Obstetrics and Gynecology Teaching

Although it is known that in Inca times the amautas were in charge of teaching the children of the nobles, previously this could have been through the forms, figures and paintings of the huacos, which were related to the characteristics of men and women, ways of life, nutrition, diseases, neoplasms, malformations, surgery, amputations, sexuality, gestation, childbirth. In other words, women, pregnancy and childbirth were the reason for the dissemination of knowledge among the inhabitants of pre-Hispanic Peru. Of admiration, the reliefs on the high stone walls of Sechin (Ancash, Peru), dating from around 2,300 BC, apart from warrior priests and mutilated bodies, present anatomical studies of various organs of the human body, possibly of the defeated and sacrificed combatants.

The teaching of safe childbirth care in Peru seems to have started at the beginning of the 19th century with the arrival of the French midwife Madame Benita Paulina Fessel. Soon after, Peruvian surgeons trained abroad performed amazing gynecological surgeries for that time and, later on, specialized hospitals were built for the care of women.

In previous paragraphs we have pointed out that, half a century ago, doctors trained in Europe and North America created schooled teaching in the specialty, first at the San Bartolomé Hospital, with Dr. Abraham Ludmir Grinberg at the San Fernando Faculty of Medicine of the Universidad Nacional Mayor de San Marcos and later in other schools in Lima and important regions of Peru, with regulations of the Ministry of Health. However, primary health care has not been implemented in Peru and the first level of health care has not been strengthened, a weakness in our health organization that became evident with the appearance of the COVID-19 pandemic, and that has required urgently and with limited budget to implement hospitals with services, equipment, materials and medicines adapted to the context and human resources that could not cope with the rapid and erratic advance of the infection.

Virtual-presential education

One aspect seriously affected by the COVID-19 pandemic - today endemic - has been the training of human resources in health at undergraduate and postgraduate levels. The mobility restrictions applied as a result of COVID-19 led to the adoption of online learning by institutions of higher education. Students of medicine, obstetrics, nursing, medical technology and health nutrition, among others, have had to vary their studies and face-to-face practice for strictly virtual education. Our specialty requires face-to face practice given its personal health care characteristic and the need to acquire medical and surgical skills. The pandemic has delayed the training of resident physicians in the aspects of knowledge, skills and abilities.

Professors and students have had to adapt quickly to virtual teaching, with the academic, administrative and daily life changes that it brought with it, schedules that intersected with the work schedules of the teachers and problems with the availability of computer equipment and internet for students, in addition to the confinement at home. However, virtual teaching has brought some benefits for medical students. The virtual classroom can be taught at a punctual time - but with flexible schedules - and can be visited and reviewed at any time. In addition to acquiring digital skills, it allows active participation, feedback and autonomy of the student, with immediate access to information sources, better time management, savings in travel costs, social communication, among others. And he has been able to freely participate in high-level national and international conferences. The limitations for the student are the difficulties of concentration and socialization, the availability of internet, costs of computer equipment, geographical remoteness. As for the teachers, they were not prepared for the abrupt implementation of the virtual computer era. Curricular plans had to be urgently adapted, with few variations and needing to be improved. The pandemic and the advances in science will force the elaboration of new curricular plans for the new generations that will live in a changing world, with rapid scientific updating, simulation, educational videos, that is to say, for the new post-covid life.

Medical education relies on direct patient contact to create work-ready students. The theoretical aspects can be learned virtually. But the doctor-patient encounter -with women and pregnant women in our specialty- cannot. Students have repeatedly requested face-to-face education with the patient, which would have entailed the risk of contact with people sick with the virus and/or cross paths with health personnel caring for patients with COVID-19. A similar situation was foreseen for health professionals and teachers of legal age, who were confined to their homes.

Important elements related to face-to-face medical education are patient-centered care, ethical considerations and prevention orientation. Our approach to each patient's health, a personalized and friendly anamnesis and clinical examination, the request for complementary tests adjusted to the necessary ones and the rapid therapeutic management based on new evidence, with cost-benefit calculation, is an invaluable learning experience for the student. These concepts can only be acquired by watching how the teacher does it and practicing it with the patient. Rather, at this stage of the pandemic, students have learned health prevention topics such as, for example, the usefulness of personal protective measures (masks, face masks, goggles), hand washing, distancing, avoiding crowds and the need for vaccines, prevention that has not only reduced COVID-19 infection, its severity and deaths, but is preventing other contagious and seasonal environmental diseases. These protective mea-sures should be permanently considered and informedly advised by future physicians to patients, family and community.

In addition to the above, young people need to acquire more health knowledge of the country and its various regions, climates and customs, with emphasis on the most frequent diseases. In health prevention, it is urgent the knowledge and application of an adequate nutrition for the different Peruvian populations, and the practice of physical exercises from childhood in school and towards older age, aspects aimed at preventing the metabolic syndrome, overweight and obesity that lead to hypertension, coronary heart disease, type 2 diabetes mellitus and other related comorbidities, today universally increasing due to the habits of life of fast food and sedentary lifestyles. In the pandemic, it has been observed how the disease rages against overweight and obese people, as well as the malnourished and those with comorbidities and immunocompromised.

