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| PERSPECTIVE ARTICLE |
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| Year : 2022 | Volume
: 11
| Issue : 3 | Page : 141-144 |
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Innovating to succeed in the now normal
Maria Antonia E. Habana
Department of Obstetrics and Gynecology, University of the Philippines Manila, Philippine General Hospital, Manila, Philippines
| Date of Submission | 10-Feb-2022 |
| Date of Decision | 31-Mar-2022 |
| Date of Acceptance | 22-Apr-2022 |
| Date of Web Publication | 5-Aug-2022 |
Correspondence Address:
Prof. Maria Antonia E. Habana
Department of Obstetrics and Gynecology, University of The Philippines Manila, Philippine General Hospital, PGH Compound, Taft Avenue, Manila
Philippines
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/gmit.gmit_20_22
How to cite this article:
Habana MA. Innovating to succeed in the now normal. Gynecol Minim Invasive Ther 2022;11:141-4 |
Gynecologic endoscopy in the Philippines was introduced following a donation of the first laparoscopy machine from the Johns Hopkins Program for International Education in Gynecology and Obstetrics.[1] The laparoscope was used in 1973 for tubal sterilization. With the improvements in imaging and instrumentation, the practice of endoscopy changed completely, and the first operative procedures were performed in 1991. In 1994, the use of videolaparoscopy was incorporated in the postresidency fellowship program of reproductive endocrinology and infertility at the Philippine General Hospital and this was followed by two other reproductive medicine fellowship programs, the St Luke's Medical Center and the Consortium.
The Philippine Society for Gynecologic Endoscopy (PSGE) was recognized by the Philippine Obstetrical and Gynecological Society (POGS) as a subspecialty society with Dr. Delfin Tan as the founding president in 2004. The first Fellows of the Society were inducted in 2007 after submission of the required number of cases as proof of their proficiency.[1]
Due to a great demand for formal training in minimally invasive gynecologic surgery (MIGS), the Society in 2012 developed a systematic and standard stepwise process, the Postresidency Modular Training Program (PRMTP or MTP).[2] In the same year, gynecologic endoscopy was incorporated in the advanced pelvic surgery postresidency fellowship program at East Avenue Medical Center. The following years saw the accreditation of two more gynecologic endoscopy fellowship programs, at the Quirino Memorial Medical Center and the Southern Philippines Medical Center (SPMC). The SPMC is the first fellowship program in gynecologic endoscopy outside Metro Manila. It is located at Davao City, Mindanao. All are 2-year straight fellowship programs.
With the COVID-19 pandemic, innovations to adapt to the now normal were instituted and these affected practices in hospital accreditation, credentialing of Fellows of the Society, postresidency fellowship training in gynecologic endoscopy, and provisions for continuing medical education. The following are our experiences and we hope by sharing these, other societies and institutions, may learn and benefit from them.
Hospital accreditation for gynecologic endoscopy training includes an evaluation of the following: (1) infrastructure, administration, and planning, (2) training activities, and (3) trainees' performance.[3] Only hospitals certified by the Philippine Board of Obstetrics and Gynecology for residency training in Obstetrics and Gynecology may apply for accreditation for fellowship training. The accreditation was previously conducted thru site visits; however, this was no longer possible due to travel restrictions imposed by the government. The Committee conducted its first virtual accreditation last March 2021. Electronic documents were shared ahead for review. A virtual meeting, using the Zoom platform, followed by a virtual tour of the facilities, including the operating rooms, were done. All the accreditors were based in Manila and the center for accreditation was located in a hospital at Davao City, Mindanao, 978 kilometers away.
