Key words gynecology - psychosomatic medicine - continued training - specialist medical training
Schlüsselwörter Frauenheilkunde - Gynäkologie - Psychosomatik - Weiterbildung - Facharzt
Introduction
The physicianʼs ability to offer professional advice and care which focusses on their patientsʼ needs is
central to gynecology.
Psychosomatic primary care is an integral part of the daily work of gynecologists; it means being able to
recognize psychogenic disorders, to assess psychosocial factors in physical disease, to offer
patient-centered advice and care, and to pilot patients through the system of psychosocial care. In
addition to helpful discussion techniques, the key element to generate a satisfying and successful
discussion is a physicianʼs conscious attitude towards psychosomatic disease.
Suboptimal communication can have clinically relevant consequences for patients. Clinically significant
psychological stresses and physical symptoms are often inadequately diagnosed and may remain untreated.
This is highly relevant, as 20–30 % of patients who visit GPsʼ suffer from psychogenic or secondary
psychosomatic disorders [1 ].
When the Regulations on the Licensing of Medical Practitioners were amended in 1972, psychosomatic
medicine and psychotherapy were integrated into medical training and are therefore a mandatory subject
for every prospective physician. The course “Psychosomatic Primary Care” has been part of the training
curriculum for specialists in gynecology and obstetrics since 2003 and is required of all physicians
wanting to become gynecologists. The required coursework corresponds approximately to that required for
services billed as EBM Nos. 35100 and 35110 [2 ]. The training course consists
of theory seminars (20 hours), communicating and practicing verbal intervention techniques (30 hours),
and work in Balint groups (30 hours).
The aim of the course is to train up physicians beyond their skills on somatic medicine, so that they can
offer their patients care which takes greater account of biopsychosocial aspects [3 ]; the goal is to enable them to make a differential diagnosis of a complex clinical picture
as early as possible [4 ]. According to current studies, the learning process
involved extends over a period of 3–5 years [1 ].
The necessity for a mandatory course as part of specialist training in gynecology has led to a critical
discussion recently. The major points discussed at the time included the questions whether the current
forms of instruction in the shape of courses paid for by the trainees are outdated and whether the
required skills should be part of regular specialist training to allow trainees to recognize and treat
psychosomatic illnesses in their daily gynecological practice [5 ], [6 ]. The discussion between representatives of the German Society for
Psychosomatic Gynecology and Obstetrics (Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und
Geburtshilfe e. V. [DGPFG]) and the Young Forum of the German Society for Gynecology and Obstetrics
(Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V. [DGGG]) resulted in a joint survey of all
members of the DGGG in training. The aim of the survey was to evaluate traineesʼ experiences of the
course “Psychosomatic Primary Care”, particularly with respect to the level of its acceptance. In
addition, the study aimed to draw attention to concerns voiced by residents and use the results of the
survey to improve psychosomatic primary care courses for gynecologists and obstetricians in respect to
their special requirements offering a great personal benefit to trainees.
The results of the internet survey are outlined and discussed below. The proposals for the training
course on psychosomatic primary care put forward by the DGPFG and the Young Forum of the DGGG together
with the German Academy for Gynecology and Obstetrics (Deutsche Akademie für Gynäkologie und
Geburtshilfe [DAGG]) are presented here.
Methods
A 3-part questionnaire with 30 items was developed. The 1st part consisted of 7 questions for the
collection of demographical data; the 2nd part included 14 questions which evaluated the respondentʼs
attitude towards and experience with psychosomatic primary care ([Fig. 1 ]).
Unless otherwise specified, evaluation was done using a scale from 1 to 6, with 1 as the best score and
6 as the worst score (very satisfied – entirely dissatisfied; very important – entirely unimportant).
Scores between 1 and 3 were evaluated as broadly favorable.
Fig. 1 Extract from the questionnaire collecting general information and asking questions
about the course “Psychosomatic Primary Care”.
The 3rd part asked the respondentʼs opinion of a new training concept for outpatient care which was
developed in collaboration with the Professional Association of Gynecologists (Berufsverband der
Frauenärzte, currently still in press). The last question left space for respondents to add their own
comments.
The anonymous online questionnaire was distributed 3 times over the period from September to December
2012 via the Newsletter of the Young Forum of the DGGG 3. According to information provided by the
office of the DGGG, the Newsletter reaches 2431 members in training. Data collection and evaluation was
done using www.surveymonkey.de .
