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EDUCATION

Undergraduate obstetrics and gynecology medical

education: why are we underrated and underappreciated?
Archana Pradhan, MD, MPH; Sarah Page-Ramsey, MD; Samantha D. Buery-Joyner, MD; LaTasha B. Craig, MD;
John L. Dalrymple, MD; David A. Forstein, DO; Scott Graziano, MD; Brittany S. Hampton, MD; Laura Hopkins, MD;
Margaret McKenzie, MD; Abigail Wolf, MD; Jodi F. Abbott, MD

bstetrics and gynecology education is one of the lowestranked medical school experiences by US medical
school graduates. The inability to provide students with
experiential excellence could be a detriment to our patients.
The causes of student dissatisfaction are not unexpected: long
work hours, minimal hands-on experience, limited faculty
interactions, ineffective teaching by residents/fellows, and
mistreatment issues. The purpose of this Viewpoint article is
to discuss these clerkship weaknesses identied by national
and local survey data. Strategies employed by nationally
recognized obstetrics and gynecology educators to develop
adaptive behaviors to address these educational shortcomings
will be reviewed.

Background
After 24 hours of call, delivering 4 babies, saving a womans
life by surgically removing an ectopic pregnancy, and performing a handful of emergency room and inpatient consults,
we are told that we are rated poorly by the medical students.
Why? The annual data from the Graduate Questionnaire
(GQ) of the Association of American Medical Colleges
(AAMC) show 79% of graduating medical students in 2014
rate the overall quality of the obstetrics and gynecology (obgyn) clerkship as good or excellent as compared to 91.6% in
internal medicine (P < .002).1 Most core clerkships are rated
above ob-gyn, including surgery (Table), which has many
similar characteristics to our specialty. A focus group of
clerkship directors from the Undergraduate Medical Education Committee, Association of Professors of Gynecology and
Obstetrics (APGO) reviewed their individual clerkship evaluations and came up with several common themes regarding
medical student evaluations of the ob-gyn clerkship. Medical
students reported several unappealing elements: long work
hours,2 minimal hands-on experience,3 limited faculty interactions,1 ineffective teaching by residents/fellows,1 and
mistreatment issues.4,5 The purpose of this Viewpoint article is
From the Undergraduate Medical Education Committee, Association of
Professors of Gynecology and Obstetrics, Crofton, MD.
Received Sept. 4, 2015; revised Oct. 21, 2015; accepted Oct. 23, 2015.
The authors report no conict of interest.
Corresponding author: Archana Pradhan, MD, MPH. archana.pradhan.
md@rutgers.edu
0002-9378/$36.00  2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.10.915

to discuss strategies to develop adaptive behaviors to address

these educational shortcomings. Best practices described on
student surveys and by medical schools with ob-gyn clerkships
that perform above the GQ national averages are reviewed.

Long work hours

The Liaison Committee on Medical Education requires
medical schools to have policies to limit student work hours.6
Most policies follow Accreditation Council for Graduate
Medical Education guidelines in which residents are not
allowed to work >80 hours per week. Regardless of work
hour limits, many medical students comment on the difculty of overnight calls and long shifts. Several studies have
cited income and lifestyle as key elements identied by our
current medical students in the decision to pursue a specialty.7 Ob-gyn is perceived as a specialty with an uncontrollable lifestyle.6
Acknowledging the challenging hours as a eld-specic
characteristic, and one each student should experience, can
potentially frame their role on the labor oor as one needed
for students to both fully participate in births and to understand the context of obstetric care. Additionally, it is
important to educate medical students that the lifestyle of a
resident in not necessarily the life of a practicing ob-gyn.
Decreased hands-on experience
Another factor as to why students rate our specialty lower is
that medical students are given less autonomy on the rotation.
In a study by Grasby and Quinlivan,8 38% of ob-gyn patients
refused involvement of students. Female patients are more
likely to refuse involvement of a student in their medical care
due to the sensitive nature of the physical examination. Data
support that female supervisory physicians prioritized patients autonomy above students learning needs.3 As educators, we must nd ways to incorporate innovative techniques
to supplement the volume of clinical experiences.
Although the sensitive nature of our eld will never
change, there are several successful ways to increase a students comfort and expertise with gynecological exams and
basic obstetrical procedures. Utilization of standardized patients and gynecological teaching associates to teach gynecological history taking and pelvic examination skills are keys
to a successful ob-gyn clerkship. Low- and high-delity
simulation drills to train students on spontaneous vaginal
deliveries are immersive educational experiences designed to
improve both patient safety and quality of medical education.
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Education

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TABLE

2014 Graduate Questionnaireequality of

educational experience

feeling that a faculty member genuinely cares about the individual students development. This is particularly important
as we are often switching them from service to service at short
intervals to give the students broad exposure to the eld.

Good to excellent, %
Internal medicine

92

Pediatrics

87

Emergency medicine

87

Psychiatry

86

Family medicine

84

Surgery

83

Obstetrics and gynecology

79

Neurology

76

Pradhan. How to improve the obstetrics and gynecology clerkship experience. Am J

Obstet Gynecol 2016.

Assigning students specic elements of patient counseling (ie,

medication counseling) will include them as team members.
Additionally, longitudinal experiences such as weekly clinics
with the same preceptor or centering groups with the same
patients allow faculty to watch a students development and
permit the student to learn a particular attendings practice
style. These strategies help students develop a sense of condence, and faculty members feel more comfortable
including medical students in patient care. Consequently,
medical students gather more hands-on experience.

