Relevance of Otago University postgraduate programmes in women’s health to general practice: a case study

KEYwords: General practitioners; gynaecology; obstetrics; postgraduate education.

In New Zealand, women attend primary health care in higher numbers than men¹ and have unique health issues related to menstruation, fertility, pregnancy, childbirth, breastfeeding and menopause.² Medical practitioners who intend to practice in primary health care consider a postgraduate programme in women’s health as important, and necessary to extend undergraduate training.^3,4 Postgraduate programmes in women’s health provide formal training in pregnancy care, sexual health, contraception and other gynaecological care. The scope of obstetric and women’s health care is dictated by public funding direction, with general practice supporting health-care models such as the Lead Maternity Carer (LMC) that allows women to choose a midwife or obstetrician for pregnancy care; and funding of services and consumables in sexual and reproductive health services in New Zealand.^5,6 In parallel, women’s participation in multiple roles such as childcare, family, household responsibilities, paid employment and community activities have increased health-care requirements related to psychosocial stress.² These changes in health priorities have influenced what general practitioners (GPs) need to know in caring for women in the community. As a result, it is important to revisit postgraduate training in women’s health to support GPs with evidence-based knowledge and new skills for women’s changing health needs in primary care.

The Department of Women’s health at the University of Otago, has offered a distance-taught Postgraduate Diploma in Obstetrics Programme (DipObst) since 1992.⁷ This programme consisted of two papers (six modules in each paper) delivered through case-based learning by audio conference. The modules were developed by practicing specialists in obstetrics or gynaecology located across New Zealand. In 2003, the programme was revised to include more papers and renamed as the Diploma in Obstetrics and Medical Gynaecology (PGDipOMG; subsequently in this paper ‘Diploma’). A postgraduate Certificate in Women’s health (PGCertWHlth; subsequently in this paper ‘Certificate’) was also introduced.³ At present, the Diploma programme can be completed in a minimum of 1 year and comprises four distance-taught papers delivered through video conference, two residential papers and one clinical training paper.⁸ The Certificate programme requires three of four distance-taught papers and one of two residential papers.⁹ The curricula of the postgraduate programmes have essentially remained the same since 2003.

The views of GPs about the relevance of the curricula have not been ascertained previously, but this is crucial to ensure that the curriculum aligns with contemporary general practice and is relevant for GP learning and practice in the area of women’s health. The primary aim of this study was to evaluate the perceived relevance of Otago University’s Diploma and Certificate curricula to GPs’ work, with the aim of identifying any need for curricular change. The second aim of the study was to investigate the views of GPs about refresher courses and a Master’s degree in obstetrics and gynaecology.

A case study research approach is used to obtain an in-depth understanding of a phenomenon in a real-life setting¹⁰ and is widely used in medical education research.¹¹ We chose a case study research design to understand the usefulness of postgraduate programmes in women’s health in the context of general practice. For our single case study, we sampled multiple years of postgraduates in women’s health and used a mixed-method survey that included multiple choice questions and optional free-text comments.

We developed a questionnaire consisting of questions about demography (ethnicity and gender), practice setting (type of GP practice, years of clinical experience, region of practice), and educational experience (postgraduate programme completed, year of postgraduate study). Questions about the postgraduate programmes explored the relevance of papers and modules and were rated using five-point Likert scale ratings with anchors of ‘extremely relevant’ to ‘not relevant at all’, and usefulness of teaching method in papers (extremely useful – not useful at all). To describe relevance ratings, we used the terms ‘very relevant’ (‘extremely’ and ‘very relevant’ combined in analysis), ‘moderately relevant’ and ‘less relevant’ (‘slightly’ and ‘not at all relevant’ combined in analysis).

To identify interest in refresher workshops and a Master’s degree programme, questions had dichotomous (YES or NO) responses. Options for free-text comments were provided after each domain of the survey (distance-taught papers, clinical paper, residential papers, teaching methods, refresher courses, Master’s degree programme). The survey was delivered via Qualtrics^XM (Core Experience Management, software company) and was piloted with seven GPs working in the Department of Primary Health Care, University of Otago, Wellington. Feedback was used to refine the survey tool. The survey tool is provided in Supplementary material S1. Ethical approval for the study was obtained from the University of Otago Human Ethics Committee (D19_375).

Both GPs and GP trainees in the General Practice Education Programme (GPEP) who had completed postgraduate studies in women’s health (Diploma or Certificate) at the University of Otago were invited to complete the online survey. The University of Otago Alumni Relations Office emailed the study invitation and survey link to the 426 graduates of Diploma and Certificate programmes from 2003 to 2019 who had consented to receive University emails. Data regarding the number of graduates who currently worked as GPs were not available, so the survey was sent to all 426 graduates. The graduates were asked to complete the survey within 3 weeks. A reminder email was sent after 2 weeks. Additionally, the Royal New Zealand College of General Practitioners advertised the link for the online survey in ‘Pulse’, an e-newsletter for GPs in New Zealand.

