Key words
training in senology - gynaecology - DGGG Young Forum - speciality training
Schlüsselwörter
Weiterbildung Senologie - Gynäkologie - Junges Forum der DGGG - Facharztweiterbildung
Introduction
Senology has an established place in gynaecological oncology care in Germany [1]. The diagnosis, treatment and follow-up of diseases of the female breast (senology/mastology)
is an interdisciplinary field involving gynaecology, radiology, pathology and other
specialities. The German Association of Senology (Deutsche Gesellschaft für Senologie
e. V., DGS) was founded under gynaecological leadership in 1981 in order to optimise
the interdisciplinary management of breast diseases. Gynaecologists continue to form
the largest speciality group within the organisation with a representation of 47 %
[2].
Training in senology is covered in the accreditation rules for specialist training
in obstetrics and gynaecology. The German medical council does not recognise or offer
a senology subspeciality or special interest qualification. On the contrary, young
doctors must attend additional training events such as courses offered by the German
Academy of Senology [3] to acquire basic knowledge and further qualification in the field. A compounding
factor is that the full spectrum of subject matter in senology, and thus the possibility
of specialised training, is almost exclusively offered in breast centres and maximal
level care facilities [4]. Due to this concentration of care in larger centres the majority of specialist
trainees does not have access to comprehensive further training in senology in routine
clinical practice. Some practices accredited for specialist training do offer exposure
to aspects of senology and associated learning opportunities, however such concepts
within structured rotations are limited to a few regions. Thus, in 2014, the German
Academy of Senology created a specific interdisciplinary curriculum [3].
The provision of adequate, practice oriented training in senology for young doctors
is imperative to maintain the high quality standards of existing senology care structures
into the future. To ensure continual improvement of training it is essential to record
the experiences of trainees and consider how they rate their training. To date there
have been no studies evaluating the quality of further training in senology. The aim
of this nationwide survey by the Young Forum of the German Association of Obstetrics
and Gynaecology (DGGG e. V.) was therefore to produce baseline data on senology training
as it is in practice, and to document how this training is perceived by specialist
trainees. In addition structured training concepts in hospitals and breast centres
were sought. Further aims of this online survey were to contribute to improved knowledge
of the needs and demands of young doctors and make suggestions for improved training
content.
Methods
Recruitment
An online questionnaire comprising 10 items was developed by the working group of
the DGGG Young Forum and distributed to over 4000 doctors in specialist and subspecialist
training via the Young Forumʼs newsletter. Data collection was performed in June 2014
over a period of 4 weeks. There were 111 participants in total (participation rate:
2.8 %). Anonymised data analysis was performed using the www.surveymonkey.com software tool. An anonymous IP address check was conducted to avoid multiple participations.
Questionnaire
The first part of the questionnaire covered basic data including sex, demographics
(e.g. age) and career details (year of speciality training, training location). The
questionnaire further explored young doctorsʼ interest in senology training and the
quality of training. Distinction was made between hospitals providing routine primary
and secondary level care, those offering maximum level care, and university hospitals.
Doctors were also questioned on important aspects of training content and quality
indicators. Unless otherwise stated questions could be rated from 1–6, with 1 the
best and 6 the worst possible ratings (very important – not important at all). The
average score was established in each case with ratings from 1–3 considered supportive
answers.
Statistics
Statistical analysis of the results was performed using Excel 2011 software, with
unpaired t-tests and normally distributed samples (significance level: p < 0.05).
Results
Demographics and work experience of participants
There were 111 study participants in the four-week-long survey of whom 79.3 % (n = 88)
were female. The average age of participants was 31.8 years. The majority (33 %) were
in their 5th year of specialist training and 99 % were employed in the hospital setting
([Fig. 1]). At only 1 %, medical centres and practices were underrepresented and thus were
excluded from the further analysis.
Fig. 1 Type of training facility at the time of data acquisition (n = 111).
Senology as a career aim: Potential for young blood
25 % of participants could imagine working in the field of senology in future, whereas
31 % did not wish to. 44 % did not yet know ([Fig. 2]).
Fig. 2 Are you aiming to work in senology in the future?
