Best practices for teaching psychosomatic obstetrics and gynecology

Abstract Psychosomatic obstetrics and gynecology (POG) encompasses a wide variety of topics. While specialists in this field agree that it is important for practicing clinicians to be familiar with psychosomatic issues related to women’s health, there is no consensus about the best practices for teaching and assessing this knowledge, or even which are the topics that should be included. By examining existing literature on educational methodology, this paper aims to suggest best practices that are proven useful in teaching issues related to POG. The paper considers learning objectives for what should be taught, recommendations as to best practices for curriculum delivery, and suggestions for how to assess learners’ ability to meet the objectives. Establishing guidelines for teaching POG may be useful for learners at different levels and in various settings.


Introduction
Clinicians engaged in the practice of women's health recognize that there is a broad range of issues relevant to the field that blend biological with psychological and sociocultural considerations.While approaching care from this multidimensional perspective is important in much of healthcare, there are many aspects of obstetrics and gynecology (ob/gyn) that make it particularly germane.The complex interactions between hormonal fluctuations and mood through a woman's reproductive life, the potential trauma suffered from bad experiences in pregnancy and childbirth and its effect on the psyche, and the demonstrated influence of mental health on maternal and surgical outcomes -these are all examples that stress the value of a psychosomatic approach to this field.Additionally, women have traditionally been subjugated to a lesser societal role that makes them more vulnerable to health-related issues such as interpersonal violence, sexual abuse, and diminished access to care.Taking social determinants of health into consideration in discussing women's healthcare is also of vital importance.
The study of the full scope of these issues has been termed psychosomatic obstetrics and gynecology (POG).Although this may be considered a subspecialty of the field, it is fundamental to the care of women and deserves attention in medical education.Not every practitioner will be expert in the field of POG, but anyone who learns to care for patients assigned female at birth should be familiar with its principles.To draw a parallel, cervical cancer may be definitively managed by gynecologic oncologists, but learners along the entire spectrum of medical education should learn basics of its evaluation and management.
While education on specific medical disorders has been well-described in ob/gyn, education on psychosomatic topics has not been well-defined.Questions arise as to which topics should all practitioners be familiar with, when should they know them, and how can they demonstrate competence once instruction is given.Another debate concerns how much of this information directly impacts obstetrics and gynecology versus medicine in general.For example, basics of interpersonal communication, ethics, mind-body medicine, and social determinants of health are central to good medical practice and are often included in general medical education.Educators in women's health may question whether these topics should be included or repeated in an already crowded specialty curriculum.
This paper will examine these questions to provide insight into best practices in teaching POG.While it may be impossible to create a consensus opinion about all of these elements, an examination of existing literature provides enough insight to suggest some answers.The paper focuses on medical education specifically.Recognizing that many practitioners play a role in POG care, it would be too broad a scope to try to make recommendations for education in psychology, midwifery, social work, or nursing.Taking into account published information, the paper aims to provide guidelines for teaching and assessing POG topics in medical education.

Methods
In order to get a sense of what instructional methods and recommendations have been tested, a literature review was conducted.The PubMed database was queried for search terms relevant to POG and education, namely: "obstetrics and gynecology," "psychosocial," "psychosomatic," "medical education," "behavioral science," "communication skills," and "sexuality"/"sexual health."Although the paper is not meant to be a systematic review, the search provided a background of reports that pertained to teaching these topics.Articles were reviewed for additional references and citations that were also relevant to these topics.For identifying content that is specifically relevant to POG, expert opinion was sought in the form of content included in textbooks specific to this area and programs of recent congresses of the International Society for Psychosomatic Obstetrics and Gynecology (ISPOG), which represents worldwide specialists with interest in the field.

