Dear Editor,
We have read with great interest the Special Article from Romão et al.,[1] with recommendations from the Brazilian Federation of Gynecology and Obstetrics
Associations (FEBRASGO, in the Portuguese acronym) regarding medical residency training
during the coronavirus disease (COVID-19) pandemic. While it is clear in considering
aspects of theoretical activities, it is less conclusive of how practical workload
should be accomplished: can we participate in COVID-19 care while practicing obstetrics
and gynecology (OBGYN)?
We agree that there are major concerns of how the COVID-19 pandemic will impact the
apprenticeship of the residents and, especially, women's health care. We are aware
of and respectful to all the necessary arrangements in dealing with the COVID-19 pandemic.[2] In Brazil, at least a third of OBGYN residents were relocated to deliver care to
suspected or confirmed COVID-19 patients.[3] Although it may represent OBGYN interrupted regular activities, it comes to our
attention that the relocation of residents was simultaneous to important modifications
in women's health care in Brazil.
First, women are afraid of seeking medical care and exposing themselves to SARS-CoV-2,
therefore tending to underestimate their health condition and to delay arrival to
medical facilities; they presume there is a great risk of viral infection. Second,
quarantine and lockdown measures have restricted health care to essential services,
decreasing access to on-time diagnosis. Health personnel were deviated from women's
health facilities, including antenatal clinics, to help emergency services. Ultrasound
and laboratory tests, which were never adequate, are now restricted to a bare minimum.
Therefore, women are admitted to hospitals in worsened medical conditions; it seems
that 10% of maternal deaths in Brazil this year are related to COVID-19.[4] Third, other health issues arise during the pandemic. To cite just a few, domestic
violence, anxiety, and perinatal depression are rising in times of social isolation
and emotional constraints.[5]
[6] We understand that OBGYN are the leading professionals in women's integral health
care, and residents must take part on it. Finally, and of the uttermost importance,
we still do not know how SARS-CoV-2 behaves in specific conditions of our field, such
as in pregnancy[7] or oncology.[8] Therefore, we can still afford COVID-19 care while offering OBGYN care.
In our view, the role of OBGYN personnel in taking care of women's health is irreplaceable.
In times of pandemics, our role is to provide a safe environment for the continuity
of our species, which is not a lesser endeavor. In this context, program directors
and institutions should focus the efforts of OBGYN residents on activities for which
they have the best training for, and in sectors where they can really help. For example,
emergency obstetrical care, which is historically overburdened in terms of resource
personnel. Many lessons can be learned from the pandemic as a whole, but in our field,
we have a clear picture of how essential our work really is. Antenatal care, labor
wards, OBGYN emergency rooms, and gynecological oncology procedures are still places
for assistance and residency training. If there is less gynecological training during
the pandemic,[3] residents must be replaced to obstetrics or oncology, which is in accordance with
the FEBRASGO statement.[1]
The pervasive feeling among some institutions that OBGYN is a common specialty is
unequivocally wrong. We have a unique set of abilities which are simply indispensable.
Obstetrics and gynecology personnel cannot be relocated without considerable impact
on the quality of care. It is a waste of precious human resources to use the OBGYN
workforce in the frontline of COVID when we have pressing needs in attending obstetrics
emergencies and oncologic cases. Perhaps more lives will be wasted – or an increase
of long-term sequelae for both mother and newborn[9]
[10]–with this shift of personnel from where they are most effectively used to performing
general COVID-19 care. Gynecological and perinatology health care must be seen as
essential areas of medical assistance and education.
Residency training in 2020 has been challenging for residents, program directors,
institutions and policy makers. Obstetrics and gynecology residents are skilled professionals
and need to work as such. In Brazil, women's health is marked by inequalities of access
and deliver of care, which impairs the maternal morbidity and mortality rate. Residency
programs need to be in line with women's needs.
Conflict of Interests
The authors have no conflict of interests to declare.
Authors' response
1Universidade de Ribeirão Preto, Ribeirão Preto, SP, Brazil
Gustavo Salata Romão, Av. Costábile Romano, 2.201, Ribeirânia, 14096-900, Ribeirão
Preto, SP, Brazil (e-mail: gsalataromao@gmail.com).
Gustavo Salata Romão1, 0000-0001-7571-1067
Dear Editor,
We are grateful to the authors for their comments about our recently published manuscript
outlining the recommendations from the Brazilian Federation of Gynecology and Obstetrics
Associations (FEBRASGO, in the Portuguese acronym) in medical residency training during
the coronavirus disease (COVID-19) pandemic. We read with interest their comments
and agree that the COVID-19 pandemic has affected both the quality of postgraduate
training and the quality of care in non-COVID conditions.
The obstetrics and gynecology (ObGyn) residency training program is indeed heterogeneous,
since acquisition of clinical, surgical and emergency management skills is mandatory.
Daily practice, along with an adequate theoretical preparation, plays a fundamental
role in achieving autonomy. Regarding the comments of the authors about the practical
workload of ObGyn residents, we recommended that it should be mainly performed in
time-sensitive care activities such as prenatal, childbirth, postpartum, gynecological
oncology, family planning, sexually transmitted infections and assistance for victims
of sexual violence. For the activities that have been suspended or postponed during
the pandemic, such as non-COVID inpatient or outpatient care and elective surgeries,
decisions must be made locally between health managers and those responsible for residency
programs. It includes providing proper resident supervision.
The need to move ObGyn residents to combat the COVID-19 pandemic will depend on epidemiological
conditions in each region. In the largest hospital complex in South America, the Hospital
das Clínicas of the School of Medicine, Universidade de São Paulo (HCFMUSP, in the
Portuguese acronym), almost 500 volunteer residents from 40 different residency programs
were recruited to work in the frontlines of the COVID-19 pandemic.[1] All residents of this multispecialty team received personal protective equipment
(PPE) and appropriate training in individual protection and orotracheal intubation,
with a maximum weekly workload of 48 hours. The team of supervisors was composed of
working physicians in intensive care units (ICUs), wards, and in the emergency department.
A total of 132 residents of this group reported their opinions through a survey. Although
many of them have expressed fear of becoming ill and concerns about the possible deficits
in their professional training, important positive aspects were also reported, such
as the quick growth in professionalism, altruism and communication in the healthcare
field.
In other countries severely affected by the pandemic, such as the United States, trainees
in different clinical and surgical areas have also been moved to provide care for
COVID-19 patients.[2]
In Brazil, medical residency is essentially time-based and not competency-based.[3] Consequently, after a period of 3 years of training, the ObGyn resident is considered
fit to practice, even if the quality of the training of a resident or of a group of
residents has been compromised. As the competencies are not systematically assessed
throughout the program, it is difficult to objectively measure the damage resulting
from the lack of training during the COVID-19 pandemic.
In 2010, the Carnegie Foundation's report on the reform for postgraduate programs
proposed a model with “fixed standards and flexible paths.”[4] This model was adopted in many countries where the readiness of the residents for
unsupervised activities is formally assessed through the Entrustable Professional
Activities (EPAs).[5]
Currently, the FEBRASGO is preparing and validating the Brazilian ObGyn EPAs, which
will serve as a reference to ensure that the resident is able to carry out the activities
properly without supervision, bridging the gap between well-designed competency structure
and clinical practice with the patient.