Results
Demographic data, work experience and career objectives of respondents
A total of 504 (20.7 %) persons sent the questionnaire filled in the online survey evaluating the
“Psychosomatic Primary Care”. The overwhelming majority of respondents were female (83.3 %), and the
average age of the residents who responded was 30 years (25–52 range); 46.9 % of respondents were in
their 1st to 4th year of gynecology training. Around one quarter of respondents was in their 5th
year of training (22 %) or already working as a trained specialist (21.5 %). At the time of the
survey 9.6 % were on parental leave. The distribution of respondentsʼ place of employment is shown
in [Fig. 2 ].
Fig. 2 Respondentsʼ place of employment (n = 501, no information n = 3 [0.6 %]).
The majority (56 %) of respondents reported that working in a hospital was their long-term career
goal, and 15.7 % of them stated that they would like a university career. 31.7 % stated that their
career goal was to work in their own practice, while 23.0 % were still undecided about their future
career path at the time of the survey, and 29.6 % could imagine any one of several different places
of employment. Only 2.8 % hoped to work in a research setting and 0.4 % in the pharmaceuticals
industry.
The majority (84.6 %) regularly attended training courses which they paid for themselves.
General questions on the course “Psychosomatic Primary Care”
The survey covered general information ranging from eligibility requirements to details of the course
“Psychosomatic Primary Care” they had attended ([Fig. 1 ]).
The majority of respondents (70.9 %) already had some experience of the course “Psychosomatic Primary
Care” and more than half of them (58.8 %) had completed the course. In general, most began attending
the course in their 3rd or 4th year of training (45.8 %) without time off from their ordinary
clinical duties (57.5 %).
The overwhelming majority (77 %) attended courses held in Germany; 13.8 % availed themselves of
in-house training courses held at the facility where they received their regular training. However,
only 4 % attended the course entirely free of charge. Overall, most respondents (84.2 %) welcomed
the concept of in-house training, with 42.4 % describing this as an extremely good idea; only 5.1 %
were sceptical about it.
The average cost of a course, as reported by those who had already attended a fee-based training
program, was 920 ± 524 € (range: from 0 to > 2000 €).
Only 8.1 % of respondents had attended the courses held by the DGPFG which are specifically tailored
to prospective gynecologists and obstetricians. Around 80 % of the persons surveyed had never heard
of the DGPFG.
Experience with and evaluation of the curriculum of the course “Psychosomatic Primary
Care”
The experiences with and evaluations of the course “Psychosomatic Primary Care” were surveyed in the
questions a to n ([Fig. 1 ]); they are summarized below and shown in [Fig. 3 ].
Fig. 3 a to d Course format and relevance of the course “Psychosomatic Primary
Care”. Green indicates the total number of responses and blue gives the percentage. n = 504,
n. s. = not specified. a Extent of training: “Do you consider the extent of training in
psychosomatic care to be adequate?” b Course curriculum: “Do you consider the course
content of psychosomatic primary care to be useful?” c Integral part of specialist medical
training: “Do you consider the course on psychosomatic primary care to be an important
part of your specialist medical training?” d Satisfaction: “If you completed the course
on psychosomatic primary care, how satisfied were you with the course offer?”
The scope of the course was rated as 3.8 ± 1.69, with 41.8 % of responses classified as positive
compared to 51.3 % of responses which were sceptical ([Fig. 3 a ]). The
number of mandatory Balint group sessions received a particularly high number of adverse comments in
the Comments section. The contents of the course on psychosomatic primary care were rated as average
(2.91 ± 1.58) and were generally (63.6 %) endorsed; only 29.3 % were not convinced by the subject
matter of the course ([Fig. 3 b ]). In the Comments section, respondents
criticized the curriculumʼs lack of references to gynecology and obstetrics and with some stating
that certain parts of the curriculum were superfluous as they treated areas already covered during
medical school. The value of the course as an important part of specialist medical training was also
ranked as average (3.15 ± 1.81), although positive assessments slightly predominated (49.3 %) ([Fig. 3 c ]).
Overall satisfaction after completion of the course was 3.09 ± 1.54. More than one third (41.8 %) of
respondents and 64.2 % of persons who had answered this question were satisfied with the course
curriculum ([Fig. 3 d ]). Respondents also attended lectures and seminars
on psychosomatic topics if they were offered at conferences and the opportunities for and
availability of such lectures and seminars were considered sufficient (mean: 2.6 ± 1.01). However,
respondents reported that in practice psychosomatics only played a minor role in clinical routine
(3.74 ± 1.65). 41.5 % confirmed that psychosomatics played a role in daily clinical practice; only
12.4 % were of the opinion that it played a significant role, and 18 % reported that it played no
role in clinical practice at all.
