Postgraduate medical education in obstetrics &amp; gynecology in Switzerland in comparison to Germany and Austria, results of an international survey

doi:10.21203/rs.3.rs-4298688/v1

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Postgraduate medical education in obstetrics & gynecology in Switzerland in comparison to Germany and Austria, results of an international survey

https://doi.org/10.21203/rs.3.rs-4298688/v1

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Background

There is frequent academic exchange between Switzerland, Germany and Austria, facilitated by the common language. Also the postgraduate training curricula in obstetrics & gynecology show some similarities. We aimed to compare self-perceived level of ability, availability of simulation training and teaching and feedback culture among residents in obstetrics & gynecology in Switzerland, Germany, and Austria. The focus was on Switzerland, to gain better understanding of strengths and room for improvement.

Methods

In a cross sectional design, a web-based survey with 30 questions was distributed under obstetrics & gynecology residents in the three countries in August and September 2020. Primary outcome was the self-perception of skills in between-countries-comparison in mid-training trainees, i.e. omitting trainees in their first year as well as very advanced trainees and specialists. Secondary outcome was reported teaching, simulation training and feedback culture. German and Austrian responses were calculated together and compared with the Swiss replies.

Results

422 participants took part in the survey, with 27.5% (n=116) from Switzerland, corresponding to a questionnaire response rate of around 19%. 48% of Swiss trainees were in training years 2-5. 57% of Swiss participants felt confident in obstetric procedures and 69% in gynecological procedures - compared to 52% and 68% in non-Swiss (p=0.005 and p=0.176). Swiss participants felt significantly more confident in performing gynecological than obstetric procedures (p=0.015). 63 % of Swiss participants had obstetric and 28% had gynecological simulation training compared to 37% and 17% in Germany and Austria, respectively (p<0.001 and p=0.007).
56% of Swiss participants reported “enough structured teaching”, 43% reported a “good teaching culture”, 47% of Swiss participants stated to receive regular feedback.

Conclusions

The majority of trainees in Switzerland feel confident in a range of procedures and interventions. Simulation training is relatively widespread, although

especially surgical simulation training should be expanded. Clinical teaching and feedback culture should be strengthened. “Teach the teacher” courses should be encouraged to promote a sustainable feedback culture.

Gynecology

Obstetrics

Postgraduate

Medical Education

Switzerland

Obstetrics and gynecology (O&G) represents the fourth largest medical specialty in Switzerland with 1917 specialists and 5% of medical specialist workforce¹. Specialists in O&G comprise specialists in surgery as well as endocrinology, reproductive medicine, gynecologic oncology, obstetrics, ultrasound, and urogynecology but they also bridge the gap and act as primary care physicians, responsible for preventive medicine and general women’s health ^2,3. This professional width requires a comprehensive training. O&G training in Switzerland is a postgraduate curriculum of at least five years of specialty training ³. At least one year has to be spent in a smaller “level B” hospital and one year in a larger “level A” hospital. This enables different perspectives and access to different population structures. Different courses, including an obligatory ultrasound course and an obligatory psychosomatic curriculum are prerequisites. Finally, a catalogue of certain interventions and procedures is compulsory. These, as well as training periods, courses and exams must be documented in an electronic logbook which is provided by the Swiss Institute for Medical Continuing Education (SIWF). All proceedings are being discussed with the supervisor or program director in a yearly evaluation interview, which is being documented. During the course of the specialty training, three exams have to be passed: two written exams and one oral exam ³.

