Comparison of OBGYN postgraduate curricula and assessment methods between Canada and the Netherlands: an auto-ethnographic study

TYPE Original Research

PUBLISHED 27 March 2024

DOI 10.3389/fmed.2024.1363222

OPEN ACCESS

EDITED BY

Erich Brenner,

Innsbruck Medical University, Austria

REVIEWED BY

Matthias Siebeck,

LMU Munich University Hospital, Germany

Elena Jost,

University Hospital Bonn, Germany

*CORRESPONDENCE

Emma Paternotte

[email protected]

RECEIVED 30 December 2023

ACCEPTED 27 February 2024

PUBLISHED 27 March 2024

CITATION

Paternotte E, Dijksterhuis M, Goverde A,

Ezzat H and Scheele F (2024) Comparison of

OBGYN postgraduate curricula and

assessment methods between Canada and

the Netherlands: an auto-ethnographic study.

Front. Med. 11:1363222.

doi: 10.3389/fmed.2024.1363222

Ezzat and Scheele. This is an open-access

article distributed under the terms of the

Creative Commons Attribution License (CC

BY)

. The use, distribution or reproduction in

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original author(s) and the copyright owner(s)

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which does not comply with these terms.

Comparison of OBGYN

postgraduate curricula and

assessment methods between

Canada and the Netherlands: an

auto-ethnographic study

Emma Paternotte

, Marja Dijksterhuis

, Angelique Goverde

Hanna Ezzat

and Fedde Scheele

Department of Obstetrics and Gynaecology, Gelre Hospitals, Apeldoorn, Netherlands,

Department of

Obstetrics and Gynaecology, Amphia Ziekenhuis, Breda, Netherlands,

Department of Obstetrics and

Gynaecology, University Medical Center Utrecht, Utrecht, Net herlands,

Division of General

Gynaecology and Obstetrics, University of British Columbia, Vancouver, BC, Canada,

Department of

Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands

Introduction: Although the Dutch and the Canadian postgraduate Obstetrics

and Gynecology (OBGYN) medical education systems are similar in their

foundations [programmatic assessment, competency based, involving CanMED

roles and EPAs (entrustable professional activities)] and comparable in healthcare

outcome, their program structures and assessment methods considerably dier.

Materials and methods: We compared both countries’ postgraduate educational

blueprints and used an auto-ethnographic method to gain insight in the

eects of training program structure and assessment methods on how trainees

work. The research questions for this study are as follows: what are the

dierences in program structure and assessment program in Obstetrics and

Gynecology postgraduate medical education in the Netherlands and Canada?

And how does this impact the advancement to higher competency for the

postgraduate trainee?

Results: We found four main dierences. The ﬁrst two dierences are the

duration of training and the number of EPAs deﬁned in the curricula. However,

the most signiﬁcant dierence is the way EPAs are entrusted. In Canada,

supervision is given regardless of EPA competence, whereas in the Netherlands,

being competent means being entrusted, resulting in meaningful and practical

independence in the workplace. Another dierence is that Canadian OBGYN

trainees have to pass a summative written and oral exit examination. This

dierence in the assessment program is largely explained by cultural and legal

aspects of postgraduate training, leading to dierences in licensing practice.

Discussion: Despite the fact that programmatic assessment is the foundation

for assessment in medical education in both Canada and the Netherlands, the

signiﬁcance of entrustment diers. Trainees struggle t o dierentiate between

formative and summative assessments. The trainees experience both formative

and summative forms of assessment as a judgement of their competence

and progress. Based on this auto-ethnographic study, the potential for

further har monization of the OBGYN PGME in Canada and the Netherlands

remains limited.

KEYWORDS

postgraduate medical education, assessment, EPA, comparison, auto-ethnographic

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Paternotte et al. 10.3389/fmed.2024.1363222

Introduction

It is widely acknowledged that well-structured postgraduate

medical training is important to deliver well-trained medical

specialists who can provide the best possible care. To certify that

trainees develop the necessary skills and attitudes in addition to

the knowledge required to practice, the competency framework

CanMEDS was developed in Canada in 1996 (

1). This competency-

based framework described the competences that trainees should

acquire during their training. In 2015, the CanMEDS framework

was enhanced by incorporating competency milestones for each

CanMED role (

2).