More than half (66.6 %) of respondents knew that completion of the course was necessary to allow them
to bill for this item, but only a minority (5.2 %) considered this relevant.
Discussion
The view that effective, patient-centered communication must be taught and can be learned just like other
medical skills has become comonplace. Many countries are aware of the special demands on effective
communication between physician and patient in gynecology; the positive results reported after
professional training are increasingly being noted and this type of training is being implemented in the
form of recommendations by experts and mandatory additional training. In Germany, this has taken the
form of the “Psychosomatic Primary Care” course, which is now part of the specialist training of
gynecologists.
On the initiative of the Young Forum of the DGGG and the DGPFG an online survey was carried out to
investigate the available courses on psychosomatic primary care; the aim of the survey was to
investigate whether the currently available courses offer a practice-oriented curriculum in
psychosomatics.
The results of the survey showed that trainees in Germany regularly attend advanced training courses in
addition to their regular training. On the one hand, this reflects the overall acceptance of additional
training and a general willingness to attend those courses. But it also raises the questions whether
there may be deficiencies in certain areas of training provided by specialist medical training
facilities and whether it might be necessary to search for alternative forms of training. Questions
which this survey does not answer.
At present, the course “Psychosomatic Primary Care” is the only mandatory course on this topic in
gynecology. The survey found that levels of satisfaction with the course varied widely among
respondents. This may be due to different experiences and varying standards. The quality of the courses
was not investigated in the survey, but this can be inferred based on the comments added in the Free
Comments section.
In the Comments section, the limited value of psychosomatics in daily clinical practice reported by the
respondents was ascribed to the currently offered courses, which had only a limited reference to
gynecology and obstetrics. Other comments indicated that the course curriculum was not very relevant to
clinical practice, making it difficult to apply what was learned in the course in daily practice. This
criticized inability to transfer the course curriculum into clinical practice shows that the
requirements for the curriculum for psychosomatic primary care, which were already formulated in 2001,
have not yet been implemented properly. One suggestion for improvement proposed by respondents was the
integration of course material into clinical practice. Additional proposals included in-house training,
which is not very common yet. The reported limited role of psychosomatics in clinical practice is in
stark contrast to studies which have shown that disease has a psychosomatic component in 20–30 % of
female patients treated on an outpatient basis [1 ]. Many studies have shown
that every life-changing illness, whether it be gynecological, obstetrical or cancer-related, but also
problems with menopause, sterility or chronic diseases such as endometriosis, has both a pyschological
and a somatic aspect. Many clinical syndromes, for example premature labor, chronic pain in the lower
abdomen or bleeding disorders, include a number of psychosocial and physical aspects during the
emergence and further course of the illness, so that every physician will come into contact with
psychosomatic problems during routine training and could apply psychosomatic skills.
It would be useful if physicians would learn about the diagnosis and therapy of psychosomatic syndromes
early on in their specialist training as they could apply and improve what they have learned in their
subsequent training; currently, however, the majority of residents only attend the course on
psychosomatic care in their 3rd or 4th year of training.
Existing courses offered by the DGPFG which focus on gynecological and obstetrical aspects are not very
well known. One conclusion which could be drawn from the study is that psychosomatic primary care must
be considered a model of success, both in terms of how it has developed since its introduction and with
regard to its empirical validation. But it must also be stated that the quality of courses on offer is
very heterogenous and that they do not or only insufficiently take account of the specific requirements
for psychomatic care in gynecology. This led to a joint initiative by the Young Forum of the DGGG,
representatives from the DGPFG and the DAGG and from the Gynecological University Hospitals of
Heidelberg and Erlangen to develop a common curriculum which would incorporate psychosomatic
gynecological care in gynecological university hospitals. The newly drafted curriculum aims to teach
practice-based state-of-the-art gynecological psychosomatics. The costs for the full course (modules
1–3) have deliberately been kept low for all of the modules. The Gynecological University Hospital
Heidelberg began teaching the 1st module in March 2014. The Gynecological University Hospital Erlangen
will start teaching a course in the near future. Both facilities will teach the same topics, so it
should be possible to attend different modules at different university hospitals in future. Central
registration for the courses is through the DAGG.
We will be reporting about the evaluation of this concept after the end of the pilot phase.
In conclusion, it can be clearly stated that psychosomatic primary care training in gynecology has an
important role to play. Yet the current range of courses on offer needs to be fundamentally reformed to
take account of the specific demands of gynecology and obstetrics. As a first step it will be important
to develop a comprehensively reformed curriculum for psychosomatic primary care in gynecology geared to
the varied demands of and working conditions in our modern healthcare system.
