Discussion.
This is a qualitative research study of factors affecting confidence and competence amongst obstetricians in performing OVDs. Factors ranged from the patient centred (respect for the primiparous OVD, fear of causing harm) to personal (self-doubt, level of experience, gender), to team (wish for senior midwifery support and teaching by consultants), to training (forceps training, importance of experience).
Strengths and limitations
This study interviewed obstetricians with a wide range of experience and both genders well represented. Obstetricians from three different units were interviewed providing a wide view. Qualitative methods allowed development of independent and novel themes that the researchers had not considered prior to the study. Using an inductive approach – moving from the data to a hypothesis – means that we can explore what people really mean and how they really behave and why. A potential limitation is that data will always be interpreted through the lens of the researcher or research team, though this is limited by use of more than one reviewer of data. The interviewer was an trainee so consultants may have felt constrained during interviews; one of the main concerns for all participants was social desirability bias – that participants would answer questions in a manner to be viewed favourably by the researcher23.
Interpretation
A strong theme emerging from all interviews was respect for the primiparous OVD. Primiparity has been proven as a factor associated with increased risk of failure of an OVD18, as well as an increased risk of obstetric anal sphincter injury24, therefore expression of unease by doctors is not surprising, and shows respect for the procedure in this population.
A senior midwife who is supportive and has plenty of experience in dealing with obstetric emergencies including OVDs was one of the most commonly talked about factor that affected both confidence as well as competence of trainees.
Midwives are the primary caregivers responsible for managing both low and high-risk labour. Most women get one to one midwifery care during labour and delivery. It is natural that the midwife providing one to one care will have an intimate knowledge of parents and their wishes and can advocate for them if required. A supportive and experienced midwife can build a trustful relationship with the patient which is essential to a positive birthing experience for mothers25. Therefore, it’s not surprising that obstetricians rely on the midwife to help them to engage with the woman and lack of midwifery support can lead to lower levels of confidence.
Presence of a supportive consultant in house made trainees feel confident and reassured. An unsupportive consultant was one of the factors affecting trainees’ confidence and made them feel uncomfortable. Unfortunately it has been shown26 that fear, hierarchy, anger, and intimidation were key elements of trainees’ perception of relationship with trainers who oversaw their training in the Irish medical system. Lack of support for doctors during training may encourage efforts to hide uncertainties, and compromises training and patient safety. If this is also true in Obstetrics and Gynaecology, it is natural that fear and intimidation can bar obstetric trainees from expressing concerns and insecurities to their consultant colleagues and in turn compromise patient safety as well as potentially lead to retaining bad habits and malpractices.
Trainees expressed the need for more direct supervision by consultant obstetricians in the early years of training. Despite perceptions from consultants that support was immediately available, senior trainees felt that the newer generation of trainees is being supervised by near peers, potentially compromising patient safety as well as trainee training. The “see one, do one, and teach one ” approach is no longer acceptable in medical practice especially when high risk care is required, and invasive procedures are performed27. It is therefore essential that trainees realise they have the opportunity to observe consultant obstetricians or very senior trainees (HST4+) performing operative vaginal deliveries, understand the mechanics of labour and are exposed to simulation training as part of their curriculum. This is not to suggest that more junior trainees cannot provide peer to peer or peer to near peer input as this has been shown be helpful in overcoming cognitive dissonance28 (where more experienced clinicians have forgotten what they did not once know) but in a supportive capacity during simulation rather than a supervisory capacity during clinical work.
All trainees and consultants expressed their fear of causing harm to mother or fetus. Consultants felt that the risk of complications and psychological trauma was their major worry when performing an OVD. This suggests that with increasing experience, clinicians became increasingly aware of what could possibly go wrong and prepared accordingly. It is an interesting findings that trainees did not mention emotional well-being of the mother as one of their concerns which suggests the need for formal training in the form of multidisciplinary obstetric drills to enhance and teach the trainees the importance of good non-technical skills and that an operative vaginal delivery is more than just delivering the baby vaginally8.
Trainees expressed the need for more training with the use of forceps. Consistent with other studies6,7, junior trainees expressed lower level of confidence with using forceps as a primary instrument and showed high confidence level in using ventouse. Studies have shown that teaching on mannequins or simulators leads to similar, and at times better, results when compared to training with human subjects29. Simulation training in OVD has now become a standard part of training in both BST and HST curricula.
The general feeling expressed by most female trainees was of nervousness, apprehension and self-doubt, whereas male trainees and all consultants reported that they felt confident and comfortable with performing operative vaginal deliveries. This theme is not unique to this study. Female specialist trainees have self-perceived themselves to be less competent in advanced emergency skills than their male counterparts15 or that females underestimated their level of performance on certain tasks when compared to males30. Women may report31,32 more negative opinions regarding their scientific abilities compared to men despite performing equally in a science quiz, and their levels of self-evaluation were less positive than men. This is an interesting finding and could possibly be linked to what is described as the“Imposter phenomenon ”. Imposter phenomenon is mostly described in the non-medical communities, but in medicine it reflects the feeling of self-doubt expressed by doctors despite showing enough evidence of competence33. Whether the feelings of self-doubt are associated with imposter phenomenon or are a true reflection of a female trainees’ limitations and abilities is beyond the scope of this study. Self-doubt is usually exacerbated in conditions where confidence must be shown but is not felt; performing an operative vaginal delivery demands both confidence and competence, and this could explain the discrepancy in trainees’ answers.