I was awarded the RCOG travel grant to represent the UK in the 23rd European Meeting and Exchange Programme of Trainees in Obstetrics and Gynaecology which took place in Slovakia from 6 to 9 May 2013.
The Slovak Republic is a landlocked state in Eastern Europe, bordered by the Czech Republic, Austria, Poland, Ukraine and Hungary. It has a population of over 5 million and an area of about 49000 square kilometres. The official language is Slovakian. The life expectancy is 73 for the males and 82 for females. The maternal mortality has significantly declined the last 30 years however, Slovakia is only ranking 165th in the world. There are three medical schools in Slovakia running six-year medical degree programmes.
The city of Trencin
My area of stay was the quaint city of Trencin, located to the west of the country, near the Czech border. It has a population of 60000 and has a very rich medieval history. The city is dominated by the formidable Trencin Castle.
Upon my arrival at about 11pm, the local team had organised to pick me up at Bratislava airport and drove me to Trencin, an hour away. I was lodged in a local hotel of good standard, close to local amenities and historical buildings; reserved and fully paid for by the local Trencin team. I shared a family room with a colleague from Slovenia (Marko) throughout my stay. Our colleagues picked us up every day at 07h15 am to work and gave us a lift back.
Range of hospital activities
During our 3 hospital days, we were able to participate in staff meetings, medical rounds, surgery, administration, deliveries, outpatient consultation and ultrasound scanning. Activities were tailored to our needs and preferences as much as possible.
The team were amazingly welcoming and interested in the exchange. They were always readily available, friendly and dedicated a considerable amount of time to us. Most of them are fluent in English and Slovakian. They have an experienced senior team with various special interests in gynae-oncology, urogynaecology and laparoscopic surgery. They are generally excellent surgeons and very keen to teach. The doctors in training are young, enthusiastic and respectful of the hierarchy. They supplement their local training with courses, conferences and hospital time in Bratislava.
The postgraduate training lasts for an average of 5 years in the same hospital. They then write the final exam after recognition of a number based competency by the supervising senior doctor. They have a life guarantee of employment in the hospital training them. The training is skills based instead of service provision based. They work an average of 48 hours a week for an average of 700 Euros/month. Few trainees, at the end of their formation will be tempted to work in bigger cities in Slovakia or elsewhere worldwide (Czech Republic, Germany, Austria, UK, USA, Canada are amongst the favourite directions), however, the majority will establish themselves in their local public hospital. Private practice is not an uncommon endpoint and mostly consists in outpatient gynaecology service and antenatal clinics.
Trencin Hospital – health system
There is a strong link between peripheral centres and private structures with the hospital for referral. Quality assurance strategies are in place (but possibly overlooked) to assess the standard of practice in the different medical structures around the main hospital. Three main health insurance companies are responsible via the state to pay for the service via a strict coding system.
The care is free at the point of delivery; however, pain relief such as epidural or the entonox are to be paid by the patients. The number of deliveries varies between 1500 and 2000 per year. The Caesareans section rate is 17% in Trencin compared to 55% in a neighbouring city; vaginal breech delivery is encouraged on appropriately selected patients as well as vaginal birth after caesarean section. The delivery forceps are not in use. The first elective caesarean section is ready for theatre before 8am. The patients are entirely doctor led. The first examination, the delivery and the placenta check are carried out by doctors. The paperwork of delivery is the sole responsibility of the attending doctor. The midwives have less responsibilities and a reduced scope of practice compared to the UK. CTGs are used intermittently and the interpretation is based on experience and perceived level of competence. There is senior support available 24/7. The most junior trainees do not have to do nights during their first year.
Patients are referred by GPs, private structures and hospital colleagues. They also use drop in access. The operating facilities are rich in up to date quality laparoscopic equipment and the surgical skills are of a high standard. Patients are discussed in a pre-op clinic by 2 seniors and the patient. The options are discussed and the consent form is done, usually the day before the operation. Patients stay in the hospital up to 4-5 days after their uncomplicated operation. There is no financial incentive for an enhanced recovery programme and early discharges.
The team structure
The unit governing system is pyramidal with a lead, his assistants and the most junior staff at the bottom of the pyramid. Historically, women have not been chief of the unit since the creation of the hospital. They do however represent more than 50% of the trainees. The lead of O&G is nominated by the Director of the hospital and stays in place until the next nomination. The actual director, Peter Kaczack of O&G is dynamic, hardworking, strict and conscientious. He leads by example and encouraging the youngsters to take up more responsibilities towards the care of the patients and the unit in general as well as opening themselves to changes in international standards of Medicine. The day starts promptly at 07h30 in the meeting room; the lead summarises the duties and allocates responsibilities to the team members. At 15h30, the team reports to the group; events of the day are reported and discussed accordingly. It is a professional and efficient way of communicating which is also used for handover purposes.
This is an area of interest for the O&G director. We discussed about risks management, audits, quality improvement projects and benchmarking. They have guidelines in place, some of them inspired by the RCOG and adapted to local resources. We had various discussions about the structure and impact of the Slovakian college of O&G on the global development of O&G practice in Slovakia. An important point was also the brain drain of talented doctors and the challenges of staff retention.
Trencin: a cultural town
We made the most of our stay to visit Trencin and the neighbouring areas. Our Trencin colleagues invited us to their local fantastic castle, the main forest, the old town, the main theatre, many restaurants, hotels and pubs, all fees generously paid by our hosts. The most popular collective sports are Ice hockey and football. We discovered the local costumes and dance as well as the more modern westernised music. We even went for a day at one of the most traditional spas of the region. We have enjoyed the local food (like the bryndzove halusky), pastries, cakes and drinks. At last, before leaving the team had nice words as well as gifts for us to take home and to never forget Trencin.
ENTOG conference, Bratislava
The ENTOG conference was held in the Crown Plaza, Bratislava for 2 days from the 10th May 2013. After the opening session, there was a presentation of the Entog and the exchange with few European exchangees sharing their experience in Slovakian and Czech towns. We then discussed leadership in O&G across Europe as well as responsibilities of trainees in Europe. There was an excellent debate on the level of supervision throughout training. The extent of responsibilities of midwives in Europe was also discussed and I will be pleased to let our UK midwives know that their scope of practice is much wider than any other midwives in Europe. The last debate about number versus competency based assessment was rich in emotion and controversies as expected. The next day was dedicated to the 2013 ENTOG Council Meeting. A new executive board was elected after a straightforward democratic process. We discussed and planned our future destinations: Scotland, Holland and Turkey.
Bratislava: a beautiful city
The conference was held in the middle of the city allowing access to the beautiful old town, rich in historical building, beautiful places, restaurants and warm pubs. The first and second nights we went to nice restaurants serving exquisite food guided by our local organiser Mikulas Redecha who did a fantastic job throughout the exchange, and then some of us went to visit the old town and its wonders. On the final day of the Conference, we had time to do a guided tour of the city before embarking a catamaran on the Danube to Vienna in Austria where, together with some of the other UK trainees we took the flight back to the UK.
It was an amazing experience, starting with a warm and humble welcome in a beautiful small city and finishing with the sole envy to come back. The exchange with colleagues throughout Europe was rich and fruitful. It reassured me as a UK trainee that the content of my training and the delivery is excellent. However, I wish I could be as skilful as my European colleagues when it comes to scanning and outpatient gynaecology. I will recommend this experience to any of my colleagues and I am actively getting ready for the next exchange in Glascow.
Dr Mathias Epee MD, MRCOG
Specialist Registrar, Severn Deanery