Another concern was the credentialing process to become a certified Fellow of the Society. Candidates should have completed residency training in obstetrics and gynecology and are certified Diplomates of the POGS. They should have completed either a PRMTP, a local straight fellowship program in gynecologic endoscopy or reproductive endocrinology and infertility, or a recognized overseas straight fellowship training program[2] [Figure 1]. A listing of cases is submitted for the evaluation,[4] and in addition, graduates of local fellowship programs are required to have a completed original research paper. | Figure 1: Training pathways to become a Fellow of PSGE. PSGE: Philippine Society for Gynecologic Endoscopy
Click here to view |
Credentialing consists of two steps: A written examination which will evaluate theoretical knowledge and once this is passed, a practical examination to evaluate surgical competence. Fellows for induction into the Society must present a surgical video in the Society's Annual Congress. No credentialing was held last 2020 due to government imposed prohibitions on travel and face to face meetings due to the COVID-19 pandemic. The Specialty Board for Gynecologic Endoscopy discussed how credentialing can be conducted keeping the safety of the examinees and examiners in mind. At the same time, the integrity of the written examination had to be assured. After deliberation, the Specialty Board endorsed the use of Blackboard Learn,[5] a learning management system that allows one to provide content to students from a central location. It also provides a browser for online exams (Respondus Lockdown Browser) which helps control the online testing environment so examinees cannot access anything but the test itself. The use of this learning management system was made available thru the University of Santo Tomas Educational Technology Center.[6]
There were 12 examinees distributed in the different regions of our country with two virtual proctors based in Manila [Figure 2]a. For the practical examination, one examiner was with the examinee in the operating room and there was another virtual examiner from Manila [Figure 2]b. The on-site examiner came from the same locality of the examinee. A designated personnel on site holds a webcam so the virtual examiner may also watch the conduct of the surgery. With stable internet connection, everything went smoothly. | Figure 2: Distribution in the different regions of the examinees. (a) Shows the distribution of those who took the written examination online and (b) Shows the distribution of those who took the practical examinations.  One figure is one person; CAR: Cordillera Administrative Region, NCR: National Capital Region
Click here to view |
PSGE has always advocated for the integration of MIGS in the residency training program. POGS, the Council for Residents' Education, Enhancement and Development, the Philippine Board for Obstetrics and Gynecology and our society, PSGE, foresee a future where majority of the gynecologists in the Philippines are competent at the least, in performing diagnostic hysteroscopy and laparoscopy. The program encourages early exposure in residency to the indications, peri-operative planning, and complications of MIGS procedures. It will include simulation training with exercises and assisting in surgical cases. With greater awareness, more graduates may be motivated to pursue postresidency fellowship training in MIGS, leading to an increase in the number of gynecologists with appropriate credentials. The integration into the residency program will be fully implemented by 2024.[7]
Arising to the challenge of enhancing MIGS training in residency, an Online Learning Program is being developed by the Society. It will be a virtual, self-paced, supplemental learning course aimed to help the residents with the acquisition of knowledge and skills necessary in performing basic procedures. The course will contain both didactics and skills exercises and will be available at the PSGE website until 2024.
The pandemic has also affected fellowship and residency training with a decrease in the number of surgical cases due to postponements and scheduling delays. It is thus essential that training by simulation be strengthened. The SPMC is the premier regional hospital in Davao City, Philippines. It is one of the largest hospitals in the Philippines with a 1500-bed capacity. Within the hospital lies the Surgical Knowledge Improvement Laboratory and Laparoscopy Simulation (SKILLS) unit. It was established in 2018, for surgical departments practicing minimally invasive surgery. There are three towers, three dry boxes, a number of abdominal and pelvic models, and a Simbionix Simulator.[8] Prepandemic it was open 8 hours daily, 6 days a week. Resident trainees in gynecology were required to report at least an hour a week and comply with the Fundamentals of Laparoscopic Surgery (FLS) exercises. Due to the drop of surgical cases, the modules of the residents were modified and they were encouraged to spend more visits to the SKILLS unit. Self-learning videos were provided and they were instructed to complete the FLS exercises in the dry boxes and do the exercises and simulated surgical procedures in the Simbionix simulator. The MIGS fellows in training assisted the residents in their rotation at the SKILLS unit and set their pace. Photographs of the residents during the conduct of their exercises were also sent to the faculty of the MIGS section thru the messenger app for assessment.
The Philippine General Hospital, the National University Hospital, is a designated COVID referral hospital. It is located in the center of Manila. Prior to the pandemic, it served more than 600,000 patients every year. It is the largest training hospital in the country and trainees include students of medicine, nursing, pharmacy, dentistry, and allied medical professions. It has 16 clinical departments, all of which offer residency and fellowship training programs.[9] The fellowship program in reproductive medicine attends to the cases for gynecologic endoscopy.