Descriptive statistics were used to analyse multiple-choice answers. Qualitative analysis of free-text survey responses was performed using thematic analysis.¹² The free-text comments on papers, teaching method, refresher courses and a Master’s degree programme were collated and coded to develop categories and themes. The descriptive data were merged with qualitative categories and are presented in the findings.

The study had 86 responses from graduates who completed the postgraduate programme in women’s health and worked as GPs, but 13 responses were incomplete (did not respond to relevance of any paper) and were excluded from analysis, giving an overall response rate of 17.1%. The characteristics of respondents are provided in Table 1. Of the 73 respondents returning completed survey forms, 29 (39.7%) had completed the Diploma and 46 (63.0%) had completed the Certificate programme. Most (60; 82.2%) were female and nearly all worked in urban settings (71; 97.3%). Most (58; 79.5%) respondents had more than 6 years of clinical experience.

Table 1.  Characteristics of respondents (n = 73)

There were 129 free-text comments, including 23 on relevance of distance taught papers, nine on relevance of residential papers, 14 on relevance of a clinical paper, 13 on usefulness of teaching methods, 45 on the refresher workshops and 25 on a Master’s degree programme.

The overall curriculum in the postgraduate programme was rated very relevant by 60 GPs (82.2%), moderately relevant by 11 GPs (15.1%) and less relevant by two GPs (2.7%). Table 2 shows ratings of the relevance to general practice of curriculum papers and modules in Diploma and Certificate programmes. Themes from the analysis of free-text responses, with supporting comments, are provided in Table 3. The combined findings from the survey rating and free-text data responses are presented below.

Table 2.  Perceived relevance of papers in Diploma and Certificate programmes to general practice

Table 3.  Themes emerging from the analysis of free-text comments

General practitioners rated distance-taught papers related to sexual and gynaecological health as very relevant for practice. In particular, >75% of GPs considered modules related to fertility regulation and contraception, sexual health, menstrual disorders, menopause and termination of pregnancy as very relevant. More than 62% of GPs considered preconceptual counselling, early pregnancy care, gynaecological conditions such as infertility, incontinence, prolapse and adolescent gynaecology as very relevant. Among residential papers, >73% of GPs rated topics related to antenatal care, management of early pregnancy loss, contraception, sexual abuse, procedures for termination of pregnancy and training in gynaecological procedural skills as very relevant. Of the 26 GPs who had completed a Diploma with supervised clinical practice, 18 (69.2%) found a clinical placement of six months and 17 (65.4%) found attachment to family planning clinics very relevant to GP practice.

Free-text analysis showed that GPs were more involved in gynaecological care than pregnancy-related care. They suggested the inclusion in the Diploma and Certificate of more clinical training about family planning, sexual health and long-acting reversible contraceptives (LARC) insertion including implants (Pipelles and Jadelles) and intra uterine devices (IUD) such as Mirena®. GPs highlighted the importance of being able to fit LARCS independently. GPs reported that they are often consulted for postnatal lactation and breastfeeding problems and suggested more education on low breast milk supply, mastitis and painful feeding, care for crying or irritable babies, and postnatal depression.

General practitioners rated the distance-taught paper (OBGY 713) with modules related to pregnancy and postnatal care in the community as less relevant. Modules related to obstetric emergencies and birth matters were considered less relevant by nearly 50% of GPs. Similarly, modules of residential papers regarded as less relevant to GP practice were obstetric and gynaecological emergencies (24; 42.1%), cardiotocography interpretation (40; 72.7%) and examination and resuscitation of newborn babies (21; 38.2%). With the clinical training paper as part of the Diploma, 13 GPs (50%) rated attachment to an antenatal clinic as moderately relevant and 8 (30.8%) considered it as less relevant.

GPs commented that training in early pregnancy and screening consultations could be useful in places where there was a shortage of Lead Maternity Carers, but they considered attending deliveries as part of clinical placement not relevant to current health service models as Lead Maternity Carers, who are mostly midwives, attend deliveries and address obstetric emergencies and neonatal issues.

Audio-conferences for distance-taught papers were rated very useful by 34 GPs (55.7%) and workshops as part of residential courses were considered very useful by 49 GPs (81.6%). Almost all respondents (21; 95.4%) considered clinical placements in hospital with attachments to antenatal and family planning clinics very useful as part of the clinical paper in the Diploma programme.

GPs considered audio-conferences interactive and useful to discuss difficult cases from their own practice. They also found pre-recorded lectures useful due to some difficulty in concentrating on audioconference discussions after working full days in clinical practice. They reported that some papers were not up to date with research evidence for clinical practice and lacked updated information. One GP stated that guidelines for GP practice are important for management of certain conditions in their busy practice schedule.

Refresher courses or workshops were of interest to 46 GPs (76.6%) who considered refresher programmes an excellent ongoing learning opportunity to keep updated with evidence-based current knowledge and guidelines for management of conditions. Refresher courses were preferred for topics such as contraception, cervical screening and management of gynaecological conditions including urinary incontinence, polycystic ovarian syndrome, amenorrhoea in obese women, endometriosis, bleeding while on contraception, abnormal uterine bleeding, fertility issues, sub-fertility, gynaecological malignancies, peri-menopausal issues and pelvic pain. GPs favoured refresher courses with both web-based distance learning for theoretical knowledge and hands on training for procedural skills such as IUD insertion and the technique of cervical blocks for IUD insertion.