There is frequent academic exchange between Switzerland, Germany and Austria, facilitated by the common language. There is also frequent exchange of workforce. Although the training curricula in the three countries are similar, there are several differences between the requirements. A comparison can be seen in Table 1:

Table 1

Comparison of Austrian, German and Swiss O&G training curricula; MC: Multiple choice
	Austria⁴	Germany⁵	Switzerland³
Duration and structure	6 years, of which: 9 months basic training, 36 months specialty training, 3x9 months rotation in sub-specialties. Rotation in a second hospital of 6–9 months is recommended	5 years, of which 12 months in a different specialty are being recognized	5 years, of which 1 year A-level hospital (> 2000 hospitalizations/y) 1 year B-level hospital (> 600 hospitalizations/y)
Courses	None obligatory	80h psychosomatic course	11 certified courses, of which: 2 psychosomatic 1 ultrasound course (5 days)
Working in private practice	Up to 1 year training in practice is being recognized	No time limit	12 months max
Catalogues	180 deliveries 40 caesareans 45 obstetric interventions/Procedures 250 gynecological procedures (20% as 1st assistant are being recognized)	200 deliveries 20 caesareans 200 gynecological procedures (100 as responsible surgeon, 100 as “participant”)	300 deliveries 40 caesareans 40 obstetric procedures 305 gynecological procedures (215 as responsible surgeon, every type of operation defined)
Ultrasound	500 ultrasonographies	1000 ultrasonographies	800 ultrasonographies
Documentation	Paper logbook	Paper logbook	e-logbook
Exams	1 MC-exam	1 oral exam	2 MC-exams of 120 questions 1 oral exam of 60-75mins

The boards of the junior professional organizations of O&G in Germany, Austria, and Switzerland together aim to support training and professional development in O&G in their respective countries. In a joint collaboration, research questions were formulated:

How do trainees perceive their level of skills and ability? How do they compare internationally?
How supportive are the respective training curricula?
Where and how do the curricula need to improve to meet future challenges?

A panel of curriculum experts compiled a survey with a total of 30 questions. Eligible for participation were O&G trainees and doctors briefly after specialization in the three countries. The questions encompassed trainees’ working situation, training content, curriculum and formally organized simulation training. To ask for fitness in practical skills, the following common standard procedures in obstetrics were chosen: caesarean section, vacuum extraction, management of postpartum hemorrhage and shoulder dystocia. Within gynecology, the following procedures were chosen: dilation and curettage (D&C), hysteroscopy and laparoscopy. The questions were single-choice questions asking for the participants’ agreement or disagreement on a 7-value Likert scale with “1” corresponding to “little agreement” and “7” to “strong agreement”. Some questions were also simple yes/no questions.

The questionnaire was formatted as an online survey by ETH Zurich, Department of Health Science and Technology, Consumer Behavior group. The survey was written in German. [See supplementary materials for the original questionnaire]. The questions were presented sequentially, requiring that each question had to be answered in order to complete the survey. An initial screen presented circumstances and background of the survey and asked for consent before starting the survey. Responses were collected anonymously. In accordance with local ethics regulations, no ethics committee votum was required for collection of non-health-related anonymized data and no respective study protocol was issued beforehand. Multiple participation by the same person was excluded with an anonymized IP address monitoring. None of the three countries has a central training registry of all trainees; the best option to reach a maximum of O&G trainees, therefore, was through the membership of the junior organizations of which a large number of trainees are members. The survey link was therefore distributed via the respective e-mail newsletters, their respective homepages and through their social media channels. Several reminders were distributed. The survey was open for participation in August and September 2020. The data collection, compilation and statistical analysis was undertaken by ETH Zurich using SPSS Version 26 (IBM Corp., 2020) and GraphPad® Software. Primary outcome was the self-perception of skills in between-countries-comparison, secondary outcome was reported teaching, simulation training and feedback culture. We focused on trainees in training years 2–5, omitting first-year trainees as well as very experienced trainees (> training year 5) and specialists.

Descriptive statistics and chi square test were used to calculate two-sided p-values, a significance level of 0.05 was regarded as significant. The null hypothesis in each case was “no difference between the countries”.

For the Likert scale questions the values 5, 6 and 7 were ranked as “agreement” while 1, 2 and 3 were interpreted as “disagreement”. The values of agreement or disagreement for German and Austrian participants were calculated together, unless stated explicitly.

