When I achieved my Diploma of Obstetrics in 1980 from the then newly incorporated Australian College of O&G (RACOG), having completed a six-month obstetric term and successfully passing my written and oral examinations, I did not feel adequately prepared to provide a full obstetric service in a rural location. The consultants, registrars and midwifery staff who led my training were fantastic, but six months is a very short time, even in a busy unit, to achieve not only competency but also confidence in the necessary skills. Hence began my long career in upskilling in obstetrics and women’s health. There was no provision for extra obstetric training or supervision for GPs in Australia at that time, so, along with several other Australian graduates, I headed overseas to ‘practise on the pommies’ as their NHS provided a predominantly public health system where new skills could be learnt, and acquired skills improved and fine-tuned.
The DRANZCOG training supervisors and recent graduates that I speak to today tell a similar story, so that, despite the transition to a minimum twelve-months DRANZCOG Advanced training program, the reduced exposure to procedural training and the increasing litigious society has left new graduates in limbo, having learnt essential skills that are desperately needed in the extensive rural and remote areas of Australia, but feeling underprepared to venture into largely unsupervised practice. Even after my extended experience in the UK, I still keenly remember the panic I felt the first time I had to make the decision to perform an emergency caesarean section without having a higher authority to defer to. The decision was obvious (a brow presentation), but it was the sudden realisation that the buck stops here and that I was on my own.
Prior to 1989 there was no official requirement for GP obstetricians (GPOs) to engage in ongoing education or the accumulation of CPD points, and before the introduction of the Rural Procedural Grants Program in 2004 there was no financial assistance provided for GPOs to leave their practices to enhance their skills. The indemnity crisis in 2000 resulted in over 75% of GPOs ceasing intrapartum care, and Australia has failed to catch up since this loss, with ongoing closures of rural birthing units and a generation of rural overworked and under-resourced GPOs that will be difficult to replace with our new cohort of graduates who, rightly, expect a better work-life balance.
Upskilling for GPOs means having the opportunity to maintain, consolidate and improve core obstetric skills like performing caesarean sections and procedural deliveries, but also incorporates the learning of new skills that might fill a need in that practitioner’s community, such as providing termination services beyond the first trimester or offering a colposcopy service.
It is imperative that urban and regional hospitals have an ongoing relationship with the rural units in their catchment area, that they offer new graduates extended supervised positions to help prepare them for rural practice and that they allow GPOs to attend their units for essential upskilling, especially in performing caesarean sections and procedural deliveries and managing obstetric emergencies. All units should invite the GPOs in their area providing intrapartum care to their regular M&M meetings, either in person or via video conferencing, as these meetings provide valuable opportunities to learn of the potential hazards of obstetric practice (and how to avoid them), and facilitates a healthy relationship within the obstetric team. Both DRANZCOG and FRANZCOG trainees achieve significant benefit from this interaction in understanding the unique needs and challenges of rural obstetric practice.
Many GPOs have had difficulty arranging hospital clinical attachments for upskilling. Many hospitals refuse requests for upskilling and others charge exorbitant fees to allow GPOs to ‘work’ on their maternity unit. Some regions do provide excellent upskilling opportunities with GPOs given the option of covering training registrars on leave or rural placement and reducing the need for locum registrars at that site. Unfortunately, most regional and urban hospitals do not currently have a program to engage GPOs.
There is currently no available assistance to arrange placements and GPOs are responsible for finding their own training sites. RANZCOG is working to improve this process by requiring FRANZCOG training sites to offer GP upskilling opportunities and by the roll out of our OGET project (read our related article), where regional centres will be responsible for, and be provided with, government funding for ongoing obstetric training within their catchment area.
My personal journey in upskilling has incorporated the usual courses, workshops and conferences. ALSO, MOET, FSEP, Anatomy of Complications, PROMPT, Ultrasound and OASIS workshops are, or were, all invaluable for GPO practice. I have always attended M&M meetings where possible and always took the opportunity when assisting in gynaecological or obstetric surgery to pick the brain of the consultant I was working with. Upskilling hospital opportunities have provided excellent skills training and the opportunity to interact with the local team. I have assisted in my local regional hospital’s public antenatal clinic and labour ward when staffing issues arise, and this has enabled me to enjoy a valuable association with the consultants and trainees in that setting.
Better engagement between regional and urban hospital birthing units and rural units in their area is essential to providing safe, optimal care for rural and remote Australian families. Where possible, low-risk pregnant persons should not have to travel long distances to access safe obstetric care with the associated risks of prolonged time away from home, family and local supports, and the very real concern of births occurring en route to the hospital. The unique skills and challenges of GPOs and midwives working remotely should be understood so that they remain well supported and provided with appropriate advice when required.
Learning as a GP never ends, and this is particularly true in the field of women’s health. I am still constantly challenged by my patients, whether with the unique symptoms they describe, their individual response to therapy or their specific needs. Australia needs an ongoing GPO workforce.