Defining content
Given that all medical interactions include a provider and a patient, communication and interplay between them is essential to all medical education.In the United States, the Institute of Medicine described six domains in behavioral and social science that were deemed critical to medical school education.These domains were mind-body interactions in health and disease, patient behavior, physician role and behavior, physician-patient interactions, social and cultural issues in health care, and health policy and economics [1].The Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME), which accredits medical schools to provide medical degrees, have incorporated these domains into their definitions of competency for a practicing physician [2].In Europe, the European Board and Congress of Obstetrics and Gynecology (EBCOG) has created a training curriculum, the Project for Achieving Consensus Training (PACT), to ensure that all specialists in women's health receive equitable and high-quality training.Their curriculum emphasizes communication as a core aspect of psychosocial skills, with an emphasis on a patient-centered approach [3].In addition to patient-centred care, their competencies include teamwork, system-based practice and personal and professional development.
While clearly a vital aspect of basic medical education, these topics may be revisited specifically in the context of ob/gyn.A standardized training program in psychosocial topics was adopted in Switzerland as a compulsory element of postgraduate education for ob/gyn trainees.The program provides targeted instruction on topics including communication skills, doctor-patient relationship, and use of the biopsychosocial model specifically in the setting of gynecologic, obstetric and endocrinological diseases [4].In Germany, a psychosomatic training program is obligatory for specialization in ob/gyn and general practicing physicians [5].This course includes instruction on characteristics of the doctor-patient relationship that are unique to ob/gyn and adopting a psychosomatic approach to specific gynecologic and obstetric disorders.A survey in the US that inquired about specific didactics in communication skills in graduate medical education programs found that only 62% of residency program directors reported formal teaching on these skills [6].
In addition to skills, education on POG should include didactics that impart knowledge about specific topics that touch on psychosocial aspects of women's health.Determining where to include each topic along the spectrum of specialty ob/gyn training may vary based on the educational system and culture.In the United States, undergraduate education in ob/gyn is guided by a complete set of learning objectives published by the Association of Professors of Gynecology and Obstetrics (APGO) [7].Among the 64 objectives that outline the core women's health knowledge expected to be mastered by all medical students, there are 6 that are specifically aligned with psychosomatic or psychosocial aspects of the field (in addition to interpersonal communication skills).These are legal and ethical issues in ob/gyn, anxiety and depression in pregnancy and the postpartum period, premenstrual syndrome and premenstrual dysphoric disorder, sexuality and modes of sexual expression, sexual assault, and intimate partner violence.
Similarly, a set of educational objectives for graduate medical education is published by the Council of Resident Education in Obstetrics and Gynecology (CREOG) [8].In their document, psychosocial considerations are woven throughout the objectives for competence in specific ob/gyn conditions, with expanded descriptions for learning in sexual health and trauma and abuse.Reading through these objectives, it is clear that there are many areas where the successful management of ob/gyn patients requires adequate psychosocial training.In the PACT objectives cited earlier [3], the topics mentioned that pertain to psychosocial conditions are atypical grief reactions to cancer diagnoses, sexual dysfunction, sexual abuse, and domestic violence.
Sexuality is frequently cited as an underrepresented topic in medical education, both in undergraduate and postgraduate arenas.A summit of experts in the field published a position paper calling for expansion of sexuality education beginning in undergraduate training [9].They posit that effective training requires longitudinal, integrated sexuality curricula throughout medical training.A separate consensus panel has identified a more specific list of competencies in sexual health for all medical students, with knowledge items that include social and behavioral principles as well as physiology and dysfunction [10].
The International Society for Psychosomatic Obstetrics and Gynecology (ISPOG) is a federation of national societies dedicated to research and education in POG.While individual countries may have specific relevant curricula for their trainees in ob/gyn, this information is not widely available and a consensus for topics to include is lacking.To gain a better sense of which topics are taught and when along the spectrum of medical education they are introduced, a survey of member societies was conducted (unpublished data).The topics included were gathered from two textbooks on POG [11,12], and organized into five categories: general psychosomatics (e.g.communication skills and mind-body interaction), hormonal effects on mental health (e.g.perinatal mood disorders and premenstrual dysphoric disorder), psychological effects on women's care (e.g.fear of childbirth and interactions between mood and cancer), social/ethical issues (e.g.interpersonal violence, reproductive justice), and sexuality (e.g.sexual health and sexual dysfunction).Results of the survey are shown in Table 1. 12 countries responded out of the current 16 members of ISPOG.Among these, 10 agreed that training on basic psychosomatic topics such as communication skills and mind-body interaction should begin in medical school, but less consensus existed for other topics.8 countries reported that social and ethical issues related to women's health were taught as part of undergraduate instruction, and half reported teaching about hormonal effects on mental health at this stage.Only 3 countries report that training on sexuality and sexual health is routinely a part of medical school curriculum.

