The Hidden Threat of Changing Curriculum: How New Standards Impact Obstetric Care
Welcome to part two of our ‘Hidden Threats’ series, a series where we summarize some of the latest research regarding medical errors and structural issues that can impact the quality of patient care, both in obstetrics and in medicine generally.
Every two weeks, we’ll be providing a short summary of the latest trends, research articles, and news that patients may want to know about the way they get their healthcare.
This week’s focus is changing curriculums in obstetric training programs.
The Hidden Threats of Changing Standards: How Obstetric Training Changes Threaten Resident Knowledge
According to fairly recent research in the Journal of Graduate Medical Education, recent trends in how obstetrics are taught have meant that the field is changing rapidly in fundamental ways – ways that mean that the field of obstetrics may need a new repertoire of teaching techniques to shore up residents’ basic obstetric skills.
The article, titled “The Changing Scenario of Obstetrics and Gynecology Residency Training,” finds that residents in obstetrics and gynecology have had very different training experiences over the past years. Obstetric logs collected by the Accreditation Council for Graduate Medical Education (ACGME) (the body of professionals that regulates the certification of obstetricians and gynecologists) have found that:
- Residents are no longer doing as many vaginal, forceps and vacuum extractor deliveries
- Residents are doing more C-sections and multifetal deliveries (deliveries of twins, triplets, etc.)
Why is this important? In a word – Safety.
Practice Makes Proficient
Residents should develop competency in the skills needed to conduct that procedure safely. To develop competency, they must practice. This is the reason why there are requirements for residents to perform certain numbers of certain procedures to become a fully-licensed physician.
Drops in the volume of certain deliveries done mean reduced safety and a higher incidence of mistakes. This is especially true for forceps and vacuum extractor deliveries. When done correctly, these kinds of deliveries can be safe and effective in delivering the baby unharmed. When done incorrectly, these kinds of deliveries lead to birth trauma, hemorrhaging, and severe disability.
Certain Obstetrics Techniques Becoming a ‘Lost Art’
Indeed, the article states that “the art of forceps deliveries has become a disappearing skill in teaching institutions.” Disappearing competency that means that more physicians are going out into the field with only incomplete knowledge of how to do a forceps or vacuum extraction properly – skills that are considered basic in the practice of obstetrics. Proper training is absolutely necessary to prevent complications – without proper training, increased birth trauma rates result (3).
The study emphasizes that “teaching the technique of forceps application needs to be reinstated in residency programs, as obstetricians are faced with situations in clinical practice where gentle and judicious application of low forceps may be preferable over a cesarean section.” In light of this decline in forceps use competency, some programs have implemented forceps skills training programs to ensure residents are able to use these tools prior to learning vacuum extractor procedures. (10)
Declining Resident Experience Cited Across Fields
Unfortunately, obstetrics is not the only field in which declining resident experience has been noted. Other research finds that residents are coming out less prepared for procedural practice than before, in areas including:
- General surgery (2)
- Neurological surgery
- Ophthalmology (4)
Other research (such as one study from New Zealand (5)) shows that residents are inadequately prepared for breech deliveries, while another study from the US finds that only 11% of last-year residents plan on even offering vaginal breech deliveries to their patients, even though 53% feel confident in their ability to perform a breech delivery (6).
In response to these declining numbers, some studies have implemented additional training (such as forceps delivery training and simulation-based curriculums for amniocentesis (7-9)).
Declining Resident Proficiency: What Should Parents Know?
Evaluating the experience of a medical care provider may be difficult as a patient. It can be easier to evaluate an OB/GYN’s experience when selecting your prenatal care provider – there are questions parents can their potential OB/GYN to evaluate their practice and experience level.
However, residents are typically at the hospital in the labor ward, learning from the attending physician and from hands-on experience. One way to avoid some of the concerns related to resident inexperience is to give birth at a non-teaching hospital. However, many babies who develop complications during labor and delivery will have to go to regional NICUs, which may be at teaching hospitals. Parents can ask to be seen by the attending physician only, or they may ask for a different provider if the physician attending the birth is not one they are comfortable with.
- Natasha Gupta et al. The Changing Scenario of Obstetrics and Gynecology Residency Training. Journal of Graduate Medical Education, September 2015. 401-406.
- McCoy AC et al. Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ. 2013;70(6):683–689.
- Kyser KL et al. Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence? Acad Med. 2014;89(1):71–76.
- Fakhry SM et al.; EAST Multi-Institutional Blunt Hallow Viscous Injury Research Group. The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma. 2003;54(1):1–7; discussion 7–8.
- Robson S et al. Registrar experience in vaginal breech delivery: how much is occurring? Aust N Z J Obstet Gynaecol. 1999;39(2):215–217.
- Chinnock M et al. Obstetric trainees’ experience in vaginal breech delivery: implications for future practice. Obstet Gynecol. 2007;110(4):900–903.
- Solt I et al. Teaching forceps: the impact of proactive faculty. Am J Obstet Gynecol. 2011;204(5):448.e1–e4.
- Ericsson KA. Necessity is the mother of invention: video recording firsthand perspectives of critical medical procedures to make simulated training more effective. Acad Med. 2014;89(1):17–20.
- Pittini R et al. Teaching invasive perinatal procedures: assessment of a high fidelity simulator-based curriculum. Ultrasound Obstet Gynecol. 2002;19(5):478–483.
- Skinner, Sasha et al. Perinatal and Maternal Outcomes After Training Residents in Forceps Before Vacuum Instrumental Birth. Obstetrics & Gynecology: July 2017 – Volume 130 – Issue 1 – p 151–158