In order to guide the postresidency fellows for level one MIGS cases, the faculty started supervising virtual assists. Consultant-assisted surgeries for more difficult cases still continued. Virtual assists limit people within the operating room and possible COVID exposure in the hospital. Cases were well chosen with the senior fellows as surgeons and junior fellows assisting. The monitor of the laparoscopic tower is connected to a laptop computer which shows the same video as the laparoscopic tower monitor. The video can be shared real-time to other people via online meeting platforms such as Zoom [Figure 3]. | Figure 3: Set-up of virtual assists. (a) Shows a laptop computer hooked to the laparoscopy monitor sharing the same video while (b) Shows the video output, sent thru the zoom platform, as seen by the trainor on her computer devices
Click here to view |
The following are the feedback from our trainees on the advantages of virtual assists: more people can watch the operation at the same time with better view, trainees gain confidence on doing surgery on their own but still guided by the trainers, trainers are able to closely supervise and can give step-by-step instructions remotely and easier accessibility of trainers. The perceived disadvantages are the following: form of the surgeon cannot be observed because it is only the view of the laparoscope camera that can be seen, manual assistance is absent, communication may at times be difficult, the trainor cannot intervene actively if needed, and highly dependent on technical set up (stability and speed of the internet and audio quality).
From the trainer's perspective, the advantages are the following: it limits the number of people inside the operating room, trainers can continue to supervise the trainees remotely and multiple viewers are possible. The perceived disadvantages are: difficulty to articulate at times what needs to be done, and similar to the feedback of the trainees, it requires stable internet connection and need for good audio quality.
Several suggestions on how to improve on it further include the surgeon's use of earphones and microphones to improve on audio quality. There should also be provisions for additional cameras with the view of the operating room where the surgeon can be seen by the trainer. A stable internet connection is a must.
As part of our mission to provide continuing medical education programs, PSGE has hosted nine webinars in 2021 together with our colleagues from the different regions of our country. We likewise hosted our very first Virtual Annual Congress last July, with invited international and local faculty. To encourage early participation of our fellows in training, PSGE started a MIGS Grand rounds. Fellows in training present an interesting case and an expert panel shares their experience and perspectives on the case. The Grand rounds would like to encourage sharing of ideas and practices among the different training centers and guide our fellows in training in organizing and presenting in a formal forum.
Despite the challenges faced during the pandemic, the fundamental factors for minimally invasive training, which includes proper training, credentialing and hospital accreditation[10] are diligently pursued by the Society. For more than a year our society has continued to reach out to our Fellows and colleagues across the 7641 islands of the Philippines to strengthen our community. As our Society navigates this NOW NORMAL we also continue to reach out globally and remain eager to collaborate albeit online for now.
Acknowledgment
I would like to thank the following for their passion and untiring support in enhancing training and practice of gynecologic endoscopy in the Philippines, Dr. Ma Corazon Zaida N. Gamilla, Chair, Specialty Board for Gynecologic Endoscopy, Dr. Marlyn T. Dee, Chair, Committee on Hospital Accreditation and Dr. Prudence V. Aquino-Aquino, Chair, Committee on Training and the PSGE Board of Trustees 2021–2022.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. Maria Antonia E. Habana, an editorial board member at Gynecology and Minimally Invasive Therapy, had no role in the peer review process of or decision to publish this article.
| References | |  |
| 1. | Aquino PA. Philippine Society for Gynecologic Endoscopy Foundation. In: Palma C, editor. POGS at 75: Our Story, Our Legacy. Quezon City, Philippines: Published by the Philippine Obstetrical and Gynecological Society; 2021.  |
| 2. | Cardoso GT. Philippine Society for Gynecologic Endoscopy Foundation Training Manual, 2018-2023, Quezon City, Philippines: Published by the Philippine Society for Gynecologic Endoscopy Foundation; 2018. |
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| 7. | Council for Residents' Education, Enhancement, and Development (CREED)-Philippine Board of Obstetrics and Gynecology (PBOG) Resolution 2021-001; June 9, 2021. |
| 8. | |
| 9. | Habana MA. Philippine General Hospital Training Manual. Manila, Philippines: Published by the University of the Philippines-PGH; 2017. |
| 10. | Lee CL. Minimally invasive therapy for cancer: It is time to take actions for training system in minimally invasive therapy after LACC report. Gynecol Minim Invasive Ther 2019;8:1-3. [ PUBMED] [Full text] |
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