Improving Teaching and Recruitment Into Obstetrics and Gynecology

Ashlesha Dayal, MD, and Peter S. Bernstein, MD, MPH

Disclosures

March 31, 2005

There is a crisis in medical education in a number of specialties, but especially in obstetrics and gynecology. There are many issues, including decreased resident work hours with the same amount of work to be done, increasing clinical responsibilities of attending physicians, and the need for continued resident education efforts. Graduating medical students have certainly expressed their opinion of this crisis situation in obstetrics and gynecology: The number of medical students graduating from American medical schools that are choosing to go into obstetrics and gynecology is the lowest it has been since the 1980s.[1] Failure to recruit more students into the specialty will only add to the crisis. Although the mandate from a number of organizations to the practicing obstetrician and gynecologist is to recruit "just one more student,"[1] feedback from students provides numerous reasons why they are not choosing obstetrics and gynecology as a career. Among the most often cited reason is that in order to be more appealing to the next generation of graduating students, the perception that the obstetrics and gynecology clerkship during medical school is an excessive service-oriented, nonteaching rotation will have to change. Unless the clerkship is more exciting and stimulating for the students, they will not be attracted to the specialty. Changing the service requirements is a difficult enterprise at best, but incorporating more formal and informal teaching is feasible.

The traditional barrier to teaching has been, first and foremost, time. Faculty in obstetrics and gynecology departments feel that they are too busy to "stand around and lecture." Lack of knowledge about objectives for learning is another commonly offered reason for diminished teaching in the clinical setting. Therefore, it is important that all faculty become familiar with basic objectives. The list of these guidelines should be in every residency program office and should be distributed to all residents. They can also be found at the Association of Professors in Gynecology and Obstetrics (APGO) Web site, https://www.apgo.org/home/ .

It is important to remember that teaching does not have to be formal. Rather, informal teaching is well suited to day-to-day interactions and is no less effective. Even the most mundane clinical situations and interactions can provide an opportunity for education for an inexperienced learner.

There are specific guidelines available regarding teaching in the clinical setting. First, it is important to prime all staff that educational activities will take place in the particular setting. This is necessary as educational interactions take time and may interrupt the usual flow of patients and activities. The staff can be critical in allaying concerns for patients when the usual interactions seem to be taking a longer amount of time. Equally important is to orient learners to the clinical setting, which includes introductions to staff and pointing out resources available (eg, Internet access). The educational goals for that particular day should also be discussed. For early learners as well as for those who are more advanced, preselecting patients improves the chances for meaningful learning experiences. A resident or student may benefit from an initial discussion with the teaching physician about the cause of a patient's presenting problem, the signs and symptoms of the disease, and any associated risk factors before he sees the patient. In the case of an established patient, a learner may benefit from a discussion concerning disease management, follow-up, and possible complications to therapy as an adjunct to a routine follow-up visit.[2]

A commonly used clinical teaching technique in many centers is called the "One Minute Preceptor."[3] The One-Minute Preceptor follows 3 steps for the attending physician to direct the patient evaluation and presentation by the learner. The first step is the case presentation, the second is probing the learner about what is happening in the case, and the third step is discussion of the patient. Key to the 1-minute "precepting" concept is obtaining a "commitment" from the learner regarding what he or she thinks is happening in the patient's case and why he or she has arrived at the proffered diagnosis. It is important to reinforce the positive skills and correct mistakes. Offering a "general rule" that can be applied to other patients that present in the same way is also useful. Consider the following example. A patient arrives for a postpartum checkup. The first step is the case presentation of the patient. The learner would determine why the patient came for her postpartum visit and what can be done to help her. In this case, a general rule that the teaching physician could offer is the following: "When patients come for a postpartum visit, we must discuss methods and choices for contraception. Have you asked the patient what she knows about this subject?"

Reflection is the last component of clinical teaching, and it addresses the questions the learner may have, the important concepts learned from the session, and the self-learning process that the student should pursue to solidify and enhance the knowledge gained. Typically, the preceptor should also offer one recommendation for improvement.[1]

Providing feedback is an important skill necessary for clinical teaching. A major perceived hindrance to offering feedback is time constraint in a busy practice. However, a few well-established strategies can enhance the efficiency of the feedback conversation. It is important to provide feedback in a neutral, private location, to discuss first-hand observation or data, and to comment on specific performances. This approach distinguishes feedback from evaluation. After completing an operative case, for example, feedback could include offering specific comments on a surgical skill, such as the operator's sewing technique or the operator's ability to anticipate the next operative need. Evaluation would entail a more descriptive comment on the operator's workup of the case, his or her knowledge about the treatments and surgery to be performed, and his or her overall performance during the surgery. Feedback always includes specific guidelines for improvement. Asking the learner to repeat the discussion as a way of demonstrating his or her understanding is reasonable and not uncommon. Finally, planning a time for follow-up to the discussion is important.[4]

Beyond these teaching guidelines, certain qualities should be adopted by teachers looking to have the greatest impact on their students. These qualities include enthusiasm for the subject and respect for learners. In addition, teachers should promote active learning, know their own limitations, and provide feedback. These qualities are often difficult to remember in stressful and demanding practice times, but even incorporating a few of them goes a long way toward creating a sense of enthusiasm among all levels of learners. Creating an active and stimulating learning environment will go far in alleviating the perception of obstetrics and gynecology as a "service only" specialty that is not stimulating and exciting for students eager to learn. By reiterating a commitment to knowledge and education, students may be stimulated and excited enough to choose the field of obstetrics and gynecology as their career. This alone may not be the ultimate solution to our recruitment problems, but it is something clearly under our control and may help more than we anticipate. Finding ways to encourage more medical students to enter our field should be a priority for everyone concerned about women's healthcare.

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