Key words
training - endoscopy
Schlüsselwörter
Ausbildung - Endoskopie
Introduction
Endoscopy is a key element of diagnosing and treating gynaecological disorders. The
ongoing technical advances and overall development, including surgical techniques
that are as minimally invasive as possible, have led to the increasing significance
of endoscopy. To ensure that gynaecological training in the context of specialty training
is adequate, the learning of endoscopic skills is therefore becoming increasingly
relevant. In many operating theatres, hysteroscopy and/or laparoscopy are routine
procedures. However, there is wide variation in the way entire range of diagnostic
and therapeutic options for endoscopic procedures is offered in the individual hospitals
and practices.
While the current Specialty Training Regulations and logbook for gynaecology and obstetrics
provides for the acquisition of endoscopic skills, they are not specifically required
(cf. Specialty Training Regulations, Saarland Medical Association). The AGEʼs internal
statistics on participants [8] in courses accompanying specialty training show that junior doctors are increasingly
interested in learning endoscopic surgical techniques. Young physicians must therefore
receive appropriate solid and practice-oriented advanced training as part of their
specialty training if the goal of meeting the highest possible quality standards is
to be met in future. However, for high-quality specialty training, it is essential
to be precisely apprised of the interests and expectations of the junior doctors.
In Germany, little is known at present about the expectations and notions of young
junior doctors specializing in gynaecology with respect to endoscopic training. This
Germany-wide survey has elicited information on the significance of endoscopy in specialty
training for the first time. It furthermore assessed the junior doctorsʼ expectations
of their own instructors and for the specialty training institution and examined the
junior doctorsʼ satisfaction with their current standard of specialty training. Moreover,
the study enabled focuses of interest with regard to learning endoscopic techniques
to be identified.
Materials and Methods
Study design
To identify the significance of the endoscopic training during specialty training,
a Germany-wide survey was conducted from 2013 to 2014 among junior doctors specializing
in gynaecology. In cooperation with the Junges Forum of the German Society of Gynaecology
and Obstetrics (DGGG) and the Working Group for Gynaecological Endoscopy (AGE), a
three-page questionnaire was compiled. This questionnaire was sent by email to all
members of the Junges Forum and by newsletter to the members of the AGE. The members
were requested to return the completed questionnaire anonymously. With several thousand
participants, it is impossible to precisely calculate an exact return rate due to
the unknown size of the distribution list.
Content of the questionnaire
The survey contained questions concerning the following areas (cf. [Fig. 5]):
Fig. 1 Results of the question “Do you think learning endoscopic techniques is important
for specialty training?” The x-axis represents the grade scale (1 = very important
to 6 = unimportant) and the y-axis represents the percentage of participants.
Fig. 2 Results of the question “Do you think that participating in courses (possibly at
another facility) for learning endoscopic techniques is worthwhile?” The x-axis represents
the grade scale (1 = very worthwhile to 6 = not worthwhile at all) and the y-axis
represents the percentage of participants.
Fig. 3 The responses to the question “How many endoscopic procedures should one ideally
assist with as part of oneʼs specialty training (up to the completion of specialty
training, regardless of the requirements of the German Medical Association)?” The
x-axis represents the number of procedures and the y-axis represents the percentage
of participants.
Fig. 4 The responses to the question “How many endoscopic procedures should one ideally
perform oneself as part of oneʼs specialty training (up to the completion of specialty
training, regardless of the requirements of the German Medical Association)?” The
x-axis represents the number of procedures and the y-axis represents the percentage
of participants.
Fig. 5 Questionnaire: “Junior doctorsʼ expectations for endoscopic training during specialty
training – Specialty gynaecology and obstetrics 2013”.
-
General information on the study participants and the specialty training institution
-
Attitude towards endoscopic specialty training
-
Participantsʼ expectations and satisfaction
The participants were asked to state the following details: sex, age, current specialty
training year and information on the specialty training institution (university hospital,
maximum care hospital, general hospital, day clinic or practice).