Only 20 (33.8%) GPs expressed interest in a Master’s degree programme in women’s health and reported cost and time as barriers to Master’s-level study. The two GPs who stated their research topics of interest would like to research indigenous women’s sexual and reproductive health experience and taking a cultural perspective to explore the effect of trauma on indigenous women’s health.

This study explored the views of GPs who had completed Otago University’s postgraduate programme in women’s health regarding the relevance of the curriculum they studied to their current general practice and the need for new training programmes. The participants considered the postgraduate programmes very relevant due to the training they provided in contraception, sexual health, abortion, common postnatal conditions and gynaecological conditions. However, they emphasised they needed more updated education for contraception, infertility and gynaecological conditions associated with pelvic pain and abnormal uterine bleeding.

Particularly, GPs valued in-depth clinical training in insertion of LARC. A recent health survey found that 80% of women aged 16–49 years who were sexually active used at least one form of contraception, including 74% who used contraception methods such as implants, IUDs, tubal ligation, injections and pills.¹³ Furthermore, introduction of government funding for Levonorgestrel Intrauterine Systems, Mirena® and Jaydess®, in October 2019 has increased the number of women consulting GPs for LARCs, including IUD insertions.¹⁴ A recent study in Australia showed the increase in LARC prescription by GP registrars, which was associated with completion of relevant postgraduate training.¹⁵ For contraception, LARCs are efficient¹⁶ and additional education and training with LARC insertion is recommended for GPs to support LARC prescription to prevent unintended pregnancies.¹⁷ Further education could support GPs to use LARC for efficient management of gynaecological conditions such as abnormal uterine bleeding.¹⁸

General practitioners indicated that the obstetric care curriculum of the Diploma was less relevant to their educational needs. This is related to the introduction of the Lead Maternity Carer model in 1996,⁵ which significantly reduced the number of GPs practising obstetric care.³ However, most GPs who responded to our survey participated in antenatal care in the first trimester and considered training with respect to antenatal care important. They were also involved in post-partum care and suggested a need for more education in lactation and maternal depression. In an Australian cohort study of GP trainees, antenatal care comprised 1.1% of trainee problems and diagnoses and post-partum care comprised 0.2% of diagnosis issues.^19,20 These consultations were significantly associated with female trainees holding previous postgraduate qualifications in obstetrics and gynaecology. Thus, for GP engagement in antenatal and postnatal medical issues, postgraduate training is important.

GPs who completed the Diploma programme had access to clinical training in family planning clinics along with obstetric wards, whereas GPs who completed the Certificate programme were not required to have clinical placements. For prospective medical practitioners aiming to work as GPs in New Zealand, a dedicated postgraduate programme in women’s health with papers with increased teaching and learning time for gynaecological care would be beneficial. A separate clinical paper of shorter duration that includes clinical placements in family planning clinics (to have supervised clinical practice for LARC (Mirena®, Jadelle, and Pipelle insertions) could help graduates use more efficient methods for implant and IUD insertions in general practice. National LARC training curricula are presently being negotiated and when they have been approved, they will be incorporated into the Diploma programme.

We suggest revision of the educational content of the modules to provide updated knowledge that reflects current research evidence. We also suggest provision of protocols, guidelines, summarised key points, and recent educational resources for management of conditions. Audio- and video-conferences as part of distance-taught papers could be provided in recorded podcast format to enable more flexible asynchronous learning. Further consideration of inclusion of online learning underpinned by principles of adult learning is also warranted.

GPs have indicated in this study that they would benefit from refresher courses or workshops to update them with the knowledge and skills needed to improve the standard of care for women. To support current practice, refresher workshops should be developed for management of contraception, fertility, pelvic pain and abnormal uterine bleeding, including procedural training for LARC insertion. Refresher courses that are of shorter duration and provide credit points for maintaining GP registration could be helpful. We recommend provision of individual modules in postgraduate programmes in women’s health to be self-selected and developed into a self-designed paper or course optimal for each individual’s needs.²¹

A key limitation of the study is a low response rate of 17.1%. A previous survey in 2006 about the current practice of past women’s health postgraduate students indicated that 63% worked in general practice.³ In the current study, it was not possible for us to determine the number of postgraduate students who worked as GPs as we did not collect these data. One of the reasons for this low response rate in our study could be that the survey was conducted in March 2020 and GPs’ focus on COVID-19 (Coronavirus) pandemic responsibilities may have de-prioritised responding to this survey. A low response rate to online surveys by medical practitioners is known to be common due to reasons such as lack of time and little interest in the research topic.^22,23

This case study informs some changes to the University of Otago’s Diploma and Certificate postgraduate programme in women’s health. This study also highlights the need for regular assessment of postgraduate programme curricula to understand its relevance to graduates’ work profiles.

The authors declare no competing interests.