Quality of training: Substantial differences between university hospitals and smaller
training facilities
Overall, participants rated their training in senology as satisfactory (score 3.34).
Satisfaction was highest among specialist trainees at university hospitals, with those
in primary and maximum care hospitals without university faculties rating their training
somewhat worse ([Table 1]).
Table 1 Overall rating of the quality of senology training according to training facility
(facility score). Comparison of university hospitals vs. primary and secondary care
facilities (p = 0.064) or maximum level care hospitals (p = 0.047).
|
Training facility
|
Score (∅)
|
|
Primary and secondary level hospital
|
3.44
|
|
Maximum level care hospitals
|
3.62
|
|
University hospitals
|
2.95
|
|
Total
|
3.34
|
[Fig. 3] shows the evaluation of current training quality in the different areas of senology.
Tertiary level, university-associated centres had the best scores in all areas covered.
Overall, training was rated best in breast surgery (mean score: 2.88). Compared to
university hospitals, training in other facilities (non-university hospitals) was
rated particularly badly in medical tumour treatment/therapeutics (university hospitals
[1.92] vs. primary and secondary level hospitals [3.56] or maximum level care hospitals
[3.29]) and plastic/reconstructive breast surgery (university hospitals [2.70] vs.
primary and secondary level hospitals [3.91] or maximum level care hospitals [4.00]).
Training towards a career in academics was also best at university hospitals (university
hospitals [3.05] vs. primary and secondary level hospitals [4.65] or maximum level
care hospitals [4.32]). The difference was significant in each case (p < 0.001). Young
gynaecology trainees criticised training in radiation therapy and pyschooncology at
all facilities.
Fig. 3 How do participants rate the quality of further training in the following areas at
their training facilities? (score).
Training content: Desire for a fixed rotation through a breast centre and regular
teaching
Participants were questioned on the necessity of various training contents in order
to identify possible areas for improvement ([Fig. 4]). All trainees considered a fixed rotation through a breast centre and comprehensive
training in breast surgery and investigation of breast disease particularly important,
as well as regular structured teaching. The completion of a logbook, which is a general
requirement for the specialist qualification, continues to be a source of worry for
trainees. Interest in a teaching career (medical education) (university hospitals
[2.34] vs. primary and secondary level hospitals [3.59] or maximum level care hospitals
[3.39]) and experimental research (university hospitals [2.54] vs. primary and secondary
level hospitals [3.74] or maximum level care hospitals [4.00]) was highest at university
hospitals. The difference was significant in each case (p < 0.001).
Fig. 4 How important is the following training content to you? Rating scale: 1 = very important
to 6 = not important at all; not rated > 4 (score).
Possible improvements in training quality
Finally, the survey evaluated which factors are relevant for good quality training
([Fig. 5]). Trainees saw particular value in a comprehensive system of mentoring. Sufficient
time for the imparting of knowledge on the part of those responsible for training
was seen as very important. All trainees wanted to be able to accomplish routine clinical
tasks within regular working hours. Structured training was desired at all hospitals.
Overall there were no significant differences here between types of training facility.
Fig. 5 What do you find important for the quality of training in senology? Rating scale:
1 = very important to 6 = not important at all; not rated > 2 (score).
Discussion
This is the first countrywide survey of obstetrics and gynaecology specialist trainees
concerning their senology/mastology training. We were able to show that senology is
regarded as an integral component of gynaecology. It was found that a predominance
of female doctors works in the field, as is also the case in medicine and gynaecology
in general [5], [6]. This increase in female doctors will lead to problems with the number of new doctors
coming through in the operative specialities: according to a recent study, women pursue
surgical careers more seldom and take up part-time posts more often, which leads to
an increased requirement for doctors [7]. In view of the high proportion of out-patients and elective operations, senology
certainly offers good chances of scheduled and regulated working hours, and thus a
particular opportunity for doctors seeking part-time employment.
In addition, our survey has shown for the first time that there is widespread interest
in the field of senology among trainees. The opportunity therefore exists to attract
young doctors to senology through good training and thus strengthen the speciality
in the long term.