With respect to endoscopic training, they were asked to rate the following parameters:
the importance of learning hysteroscopy/laparoscopy/robotics based on a grade scale
(1 = very important to 6 = unimportant); the importance of courses for learning endoscopic
techniques and their frequency in the context of the specialty training, here too,
based on a grade scale or based on defined response items. The willingness of the
participants to make their own financial contribution to endoscopic specialty training
was then asked about. The participants were asked to use a grade scale to describe
the importance of independent training using simulators to supplement the course offerings.
With respect to expectations and satisfaction, the participants were asked to rate
the following parameters: the ideal number of assisted endoscopic procedures and such
procedures they performed themselves, broken down into diagnostic and surgical hysteroscopy
or laparoscopy with four predefined response items each. They were then asked about
the realization of the respective expectations and about their willingness to change
from their current workplace if they were dissatisfied. The participants were also
asked to use a grade scale to rate their expectations for their instructors and their
training institution.
Finally, the participants were asked to rate their overall satisfaction with the current
state of their own specialty training and their probable place of employment after
completing their specialty training (hospital vs. private practice).
Evaluation
The evaluation of the results was broken down by the sex of the physicians and training
year, as well as by the current specialty training institutions (university hospital
vs. maximum care hospital vs. general hospital). The statistical assessment was performed
with an unbound, normally distributed sample using a t-test and ANOVA (significance:
p < 0.05).
The data were first presented during the ESGE Congress in 2014 and during the DGGG
Congress in 2014. This publication presents the data in their entirety.
Results
Study population
The evaluation of the study was based on 109 completed questionnaires. The resident
junior doctors were 31 years old on average. The survey participants were in the 3.2nd
specialty training year on average and comprised 76.1 % women and 23.9 % men. Of the
survey participants, 36.7 % worked in a university hospital, 30.6 % in a maximum care
hospital and 32.7 % in a general hospital.
Interest in endoscopy
Ninety per cent of the participants rated the learning of endoscopic techniques in
specialty training with regard to laparoscopy as very important and 80 % of those
surveyed rated such learning with regard to hysteroscopy as very important (cf. [Fig. 1]). The learning of 3D robotics techniques tended to be considered to be unimportant.
Course participation
Nearly 50 % of the participants considered participating in courses for learning endoscopic
techniques with respect to laparoscopy as very worthwhile or worthwhile (37 %), while
38 % of the participants considered courses on hysteroscopy to be very worthwhile
or worthwhile (30 %) (cf. [Fig. 2]).
Forty-five per cent of the participants said they would like to participate in a course
for learning endoscopic techniques once or twice during their overall specialty training,
while 37 % reported that they would like to attend such a course once a year. Of the
participants, 17 % stated that endoscopy courses should be attended only based on
the participantsʼ own interest and only 1 % of the participants categorically rejected
participation in courses.
Finances
With respect to the participantsʼ own financial contribution to learning endoscopic
skills as part of the overall specialty training (over the course of five years),
18 % of the participants would invest €500 themselves, 28 % of the participants would
invest €500 to €1000, and 49 % would invest €1000 to €1500 themselves. Five per cent
of the participants would invest more than €1500.
Simulator training
Nearly 50 % of the participants considered the opportunity to undergo training using
a laparoscopy and/or hysteroscopy trainer and/or simulator to be very important.
Number of procedures
The junior doctorsʼ ideas about the number of endoscopic procedures that they should
ideally be able to assist with or perform themselves during their specialty training
are presented in [Figs. 3] and [4].
Over 30 % of the participants said that they would like to assist with 20 to 50 or
more than 50 diagnostic/surgical hysteroscopies and laparoscopies each and over 60 %
of the participants reported that they would like to perform more than 30 diagnostic/surgical
hysteroscopies or laparoscopies themselves as the surgeon.