Limited faculty observation

When students are given opportunities to perform history
and physical examinations on the ob-gyn clerkship, they
report signicantly less direct observation by faculty. In the
2014, AAMC GQ, 92% of students on the internal medicine
clerkship strongly agreed or agreed that a faculty member
watched them perform a history as compared to only 79% on
the ob-gyn clerkship (P < .002).1 Medical students are not
observed because of a lack of faculty time, a lack of faculty
skills, a potential stressful effect on the learner, and a
perceived lack of validation of the assessment.9 Although
these concerns are valid, a concerted effort to address these
issues needs to be made by medical student educators.
Medical schools with highly rated ob-gyn clerkships have
designed ways to improve faculty engagement with medical
students. Improved presence in the preclinical years by
allowing clinical faculty to teach reproductive endocrinology
allows students to interact with faculty in a classroom setting.
Early interaction with ob-gyn student interest groups
also allows students increased exposure to the eld and to
clinicians who are passionate about their lifes work.
Including nonphysician faculty in student clinical placements
(eg, midwives and nurse practitioners) allows increased opportunities for clinical mentorship and involvement. Implementation of one-on-one mentor experiences while students
are on clerkships gives students a sense of continuity and the
346 American Journal of Obstetrics & Gynecology MARCH 2016

Ineffective teaching by residents/fellows

Medical students also report signicant disappointment with
resident/fellow teaching encounters on the ob-gyn clerkship.
The AAMC GQ asks students whether resident/fellows provide effective teaching during core clerkships. In the 2014
AAMC GQ, 92% of respondents reported that resident/fellow
teaching on the internal medicine clerkship was good or
excellent, compared to 75% on the ob-gyn clerkship.1 This is
another area that every residency program currently without
a resident-as-teachers curriculum can impact.
Highly rated ob-gyn clerkships have some best practices
in place with regards to resident teaching. A 2004 article by
Hammoud and colleagues10 report that teaching residents
how to teach can improve the quality of the ob-gyn clerkship. In the study, a 1-day workshop was delivered to 18 of
20 ob-gyn residents. The study was shown to have a positive
inuence on the student evaluations both at 3 and 9 months
postintervention. Residents-as-teachers curricula need to be
tailored to the needs of a specic program and should be
delivered at regular intervals to have a meaningful impact.
Many programs nd it difcult to identify on-site resources
to deliver such programs. Many best practice clerkship sites
send all rising fourth-year residents to a 3-day workshop for
residents developed by the Council on Resident Education
in Obstetrics and Gynecology (CREOG). This thorough
curriculum is delivered by medical education experts in our
eld with the purpose of training residents to serve as
leaders and teachers for junior residents and medical
students.
Mistreatment
Another issue that garners much attention is mistreatment.
The AAMC has dened different aspects of mistreatment and
asked students to specify which health care professional
subjected them to public embarrassment, public humiliation,
threat of physical harm, actual physical harm, requirements to
perform physical services, and offensive sexist remarks, to
name a few. In the 2014 AAMC GQ, 39% of respondents
reported that they were mistreated (excluding public
embarrassment) during 4 years of medical school.1 Most
incidents included public humiliation and offensive sexist
remarks. The sources of mistreatment incidents have been
attributed to mainly clerkship faculty and residents/interns.
Although the GQ does not parse out mistreatment data by
clerkship, data from clerkship evaluations from medical
schools across the country and multiple presentations at
annual CREOG-APGO meetings identify ob-gyn as
offenders.4,5
Clerkships and institutions that have a lower percentage of
students reporting mistreatment tend to have 2 things in
common: (1) a culture of mutual respect and open dialogue,

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and (2) a low tolerance for abusive behaviors and coordinated
interventions when such behaviors do occur. Medical schools
need to ensure that faculty and students are aware of policies
and consequences of poor behavior. Anonymous mechanisms
to report mistreatment incidents should be implemented.
Every department should gather departmental data from the
students and act on the information received. Remediation
programs for faculty and residents need to be a part of the
learning environment, and if those programs fail, senior
administration must not be afraid to remove the offending
teacher from a milieu that involves students. Chen and
colleagues recently wrote an article on bullying in medical
school: .the culture for all these years has been to just take
the mistreatment and not say anything. It wasnt right back
then and it shouldnt be tolerated anymore.11

Conclusion
The fast-paced and unpredictable nature of ob-gyn is a
dening characteristic of our exciting eld. However, these
same elements can make the ob-gyn clerkship a challenging
environment for learners. Medical students recurrently
identify issues such as minimal patient experience, limited
faculty interactions, ineffective teaching by residents/fellows,
and mistreatment as areas for improvement. Our role as
womens health advocates require our commitment to an
effective educational environment for all medical school
graduates. High-performing ob-gyn programs across the
country have identied characteristics and programs that
can be implemented with successful results. To provide
maximal positive impact toward both womens health and
student education, we have an obligation to work toward

Viewpoint

incorporating these best practices into our educational

programs.
REFERENCES
1. Association of American Medical Colleges. Graduation Questionnaire.
Available at: http://www.aamc.org/data/gq. Accessed October 15, 2015.
2. Dorsey ER, Jarjoura D, Rutecki G. Inuence of controllable lifestyle on
recent trends in specialty choice by US medical students. JAMA
2003;290:1173-8.
3. van den Einden LC, te Kolste MG, Lagro-Jansse AL, Dukel L. Medical
students perceptions of the physicians role in not allowing them to
perform gynecological examinations. Acad Med 2014;89:77-83.
4. Breed C, Purkiss J, Santen S, et al. Evaluating clerkship-specic
medical student mistreatment. Obstet Gynecol 2015;126:48-9S.
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10. Hammoud MH, Haefner MK, Schigelone A, Gruppen LD. Teaching
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11. Chen P, Kogan JR, Bellini LM, Shea JA. Implementation of the miniCEX to evaluate medical students clinical skills. Acad Med 2002;77:
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