Overall, the quality of currently practiced training was rated as satisfactory, though
there is potential for improvement. This is in agreement with the results of an evaluation
on training by the German medical council. The data from 2011 produced an average
score of 2.54 for the global evaluation of all specialities, trainees rating gynaecology
training with a score of 2.60 slightly worse than the national average [8], [9].
According to our data scientific training and associated specialities such as pathology
and radiotherapy as well as psychooncology appear to be underrepresented in training
content/curricula. In this respect the Young Doctors Alliance (das Bündnis JUNGE ÄRZTE)
has called for the structured integration of research content into speciality training
in order to avert a shortage of new doctors entering academics [10]. This is also true for senology. A funding programme could support interested trainees
in becoming acquainted with the field of senology, assisting them academically, building
a structured curriculum and making recommendations to departments involved in training.
The effects of a structured, evidence-based curriculum for the breast surgery rotation
was tested in a prospective study from Phoenix, USA, which showed a significant increase
in satisfaction and knowledge among participants [11]. Plichta et al. investigated the influence of surgical assistance at breast operations
on tumour free excision margins [12]. It was shown that a continuous learning curve for trainees on the breast surgery
rotation can reduce the rate of positive excision margins. Another recent study of
American surgical trainees showed that 72 % of essential breast surgery techniques
can be learned within the first three years of specialist training [13]. Although these data can only partially be applied to the German system, they do
show that the spectrum of senology can be taught at an early stage of specialist training
and that young doctors benefit from an intensive training programme. Our study also
supports the idea that further training in senology should ideally be in the context
of a fixed rotation through a breast centre. The aim should be to offer interested
trainees support in their career development early on and assist in developing long-term
career goals.
It was shown that senology training is rated best at university hospitals at almost
all levels of content. This could be due to the interdisciplinary approach at university
hospitals, which, unlike the other facilities evaluated, provides exposure to all
areas of senology. Also most certified breast centres are affiliated to university
hospitals and have a bigger team at their disposal [4]. As certified centres they must have e.g. oncology out-patient care, psychooncology
expertise and a pathology institute, which all constitute important aspects of training.
In this way interaction with complementary specialities, a prerequisite for certification,
is assured. This is certainly also good for training. A point of criticism was that
tumour board participation, which is compulsory at breast centres, is often not possible
in smaller hospitals. Insufficient opportunity to manage senology patients particularly
at primary and secondary level hospitals was a further important point. A programme
of trainee rotation through different hospitals is a possible solution to this problem
of too little exposure to certain training aspects. There are almost certainly significant
differences between individual hospitals, both university hospitals and primary/secondary
level institutions, so that the results of this survey should not be generalised prematurely;
the questionnaire did not assess hospitals individually.
Through purposeful invitation to survey participation via the DGGG Young Forum newsletter
we were able to address the target group of specialist trainees directly, achieving
a homogeneous study population. The online nature of the survey allowed for anonymity.
A disadvantage of the online format in general is possible lack of representivity,
since bias can arise e.g. through computer problems. There were no interview drop-outs
registered, probably because the questionnaire was short. A low participation rate
(2.8 %) is the main weakness of this study. Positive and negative selection bias can
be assumed: on the one hand motivated, on the other, frustrated trainees. The bulk
of trainees nationwide did not participate, possibly due to lack of interest in political
participation, which is a factor that has been confirmed in other surveys [14]. This is regrettable since such surveys enable active participation in the improvement
of training structures.
Conclusion
This is the first baseline survey of current training quality in senology in Germany.
Results show that a substantial number of young doctors could potentially enter the
speciality field. The subjective experience of training quality varies significantly
between types of training facility. These findings could serve as a basis and impetus
for improved provision of comprehensive training in senology, thus making the speciality
more attractive to future senologists.
Further information at: http://www.dggg.de/junges-forum/
Take home message
-
There is significant potential for young blood entering speciality training in senology.
-
Subjective experience of training quality varies significantly between types of training
facility.
-
These findings could serve as a basis and impetus for improved provision of comprehensive
senology training.
Acknowledgements
We would like to thank all the members of the Young Forum working group for the fruitful
discussions towards compilation of the questionnaire, and we thank the DGGG for publicising
the survey in the newsletter. In addition we thank all those who participated in the
survey.