This approach has been implemented in several

medical education systems globally. For instance, the CanMEDS

roles have been used in the oﬃcial training blueprints of all

postgraduate medical education (PGME) in the Netherlands (

3).

Further expansion of the CanMEDS has led to the development

of EPAs. EPAs are described as Entrustable Professional Activities.

The Netherlands was among the pioneers in implementing EPAs

in their training programs (

4–8). The Obstetrics and Gynecology

PGME training in Canada also transitioned toward EPAs (see text

footnote

1). EPAs are “units of professional practice, deﬁned as

tasks or responsibilities to be entrusted to unsupervised execution

by a trainee once he or she has attained suﬃcient competence” (

9).

The EPAs are designed to ensure a gradual level of

entrustment, known as progressive independence. Entrustment

is intended to mean trust, meaning that if the postgraduate

trainee is entrusted to perform a certain activity, they would

be expected to carry out the procedure without supervision (

4).

For instance, potential applications of EPAs include assessing

competence, making entrustment decisions for independent

practice, facilitating professional development, and informing

curriculum development. It is known that the uptake of EPAs

in the curricula varies among the diﬀerent specialty training

programs (

10).

Although competency-based training , CanMeds roles, and

EPAs have been implemented in postgraduate OBGYN-training

in several countries, assessment methods considerably diﬀer.

Diﬀerences can be attributed to political, social, and cultural

reasons (

4, 11). It has been sug gested that patient outcomes, notably

major complications, are associated with the quality of training

received. Interestingly, quality of training is not associated with

licensing examination scores (

12). Aabake et al. demonstrated that

in Europe, examinations during OBGYN training were used in

89% of the included countries. All examinations were mandatory,

but the study did not clarify whether they were formative or

Abbreviations: OBGYN, Obstetrics and Gynecology; EPA, Entrustable

professional activities; PGME, Postgraduate medical education; EP, Emma

Paternotte; FS, Fedde Scheele; MD, Marja Dijksterhuis; AG, Angelique

Goverde; HE, Hanna Ezzat; LOGO, Landelijk Opleidingsplan Obstetrie en

Gynaecologie (Formal national Education document of Obstetrics and

Gynecology); OSATS, Objective Structured Assessment of Technical Skills;

Mini-CEX, Mini-Clinical Evaluation Exercise; CbD, Case-based discussion;

NOTSS, Non-Technical Skills for Surgeons; O-score, Ottawa Surgical

Competency Operating Room Evaluation.

https://www.royalcollege.ca

2 https://www.knmg.nl/ik-ben-arts/cgs/regelgeving/specialismen

summative (11). In other words, formative assessments are often

considered assessments for learning, while summative assessments

are assessments of learning (

13). It is interesting to ﬁnd out

why some postgraduate OBGYN training programs use certain

assessment tools, and why ot hers do not. For instance, despite

Canada having implemented competency-based training and EPAs,

the adoption of new assessment methods and the utilization of a

training logbook are not yet widespread practices (

14). As stated on

the Royal College website,

new formal assessment methods have

been implemented and formalized since Garofalo’s ﬁndings in 2017.

Worldwide, t he Netherlands and Canada hold leading positions

in the advancements and modernization of medical education

(14). Given the similar foundations of PGME in Canada and the

Netherlands, it is interesting to discuss diﬀerences, particularly

in competency-based education and programmatic assessment.

Therefore, our research questions are “Which diﬀerences in

formal assessment methods exist in Obstetrics and Gynecology

postgraduate medical education and how does this impact the

advancement to higher competency for the postgraduate trainee?”

To answer these questions, we employed the auto-ethnographic

obser vation method to gain insights in which diﬀerences exist and

how these diﬀerences are perceived by the postgraduate trainees.