A total of 422 participants from all three countries took part in the survey. 209 (49.5%) came from Germany, 116 (27.5%) from Switzerland and 97 (23%) from Austria.

According to the registry of the SIWF there were 623 training posts for O&G in Switzerland in 2019 ⁶, therefore 116 replies correspond to a questionnaire response rate of 19% for Switzerland. 89% were female, the average age was 32 years. 48% of Swiss trainees were in training years 2–5. For further demographics, see Table 2:

Table 2

Demographics by training year per country
	Training year	1	2.-5.	> 5	specialist	total
Switzerland	n=	1	56	22	37	116
	%	1%	48%	19%	32%
Germany	n=	30	146	13	20	209
	%	14%	70%	6%	10%
Austria	n=	12	60	16	9	97
	%	12%	62%	16%	9%
Total	n=	43	262	51	66	422

Regarding the self-perceived confidence in performing interventions and procedures, an overview can be obtained from Table 3 and Table 4 below.

Table 3

– Confidence in performing obstetric interventions/ operations
Confidence in obstetric interventions/operations
How confident do you feel in ….
… vacuum extraction
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	20	15	21	56
Swiss	%	36%	27%	38%
Germany/ Austria	n=	118	31	57	206
Germany/ Austria	%	57%	15%	28%	p=	0.025
… management of postpartum hemorrhage
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	6	11	39	56
Swiss	%	11%	20%	70%
Germany/ Austria	n=	35	38	133	206
Germany/ Austria	%	17%	18%	65%	p=	0.257
… management of shoulder dystocia
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	18	18	29	65
Swiss	%	28%	28%	45%
Germany/ Austria	n=	82	58	66	206
Germany/ Austria	%	40%	28%	32%	p=	0.375
… primary caesarean section
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	3	9	44	56
Swiss	%	5%	16%	79%
Germany/ Austria	n=	18	19	169	206
Germany/ Austria	%	9%	9%	82%	p=	0.487
Obstetric interventions, total:
Training year 2–5		not at all confident - rather not confident		rather confident - very confident	total
Swiss	n=	47		133	180
Swiss	%	26%		74%
Germany/ Austria	n=	253		425	678
Germany/ Austria	%	37%		63%	p=	0.005

Table 4

– Confidence in performing gynecological interventions/ operations
Confidence in gynecological interventions/operations
How confident do you feel in ….
… dilation & curettage
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	2	3	51	56
Swiss	%	4%	5%	91%
Germany/ Austria	n=	13	13	180	206
Germany/ Austria	%	6%	6%	87%	p=	0.425
… hysteroscopy
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	5	9	42	56
Swiss	%	9%	16%	75%
Germany/ Austria	n=	29	23	154	206
Germany/ Austria	%	14%	11%	75%	p=	0.369
… laparoscopy
Training year 2–5		not at all confident - rather not confident	indifferent	rather confident - very confident	total
Swiss	n=	18	15	23	56
Swiss	%	32%	27%	41%
Germany/ Austria	n=	83	39	84	206
Germany/ Austria	%	40%	19%	41%	p=	0.506
Gynecological interventions, total:
Training year 2–5		not at all confident - rather not confident		rather confident - very confident	total
Swiss	n=	25		116	141
Swiss	%	18%		82%
Germany/ Austria	n=	125		418	543
Germany/ Austria	%	23%		77%	p=	0.176

For the obstetric procedures, Swiss participants in training years 2 through 5 reported to feel confident in 57% of the cases in the obstetric procedures compared to 52% in non-Swiss participants (p = 0.005). For the gynecological procedures, Swiss participants in training years 2 through 5 reported to feel confident in 69% of the cases in the gynecological procedures compared to 68% in non-Swiss participants (p = 0.176). Swiss participants felt significantly more confident in gynecological than in obstetric procedures (p = 0.015).

