| Development
of a Competence-based
Colposcopy Curriculum
C.W.E Redman, E.Dollery, J. Byrom and J.A. Jordan
North
Stafforshire Hospital, Stoke-on Trent, United Kingdom
Summary
Description of how the European Federation for Colposcopy
identified the core competences for a European colposcopy
training programme curriculum.
Introduction
Colposcopy is a test. Its performance depends on the
observer as well as on the clinical context in which
it is used. Colposcopic findings are subjective and
the related management decisions require problem solving
skills and experience. Both diagnosis and subsequent
management require not only adequate training and
also a sufficient workload to maintain those skills.
Throughout Europe, there is increasing concern that
patients receive high quality and cost-effective care.
The need to protect against inadequate practise is
particularly relevant to colposcopy because of its
subjective nature and that the large numbers of women
who are examined are usually well. Performed correctly
colposcopy minimises damage but if performed badly
the scope for needless damage is great. Whereas the
indications for colposcopy may vary throughout Europe,
its objective is the same, namely to detect cervical
disease, particularly pre-invasive changes.
It is against this background that a number of pan-European
bodies are starting to address the need for shared
standards throughout the continent.
At the European Colposcopy meeting held in Dublin
in 1998, representatives from each of the European
Colposcopy societies met and agreed that a pan-European
group should be established. In Buenos Aires the European
Federation for Colposcopy (EFC) formally came into
being. At the outset it was agreed that a priority
for the EFC should be to work towards standardisation
of training for colposcopy and agreement on audit
methods and outcomes of treatment. In order to realise
this goal it will be necessary to reach a common consensus
on what is desires and how to go about it.
Should there be European Standards in Training and
Accreditation?
In recent years a number of European medical groups
have been formed reflecting a widespread desire for
doctors within Europe to share their collective experience
and expertise. Furthermore, within the EEC there is
increasing concern about the cost effectiveness of
health care and the need to protect patients through
quality assurance. For example an EEC funded initiative
on breast cancer screening has recently been launched
and there is no reason why these principles cannot
be applied to colposcopy. There is now greater opportunity
for doctors within the EEC to receive training in
one country and employment in another, which would
suggest that uniformity in training and practise is
desirable.
Despite the self-evident value of sharing common standards
for training and accreditation throughout Europe,
the task of achieving this goal is immense. Not every
country has the unifying factors, which exist in the
UK (the NHS, for example) and this hampers communication
and obtaining a consensus. In addition, throughout
Europe, apart from the obvious language difficulties,
there are various systems of nomenclature and terminology
which complicate discussion. Nonetheless, if the principles
are right and the goal worth achieving, then these
problems have to be overcome. It was Victor Hugo who
said that there were few things more powerful in this
world than an idea when its time has come.
How Can European Standards in Training and Accreditation
Be Introduced?
If European standards in training an accreditation
are going to be brought about there are a number of
essential requirements. There has to be some overall
organisation or forum that represents European colposcopists
and, equally, is seen to be representative. An initial
task for this body would be to determine what are
the core elements of colposcopy so that a programme
of training and accreditation can be designed. Unlike
the UK experience, it cannot be assumed at the outset
that all are agreed on what colposcopy is and what
its functions are. Similarly one cannot assume that
there will be an automatic consensus on what should
be included in a training curriculum or form part
of a contained educational programme. What is clear
is that a consensus has to be obtained and at this
stage one needs to considerer how this might be obtained.
One approach is to consider the problem from a competence
point of view.
Competence-based
Assessment and Education
Competence-based education and training is an appealing
concept. Its aim is to delineate, in explicit terms,
the competencies that an individual requires either
at the and of an educational course or indeed those
required to be able to continue to practise. The specialised
nature of colposcopy naturally lends itself to competence-based
studies, which can identify areas where practitioners
are lacking in complete competence and thus determine
the priorities for a programme of structured continuing
education.
How
Can the Competencies of Colposcopists Be Decided?
There are a number of options, which include:
• Subject-centred or ‘content knowledge’
approach
• Task analysis
• Delphi technique
The subject-centred or ‘content knowledge’
approach is the traditional approach by which almost
all doctors have been and are being trained in the
UK and Europe generally. The training methodology
is theory dominanted and demands factual knowledge
at the expense of practical experience and clinical
competence (i.e. abstract rich and concrete-poor).
The drawbacks of this approach are widely acknowledged.