We scrutinized the Obstetrics and Gynecology PGME blueprints

of both countries to ﬁnd similarities and diﬀerences. Highlighting

the diﬀerences between both Canadian and the Dutch assessments

systems with respect to cultural and political diﬀerences may

provide insight into assessments that could enhance e ach

training program. By harmonizing curricula, variability in training

outcomes will decrease, which could improve the quality of

training overall. Moreover, it would facilitate benchmarking and

comparisons across centers and streamline the exchange of trainees

between countries (

14).

Materials and methods

This study is grounded in auto-et hnography, a qualitative

research methodology in which the author uses writing and self-

reﬂection to probe personal experiences, thereby deriving broader

sociocultural meaning and understanding (

15).

Auto-ethnography combines elements from autobiography

and ethnography and represents both a scholarly “process”

and “product.” It moves away from traditional approaches to

understanding and representing “culture” which has historically

been rooted in rigid structures. Instead, auto-ethnography

“acknowledges and accommodates subjectivity, emotionality, and

the researcher’s inﬂuence on research, rather than hiding from these

matters or assuming they don’t exist” (

16).

Participants and setti ng

This is qualitative research includes an introduction of the

enrolled researchers. This project involved ﬁve participants: EP,

FS, MD, AG, and HE. The main auto-ethnographer was EP, a

3 https://www.royalcollege.ca/en/credentials-exams/assessment-

canadian-us.html

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Paternotte et al. 10.3389/fmed.2024.1363222

Dutch 6th-year postgraduate trainee in OBGYN who ﬁnished an

elective in Vancouver, Canada. She is the subject of the performed

auto-ethnographic study and received support and supervision

throughout the project from the other four participants. FS

is gynecologist and professor in Health Systems Innovation

and Education in the Netherlands, where he supervised PhD

students and conducted research in assessment methods. MD is a

gynecologist in the Netherlands with a PhD in assessment methods

in medical education. AG is gynecologist and program director

of EP in postgraduate medical education of OBGYN in Utrecht,

the Netherlands. HE is gynecologist and program director of the

postgraduate residency program in British Colombia, Canada. The

connection among our te am members was forged serendipitously.

Data collection

The predetermined guiding t heme for this auto-ethnography

was how postgraduate trainees perceive assessment methods and

how formal assessment methods are shaped throughout the course

of residency training. EP’s experiences as an elective OBGYN

postgraduate trainee were discussed with the other researchers. As

the process of reﬂection and discussion developed, the need to

scrutinize the blueprints of PGME of Canada and the Netherlands

became apparent. Diﬀerences and similarities were found. These

ﬁndings were then discussed with gynecologists and postgraduate

trainees of both the Netherlands and British Columbia, Canada.

Extensive reﬂection and dis cussion between EP and these trainees

and gynecologists yielded insig hts into how postgraduate trainees

perceive their assessment methods and how does this impact the

advancement toward hig her competency. These reﬂe ctive sessions

were either audiotaped or noted.

Results

The results are presented in two sections. The ﬁrst section

provides a general overview based on the blueprints of the

Canadian and the Dutch curricula, with a focus on assessment

methods. In

Table 1, an overview of postgraduate medical

education in OBGYN in both Canada and the Netherlands is given.

Table 2 describes the EPAs in the Netherlands, whereas Table 3

describes the EPAs in Canada.

The second part is a discussion of how these assessment

methods manifest in the workplace. This discussion is based on the

experiences of EP and is the auto-ethnographic part.

PGME and assessment of OBGYN in the

Netherlands

Postgraduate training can be pursued directly after 6 years

of undergraduate medical training. Typically, candidates undergo

a period of work in non-training grade posts in order for the

candidate to gain practical experience and increase their chances

of successfully applying for a postgraduate training program.

Entering a postgraduate training program is based on an interview,

which may sometimes be combined with a personal assessment.

TABLE 1 Overview of PGME in OBGYN focused on assessment.

Canada The Netherlands

Years of

UGME/Med school

4 6

Years of PGME

OBGYN

5 6

EPAs in PGME

OBGYN

36 12

Working hours per

week

No duty hour

restrictions

Maximum 48 h

Feedback Formative

throughout the

whole year

Formative throughout the

whole year

Progress assessment Every 6 months by

competency

committee

In the ﬁrst year every 3

months, after ﬁrst year at least

annually, progress meeting by

trainee and program director

Progress test Yearly, formative,

not required by

Royal College

Yearly, formative, mandatory

Surgical

examination

Year 2, summative Mandatory courses

Final examination Written and Oral None

Postgraduate

training program

paid by:

Ministry of he alth.

