Obstetrics and gynaecology

Dharani Hapangama and Melissa Whitworth  explain the possibilities in the exciting field of obstetrics and gynaecology in the light of the changing world of Modernising Medical Careers

For obvious reasons, obstetrics (care during pregnancy and childbirth) is as old as humankind. No other specialty gives the opportunity to be a surgeon and a physician and to save two lives for the price of one. Gynaecology complements obstetrics perfectly, allowing the practitioner to follow patients' reproductive health from infancy to old age. However, misconceptions among medics regarding stress levels and workload and misperceptions about career opportunities have left this dynamic and exciting specialty undersubscribed.

The spicy diverse medical specialty

What does the job entail?

If variety is the spice of life, obstetrics and gynaecology must be the red hot chilli pepper of medicine (figure 1). The usual working week takes a meandering course through a variety of specialist activities, flowing through the white waters of gynaecology theatres, to the waterfalls of the labour ward, before settling down in the motionless pools of gynaecology and antenatal outpatient clinics. Contrary to common belief, we still "play God" by creating and regrettably sometimes destroying life, which means that ethical and moral discussions occur on a daily basis. Furthermore, in andrology clinics we occasionally treat male patients as well.

Training programme

The training programme is currently being restructured with the advent of Modernising Medical Careers. At present, after a basic medical degree and house officer year or foundation year 1, up to three years are spent as a senior house officer completing a basic logbook, acquiring basic skills in the specialty, and attempting part 1 of the exam for membership of the Royal College of Obstetricians and Gynaecologists-that is, accumulating enough points to be shortlisted for a national training number. Additional activities such as audit and research also pave the way to a national training number.

Specialist training includes three years geared towards acquiring generic skills in obstetrics and gynaecology and completing the membership exams and a core logbook. After this, years 4 and 5 are spent gaining special skills, as outlined below, before acquiring a certificate of completion of training. A few trainees apply for a limited number of subspecialty training posts, which generally lead to the trainee following a purely gynaecological or obstetric path.

Changes are afoot regarding the membership exams for the Royal College of Obstetricians and Gynaecologists to try to bring them in line with more modern exam techniques and provide more of a continuum from the problem based learning methods of teaching and examining found in most medical schools.

As yet, unlike the surgical specialties, there is no exit examination. As with all specialties, the exact impact of Modernising Medical Careers on the training structure is not known. However, following problems with workforce planning in obstetrics and gynaecology in the late 1990s the Royal College of Obstetricians and Gynaecologists has been proactive in developing a new training pathway.

Subspecialties

Subspecialisation currently occurs after year 3 of specialist registrar training. Following changes proposed by Modernising Medical Careers, this will occur after the certificate of completion of training is acquired. Trainees with a special interest in a relevant field will compete for the opportunity to subspecialise in five well established areas: maternal and fetal medicine, urogynaecology, reproductive medicine, sexual and reproductive health, and gynaecological oncology. This will provide intensive training in an area of interest and a higher degree of competence. The Royal College of Obstetricians and Gynaecologists is keen to enhance the profile of academic obstetrics and gynaecology and there will undoubtedly be opportunities to follow an academic career path akin to subspecialisation.

Special skills

Currently, during the last two years of specialist training trainees work towards obtaining "specific skills that are beyond those required for the acquisition of a CCT (certificate of completion of training) in clinical, teaching, and managerial aspects of obstetrics and gynaecology" in selected areas. Modules have been developed, in conjunction with specialist societies, in the following areas:

• Assisted reproduction
• Management of infertile couples
• Maternal medicine
• Menopause
• Preparing for obstetric leadership on the labour ward
• Ultrasound imaging in gynaecological conditions
• Urodynamics
• Medical education
• Fetal medicine
• Advanced hysteroscopic surgery
• Intermediate level laparoscopic surgery
• Paediatric and adolescent gynaecology.

Several other modules are being prepared, and on average a trainee is expected to complete two special study modules during specialist registrar years 4 and 5. As yet it is not clear how these modules will fit into the post Modernising Medical Careers picture, but we would envisage them being undertaken during specialist registrar years 4 and 5.