The majority of Swiss participants reported to have a structured obstetric simulation training available in their hospital (63% vs. 37% from Germany and Austria, p < 0.001) and also for gynecological surgical training (28% vs. 17%, p = 0.007).

Swiss participants reported “enough structured teaching” in 56% of answers compared to 29% of German and Austrian participants (p < 0.001). While 43% of Swiss participants reported a “good teaching culture”, 16% were indecisive and 41% disagreed; yet, for German and Austrian participants, the responses were 25%, 16% and 59%, respectively (p < 0.001).

Of Swiss residents, 50% reported a “structured teaching rotation” opposed to only 31% of non-Swiss residents (p < 0.001). For details, see Table 5.

Table 5

Availability of teaching
		In my hospital there is….
		… enough structured teaching	… a good teaching culture	.. Enough case load for teaching	… arbitrary decisionmaking by superiors	… a structured teaching rotation
Switzerland	Agree (n=)	65	50	68	57	58
	%	56%	43%	59%	49%	50%
	Indifferent (n=)	25	18	23	16	19
	%	22%	16%	20%	14%	16%
	Disagree (n=)	26	48	25	43	39
	%	22%	41%	22%	37%	34%
Germany/ Austria	Agree (n=)	90	76	234	164	94
	%	29%	25%	76%	54%	31%
	Indifferent (n=)	43	48	36	36	55
	%	14%	16%	12%	12%	18%
	Disagree (n=)	173	182	36	106	157
	%	57%	59%	12%	35%	51%

47% of Swiss participants stated to receive regular feedback regarding their work, opposed to 33% German and Austrian participants (p = 0.005). 48% of Swiss stated that their clinical teachers would take “sufficient time to answer questions” compared to 39% of German and Austrian participants (p = 0.081). 79% of Swiss participants agreed that they received an annual evaluation opposed to 46% of German and Austrian participants (p < 0.001). 84% of Swiss residents reported that they had someone in their department with whom they could consult regarding questions concerning their training (69% in Germany and Austria, p = 0.002) and 72% that they could address a dedicated person with regard to career planning (48% in Germany and Austria, p < 0.001).

The O&G training curricula in all three countries share similarities, with differences in courses, required obligatory numbers of self-performed interventions and mode of exams. The comparison of the confidence levels in obstetric and gynecological procedures between Swiss, German and Austrian trainees in their second through fifth year of training showed similar levels.

Independent from their level of training, Swiss participants quoted more structured teaching, more structured teaching rotations and a better teaching culture than their Austrian and German colleagues. This teaching culture also translates into a feedback culture: Swiss participants answered to have more regular and structured feedback and that their superiors took time to explain things or answered questions.

With 63% of responses, obstetric simulation training seems to be by far more established in Switzerland than gynecological simulation training with 28%. Already 20 years ago leading opinion makers in Switzerland, Germany and Austria voiced concerns about a deterioration of surgical training in gynecology due to the limitation of working hours ^7,8. While it is beyond the scope of this paper to discuss working hour restrictions and their impact, it is surprising that since then, so few countermeasures have been taken to tackle this issue. The advantages and success of simulation training especially regarding laparoscopic skills is without doubt ^9–11 and yet it seems hardly established. This finding uncovers a huge potential for improvement within surgical training in gynecology. While simulation is common in obstetrics in most hospitals, it seems reasonable and easily implementable to provide a comparable option for surgical training as well.

The European Board and College of Obstetrics and Gynaecology (EBCOG) has issued a model curriculum and recommendations for teaching and simulation training¹². While the aim of the model curriculum is to harmonize training contents on a national level, the teaching and simulation recommendations can be adopted on single institution level, to improve structured teaching.