Money to cover

resident salaries not

given directly to

hospitals, but to

health authorities

or larger bargain

units. No funding

for “disutility”

provided.

Ministry of health, welfare and

sports, executed by the

Dutch healthcare Authority

(NZA). Money is forwarded

to the teaching hospital where

the trainee is currently

employed. It covers both costs

for training (s alary and

education) and disutility.

The postgraduate training program in OBGYN lasts 6 years

on full-time basis, although part-time placement is allowed to

a certain degree. The program consists of hands-on practical

training in delivering patient c are, complemented by formal

teaching, and academic study. Programs are completed in a

structured learning environment in teaching hospitals supervised

by faculty. Rotations are evenly divided between academic and

district teaching hospitals.

The national training curriculum is based on EPAs (

Table 2),

and progress is registered in the personal electronic portfolio.

The curriculum focusses on delivering competent general

OBGYNs who share common basic skills but have speciﬁc

areas of diﬀerentiation, depending on their area of interest. The

curriculum of the OBGYN post graduate training is captured

in a national training curriculum for obstetrics and gynecology

LOGO (Landelijk Opleidingsplan Obstetrie en Gynaecologie)

(

17), where a daily feedback culture is a basic requirement for the

programs. One of the most salient features of current training is the

increased number and variety of formative assessment moments:

assessments that are aimed at providing feedback that can direct

and stimulate learning. Additionally, an annual formative online

progress test, which consists of 160 multiple choice questions,

is mandatory. This test is designed to generate learning goals

based on t he test results. The low-stakes formative assessments

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TABLE 2 Overview of EPAs of OBGYN in the Netherlands (17).

Core EPA # 1: Pregnancy and labor, low-risk

Core EPA # 2: Pregnancy and labor, high-risk

Core EPA # 3: Postpartum healthcare

Core EPA # 4: Abnormal uterine bleeding

Core EPA # 5: Early pregnancy

Core EPA # 6: Prolapse and pelvic ﬂoor complaints

Core EPA # 7: Abdominal pain (acute and chronic)

Core EPA # 8: Vulvar and vaginal abnormalities

Core EPA # 9: Healthcare for pre-malignant lesions

Core EPA # 10: Basic oncological care

Core EPA # 11: Fertility healthcare

Core EPA # 12: Lifecycle endocrinology

and learner self-reﬂection are pivotal to progression within the

training program and not the formative annual national written

progress test (

8). There is no ﬁnal oral or written examination.

Moreover, postgraduate trainees may participate in mandatory

or non-mandatory courses, such as an ultrasound course. All

formative assessments, together with progress reports, proof

of experience, feedback of supervisors [for example Objective

structured assessment of technical competencies (OSATS) and

mini clinical evaluation exercise (mini-CEX)], individual reﬂection,

and the results of the annually formative progress test are collected

in a personal electronic portfolio.

Assessment for entrustment of speciﬁc EPAs and the ﬁnal

conclusion on whether or not the postgraduate trainee is competent

to deliver high standards of care is conducted by the educational

team chaired by the program dire ctor and is based on the records

in the electronic portfolio (all activities and development). If

the EPA is entrusted, the trainee is allowed to perform this

EPA independently.

PGME and assessment of OBGYN

in Canada

Medical school students seeking to start postgraduate training

in OBGYN apply to the Canadian residency matching program.

This residency matching program includes a detailed portfolio,

and the selection process includes a ﬁle review of medical

school performance records, reference letters, and an interview.

The specialty training requirements in OBGYN include a 5-year

training program governed by the Royal College of Physicians and

Surgeons of C anada. A new curriculum, called Competency by

Design, was introduced in 2019 (

16).

The curriculum is framed

around 36 EPAs (

Table 3).