In the education of residents in obstetrics and gynecology, while remembering the basic sciences on the physiology and pathophysiology of women, emphasis should be placed on knowing the differences of these health situations with those of men, their variation in adolescence, gestation and senility, as well as the prevention of the most frequent causes of morbidity and mortality in the country. It will include the need to know about early prenatal care, sexuality, fertility, family planning, early diagnosis of cancer, aspects of menopause and older age of women. In the current five-year period 2021 to 2025, women have a life expectancy of 79.8 years and men 74.5 years in Peru⁷, which obliges us to know the health complications of older women and their prevention from an early age. The attention to the female patient will always be sympathetic, ethical, attentive listening, with concrete and intelligent questions, digitization of information in the digitalized clini cal history, filling out the perinatal card and other health surveillance documents. In other words, they will be taught to practice comprehensive care centered on the woman during her life, in health and disease.

Obstetrics and gynecology education of students and resident physicians should include community health activities (primary care), with integrated programs of the Ministry of Health (MINSA), Essalud and the University, the Medical College and public and private health institu tions. Likewise, and due to the bad experience in this aspect during the pandemic, care at the first level of care will be considered, where the student and the young physician will apply their knowledge to medical practice, as well as be able to communicate intelligently to the community how to take care of their health⁸.

With the current decrease in infections and deaths due to the pandemic, the student's early face-to-face practice is on the horizon. But, how long this situation will last is still unknown. The panorama is complicated by what is happening in Europe, Asia and North America, where vaccination has advanced significantly, but the presence of new variants of SARS-CoV-2 -mainly delta- and the resistance of an important population of people who do not accept to be vaccinated, are altering the favorable predictions. The student will have to continue to guard against the coronavirus for a long time to come.

Medical education does not end at the end of the residency in obstetrics and gynecology. Once graduated, the obstetrician-gynecologist is being trained in related subspecialties -ultrasound, endoscopy, robotization, fetal medicine, fetal surgery, reproductive medicine and infertility, pelvic surgery, climacteric and menopause, among others-; and, in the aspect of health management and academic degrees, he/she studies diploma, master's and doctorate degrees. In addition, they are required to undergo periodic evaluation through certification and recertification by the Peruvian Medical College, where they reaffirm their continuous training, skills and abilities, as well as their participation in academic activity and in research and publication. The health professional's education is lifelong.

Obtaining the Best Information, Scientific Knowledge and Clinical Expertise

With regard to medical information, the pandemic has transformed from reading physical books and journals and visiting libraries to obtaining information from virtual journals, books and documents. At the same time, teachers are teaching their students to avoid non-validated, false or biased information, and to obtain knowledge only from reliable sources, peer-reviewed articles, systematic reviews from prestigious academic databases. The student is prepared to safely investigate every question that arises during their medical training or in patient care.

Since the onset of the COVID-19 pandemic, there has been an increased urgency to identify the pathophysiological features that lead to severe clinical course in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the first months of 2020, scientists quickly discovered the structure and mode of action of the new coronavirus, its modifications to perfect its penetration into humans, as well as pointed out measures that could be used to prevent the disease, improve the health of those infected and prevent their mortality. Physicians, teachers and students increased the habit of checking the internet permanently in order to know what is new about the pandemic, its prevention and management. Given what was learned with other coronaviruses, rapid progress was made in formulating candidate vaccines that were used on an emergency basis. As for the treatment of those infected with COVID-19, we saw with despair the successive failure of drugs, which were replaced by new anti-inflammatory molecules, anticoagulants, antibiotics and other medicines with long and difficult to pronounce names, without there still being a specific therapy for the new coronavirus. And, although we were forced to brush up on basic science, genetics, mutations and variants, immunology, infectology, hematology, lung capacity and others, we are only now learning that the variability of response of those affected to medical management may be due to the fact that not all humans have the same genomic sequence. Human leukocyte antigen (HLA) alleles have been suggested as possible host genetic factors affecting individual immune response to SARS-CoV-2. HLA-C*04:01 carrier status has been found to be associated with severe clinical course of SARS-CoV-2. That is, HLA class I alleles would play a relevant role in the immune defense against SARS-CoV-2⁹.