Task analysis involves detailing all the functions,
which constitute the practise of colposcopy. One could
then prepare a training programme founded on these
activities. The obvious disadvantage of this approach
is that it refers only to functional tacks and not
how best to perform them.
Such as exercise can only have doubtful worth.
The Delphi technique relies on the judgement of an
expert panel or ‘wise men’. This is one
of the most commonly and successfully used mechanisms
for identifying professional behaviour / competencies.
In brief an expert panel is identified. For the purposes
of deriving a competence-based core curriculum, these
experts are asked to identify specific competencies
required for successful colposcopic practise. Their
replies are collated confidentially into a single
compilation incorporating all the items.
This single list is then returned to all the participants
with the request that they add to (or delete from)
the appropriate section any competencies they regard
as necessary.
The final list is then returned to the experts who
are asked to indicate beside each on, using a five-point
scale, how essential it is, in their opinion that
a colposcopist should possess that particular competency.
These rating would be analysed and the results obtained
would indicate the principal competencies necessary.
This would be used as the basis for a training curriculum
and a continuing education scheme.
Table 1: Core Competencies Identified in EFC Delphi
Exercise
1.
-Basic Skills
1.1 History taking
1.2 Positioning of patient
1.3 Insertion of vaginal speculum
1.4 Perform cervical smear (including Cytobrush)
1.5 Perform bacteriological swabs
1.6 Take samples for HPV testing
2. -Colposcopic examination
2.1 Position and adjust the colposcope
2.2 Determine whether or not the entire transformation
zone (TZ)is visible
2.3 Determine whether or not colposcopy is satisfactory
2.4 Recognise abnormal vascular patterns
2.5 Examination of TZ with saline and green filter
2.6 Examination of TZ with acetic acid
2.7 Quantify and describe acetic acid changes
2.8 Use endocervical speculum
2.9 Schiller’s Test
2.10 Examination of vagina with acetic acid
3. -Colposcopic features of the normal cervix
3.1 Recognise Original squamous epithelium
3.2 Recognise columnar epithelium
3.3 Recognise metaplastic epithelium
3.4 Recognise Congenital Transformation Zone
3.5 Recognise features of a postmenopausal cervix
4.
-Colposcopic features of the abnormal lower genital
tract
4.1 Low grade pre-cancerous cervical abnormality
4.2 High grade pre-cancerous cervical abnormality
4.3 Features suggestive of invasion
4.4 VaIN
4.5 VIN
4.6 Extent of abnormal epithelium
4.7 Acute inflammatory changes
4.8 HPV infection
4.9 Changes associated with prior treatment
4.10 Benign cervical polyps
4.11 Post-radiotherapy changes
5.
-Practical Procedures
5.1 Local analgesia
5.2 Directed cervical biopsies
5.3 Directed vaginal biopsies
5.4 Directed vulval biopsies
5.5 Control bleeding from biopsy sites
6.
- Administration
6.1 Document findings
6.2 Manage patients within guidelines
7.
- Communication
7.1 Ensure adequate information
7.2 Obtain informed consent correctly
7.3 Break bad news
In rounds two and three a rating score was used which
rated each competency as follows, viz:
Score
Description
1.- definitely unnecessary
2.- not important.
3.- advisable
4.- important
5.- definitely necessary
In the final analysis competencies with an overall
average score of 4.5 or greater were deemed to be
essential care competencies.
Materials
and Method
The above methodology was used. Representatives from
every European colposcopy society (or relevant obstetric/gynaecological
body if there was no colposcopy society) were invited
to participate.
The
Results
Every European Colposcopy Society was invited to nominate
up to two representatives. Where no society existed
the relevant Obstetric and Gynaecological Society
was approached. In all, 28 colposcopic experts from
21 countries have fully participated in this exercise.
A list of 75 competences were identified and circulated
for comment.
From the outset there was a high level of agreement
on which competences were considered to be important
or essential for colposcopy. During the Delphi exercise
the group opinion significantly changed in 4 items
and there was a shift to closer agreement in a further
4. A total of 43 core competencies were identified
as essential objectives for any diagnostic colposcopy
training programme. The list of essential core competencies
are shown in Table 1.
Concluding
Comments
The recognised need for professional accountability
and quality assurance are especially relevant to colposcopy.
The advantages of having throughout Europe commonly
agreed standards on training and continued medical
education are obvious though how they might be brought
about has been unclear. This agreement on the core
competencies needed for colposcopy is a major step
forward and will serve as an important foundation
for unifying training standards throughout Europe.
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