Methods of instruction
Optimal techniques for delivering curriculum vary greatly depending on the content being taught.Training learners in appropriate communication skills and comfort in discussing psychosocial issues requires more than simple didactic instruction.Although all medical students are taught how to gather information in a medical history, communications regarding delicate psychosocial topics are more complex and require specialized instruction.Expert consensus recommendations for teaching such interactions emphasize the importance of instruction in the clinical setting with a combination of role modeling, reflective exercises, and timely feedback [13].Specific information regarding screening for psychosocial disorders (e.g.trauma or substance abuse), counseling techniques (e.g.motivational interviewing), or special types of communication (e.g.delivering bad news) may require additional instruction in a didactic forum.
Enhancing psychosomatic communication skills in the ob/gyn arena relies on similar principles.In the German training program cited above [5], curriculum is delivered through 20 h of seminars that address general psychosomatic approaches and specific obstetric and gynecologic disorders that demand such an approach.These are followed by 30 h of small Many aspects of POG involve specific disorders that require instruction that emphasizes knowledge acquisition to familiarize trainees with the presentation, risk factors, evaluation and management of those conditions.In these settings, didactic instruction may be favored to deliver this information.A survey of American medical schools inquired about the method of instructions on specific learning objectives related to perinatal mood disorders, premenstrual dysphoric disorder, interpersonal violence, and sexual health [14].The most common instructional method for each of these conditions was lecture, often supplemented by required readings.Small group discussions and computer-based learning modules were also cited as instructional methods.
The ISPOG survey mentioned earlier also inquired of its member societies how POG topics were taught.Most respondents report the use of lecture and case studies, with few reporting video or online modules.Workshops for practicing physicians are popular in European countries but not offered routinely in the US, Korea and Australia.
The POG topic that has garnered the most attention in educational research literature is female sexual health.While there is consensus that education in this area bears improvement, there is no standardized plan for providing it.In a review of expert recommendations, its authors suggest that didactic teaching should be supplemented with panel presentations, case-based seminars, small group discussions, role play, and standardized patient scenarios [15].A survey of American postgraduate trainees demonstrated that the interventions that would be most helpful in making them feel confident about caring for women with sexual dysfunction would be specific lectures, patient observations, and rotating with a specialist to get inperson clinical training [16].
Since 2021 in Germany, a new curriculum for sexual education offered by the national society of POG is sponsored by the medical council of Bavaria [17].This training program involves 240 h of lectures, Balint work in small groups, psychodynamic self-reflection and supervision of clinical treatment by the candidate.
The training confers a subspecialty status for physicians who are already specialists in other fields such as gynecology, urology, or psychiatry.
The idea of interaction with a specialist in the clinical setting has appeal in other areas of POG as well.A survey of American ob/gyn residency programs inquiring about instruction in mental-health related topics found that there was often a lack of training on these issues, and the greatest barrier was the lack of a psychiatrist integrated into the curriculum [18].The authors suggest that integration between ob/gyn and psychiatric faculty would have the greatest impact on increasing mental health education for ob/gyn residents.In fact, programs that have adopted such an approach have demonstrated improved educational outcomes for both ob/gyn and psychiatry residents [19].
Teaching ethical and psychosocial issues in the setting of gynecologic cancer is also likely to benefit from a multidisciplinary approach.One residency program has described a curriculum of ethical, legal and psychosocial topics incorporated into their gynecologic oncology rotation and taught by a medical ethicist who accompanies the team on rounds [20].While not formally evaluated, the resident feedback indicated that this involvement was regarded as valuable.
A subcommittee of the American Academy of Pediatrics devised a set of educational strategies to improve mental health competencies for pediatricians in training throughout the educational spectrum [21].Their review of existing programs included a similar variety of instructional methods including didactics, role play, videos, and standardized patients.In their recommendations for improving the educational experience in this field, they also mention inclusion of mental health specialists in teaching clinics, inpatient rounds, and other clinical teaching settings to augment psychosocial education for trainees.

Assessment of competence
Competence in any field can be determined by assessing the learner's progress in mastering their education.In determining a trainee's competence in a particular skill, it may be helpful to use a framework that assigns specific roles that the trainee must fill in order to successfully execute the skill.The CanMEDS project [22] is a model that defines seven of these roles appropriate for an expert in a medical specialty.One textbook of POG has used this model to demonstrate the level of mastery in POG topics to fill each role [11].
As with assigning appropriate instructional methods, assessment can be different for knowledge versus skills.Much POG-related content centers around specific conditions or disorders for which practitioners should display familiarity and know-how.Perinatal mental health disorders, mind-body interactions affecting gynecologic conditions, and hormonal effects on mood and psyche are generally areas where knowledge can be tested to determine mastery of the subject.
Testing of knowledge is most frequently accomplished through objective standardized tests.Multiple choice examinations have become most common due to their reliability, efficiency, and option for automated review [23], though short answer formats based on problem-based learning have been advocated as providing more depth and insight into student knowledge [24].Which questions should be included in such examinations is determined by the objectives for the particular course of study.Trainees should expect that the scope and difficulty of questions will match the level of training; undergraduate medical students may expect questions on basic elements of evaluation and pathophysiology, while practicing specialists would be questioned on more sophisticated elements of diagnosis and management.As competency examinations are often determined on an institutional or national level, standardized questions may be used by a large distribution of learners.Specialists with expertise in POG should contribute to the qualifying or licensing examinations for trainees in ob/gyn at all levels.
Assessing skills such as patient interviewing and counseling is less straightforward.A review of evaluation methods for assessing physician communication skills cites three approaches [25].The first is selfassessment, in which trainees are asked to rate their own comfort or perceived ability.This technique is subject to response bias, and respondents tend to rate their improvement more highly than objective outsiders.
The second approach is behavioral observation, which may be rated by an instructor or by the patient, who may be a real or standardized patient.A standardized patient is typically used in the objective structured clinical examination (OSCE), which has been demonstrated to reliably assess communication skills in evaluation of patients with mental health issues [26].Use of a single assessment form by the student, the patient, and the third-party observer has been used in some studies, which helps to differentiate student bias from actual performance [27].Observation requires a greater time commitment by the assessor but may be captured on audio or video for review and scoring at a later time.Video may also be used for viewing by the student and observer together, as a more direct and helpful form of delivering feedback [28].Video review of practical examinations has the added benefit of use even when physical separation is needed, which has been the case through much of the COVID pandemic [29].
The third approach to assessing communication skills is by examination of patient outcomes, such as satisfaction with the encounter or patient mood or health status following the interaction.In the review of studies that compared assessment techniques, mixed results were found, with no demonstrable improvements in health status but some utility in examination of patient satisfaction [23].
In a review of studies that assessed psychosocial competencies in a variety of learner levels, the most common skills assessed were communication skills, though assessments of cultural competence, behavior change counseling, and professionalism were also commonly assessed [2].Standardized patients assessing learners' performance was used more often than actual patients, and direct observation by an instructor was used rarely, despite the authors' assertion that this technique is valuable.