These EPAs represent essential specialist

4 https://www.royalcollege.ca/en/cbd/understanding-cbd.html

5 https://www.royalcollege.ca/content/dam/documents/accreditation/

competence-by-design/non-resource-documents/epa-observation-

templates-e.html

TABLE 3 Overview of EPAs of OBGYN in Canada

∗

(see text footnote 4).

Transition to Discipline EPA #1:

Performing initial assessments for uncomplicated obstetric patients.

Transition to Discipline EPA #2:

Performing initial assessments for uncomplicated gynecological patients.

Foundations EPA #1:

Providing routine prenat al care to a low-risk, healthy population.

Foundations EPA #2:

Performing assessments of antenatal fetal well-being.

Foundations EPA #3:

Assessing and providing initial management for patients with common obstetric

presentations.

Foundations EPA #4:

Managing labor and childbirth.

Foundations EPA #5:

Performing uncomplicated cesarean sections with a skilled assistant.

Foundations EPA #6:

Providing early postpartum care.

Foundations EPA #7:

Providing consultation and initial management for patients with urgent and

emergent gyne cologic presentations.

Foundations EPA #8:

Counseling and management for patients requiring family planning.

Foundations EPA #9:

Providing consultation for patients with gynecological conditions.

Foundations EPA #10:

Performing minor g ynecologic operative procedures.

Foundations Special Assessment #1:

Performing critical appraisal of health literature and initiating scholarly projects.

Core EPA #1:

Providing preconception and antenat al care to women with high-risk

pregnancies.

Core EPA #2:

Managing patients with acute conditions presenting in the antenatal and

perinatal periods.

Core EPA #3:

Managing complex vaginal deliveries.

Core EPA #4:

Performing complex ces arean sections.

Core EPA #5:

Diagnosing and managing postpartum complications.

Core EPA #6:

Performing obstetric and gynecologi c ultrasound.

Core EPA #7:

Providing deﬁnitive management for patients with acute gynecologic

emergencies.

Core EPA #8:

Providing care for patients with complex gynecologic conditions and/or medical

comorbidities

Core EPA #9:

Assessing and initiating management for patients with reproductive

challenges

Core EPA #10:

Diagnosing and managing pediatric and adolescent patients with common

gynecologic conditions.

Core EPA #11:

Providing care for patients with pelvic ﬂoor dysfunction.

(Continued)

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TABLE 3 (Continued)

Core EPA #12:

Assessing, diagnosing, and managing patients with chronic pelvic pain and

sexual health concerns.

Core EPA #13:

Assessing and managing patients with gynecologic malignancies.

Core EPA #14:

Performing advanced hysteroscopy.

Core EPA #15:

Performing major vaginal and vulvar procedures.

Core EPA #16:

Performing major laparoscopic gynecologic procedures.

Core EPA #17:

Performing major open abdominal gynecologic procedures.

Core EPA #18:

Managing patients with surgical complications.

Core EPA #19:

Managing the birthing unit.

Transition to Practice EPA #1:

Managing complex patients, including those requiring longitudinal care.

Transition to Practice EPA #2:

Discussing diﬃcult news.

Transition to Practice SA #1:

Conducting scholarly work.

Transition to Practice SA #2:

Teaching and managing learners.

∗

The Canadian system of EPAs is subdivided into stages. Stage 1 is transition to discipline,

stage 2 is foundations, stage 3 is core, and stage 4 transition to practice. This structure is

maintained across all postgraduate programs in all disciplines. The trainee must obtain all the

EPAs for a certain stage before the competency committee promotes them to the next stage,

and they can start working on the associated EPAs for that stage.

competencies, leading to optimal OBGYN care outcomes. The

EPAs are designed to align with the stage the trainee is in. The

pedagogical concept is that EPAs should not be time based, but

based on whenever a competency has been demonstrated. However,

as has been stated in The Future of medical education in Canada

“this approach to using competencies to assess the performance of

physicians in practice is still in its infancy.”

