Development and launch of the first obstetrics and gynaecology master of medicine residency training programme in Botswana

Background: Sub-Saharan Africa (SSA) faces a severe shortage of Obstetrician Gynaecologists (OBGYNs). While the Lancet Commission for Global Surgery recommends 20 OBGYNs per 100,000 population, Botswana has only 40 OBGYNs for a population of 2.3 million. We describe the development of the first OBGYN Master of Medicine (MMed) training programme in Botswana to address this human resource shortage. Methods: We developed a 4-year OBGYN MMed programme at the University of Botswana (UB) using the Kern’s approach. In-line with UB MMed standards, the programme includes clinical apprenticeship training complemented by didactic and research requirements. We benchmarked curriculum content, learning outcomes, competencies, assessment strategies and research requirements with regional and international programmes. We engaged relevant local stakeholders and developed international collaborations to support in-country subspecialty training. Results: The OBGYN MMed curriculum was completed and approved by all relevant UB bodies within ten months during which time additional staff were recruited and programme financing was assured. The programme was advertised immediately; 26 candidates applied for four positions, and all selected candidates accepted. The programme was launched in January 2020 with government salary support of all residents. The clinical rotations and curricular development have been rolled out successfully. The first round of continuous assessment of residents was performed and internal programme evaluation was conducted. The national accreditation process was initiated. Conclusion: Training OBGYNs in-country has many benefits to health systems in SSA. Curricula can be adjusted to local resource context yet achieve international standards through thoughtful design and purposeful collaborations.

