attitudes do we assess in O & G?

We assess more or less all professional values and attitudes, which are essential or desirable to work in Obstetrics and Gynaecology. For example, the job description in O & G require a trainee to be appropriately qualified, competent, and flexible, a good motivator, communicator, team player, leader, and manager with organisation skills and commitment to learning. “Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationship with patients and colleagues, are honest and trustworthy, and act with integrity” (GMC 2006). We learnt some of these components in a formally taught curriculum, whereas, the rest are learnt from clinical exposure or from role model in the speciality. This “concept of a lengthy state in which the learner develops the skills and knowledge, and gains the experience needed to acquire professionalism is called proto-professionalism” (Hilton 2005).

Who are the assessors and what methods do they use to assess.

There are various measures of professionalism reported in the literature. Few measures either address professionalism as a whole or address attributes of attitudes towards professionalism. Jha et al (2007) in their systematic review of studies assessing and facilitating attitudes towards professionalism in medicine concluded that there are strengths and weaknesses in existing measures of professionalism, particularly with regard to their psychometric properties. They also provided evidence for the effectiveness of interventions aimed at promoting these attitudes in medical education. Cohen (2006) also feels that “although many promising approaches are under evaluation, no single measure or set of measurements has yet proven sufficiently reliable and valid to meet demanding psychometric criteria. This is not to say, however, that useful information cannot be gained from multiple observations over time. Indeed, educators have employed both formative and Summative evaluations often coupled with directed self-assessment and self-reflection, to provide feedback to learners about their professional development.”

In our speciality, assessment is by ‘Multi- Source Feedback’ (MSF), which means, we are continuously being observed during our clinical and teaching commitments by our consultants, colleagues, midwives, nurses, subordinates, other secretarial staff and patients. They then fill up structured ‘Team Observation’ (TO1 and TO2) forms designed by RCOG and rate us as ‘good’, ‘satisfactory’, ‘unsatisfactory’ or ‘improvement needed’. Multi-source feedback is increasingly being used in medicine and healthcare in formative assessment, but also in decisions about progression, promotion and professionalism. “MSF is intended to guide learning and performance improvement. However, this may not always result in these outcomes especially in response to negative feedback. Almost half of doctors who received negative feedback did not accept or use it. The feedback most consistently used was specific, received from patients and addressed communication skills. The feedback least frequently used addressed clinical competence and came from medical colleagues. It seems a good idea and we have evidence that supports the validity and reliability of peer assessment” (Sargeant 2007). Schonrock-Adema et al (2007) feel that “In undergraduate medical education, peer assessment has a positive influence on professional behaviour. However, peer assessment is only effective after students have become adjusted to the complex learning environment”.

Over and above, there is regular appraisal for the trainee and the appraiser. In this meeting trainee’s strengths and weaknesses are discussed and a learning plan is agreed for the coming year. In this way, the trainee tries to achieve the required professional standard for the speciality. In addition to workplace-based assessment, RCOG also assess performance assessment in professionalism through formal examination (MRCOG- Membership examination of Royal College of Obstetricians and Gynaecologists). “Relatively few rigorous studies have developed methods of doctor performance. The long-term impact and effectiveness of formative performance assessments on education and quality of care remains hardly known” (Overeem, 2007). The different components of examination determine the various aspects of professionalism. For example, ‘Short Essays’, ‘Multiple Choice Questions (MCQ), Extended Multiple Questions (EMQ) assess the knowledge, logical and lateral thinking ability, and the holistic approach to solving women’s problem in the clinical setting. The Objective Structured Clinical Examination (OSCE) part of MRCOG examination assesses how effectively and competently the doctor utilises the knowledge in the clinical situations. “OSCEs have been proposed as appropriate for assessing some aspects of professionalism” (Mazor 2007). This study also highlights the complexity of the process involved in assigning ratings to doctor-patient encounters. “Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as rates appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessments of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives from the same constituency” (Mazor 2007). The standard of this examination is very high as there are twelve stations (examiners) and RCOG sets standards for each question separately and gives mark to the candidate according to the set standard. This helps maintain a high quality of professionalism in this speciality and as a result, this qualification has become internationally recognised and accepted all over the world. This examination provides an opportunity for positive and constructive feedback and will set standards and expectations regarding knowledge and competence of the professional. However, the examination mainly tests factual knowledge and fails partly to assess appropriate attitudes, sense of responsibility and decision making skills in professionals in this speciality.

The examination also assesses communication skills of doctors. But the tool for assessing communication is subjective, less valid and reliable, and is dependent on prejudice and bias of the examiner. Research into communication skills relies on valid and reliable assessment instruments. Many communication assessment instruments have been developed during recent decades, but they seem to differ in many ways making it a troublesome task to make a choice. Van Nuland et al (2007) evaluated two such instruments (Mass Global [MG] and Common Ground [CG]) that have been rated as among the best to assess communication. Results show that the two instruments have convergent validity, but the drawbacks of the CG, which has fewer items to be scored, include lower inter-rater variability and score variance within trainees.”

“Although facilities and technology are important, the delivery of health care is increasingly provided by teams of individuals from different health professions working together, each contributing their particular expertise to make the most appropriate decisions in a timely and efficient manner” (Hays 2007). This emphasises the importance of incorporating ‘inter-professional education’ (IPE) in the speciality curriculum.

In addition, trainees in this speciality have to complete a training portfolio during the period of training. This portfolio encompasses all the domains of patient care, personal and professional development and other components of professionalism. This is a structured way of assessing competence and professionalism to work efficiently in this field. “Portfolio has been an accepted tool to assess and demonstrate professional development and ongoing competence” Wilkinson, 2002). However, Driessen et al (2007) feel that “for portfolios to be effective in supporting and assessing competence development, robust integration in to the curriculum and tutor support are essential. Further studies should focus on the effectiveness and user-friendliness of portfolios, the merits of holistic assessment procedures, and the competencies of an effective portfolio mentor”.