Currently, the assessment philosophy of Canadian medical

education is based on this competency by the design structure. This

philosophy includes formative assessments throughout the whole

year. The workplace-based assessments include the following, for

instance: OSATS, mini-CEX, Case-based discussion (CbD), Team

obser vation forms, bi-Annual Review of Competence Progression

by the competency committee, and Non-Technical Skills for

Surgeons (NOTSS). The concept is that continuous assessment

drives and promotes learning. In year 2, the postgraduate

trainee of surgical specialties, such as OBGYN, needs to pass

a summative surgical foundations examination examination (see

text footnote

3). In year 5, a summative written examination

is taken, followed by the ﬁnal summative oral examination 6

months later. If the postgraduate trainee fails one of these

6 https://www.afmc.ca/wp-content/uploads/2022/10/FMEC-

CPD_Synthesized_EN_WEB.pdf

summative examinations, the trainee is required to retake the failed

examinations. Additionally, there is an annual formative written

progress test, which is not mandatory but is utilized to prepare

trainees for the ﬁnal examination (see text footnote

1) (14).

The formal methods of assessment are described in the

“Standards of Accreditation for Residency Programs in Obstetrics

and Gynecology” (see text footnote

1). The competency committee

comprises supervisors (gynecologists) from various clinics, as well

as the program director. Together, they decide whether an EPA

is entrusted. Even after an EPA is entrusted, some degree of

ongoing direct or indirect supervision remains the cultural, legal,

and practically enforced norm.

Reﬂection

Postgraduate medical education in Canada and t he Netherlands

share the same philosophy, including programmatic assessment

in competency based medical education. Medical education in

Canada and the Netherlands are regarded as the highest standards

worldwide (

13). In both countries, de velopment and improvement

are key factors in medical education.

In both the Netherlands and Canada, EPAs and programmatic

assessment have been implemented successfully and this has been

conﬁrmed by stakeholders. Despite these similarities, there are

a few key diﬀerences in the curricula and assessment methods

experienced by EP and discussed with the research team.

The ﬁrst diﬀerence between OBGYN education is the

total duration of medical training. In Canada, medical school

(undergraduate training) and residency (postgraduate medical

training) embrace a total of 9 years, whereas in the Netherlands,

total duration is 12 years, usually longer due to junior doctors

commonly working in non-training posts. Another key ﬁnding

that aligns with the ﬁrst diﬀerence is that non-training posts are

not possible in Canada. In Canada, non-training posts for junior

doctors who have ﬁnished medical school do not exist.

The second diﬀerence is the total amount EPAs. In the

Netherlands, the 12 EPAs are used for the whole 6 years of

postgraduate training, while in Canada, EPAs are organized into

stages. The stages represent a stepwise progression of competence

during t he training period. Comparing the content of the EPAs

informs us that there are no big diﬀerences in the end terms of t he

OBGYN training. However, it appears that the Canadian OBGYN

EPAs are more fragmented than those in the Netherlands.

The third diﬀerence lies in how entrustment is applied by

both countries. In the Netherlands, OBGYN has implemented

this entrustment process in daily clinical practices; a trainee,

entrusted to per form a cesarean se ction, is legally and culturally

allowed to perform the procedure unsupervised. For the trainee,

the entrustment granted during the training years contributes to

an inner sense of conﬁdence that they indeed are capable of

working as a gynecologist (unsupervised). Most PGME programs

in the Net herlands oﬀer the trainees with rotations where they

can experience the role of supervising younger trainees, which

contributes to their conﬁdence and professional growth toward

independent practice. In the Netherlands, entrustment translates

into a meaningful change in st atus. In contrast, in Canada,

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entrustment means that the resident is progressing as would

be expected for their training. Canadian trainees are usually

supervised during (surgical) procedures until their certiﬁcation as a

gynecologist. Both postgraduate trainees and supervisors describe

this as the norm. A quote from one of t he supervisors is as

follows: “Competency by design is still a bit out of reality of daily

clinical education.”

An explanation for this signiﬁcant diﬀerence in the meaning

of entrustment might be found in how the levels of entrustment

are interpreted. As explained on the website of the Royal College,

the steps of assessment to full entrustment of an EPA are described

by the use of the O-score. This score is a 9-item evaluation tool

designed to assess technical competence in surgical trainees using

behavioral anchors. This O-score seems to be written throug h the

eyes of the supervisor (highest level: “I did not need to be there”),

whereas in the Netherlands, this scoring system is through the eyes

of the trainee (highest le vel: “I supervise this procedure or EPA”).