The University of Botswana (UB) established the only medical school in the country in 2009 and is the only institution offering post-graduate medical training. UB has a clear process for programme approval and pathway to national accreditation, with existing MMed residency training programmes in Internal Medicine, Paediatrics, Family Medicine, Emergency Medicine, Pathology, Anaesthesia and Public Health. Except for Family Medicine and Public Health, all MMed training programmes are “sandwich” programmes, with partial training in Botswana and more specialized tertiary and quaternary training in South Africa. OBGYN aimed to create a fully in-country MMed programme that meets international curricular standards, anticipates national and international accreditation, and enables further sub-specialization. We approached our OBGYN MMed training programme development using the Kern’s 6-step approach namely: 1) general needs assessment, 2) targeted needs assessment, 3) delineating learning outcomes, 4) designing educational strategies, curricular structure and content, 5) implementing the curriculum and 6) evaluating the curriculum [17]. The Faculty of Medicine conducted a general needs assessment for medical training in the country prior to establishing the medical school. They reviewed key government documents and policies, Botswana Health Professions Council records, hospital staffing levels, availability of citizen doctors and specialty service availability. Their findings demonstrated a lack of available specialty services and a public desire for access to Batswana doctors. The department of OBGYN conducted a targeted needs assessment specific to OBGYN and women’s health in the country. The Botswana Ministry of Health and Wellness’ (MOHW) Integrated Health Service Delivery Strategic Plan for 2010–2020 delineated their priorities for the health services sector, including achieving optimal comprehensive sexual and reproductive health for women and ensuring access to high quality antenatal and perinatal care [18]. Principal challenges preventing achievement of the strategic objectives included excessive shortage of skilled human resources, poor quality of care, and lack of quality management and regulation in both the public and private sector. Particularly for OBGYN, the few specialists working in the public sector only staff 4 of the 31 hospitals where the general public can seek free care. The waiting time to see a specialist at the tertiary referral hospital in the Southern Region is at least eight months, and surgical waiting times after evaluation is another eight to twelve months. There is limited access to sub-specialty gynaecologic care. There is one Gynaecologic Oncologist who provides care in the public sector and one Reproductive Endocrinologist who offers services in the private sector. There are no maternal-fetal medicine, urogynaecology, nor minimally invasive gynaecologic surgical specialists in the country, and no pipeline of trained OBGYNs to send to these training programmes. In addition to the lack of specialists, there is no regulation of the quality of services provided, nor national standard OBGYN practice guidelines. The OBGYN MMed programme was developed in consultation with relevant stakeholders. Involvement of the MOHW, Botswana Health Professions Council, and the Botswana Qualifications Authority ensured that the programme complies with the national vision for comprehensive sexual and reproductive health services and meets national accreditation standards. Input from OBGYN specialists with diverse training backgrounds from both public and private sectors in Botswana ensured that our curriculum aligned with practice expectations. Departments associated with academic programme development at UB and departments concurrently developing MMed programmes provided essential guidance on the process. Finally, we assessed the demand for specialty training in OBGYN by involving potential future trainees in consultative meetings with stakeholders. In addition to the five cohorts of graduated medical students from UB, there are Batswana and non-Batswana graduates of foreign medical schools who are working in the country while awaiting opportunities to specialise. In-country training is an attractive option to many, particularly those with families and other personal commitments in Botswana. Six essential learning outcomes were delineated in-line with international graduate medical education standards, alongside evaluation criteria that guide resident assessment of outcome attainment [19]. The learning outcomes were aligned and mapped to the Botswana Health Professions Council and Botswana Qualifications authority guidelines for accreditation of a programme. A formal comparison of the UB curriculum to regional and international training programmes in regards to learning outcomes, curriculum domains covered, credit weighting, assessment strategy, qualification requirements and employment pathways was produced. Additionally, specific minimum standards for procedure numbers and competence were delineated for general OBGYN skills and benchmarked against international programmes. All clinical post-graduate medical training programmes at UB are designed as MMed programmes, and include didactics, clinical apprenticeship training, and research requirements. The OBGYN programme is structured as a 4-year integrated and spiralling clinical apprenticeship and capitalizes on the infrastructure of existing MMed programmes at UB, particularly for courses beyond the OBGYN-specific course content (Table 1). The spiralling nature of the curriculum allows residents initial exposures to curricular content through clinical work and didactics, and then repeated exposure allowing deeper understanding during their training. The spiralling approach is purposefully applied to deliver increasingly complex content, at various learning events across multiple levels of the training. Residents are expected to mature in competence and confidence as they progress through the programme. Advanced clinical knowledge and skill is accompanied by graded clinical responsibility fostered through a multi-year student and resident team structure, led by senior residents. The Obstetrics and Gynaecology Master in Medicine course sequence aUB University of Botswana An example of the spiralling curriculum is how we planned to teach the topic of labour. In the course Introduction to OBGYN in year one, the resident will master knowledge and skills in the mechanism and physiology of labour, as well as the management of labour. In their clinical rotations they will participate in care on the labour ward. In the course Intermediate OBGYN in year two, they are expected to understand management of normal and abnormal labour while additionally mastering operative vaginal delivery and labour complicated by malpresentation. They will have increased responsibility in their clinical rotations on labour ward and be expected to perform supervised procedures, operative vaginal delivery and external cephalic version. Finally, in Advanced OBGYN in years three and four, the resident will be expected to understand and independently manage pregnancy complications such as preterm prelabour rupture of members, high-risk medical conditions in pregnancy and coordinate interdisciplinary teams managing high-risk pregnancies. In their clinical rotations, they will lead and teach junior residents and medical students in antepartum care and on labour ward. OBGYN curriculum development required review of content and competencies from regional and international OBGYN training programmes. In addition to review of formal curricula, a regional benchmarking visit to the University of Cape Town provided the opportunity for discussion and clarification of essential and advanced content available at a rigorous programme in the region. Considering regional and international curriculum standards, we created our unique curriculum in accordance with UB templates and requirements for proposal of a new academic programme. After refinement of overall curriculum, the content was allocated to semester courses within the UB MMed framework to guide educational programming. Clinical rotations were purposefully designed to provide exposure to course content, provide strong core and subspecialty OBGYN training, as well as exposure to other essential fields (such as surgery and radiology). Learning outcomes and curriculum content were mapped to educational events in specific courses to ensure the delivery of courses would facilitate attainment of the specified learning outcomes and requisite curricular content to become competent independent practitioners. The OBGYN specific courses in the MMed curriculum were designed as synchronous apprenticeship-based learning. Residents are in the clinical setting on a near daily basis. Clinical learning events include daily specialist ward rounds, precepted outpatient clinics, and supervised theatre cases. Residents have the opportunity to work one-on-one with specialists, as well as together in a team of learners of all levels of the medical training hierarchy. The graduate medical education courses required for all MMed programmes at UB are designed as week-long intensive courses and residents are excused from clinical duties during these courses. UB Faculty of Medicine uses asynchronous learner-centred, problem-based curriculum, and this framework guided the design of didactics [15]. Learning is largely self-directed, complemented by two hours per week of synchronous faculty-facilitated discussions or resident presentations. Additional synchronous learning events include monthly journal clubs, patient management sessions, research supervision sessions, and maternal and perinatal morbidity and mortality conferences. Among these sessions, opportunities for interdepartmental engagement with Surgery, Emergency Medicine, Paediatrics and Anaesthesia allow relevant interdisciplinary topics to be explored. The programme operates under the general regulations of the UB School of Graduate Studies and the Faculty of Medicine. Continuous and summative assessments enable formal resident feedback. Biannual continuous assessment uses the milestone framework, in addition to logbook evaluation [20]. Summative assessment is designed as an internally and externally moderated annual examination. Engagement in research and submission of an original thesis is a qualification requirement for all UB MMed candidates. Opportunities for remediation and requirements for progression are clearly elaborated. Annual programme and faculty evaluations were designed to be administered through anonymous resident surveys. Additionally, residents are provided the opportunity to give confidential direct feedback at their biannual continuous assessment reviews with programme leadership. This feedback and evaluation allow the opportunity for the programme to respond dynamically to meet the needs of its trainees and improve the quality of delivery of its content. Increased OBGYN department staffing to serve as clinician educators was identified as essential to the successful rollout of the programme. The department had 4 OBGYN generalists at initiation of design of the programme, from Ethiopia, Tanzania, Uganda, and the United States of America. Purposeful faculty recruitment to strengthen clinical, educational and research activities in the department was undertaken, with the aim of attaining a 2:1 trainee to teacher ratio. Clinical sites were considered based on volume and variety of cases to ensure adequate exposure to the curricular content. The primary training site was determined to be the largest referral hospital in the country, which has 570 beds, an adequate variety of cases, adequate theatre volume, essential specialty clinics, and high-volume inpatient wards. Other specialities including surgery, radiology, anaesthesia and intensive care which support optimal OBGYN training are also available on-site. Full-time UB OBGYN faculty supervise and teach residents. Additional training sites would be considered in the future, given adequate supervision, volume, and acuity. UB has a well-resourced library with comprehensive resources, including books, journals, electronic databases, and mobile applications. UB had allocated funding for increased senior-level staffing. Additional costs were anticipated for visiting scholars to supplement subspecialty training. Funding for resident salaries, tuition and accommodation was sought from the MOHW.

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