Expectations for the specialty training institution and instructors
Among the participants, 11.3 % reported that the expectations they have for the specialty
training institution had been met in full and 26.4 % reported that they had been met
for the most part. A further 26.4 % of the participants reported that their expectations
were met in part and 22.6 % said they were not adequately met. Another 7.5 % of the
participants reported that their expectations had hardly been met and 5.7 % said they
had not been met at all. Of the participants, 83 % said they were prepared to change
hospitals in order to achieve their own goals, while 17 % said they were not prepared
to do so.
The highest expectations that the respondents had of the instructors concerned their
technical expertise, with over 80 % reporting this, while over 60 % mentioned the
instructorsʼ willingness and time for teaching and just under 60 % mentioned the instructorsʼ
patience. If the expectations are broken down by training year of the junior doctors,
a significant difference in the expectation for patience is revealed in the statistical
evaluation: Junior doctors in their first to third training year considered patience
on the part of the trainers to be more important than their counterparts in their
fourth or fifth year. When broken down by sex, there was a significant difference
in expectations with respect to feedback/constructive criticism. Female junior doctors
found this to be more important than male junior doctors (cf. [Tables 1] and [2]). Among the participants, 11 % reported that their expectations of the instructors
had been met in full and 41 % reported that they had been met for the most part. A
further 39 % of the participants reported that their expectations were met in part
and 9 % said they were not adequately met.
Table 1 Junior doctorsʼ expectations of their instructors depending on training year. Grade
scale: 1 = very important to 6 = unimportant.
|
Year 1 to 3
|
Year 4 to 5
|
p value
|
|
n = 57
|
n = 48
|
|
Patience
|
1.4 ± 0.61
|
1.7 ± 0.68
|
0.019
|
|
Technical expertise
|
1.2 ± 0.71
|
1.2 ± 0.39
|
1
|
|
Teaching skills
|
1.8 ± 0.80
|
1.9 ± 0.72
|
0.506
|
|
Feedback/praise/constructive criticism
|
1.6 ± 0.97
|
1.8 ± 0.66
|
0.252
|
|
Willingness/time for teaching
|
1.4 ± 0.55
|
1.4 ± 0.53
|
1
|
|
Certification (e.g. MIS surgeon)
|
2.9 ± 1.36
|
3.3 ± 1.30
|
0.129
|
Table 2 Junior doctorsʼ expectations of their instructors broken down by sex. Grade scale:
1 = very important to 6 = unimportant.
|
Female
|
Male
|
p value
|
|
n = 79
|
n = 26
|
|
Patience
|
1.5 ± 0.61
|
1.6 ± 0.8
|
0.505
|
|
Technical expertise
|
1.2 ± 0.63
|
1.2 ± 0.4
|
1
|
|
Teaching skills
|
1.9 ± 0.77
|
1.7 ± 0.72
|
0.246
|
|
Feedback/praise/constructive criticism
|
1.6 ± 0.6
|
2 ± 1.32
|
0.036
|
|
Willingness/time for teaching
|
1.4 ± 0.53
|
1.5 ± 0.58
|
0.417
|
|
Certification (e.g. MIS surgeon)
|
3 ± 1.22
|
3.5 ± 1.66
|
0.102
|
The highest expectation participants had for their training institution concerned
the number of surgical procedures, at 50 %, followed by leave from work for training,
at 48 %, and the range of surgical procedures, at 45 %. If the expectations are broken
down by the hospital where the junior doctors work, a significant difference was observed
between junior doctors working at a university hospital vs. a maximum care hospital
or general hospital in terms of expectations for cost coverage for the training. For
the other categories, no significant differences were observed. When broken down by
sex, there was a significant difference with respect to the expectations with respect
to being released from work for training. Female junior doctors considered this to
be more important than their male counterparts (cf. [Tables 3] and [4]). Among the participants, 13 % reported that their expectations for the specialty
training institution had been met in full and 42 % reported that they have been met
for the most part. A further 28 % of the participants reported that their expectations
had been met in part and 17 % said they had not been adequately met.