In our speciality, we need a system in place, to identify doctors with poor performance, so that we can design and implement a corrective intervention and monitor the outcome. This process closely resembles Berwick’s (1989) proposals for ‘continuous quality improvement’ and ‘total quality management’.

Benefit of professionalism in O & G

As Obstetrics and Gynaecology is the most litigious speciality, by being professional, doctors will be reassured that they are competent and are performing well. Thus, it will reduce the chance of litigation and the cost of medical indemnity. This will also protect them from potential charges of incompetence. The assessment process being structured, transparent and fair, morale will be improved among the profession. Moreover, doctors will have opportunity to pursue personal and professional learning. Nonetheless, this will also encourage the future doctors to join the speciality. Thus, RCOG can do better workforce planning for the future by maintaining professionalism in the speciality.

By maintaining professionalism, employers will be able to promote their institution as a provider of quality care for women and pregnant mothers. They will potentially reduce the cost for negligence or poor clinical care, cost for disciplinary procedures, as well as expenditure on medical defence.

Challenges to medical professionalism in the changing world

The National Health Service (NHS) is rapidly changing due to increasing workload, work-life imbalance, patients’ increasing demands and knowledge, commercialisation, financial incentive and increasing managerial pressure. As a result, there is growing conflict between altruism and self-interest. Greed, arrogance, misrepresentation, lack of conscientiousness and conflict of interest are eroding moral values. We need more research to develop more and more valid and reliable tools to assess and improve professionalism.

Teaching professionalism in O & G

Few studies have evaluated the delivery of professionalism teaching in undergraduate medical curricula. Goldie (2007) in his study has shown that “critical reflection is integral to professional development. Early clinical contact is an important part of the process of socialisation . As students move towards fuller participation, the clinical milieu should be controlled to maximise the influence of role models, and opportunities for guided reflection should be sustained.” A case-control study of all University of California medical graduates from 1999 to 2000 showed that unprofessional behaviour in medical school is associated with subsequent disciplinary action by the state medical board. “The natural conclusion is that where leadership conviction and direction in the attitudinal aspect of the formal and hidden curricula are lacking, students have a greater chance of failing and becoming dangerous doctors” (Papadakis 2004).

The purpose of teaching professionalism in obstetrics and gynaecology in undergraduate medical education is to help students develop an initial professional identity, inform students about professional boundaries, foster healthy inter-professional relationship, and ensure that highest level of professionalism is maintained in future workforce of the speciality. Teachers must use both explicit and implicit means of teaching and provide a positive role to students in the form of integrity and commitment. Teachers also need to understand the limits of their own competency in clinical field and in teaching.

“Teaching of professional values occurs most often in an informal setting, such as whilst having dinner or working together on call rather than in more formal settings such as lectures or attending rounds” (Stern, 1998). This is true for some of the components of professional values such as honesty, integrity, respect, teamwork, compassion and empathy. This is why learning of professional behaviour must occur on a day-to-day informal basis in the context of practice. Role modelling definitely can teach some aspects of professionalism. However, the other components of professionalism, such as knowledge, skill, and communication and so on are already incorporated in a formal curriculum of training in Obstetrics and Gynaecology. The content of the curriculum will address the required competencies for all levels. Nevertheless, patients must also provide valuable input pertaining to the role of Obstetricians and Gynaecologists. Swick (1999) felt that “There is a growing consensus among medical educators that to promote the professional development of medical students, school of medicine should provide explicit learning experiences in professionalism”. Cruess et al (1997) emphasised - “We believe that doctors will meet their obligations if they understand their origins and their nature. Thus, professionalism must be taught”. In the teaching of professionalism, educators need to take account of the needs of different cultures and to be responsive to changes over time. Shapiro et al (2006) reported on an innovative medical student elective entitled ‘Teaching the art of doctoring’, which covered aspects of ethical and professional behaviour. Rather than attempting directly to change students’ behaviour, the course focussed instead on whether devoting intense thought and study to ethical dilemmas may improve students’ attitudes and practice of medicine.

“Professional skills teaching does help medical students communicate better with patients” (Noble 2007). Harrison (2007) states that ‘Calgary-Cambridge framework’ is effective in teaching and improving doctor’s ability to communicate. “This ability to identify and respond to concerns is one of the most important determinants of patient satisfaction, so we need to continue to pursue effective techniques to teach these skills”. “Any improved confidence in professionalism will improve the quality of clerkships and eventually enhance the quality of medical practice. Professional development needs fostering as an integral part of all medical training, embedded in experience and associated practices” (Stephenson et al 2006).

Teaching methods

Various teaching methods can be used to teach professionalism such as lectures, courses, journal clubs, ward rounds, small-group seminars, problem-based learning, computer assisted learning, one-to-one observation, counselling and preceptor role modelling.

Conclusion

In summary, assessment of professionalism already exists in postgraduate training programme in Obstetrics and Gynaecology. The RCOG must clearly define appropriate standards of professionalism for the health care professionals working in this speciality. Fair and valid assessment tools to measure professional standards should be used. Teaching of professionalism should be included in the undergraduate curriculum of obstetrics and gynaecology in line with the current professional requirement and developments.

Finally, times are changing remarkably rapidly in NHS and the obstetricians and gynaecologists are going through a phase of turmoil, triggered by many challenges, both within and outside the speciality. Evidence shows that public trust in medical profession is declining. In addition, commercialism is intruding at a high speed into healthcare system. This means our speciality must take a greater responsibility for nurturing professionalism in next generation of obstetricians and gynaecologists.

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