Conclusions
Psychosomatic obstetrics and gynecology is a complex topic involving a variety of clinical topics and situations.Due to its complexity, as well as the differences in medical education and practice throughout the world, it is difficult to establish guidelines that would be universally applicable to teaching trainees about this specialty.Nevertheless, attendees at ISPOG's meetings have expressed interest in having some guidance in best practices for education in this topic.Based on the review of studies cited here, there is enough evidence for some consistent recommendations in teaching at the trainee level.Although POG should be a part of the knowledge set for practicing clinicians, the information reviewed is most relevant to education in preparation for practice.A notable limitation of the review is a paucity of studies published on the subject from different countries and educational institutions.More publication is needed of reports that share successful strategies for teaching POG.These recommendations may be more convincing with more complete evidence published in the literature.
While specialized knowledge on psychosomatic topics may be better tailored to practitioners who have already chosen to specialize in ob/gyn, the basics of POG should be introduced early in medical education.Principles of good communication and mindbody interaction should be incorporated in undergraduate medical education, and these trainees should be made aware of the unique aspects of ob/gyn that create a strong overlap with psychosomatic medicine.Sexuality in particular is a topic that experts feel is not given sufficient weight in undergraduate curriculum, and educators should consider incorporation of sexuality-related topics early in medical curriculum.Table 2 illustrates a proposed set of competencies that should be achieved by learners in this field, with suggestions for when and how they should be mastered.Although this is not a comprehensive list of competencies for this field, it offers examples of how a more thorough list may be organized, depending on the objectives of the institution.Specific didactic modules may be individually created by institutions to suit their needs, or shared through an online and peer-reviewed platform.Sharing descriptions of successful models in this area would be a welcome addition to the educational literature.The method of instruction used will depend on the level of training of the learner.POG specialists should contribute to writing learning objectives for trainees at all levels.Those objectives that involve understanding of general principles and facts should be taught with ample didactic methods, such as lectures and case presentations.For developing skills in counseling and communication, instruction with workshops or Balint groups may be helpful, as would clinical instruction through direct observation and supervision of patient encounters.Additional faculty development may be provided by each institution to ensure that the trainers are appropriately versed in leading such groups in an informed manner, and they are able to accurately assess learners in an objective fashion.Involving content experts in other areas such as ethics or psychiatry to join the clinical team is also beneficial.
Assessment of competency in POG should also be divided between knowledge and skills-based training.Using standardized tests, whether written or multiple choice, are useful for determining the knowledge base and level of understanding for discrete topics in the field.POG specialists should contribute to formulating exams to ensure the standardized content is relevant and accurate.Assessing skills in counseling and caring for patients with POG-related disorders should be based on direct observation, whether of learner interaction with patients or through a standardized examination such as OSCE.
With the overwhelming amount of information that medical trainees need to master in their pursuit of a career in ob/gyn, issues related to psychological and social topics are often overlooked or viewed as secondary.Hopefully a better focus on these topics throughout ob/gyn education will increase awareness of POG and improve the care provided to all patients.

Table 1 .
Number of ISPOG member societies reporting coverage of educational topics at different stages of learning continuum.groupinstructionthatfeatures live interviews, role playing and group discussion.Additionally, there are 30 h of Balint work in small groups, which are very popular in Germany, and they are highly recommended for all practicing physicians.The Swiss program likewise involves a set of initial courses over 40 h to deliver theoretical knowledge, followed by small groups that incorporate case presentations and role playing[4].

Table 2 .
Example of proposed competencies for POG education.CE: clinical instruction; D: didactics; ST: standardized test; DO: direct observation.