Introduction
In November I was invited to take part in the ENTOG exchange program, spending three days in the Obstetrics & Gynaecology department of Landeskrankenhaus, Feldkirch, Austria. Situated in a small valley surrounded by the Alps, the hospital was an attractive glass-fronted building constructed in the shape of a mountain. Its design also maximised the opportunity for patients and staff to enjoy spectacular views of the snow capped mountains.
This opportunity was sponsored by Shire Pharmaceuticals.
ENTOG is the European Network of Trainees in Obstetrics & Gynaecology. This is a Europe wide organisation established in 1997 which aims to encourage exchange and interaction between European trainees in order to promote harmonization and improve training, striving for high and comparable standards of training within all European countries. ENTOG organises an annual exchange program and meeting to provide the opportunities for trainees and trainers to experience different training programs and methods, and also to meet to discuss thoughts and experiences regarding training in obstetrics and gynaecology.
I was greeted with warm hospitality in Austria and was invited to stay in the Professor's house during my visit as he was away. He had a beautiful home set into the mountain overlooking the hospital, which made my stay extremely comfortable. Everyone in the department made me feel welcome and I was impressed at the fluency of English spoken by staff and patients alike.
The Hospital and Services Offered
Feldkirch is a town in the state of Voralberg, the most Western state of Austria and is very close to the borders of Germany, Switzerland and Liechtenstein . The hospital, Landeskrankenhaus, is a tertiary centre with only 1500 deliveries each year. The unit has six consultants, one of whom is the Professor and head of the department (Primarartz), and there are four specialist trainees.
In striking contrast to the UK, there is a well established community obstetric & gynaecology service. After completing their hospital training, many specialists set up their own clinics in the community where they provide the majority of antenatal care and outpatient gynaecology services. Patients are referred to the hospital after first being assessed or treated by their own community specialist. Consequently, there were very few hospital outpatient clinics with women only attending for delivery, surgery, a second opinion or if they required investigations or treatment not available within the community setting.
There is a daily theatre list, with an emphasis on minimal access surgery for benign gynaecological disease. Many of the trainees and even consultants have very limited experience in open abdominal surgery.
Breast cancer is often the responsibility of the gynaecologist in Austria, although in some cases there may be shared care with the general surgeons. Women with gynaecological cancers can be treated by general gynaecologists, and much of the chemotherapy is given on the general gynaecology ward rather than in a specialist oncology unit.
The wards are smaller and appeared quieter than those in the UK, with the majority of women being nursed in closed rooms with usually no more than four patients to each room. The healthcare staff appeared much less concerned about hospital acquired infection than we are in the UK as this occurs infrequently in Austrian hospitals.
A large majority of Austrians disapprove of abortion and hold conservative attitudes toward termination of pregnancy services. A small, but significant minority also oppose abortion in the case of a known severe fetal abnormality. Termination of pregnancy can be legally performed within the first 14 weeks of pregnancy, although this must be privately funded. Interestingly, all women are offered screening for Down Syndrome, but must pay for the screening and diagnostic tests if requested. In the case of confirmed Down Syndrome the parents are given the diagnosis from the hospital, but must arrange and pay for the abortion through the same services as those women who choose abortion for social reasons. Pregnancies affected by severe fetal abnormalities detected after 14 weeks pose more complex issues for parents and medical staff alike. Although all women are offered a fetal anomaly scan, there is significant difficulty in offering termination of pregnancy to those with severe abnormalities. If a severe abnormality is detected after 14 weeks gestation and the parents wish to consider termination of pregnancy, the case must first be discussed at a tribunal. Members of the panel include the obstetricians, neonatologists and a representative from the local ‘Pro-Life'group. At the end of the meeting there is a vote, and termination can only proceed legally if there is a consensus vote.
The Systems
On my arrival to the department I was promptly changed into an all white uniform consisting of trousers, T-shirt, coat and even white shoes. All doctors throughout the hospital are expected to wear the uniform, including the consultants.