Qualities needed

Obstetrics and gynaecology is a diverse specialty. You can start your day dealing with a woman with menstrual problems and end the day managing a shoulder dystocia in which you have five minutes to deliver a baby before the onset of cerebral ischaemia. The ability to adapt to rapidly changing situations is essential, and a sense of humour is useful when you are faced with difficult situations. Enthusiasm, agility, and an intention to enjoy life are key features for this role.

How can I improve my chances of getting a job in obstetrics and gynaecology?

At many medical schools there is the opportunity to do a special study module and gain extra exposure to obstetrics and gynaecology. Many foundation year 2 and a few year 1 posts include obstetrics and gynaecology, and it is wise to spend this time doing an audit or some teaching to improve your CV. At present, the part 1 exam for membership of the Royal College of Obstetricians and Gynaecologists can be taken as soon as you get your medical degree. An early successful attempt will mark you out as an enthusiast in the specialty. The college is currently setting up a mentoring scheme for those keen on a career in obstetrics and gynaecology, which is expected to be introduced to every medical school in the United Kingdom.

What does the future hold?

For budding obstetricians and gynaecologists, the future is bright. Currently, the UK has about 1500 consultants in obstetrics and gynaecology. If the college plans for the future are realised, 1000 more consultant posts will be created over the next decade or so. Flexibility in training is greater than ever, and the Royal College of Obstetricians and Gynaecologists is pursuing many changes to improve training, in particular with regard to part time training posts.

The college is also keen to develop a strong, clear academic career pathway for budding academics to combine clinical training and research from early years-that is, just after the foundation year training. With changes imposed on obstetrics and neonatology as a result of the European Working Time Directive, it is likely that future consultants will work in larger units. This will increase the case mix and give more opportunity to subspecialise.

The future consultant's role is being redefined and restructured with a work-life balance in mind. The service demands of the NHS require most future consultants to provide an obstetrics and emergency gynaecological service, while only a few will do major gynaecological surgery. Therefore, the future consultant is likely to be one who enjoys the job more, will be rewarded better for the on-call commitments than at present, and will have shorter working hours.

So, if you want a challenge, excitement, and an adrenaline rush, but also a fulfilling career, look no further than obstetrics and gynaecology.

       

           

	CAREERS Obstetrics and gynaecology        Dharani Hapangama and Melissa Whitworth (January 2006)
	George Sunny (December 25th, 2006)        Medical graduate, India doclife@gmail.com
	Obstetrics and gynecology is definitely an exciting specialty, and I appreciate the authors for describing the possibilities in this field well {1}. However considering the recent trends in health care, I feel the article is very quiet regarding certain hard facts which aspiring Obstetricians should be aware of. Probably this is the only specialty where, as a doctor you are involved in creating some of the best moments in a couple's life. However, as in any other specialty some unfortunate complications do occur even with the best care, causing great pain to everyone involved especially the parents. It is unlikely that the parents would take these incidents lightly and in most situations the blame ends up with the doctor for providing substandard care. Litigation has brought in a lot of bad reputation to this specialty which is otherwise an exciting field in health care. Obstetrics is the most litigious of all specialties. Defense fees for private obstetrics currently so hi gh that only a few consultants dare to practice private obstetrics in UK {2}. The scenario is worse in some other countries like USA. It was reported recently that OB/GYN residency positions go unfilled as medical residents are shunning specialties most at risk of lawsuits {3}. A recent survey conducted among the fourth year medical students in Florida, USA also showed that many students who considered OB/GYN, later decided against it mainly because of the "fear of malpractice"{4}. These realities have even resulted in a shortage of practicing Obstetricians in certain US states. The concerned authorities should perceive these trends and take the necessary steps to reverse it. Dharani Hapangama, Melissa Whitworth. Obstetrics and gynaecology. studentBMJ 2007;15:1-44 January ISSN 0966-6494 Andrew Pickersgill. Obstetrics and gynaecology. BMJ 7138 Volume 316: Saturday 11 April 1998. Stuart L. Weinstein . Medical liability repair. http://www.washingtontimes.com/commentary/20060429-084940-5697r.htm USF survey: Malpractice concerns may deter Florida medical students from entering obstetrics and gynecology. http://health.usf.edu/publicaffairs/newsreleases/newsrelease08292006.html