Table 3 Junior doctorsʼ expectations for their hospital broken down by specialty training
institution. Grade scale: 1 = very important to 6 = unimportant.
|
University hospital
|
Maximum care hospital
|
General hospital
|
p value
|
|
n = 38
|
n = 30
|
n = 36
|
|
Instruments
|
1.8 ± 0.81
|
2 ± 1.01
|
1.9 ± 0.80
|
0.641
|
|
Coverage of costs for specialty training courses
|
2.1 ± 0.92
|
1.5 ± 0.62
|
2 ± 1.18
|
0.008
|
|
Range of surgical procedures
|
1.6 ± 0.81
|
1.7 ± 0.65
|
1.6 ± 0.63
|
0.808
|
|
Number of surgical procedures
|
1.6 ± 0.85
|
1.6 ± 0.49
|
1.5 ± 0.56
|
0.767
|
|
Leave to attend specialty training courses
|
1.8 ± 0.90
|
1.6 ± 0.85
|
2,0 ± 1.22
|
0.28
|
|
Certification (e.g. MIS training centre)
|
2.3 ± 1.18
|
3.2 ± 1.46
|
3.1 ± 1.52
|
0.013
|
Table 4 Junior doctorsʼ expectations for their hospital broken down by sex. Grade scale:
1 = very important to 6 = unimportant.
|
Women
|
Men
|
p value
|
|
n = 79
|
n = 26
|
|
Instruments
|
1.8 ± 0.73
|
2.1 ± 1.19
|
0.128
|
|
Coverage of costs for specialty training courses
|
1.9 ± 0.91
|
2.2 ± 1.28
|
0.193
|
|
Range of surgical procedures
|
1.7 ± 0.73
|
1.6 ± 0.64
|
0.534
|
|
Number of surgical procedures
|
1.6 ± 0.64
|
1.5 ± 0.70
|
0.501
|
|
Leave to attend specialty training courses
|
1.6 ± 0.88
|
2.2 ± 1.28
|
0.009
|
|
Certification (e.g. MIS training centre)
|
2.9 ± 1.26
|
3.5 ± 1.66
|
0.055
|
Satisfaction
With respect to the participantsʼ satisfaction with the state of current endoscopic
basic and advanced training in general, 15 % of the participants were fully satisfied,
and 23 % were mostly satisfied. A further 39 % of the participants were partly satisfied
and 23 % were inadequately satisfied with the current state of their own endoscopic
specialty training. With respect to their further career plans, 81 % of the participants
reported that they expected to work at a hospital after completing their specialty
training and 19 % expected to work in private practice afterwards.
Discussion
This survey gathered information on expectations and requirements of young junior
doctors in gynaecology with respect to endoscopic training and also addressed their
level of satisfaction.
The survey results show the significance of endoscopy in specialty training: Among
the participants, 89.9 % considered learning to perform laparoscopy and 85.3 % considered
learning to perform hysteroscopy to be very important. This reflects the growing significance
of endoscopy in the context of gynaecological specialty training. Course offerings
and the opportunity to attend courses are also considered to be significant in line
with the willingness of the participants to make their own financial investments.
This willingness on the part of the junior doctors to invest a substantial amount
of money in their own future and their own specialty training reflects the participantsʼ
desire for solid training in endoscopic techniques. The need for financial contributions
in the context of the specialty training and the acceptance of this by the junior
doctors also demonstrates the participantsʼ acknowledgement of the fact that adequate
specialty training also requires active participation on the part of the trainees.
In addition to courses that are linked to a certain amount of additional time and
expenses, nearly 50 % of the participants considered the opportunity for independent
training using hysteroscopy simulators and, in particular, laparoscopy simulators
as very important. This in turn demonstrates the junior doctorsʼ motivation to improve
and expand their own skills through their personal commitment.