Each day began at 7am with a departmental meeting attended by all medical staff. All deliveries and admissions occurring during the previous 24 hours were presented and discussed. The day's elective theatre list was then scrutinized by the team to ensure that everyone was in agreement with the intended surgery and that the surgeon had appropriate skills to perform that particular procedure. Patients notes are all computerized which greatly facilitated the meetings as they were projected onto the whiteboard for all to see. The timetable for the day was also displayed and discussed to ensure that all clinical duties were covered appropriately. A similar meeting was held again at 16.30pm with a handover of patients to the overnight on-call team. Once a week, the morning meeting was also used as an opportunity for the doctors to present and discuss an educational topic.
These meetings especially impressed me as I felt that they provided a forum to facilitate communication and to provide supervision and support for medical staff in managing their patients.
Although there are only six consultants in the unit they all remain resident in the hospital when on call. GP and career trainees were on the same tier of the on call rota despite the big difference in experience and expertise. The consultants are required to attend every caesarean section and instrumental delivery, even if working with experienced career grade trainees. The consultants are heavily involved in the day-to-day management of all patients. A consultant-led ward round of all inpatients was conducted everyday, and most patients attending the outpatient clinics were seen by the consultant.
There were very few local or national guidelines, although the RCOG on-line resources were often referred to if required.
Training and Education
The training program in Austria is rather informal. Until 2002 no formalised training program existed, and even now training requirements are limited and evolving slowly. The development of a formalised training program seems to be hindered by the relatively small population of Austria and that training is organised by the Medical Board, which advises government rather than the other way around.
Individual trainees are appointed by each hospital, with no equivalent of a deanery or commitment to ongoing employment or training. Trainees are required to complete a minimum of four years working within obstetrics & gynaecology and two years additional experience in other specialities. Most trainees choose to start their careers with the GP training scheme which covers their alternative speciality experience and gives them the opportunity to practice as a GP if their specialist training is not successful. There is no formal teaching program or system of regular appraisal or assessment, and the quality of training is therefore highly variable. The best hospitals are producing excellent specialists, but there is also an overproduction of poorly trained specialists (in the words of the Professor responsible for developing Austria's training program). On completion of four years of specialist training they are required to have completed a basic logbook of surgical procedures, based on numbers of procedures rather than competencies, and to have passed a final exit exam. First piloted in 2002, the exam consists of a single MCQ paper, which trainees can attempt once a year. The pass rate is currently greater than 95%. The exam committee are currently struggling to develop the exam into a more rigorous assessment, but are hampered by the small committee size (only two!) and the limited numbers of trainees needing to sit the exam each year (only 50). Following completion of specialist training there is no formalised system of ongoing appraisal or assessment of consultants. A voluntary system has been established which is self-regulated with no pressure from the government, and is therefore not highly respected.
All obstetricians and gynaecologists are trained in ultrasound scanning, as there are no ultrasonographers. Although there is no formal training system in Austria, most of the trainees appeared confident in their ability to use scanning as a routine part of their assessment of a clinical problem. There was widespread availability to good quality scan machines throughout the department. Those trainees who are particularly interested in fetal medicine scanning were encouraged to spend time abroad (for example at King's College Hospital, London), to formalise their skills and increase their experience of abnormalities.
In Feldkirch the trainees worked incredibly hard and were motivated by the extremely competitive environment. If they did not impress the Professor there were plenty of other very good trainees very keen to join the department. They usually worked a minimum of 10 hours each day in addition to weekly 24 hour on call duties. The trainees appeared to be unaware of the European Working Time Directive and were perplexed as to how British trainees could let such a directive affect their training and work patterns.
ENTOG Meeting, Vienna
Following the exchange program I took an enjoyable 700km train journey across country to Vienna for the meeting.
Although my own exchange experience in Feldkirch largely impressed me, it appears that in Austria many of the pitfalls in the training program may be due to the small population and number of consultants. Attending the meeting at the end of the week offered hope as perhaps many of these hurdles could be overcome if we could develop a more united European standard of training and share each countries experience.
Helen Bolton