Madhva Prasad Sarvothaman
There are many qualities that define a good doctor, and medical training should aim to inculcate all of these in medical trainees. The first few years of the medical career- the undergraduate and the postgraduate training period are the most important formative years. Academic improvement, obtaining of knowledge and skill enhancement are the main areas which are taught in medical school curricula. However, conscious efforts that impart attitudes and behavioral improvement to budding doctors are also part of an ideal teaching program. The complex matter of evolving medical education in Obstetrics and Gynecology (Ob/Gyn) is discussed here.
Knowledge of the subject and assimilation of principles and facts are not the only things to be learnt in residency. Apart from factual accuracy, being vocally articulate is also a very important characteristic. Stohl et al demonstrated this using fetal heart rate parameters as the conversation point. They showed that it is important for residents to read (and have knowledge about) what they are supposed to see, to see what they are supposed to see and say what they see. Most importantly, they showed that this can be taught.
Knowledge of the subject and assimilation of principles and facts are not the only things to be learnt in residency. Apart from factual accuracy, being vocally articulate is also a very important characteristic. Stohl et al demonstrated this using fetal heart rate parameters as the conversation point. They showed that it is important for residents to read (and have knowledge about) what they are supposed to see, to see what they are supposed to see and say what they see. Most importantly, they showed that this can be taught.
Resident doctors treat patients round the clock. Many a time, they are faced with a situation of having to choose between patients, especially in an obstetric emergency room. Actively or passively, the concept of prioritisation is eventually learnt. Whether a formal obstetric triage system should be taught to Ob/Gyn residents has been pondered over. One such contemporary obstetric triage teaching, highlighted by Sandy et al, attempts this. The doctors have to answer two simple questions “Sick or not sick”, “In labor or not in labor”, as a guide to performing obstetric triage. Learning to prioritise activities in patient care, in the wake of reduced resources and time, is best learnt during residency.
Even the Millenium Development Goals have now been transformed to Sustainable Development Goals. Even at the medical professional level, sustainability is the key. Being an obstetrician-gynecologist is stressful. Naturally, residency in the same can also be stressful.
Job satisfaction, burn out and depression among Ob/Gyn residents have been rarely tested formally. In one study in the USA by Govardhan et al, it was found that a mere 13% were fully satisfied with their current status. More than 50% demonstrated high level of depersonalisation and emotional exhaustion, indicating “burn out” issues.
Owing to these and probably many other reasons, there have been some major changes in the amount of time spent by resident doctors in training. In the west, there is a restriction in the number of duty hours for resident doctors, and what kind of impact this change has caused, is still being determined. In this context, Occhino et al performed a two-institution comparison between the amount of operative experience among resident doctors, before and after duty restrictions were implemented for resident doctors. It was concluded that though there were change in number of procedures performed, overall experience appeared to be the same.
The millennials are a new crop of youngsters who are very different from the previous generation. Virtual learning, machine-based learning, interactive learning have all created a disruptive environment and clinical teaching is transforming rapidly. Mobile applications have now become the order of the day. Attempts at standardization and encouragement of applications that are accurate and acceptable; and addressing possible issues regarding inauthentic and inaccurate applications by resident doctors should be considered. Simulated obstetric teaching also forms an important part of modern medical curricula. Newer paradigms like competency based curricula are also being developed and evaluated.
Despite, all these advances, the operating room remains one of the most important places where Ob/Gyn residents gain knowledge and skill. Trainees invariably model their behaviour based on what they observe and the importance of consultants to show them the correct methods, attitudes and behaviour has been emphasized. Similarly, they can be given the responsibility of being a good role model for their juniors. This has been formally tested and positive effects have been demonstrated by Sobbing et al.
While the actual technical details of what and how things are to be taught is not being touched upon here, some issues that teaching consultants should attempt to impart are discussed below. Cost consciousness is important value that has to be picked up by resident doctors. One study showed that there could be a gap between the quality of “being aware” of costs, and actual performance of the acts of cost reduction. In medical parlance, “debriefing” is the concept wherein a teaching consultant systematically revisits or reviews how a resident doctor performed a particular procedure or technique, giving step by step comments and improvements. The concept should be popularized, especially in the context of adverse clinical events. Inclusion of formal ethics teaching also appears to be an important consideration. Consultants should also ensure that there is no gender bias among Ob/Gyn trainees especially at junior levels.
In one study which asked consultants about what attitudes they look forward to impart to medical trainees, the four main responses were “ability to be caring”, “respect to everyone around”, “efficient and correct communication” and “integrity”.
The emotional make-up of a doctor also appears to be a determinant of the kind of care provided to patients and the nature of response by each doctor. These have been analysed by various psychological methods. The “DISC” profile (Dominance, Influence, Submission and Conscientiousness) of resident doctors was analysed in a study by Ogunyemi et al. Doctors who showed a profile more suggestive of dominance and conscientiousness appeared to have better patient outcomes. The authors concluded that methods to improve emotional intelligence among resident doctors can be a useful tool to improve patient outcomes. The same set of investigators had done a prior analysis of emotional quotient among doctors using an instrument which tests the parameters of Self-Awareness, Self-Management, Social Awareness, and Relationship Management. They had come to a conclusion that emotional quotient can be improved with training. In this context, it should be appreciated that there are departments in the country which take an active part in resident development by offering courses on stress management, time management, communication skills and anger management.
Notwithstanding the technological advances that have taken place, and the millennial disruptions that have occurred, bedside clinical teaching continues to be the most valuable resource for mentoring a medical trainee. This time-tested fact is validated even by recent studies on the matter. This will never go out of fashion, and will always form the pillar of medical training, or so it is hoped.
The transition from being a resident doctor to a consultant is a complex phenomenon. Very few studies have identified how to make residency more complete and how to make medical trainees more prepared for this transition. Readers are encouraged to refer to Westerman et al. for further understanding of this subject.
With this we bring to you the journal’s September issue