At the international level, too, it has been shown that regular independent and mentor-guided
training using simulators can improve technical skills, shorten surgery time and in
turn, lead to better patient outcomes [1]. A standardized curriculum with respect to gynaecological endoscopic training is
recommended. Difficult endoscopic techniques such as suturing of the vaginal cuff
after total laparoscopic hysterectomy were significantly improved by means of simulation
training [2].
A further important aspect involves the participantsʼ ideas concerning the ideal number
of endoscopic procedures to be performed both as assistants and independently as surgeons
in order to ensure that specialty training is adequate. More than one third of the
participants said that at least 20 to 50 assisted endoscopic procedures each for diagnostic
and surgical hysteroscopy as well as diagnostic and surgical laparoscopy would be
ideal. Another third said that in fact more than 50 assisted procedures would be ideal.
Over 60 % of the participants would ideally like to perform over 30 endoscopic procedures
each themselves as the surgeon. Whether or not the participantsʼ desires can actually
be put into practice remains to be seen, especially with respect to the variations
in the range of surgical procedures at the hospitals of different sizes. However,
here too, the participantsʼ high level of interest in endoscopy and their strong desire
for in-depth endoscopic training are demonstrated.
The great need to improve specialty training with respect to endoscopy is reflected
by the fact that while at present, 37.7 % of the participants consider their expectations
for their current training institutions to be met in full or mostly, 49 % of the participants
consider their expectations to be met only in part or even only inadequately. Eighty-three
per cent of the respondents reported that they would change hospitals or their current
training institution in order to achieve their own goals if they were dissatisfied.
This shows potential for improving the current situation, since it would be desirable
to have a much higher percentage of junior doctors whose expectations were met at
least most of the time.
Another important result of the survey was the insight gained on the junior doctorsʼ
expectations for their instructors and their training institution. Based on the statements
in the survey, over half the participants assess technical expertise or technical
competency as very important. This demonstrates the junior doctorsʼ desire for their
instructors to convey solid technical expertise. This calls for a high level of quality
and sufficient experience with respect to surgical endoscopy on the part of both the
instructors and the training institutions. The willingness and the time for teaching
as well as patience on the part of the instructors were considered to be very important.
In this area, there was a significant difference between junior doctors in the first
to third training year and in the fourth to fifth training year, with the younger
junior doctors considering these aspects to be more important. There was also a significant
difference between female and male junior doctors with respect to the significance
of feedback/praise/constructive criticism, with women considering this aspect to be
more important. Among the participants, 48 % reported that their expectations were
met only in part or not adequately. With respect to the expectations for their training
institution, over 40 % of the participants assessed the number and range of operations
and being released for specialty training as very important, followed by modern instruments
and the coverage of costs for the training. There was a significant difference between
the various workplaces with respect to cost coverage for the training. Being released
from work to attend specialty training was more important for female junior doctors
than for their male counterparts. Among the participants, 45 % reported that their
expectations had been met only in part or inadequately. These results demonstrate
on the one hand that the conditions for adequate endoscopic specialty training are
in place with respect to the instructors and the training institutions, but that there
is a great deal of room for improvement when it comes to implementing the training
in practice. On the other hand, the high rate of participants who reported that their
expectations had been met only in part or inadequately shows that there is also a
great deal of room for improvement for endoscopic training during specialty training.
These data are comparable to the results of the German Medical Associationʼs evaluation
of specialty training conducted in 2011. During the evaluation, the overall assessment
for all disciplines was an average of 2.54 (1 = best possible mark), while the junior
doctors rated gynaecological specialty training in particular somewhat lower, with
an average mark of 2.60 [3].
On the specific question as to the participantsʼ degree of satisfaction with the current
situation, only 38 % of the participants reported that they were fully or mostly satisfied,
while 39 % said they were only partly satisfied and 23 % were even dissatisfied. It
would be desirable to significantly improve the junior doctorsʼ level of satisfaction
with regard to their endoscopic training, also taking into consideration the fact
that 81 % of the participants reported that they planned to work at a hospital after
completing their specialty training.