The responses regarding teaching culture must be seen in the light of a high proportion of Generation Y under the participants. The special considerations of teaching Generation Y are being discussed e.g. by Schmidt ¹³ or Eckleberry-Hunt ¹⁴: this generation rejects steep hierarchies and authorities and demand open communication and direct feedback. While most responses regarding teaching prove good results for Switzerland, the “teaching culture” leaves room for improvement. Most participants are discontent with the teaching culture in their departments, even more so in Germany and Austria. “Institutional teaching culture” has been described as “[a culture that] recognizes the importance of teaching, constructively assesses teaching […] and supports teacher development.” ¹⁵. This implies that teaching in a clinical setting is being recognized as such and institutionally supported. It also implies that teaching is regarded as a part of daily clinical work. Just under half of Swiss participants agreed that their superiors would take sufficient time to explain things and give feedback, even less so for German and Austrian participants. Swiss participants did, however, significantly more often state that they had regular feedback on their work as compared to non-Swiss participants, and this is because it is a compulsory prerequisite in the Swiss curriculum. The responses imply that less than every second Swiss and only around every third German or Austrian trainee receives regular feedback or explanations when required. This is alarming when considering the needs of the workforce of Generation Y for regular and direct feedback and support. The institutional teaching culture can therefore have direct impact on workplace satisfaction and staff retention.

There are inherent limitations to an online survey. Although it is plausible that all participants were in O&G, this cannot be guaranteed. Although an IP-address tracking was implemented to exclude double participation, this can technically be bypassed by a virtual private network (VPN) – although this effort seems rather improbable. The language chosen represents a limitation, as Switzerland has four national languages and not everyone speaks German; by default, a part of residents is thereby excluded. This was, however, decided upon on purpose as the number of (only) Italian speaking trainees is rather small; the collaboration between the countries is strongly facilitated by the common language and the French-speaking part of Switzerland is usually more oriented towards France. In the German group, the response rate seems relatively small compared to the other countries; this limits the generalizability. A final important limitation is the character of the answers being a self-perception, not an objective evaluation. An obvious strength of this study is the international comparison.

Overall, the majority of trainees in Switzerland feel confident in a range of procedures and interventions. There is, however, room for improvement: especially surgical simulation training is not broadly established. Furthermore, feedback and teaching culture need to be improved to make training sustainable and fit for the future. “Teach the teacher” courses should be encouraged to promote a sustainable feedback culture. Ideally, teaching should be recognized as part of daily clinical work.

To our best of knowledge, this is the first study examining the differences in training in O&G between different countries.

O&G Obstetrics & Gynecology

EBCOG European Board and College of Obstetrics and Gynaecology

SIWF Swiss Institute for Medical Continuing Education

VPN Virtual Private Network

Ethics approval and consent to participate

Not applicable – ethics approval is not necessary as per national regulations (Swiss human research ordenance, Art. 2), as no health related data were processed and the information are fully anonymized. Therefore ethics approval was not sought. Informed consent to participate was obtained from all participants prior to participation.

Consent for publication

Not applicable - no such images or identifiable information in this manuscript

Availability of data and materials

Data is provided within the supplementary information files

Competing interests

No competing interests declared.

Funding

The professional organizations of O&G in Germany, Austria, and Switzerland (DGGG, ÖGGG, SGGG) funded the expenses by ETH Zurich for data compilation and processing, contributing in equal parts each. They did not have influence or insights into the research or writing of the publication.

Authors' contributions

All authors composed the questionnaire and contributed to the data collection. BK performed the statistical analysis, drafted, and wrote the paper. RB, MFr and KW contributed to the final version. GB, MF, PF, MFr, MW and FW gave input to the final version.

Acknowledgements

We thank Mrs. Larissa Luchsinger for support in drafting the questionnaire and compiling the data. We also acknowledge the financial support of our respective professional societies and thank their presidents and boards for their trust and support.

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No competing interests reported.

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Postgraduate medical education in obstetrics & gynecology in Switzerland in comparison to Germany and Austria, results of an international survey

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Background

Methods

Results

Discussion

Conclusion

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Availability of data and materials

Competing interests

No competing interests declared.

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Authors' contributions

Acknowledgements

References

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