The entrustment rating of an EPA by the Royal College is as follows:

“Rating trainees as independent does not mean that they are now

always allowed to independently perform that task. It means that

they were independent on this occasion” (

18). The entrustment

rating of independence does not reﬂect the medico-legal reality,

nor the expectations of patients and trainers of the presence of

a certiﬁed specialist who is ultimately responsible, especially in

surgery. The re ason for this may be found in how the regulation and

granting of postgraduate medical education is arranged in Canada

as the Royal College is responsible for pres cribing and assessing

the learning standard, but not for regulating or granting a license

to practice. Ultimately, all trainees, even until the last moment

of training, have an educational license only, which means that

they have no license to practice independently and everything they

do must be supervised. The supervisor is the “most responsible

physician” if something goes wrong. It is understandable why a

faculty surgeon, who owns that responsibility, might hesitate to

allow a resident, even one they believe is highly competent, to

perform a cesarean section without supervision just because the

competency committee (CC) said that they were competent to do

so. However, t he designation by the CC holds little weight outside

the program.

A fourth diﬀerence is the formative and summative

examination systems. Both countries have a yearly progress

test, in the form of a written examination. This is obligatory for

the Dutch resident, and its results are used formatively to identify

areas for further study. However, in Canada, the yearly formative

test is not mandatory; the Royal College does not require, endorse,

or even suggest this test. Instead, the program directors and

teachers want trainees to take the test as a necessity to prepare

trainees for their ﬁnal examination. This ﬁnal examination has to

be taken by postgraduate trainees in Canada but is not known in

the Dutch postgraduate training program. Though competency by

design in Canada preaches programmatic training of competencies

and formative assessments, the ﬁnal assessment is summative.

Postgraduate trainees in Canada ﬁnd it inconceivable to not have

a ﬁnal examination. The trainees described that supervisors treat

them diﬀerently as soon as they passed this examination. Ending

the PGME without this ﬁnal examination is unimaginable for

them, which gives them the feeling that t hey have met a certain

standard and that this will allow t hem to get a job anywhere else

in Canada. Legally the resident still does not have a license after

passing the examination to act independently, but the examination

certiﬁcation is the key requirement to that license. In contrast,

Dutch postgraduate trainees are satisﬁed with their assessment

system without a summative exit examination, mainly because

the Dutch trainee work totally independent at the end of their

training and, therefore, a summative exit examination would not

add anything to the growing process. Growing into being fully

entrusted is an organic process that develops along the way. Dutch

trainees view examinations as a snapshot of their performance

and query how well any such examination would represent their

competence. Interestingly, despite the formative intent of PGME

in OBGYN in both countries, neither set of postgraduate trainees

perceive their training as such. Many post graduate trainees regard

all the feedback moments as small summative assessments and feel

continuously judged about their performance.

Discussion

To answer our ﬁrst research questions (“which diﬀerences in

formal assessment methods exist in Obstetrics and Gynecology

of postgraduate medical education?”), we created an overview

of the formal assessment methods. For the second research

question (“how does this impact the advancement to higher

competency for the postgraduate trainee?”), we observed four

main diﬀerences in the curricula of PGME of OBGYN between

Canada and the Netherlands. The most striking diﬀerence lies

in the way that entrustment is interpreted and put into practice

in both countries, since this is of consequence for the role of

assessment in the entrustment process and even more trainees

feeling adequately prepared to work as a gynecologist. However,

the Royal College explains the entrustment of EPAs as the resident

is progressing as would be expected for their stage, for the

Dutch trainees entrustment reﬂects their professional development

toward independent practice. Additionally, the number of EPAs

diﬀers enormously, which might also reﬂect the diﬀerence between

wanting control and needing a “pass” on smaller parts, vs. believing

in trust the knowledge that the whole is more than the total

sum of small parts. In addition to this consideration, there

is the requirement for passing a summative exit examination

in Canada, whereas in the Netherlands, this requirement has

been rendered redundant. In conclusion, a higher competence is

reached more or less on a similar way in both Canad a and the

Netherlands. However, the meaning of this higher competence is

interpreted diﬀerently.

