In Gippsland, Victoria, we have created a post-DRANZCOG pathway to successfully facilitate the transition from hospital house medical officer to independent, competent and confident GP obstetrician.
Many DRANZCOG and DRANZCOG Advanced trainees feel ill-equipped to undertake independent intrapartum care at the completion of their training term. This represents a missed opportunity to realise the potential to create new GP obstetricians (GPOs). This is unfortunate as GPOs have much to offer women at all stages of their pregnancy journey. Contributing factors may include the lack of a clear career pathway (more likely if trained in a unit where there are no practising GPOs), lack of confidence in their skills (real or perceived) and a perception that procedural medicine is no longer a part of modern general practice. The latter is often reinforced by colleagues and superiors who are now, more then ever, likely to be non-proceduralists.
In Gippsland, like most rural areas of Australia, the declining numbers of GPOs has threatened the viability of maternity services. If these units were to close, it would result in greater pressure on the larger regional units and their specialist obstetricians. In recognition of this, there has been an increasingly coordinated Gippsland-wide approach to the development of GPO training and continuing professional development (CPD) program. This has included expansion of DRANZCOG training at the larger (specialist-led) units, including a three-month rotation to Dandenong Hospital; post-DRANZCOG posts – Community Obstetric Bridging Posts (COBP) – at the same units in addition to the smaller (GPO-led) units; upskilling of existing GPOs to provide lower uterine segment caesarean section (LUSCS); regional GPO days; specialist support/mentoring to regional GPOs through an informal email Q&A forum; and specialist involvement in subregional education meetings. The program is continuing to evolve with new developments, such as rotations to Katherine in the Northern Territory and shared care credentialing.
These combined efforts have resulted in a resurrection of GP obstetrics as an exciting and vibrant subsection of general practice in Gippsland. There is a sense that GPOs belong to a special club of proceduralists. Registrars are now competing for training positions, leading to a higher calibre of trainees. One GP registrar who wasn’t participating in intrapartum care, despite having completed her DRANZCOG in Melbourne, commented she felt that she was missing out compared to her participating colleagues. She is now planning to undertake DRANZCOG Advanced training.
One of the key elements to the success of the regional GPO training has been the post-DRANZCOG pathway, referred to locally as COBPs. The COBPs are the result of a partnership between Southern General Practice Training (SGPT), the local provider of GP training, general practices, hospitals and the Victorian Department of Health. They involve 12 months of full-time training consisting of a general practice training term and a community-based obstetric term run concurrently over the year. The trainee is based in a general practice clinic where, ideally, there are established GPOs and procedural medicine is encouraged.
The COBP can contribute to the fourth year of training (advanced special skills) in both the Royal Australian College of General Practitioners (RACGP) and Australian College of Rural and Remote Medicine (ACRRM) training pathways.
The COBP follows on from the hospital-based DRANZCOG training term so, from day one within the GP clinic environment, trainees are developing their identity as a procedural GP. Specific activities of the post depend on the requirements of the trainee, but common components include:
- participation in antenatal clinics, working alongside a specialistor GPOs;
- facilitation of a significant intrapartum workload, in other words first on call for labour ward, with a senior doctor available as back up;
- supernumerary attendance at elective LUSCS lists (often atlarger regional or metropolitan hospitals);
- attendance at RANZCOG Provincial Fellows Meetings and the Annual Scientific Meeting;
- completion of any recommended courses not achieved during training term, for example, the Vacca Research Vacuum assisted Delivery Workshop, and intermediate ultrasound; and
- the consolidation of a network of experienced colleagues for support and mentoring.
‘There is a steep learning curve going from resident-type obstetrics to GPO and the bridging post allowed that transition to happen in a more secure or protected setting. I gained a lot of advice from my GPO colleagues and the consultant obstetricians to help make myself a framework for my scope of practice, my comfort zone and my boundaries as to what I am comfortable with and what needs referral. I got the sense that I was a valued member of the team in our local maternity services and, as such, my colleagues had an interest in making sure I didn’t get burned too early in the game. It was good to be able to see a blend of antenates both in general practice and the shared-care women in the hospital antenatal clinic and, of course, the rostered night first on call for the week ensured I still had a lot of supported labour ward experience while I built up my case load in my first few months as a basic term GP registrar. The most satisfying part of the bridging post was the continuity of care with women and their families from pre-conception counselling through to the postpartum period and, excitingly, the subsequent pregnancies.’
Throughout the COBP, supervision is commensurate with the trainee’s abilities and inevitably it is reduced over the course of the year as the trainee’s confidence and competence builds. For example, supervisors may attend initially for all mid-cavity instrumental deliveries, then may be onsite, then informed and, finally, simply be available should the trainee request advice or assistance.
In our situation funding is supernumerary, allowing the trainee to be paid via a salary and the supervisor according to their usual remuneration. Around the country different funding options are potentially available.
So far, the results have been very positive. Of 12 doctors who have undertaken a COBP, ten continue to practice intrapartum care. The other two doctors provide significant antenatal and postnatal care to women in their communities (one metropolitan). Owing to the success of the program, we have nearly saturated the capacity of the Gippsland maternity services to accommodate new doctors. This is a very nice ‘problem’ to have.
Other key elements to the success of our regional program have been the good will and vision of key clinicians such as Dr David Simon, staff specialist at the West Gippsland Healthcare Group, and Dr James Brown, director of training at SGPT. They are currently undertaking a formal evaluation of the program in partnership with Monash University.
A structured post-DRANZCOG pathway has proven to be an effective method to transform DRANZCOG holders into valuable independent competent and confident GPOs in Gippsland, contributing to a vibrant and flourishing obstetric workforce.