In general, the results show that while junior doctors do in fact participate in endoscopic
training during their gynaecological specialty training, such endoscopic training
can be expanded. Higher participation rates on the part of the junior doctors would
have made the results of the study more meaningful. In light of the fact that the
survey was sent out throughout Germany, the number of participants cannot be considered
to be fully representative. Furthermore, both a positive and a negative selection
bias can be assumed: participation by active and committed junior doctors who are
interested in improvement and further development, on the one hand, and participation
by junior doctors who are frustrated about the current situation, on the other.
A realistic and certainly effective means of increasing the junior doctorsʼ satisfaction
with the endoscopic specialty training would be to increase the number and frequency
of course offerings. The possibility for junior doctors to undergo training independently
using appropriate simulators could also significantly increase the junior doctorsʼ
satisfaction. In interdisciplinary and international comparison, too, the data situation
shows that independent training, e.g. with simulators, has been proven to enhance
effectiveness, technical expertise and technical skills [4], [5].
Endoscopic training leads not only to higher satisfaction on the part of the junior
doctors resulting from the improvement of their own skills, but also leads to shorter
operation times and smoother surgical work flows [6], [7]. At present, there is no reliable evidence for whether or not it can improve patient
outcomes or significantly lower overall costs [6].
In 2011, a survey on overall satisfaction in gynaecological specialty training was
conducted Germany-wide in which the current situation was evaluated both by junior
doctors and training instructors [8]. This survey also used an anonymous questionnaire; it involved 188 junior doctors
and 154 instructors. The assessment of satisfaction by the junior doctors was significantly
worse than the assessment of the training instructors. Here too, suggestions for improvement
included adaptation of the training content to the specialty training catalogues,
increasing investments in training models and standardizing curricula and surgical
training.
To improve endoscopic training in the context of gynaecological and obstetric specialty
training, the desires and ideas of the junior doctors should be addressed. The participantsʼ
desires with regard to the number of operations performed both as assistants and as
the surgeon coincide with the requirements for the MIS I certificate. It would be
desirable to adapt the requirements for the MIS I certificate to the results of this
survey and the junior doctorsʼ expectations. The objective should be the capacity
to meet the requirements for the MIS I certificate at the time of the specialty training
examination.
The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA)
also acknowledged the need to standardize endoscopic training in order to ensure the
highest possible quality of surgical treatment with a low rate of patient mortality
and morbidity. Similar to the MIS certification (I–III), here too, a two-step model
was developed for achieving a certificate in gynaecological endoscopy with the possibility
of structured further training culminating in the Master level [9].
With respect to advanced laparoscopic surgery in general, especially regarding sophisticated
suturing techniques, bimanual coordination and dealing with difficult anatomical circumstances,
there appears to be a need for a set curriculum for junior doctors in the area of
minimally invasive surgery [10].
The Working Group for Gynaecological Endoscopy (AGE), the German Society of Gynaecology
and Obstetrics (DGGG), and the Junges Forum of the DGGG all already endeavour to achieve
a high-quality training programme for junior doctors by offering support and research
grants. For example, this year a new course will be offered by the Junges Forum in
collaboration with the AGE: a basic MIS I course specifically for specialty training
assistants as an introduction to gynaecological endoscopy.
In general, 35 % of the surveyed junior doctors reported that their expectations were
inadequately or hardly met or were not met at all. However, in order to offer adequate
training, solid high-quality expertise and skills on the part of the instructors is
indispensable. For this reason, the instructorsʼ expectations, training status and
ideas are just as important. The only way to achieve the highest possible quality
standards is to work together. With this survey, current data on this topic have been
gathered and evaluated Germany-wide for the first time. The outcome will ideally serve
as an impetus and starting point for further improvement of endoscopic training in
Germany.
Acknowledgements
We would like to express our gratitude to the participants in this survey. We also
thank the Working Group of the Junges Forum of the DGGG for its support and for sending
the questionnaire via its distribution list. In addition, we would like to thank AGE
for its support and for sending the questionnaire.