To summarize, programmatic assessment in Canada appears

to be based on the “assessment for learning” principle. The fact

that there is a summative ﬁnal examination also makes assessment

feel more like an “assessment of learning” or perhaps it is a

combination of the two. In contrast, programmatic assessment

in the Netherlands tends more toward “assessment for learning”

alone. However, in both countries, trainees tend to experience the

assessments as more summative than formative, in general, and

there is ongoing discussion about how to make assessments feel

formative for postgraduate trainees. We propose that there is a role

for both kinds of assessment, in line with the diﬀerent levels of

knowledge and skills as described in Miller’s pyramid (

19).

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Paternotte et al. 10.3389/fmed.2024.1363222

Formative assessment is the instrument for coaching a trainee

from the “does” level in Miller’s pyramid to the “shows” level,

for instance in surgical procedures. Summative assessment is the

instrument to actually ascertain and document whether the trainee

has reached the higher “shows” level and to inform supervisor

and trainee about the level of independence in speciﬁc tasks or

procedures. Making the aim of t he formative assessment explicit

could help the trainee to focus more on the learning process, while

clearly laying out the summative assessment moments gives the

trainee a perspective on entrustment decisions (

20).

Conclusion

There is no one-size-ﬁts-all solution, and no speciﬁc

programmatic assessment has been proven to be superior to others

(

21). A tip for both countries regarding their assessment methods

is that clear communication about the purpose of assessment

and the use of assessment outcomes needs to be formulated (

22).

All supervisors need to be trained to provide non-judgmental

constructive formative feedback (

20). Competency-based medical

education requires an ongoing process to evaluate and improve the

assessment methods (

13). This diﬀerence in assessment program

is largely explained by cultural and legal aspects of postgraduate

training and consequent diﬀerences in licensing practice. Based on

this auto-ethnographic study, the harmonization of the OBGYN

PGME in Canada and the Netherlands appears limited since

cultural, legal, and practical aspects of assessment and licensing

predominate. In our opinion, this is a missed opportunity because

harmonization could help to resolve labor shortages where needed.

We recommend investigating whether there are options to facilitate

the harmonization process between postgraduate trainees between

the Netherlands and Canada.

Limitations

A limitation of this study is that not all perspectives could

be captured. There may be opinions and experiences of trainees,

teachers, and supervisors that were missed. Other limitations

include the inherent subjectivity of the ethnography method and

the limited sample size.

Data availability statement

The raw data supporting the conclusions of this article will be

made available by the authors, without undue reservation.

Ethics statement

Ethical approval was not required for the studies involving

humans because it is an auto ethnographic study which does

not contain personal information but only interpretations

of t he writer based on humans. The studies were conducted

in accordance with the local legislation and institutional

requirements. Written informed consent for participation

was not required from the participants or the participants’ legal

guardians/next of kin in accordance with the national legislation

and institutional requirements because no direct material of

humans was used.

Author contributions

EP: Conceptualization, Data curation, Formal analysis,

Methodology, Project administration, Writing – original draft,

Investigation. MD: Conceptualization, Supervision, Writing –

review & editing. AG: Supervision, Writing – review & editing.

HE: Writing – review & editing, D ata curation, Methodology.

FS: Writing – review & editing, Data curation, Methodology,

Conceptualization, Supervision.

Funding

The author(s) declare that no ﬁnancial support was received for

the research, authorship, and/or publication of this article.

Conﬂict of interest

The authors declare that the research was conducted in the

absence of any commercial or ﬁnancial relationships that could be

construed as a potential conﬂict of interest.

Publisher’s note

All claims expressed in this article are solely those

of the aut hors and do not necessarily represent those of

their aﬃliated organizations, or those of the publisher,

the editors and the reviewers. Any product that may be

evaluated in this article, or claim that may be made by

its manufacturer, is not guaranteed or endorsed by the

publisher.

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