Management of apparently recovered COVID-19 patients

It is now known with astonishment that a high percentage of patients recovered from severe, and even mild, covid-19, and more so in women, maintain varied symptoms that persist for weeks and affect their life and work. Half of hospitalized COVID-19 survivors experience at least one persistent symptom one year after discharge. At six months, 68% appear to have at least one sequela symptom, decreasing to 49% at 12 months (p<.0001). The proportion of patients with dyspnea is about 26% at six months and 30% at 12 months (p=.014). In addition, more patients have anxiety or depression at 12 months (26%) than at six months (23%), always more in women than in men¹⁰. Seventeen percent of patients with longterm COVID reported fatigue, 13% had breathing difficulties and loss of taste or smell, and 11% reported muscle or joint pain. Five percent of respondents were hospitalized because of the virus¹¹. In other words, although COVID-19 is known to primarily affect the lungs and usually leaves scarring damage, it can also damage many other organs, such as the heart muscle and nervous system, and can cause strokes, seizures, Guillain-Barré syndrome, Parkinson's and Alzheimer's disease¹² and much more.

We must prepare to care for these millions of people who will continue to require health care and rehabilitation for an as yet undetermined time after they have COVID-19. Undergraduate and graduate students should be trained to ask, diagnose and guide the treatment of any patient who have been ill with the coronavirus, and recommend follow-up and possible rehabilitation by specialized medical personnel.

Accelerated Training - Research

The young physician has needed accelerated training in this pandemic, guided by the pre-print published literature -without external evaluation until after its online publication -, to find lights in the dark, but at the same time found that treatments and drugs were replaced by others for its lack of effectiveness and/or harmfulness.

We imagine that the student and the physician have wondered if something different could be done to defeat the virus and the disease, since the wealth of information does not yet have firm answers. This could be the possibility to encourage research in health, so little present in our countries due to the lack of stimulus to scientists and the lack of economic resources. The National Council of Science, Technology and Innovation -Concytec is the governing body in charge of directing, promoting, coordinating, supervising and evaluating the research actions of the State in Peru. Apart from regulating and supporting research directly or through universities, it is integrating and classifying Peruvian researchers, has created the status of teaching researcher and encourages the advancement of new Peruvian technology and entrepreneurship, especially in young researchers. It is fair to highlight that several of the SPOG members are researchers in the specialty with publications in indexed journals and certified as teaching researchers and members of research groups in the National Scientific, Technological and Technological Innovation Registry - Renacyt, San Marcos Registry of Research Activities, ORCID, Google Scholar and h-index.

In addition, Concytec encourages the publication of research in indexed scientific journals, while supporting the permanence and excellence of scientific journals in the country. The Peruvian Journal of Gynecology and Obstetrics (RPGO), founded in 1955 and with continuity until to day thanks to the work of its 11 Directors -six of them past-presidents of SPOG-, is indexed in Scielo Peru, Redalyc, IMBIOMED, Dialnet, DOAJ, Redib, ESCI Web of Science, MIAR, EuroPub, Latindex, among others, which supports Peruvian and international obstetrics and gynecology researchers who publish in the RPGO, who do so in a journal with academic excellence. The RPGO has received financial support from Concytec to increase its indexing.

The emotional impact

Over the past two years, the health professional and students have had to face the pain, the fear, the continued work beyond their schedule, the fatigue, and the ethical decisions in dealing with the unknown and death. Observing the rapidly progressing, severe conditions, with machines, tubes, oxygen and IVs in patients who were begging for their lives, with no family around, only to lose their lives and be cremated, leaves a deep impression that the human being is fragile. The pandemic represents an especially critical element in medical education, as the demand for personnel has accelerated the graduation of many medical students and placed them in a highly stressful situation very early in their careers.

Undergraduate and graduate students are learning the need for rapid response to severe morbid cases, deferring emotions for what little downtime they may have when the workload grows. This is also an apprenticeship for our students, facing the unknown, knowing how to promptly choose the most appropriate procedure for each case, modifying it in time if necessary, knowing how to transmit the state of health to the patient and the news to the relatives, containing emotions, post-traumatic stress and anxiety, knowing how to overcome fatigue, knowing how to win and lose. In addition, they affirmed the need for teamwork to achieve the goal of a recovered patient.

On the other hand, the doctor and the student have learned how to take care of their own health, seeing their colleagues, teachers and relatives fall ill and die. As well as how to take care of their own family, many isolating themselves from them for some time, to avoid carrying the virus.

Medical education in the future

The coronavirus crisis has shaken the foundations of almost every aspect of our world, so much so that it is very difficult to predict the future. We must adapt to the new reality and have a critical need to transform various aspects of medical education to reflect the changing medical landscape.

In university academia, we faculty understand that virtual and artificial reality is one of the biggest technology trends that will transform medicine and healthcare in the second decade of the 2000s.

Apart from e-learning, healthcare professionals and students are adapting to new technologies that will allow the monitoring of minor illnesses from home, including COVID-19 in cases where the condition is manageable. But also after recovery, which can be very prolonged, as we noted above. An example of novelty is given by sensors that monitor personal health through mobile devices and cell phones.

Telehealth has shown its immense usefulness in remote communication with the patient, as well as the exchange of knowledge among health professionals to solve difficult cases. Our future professionals have a new tool to solve health problems, as well as to transmit health education and semi-presential care to the population. This telemedicine is being complemented by the provision of necessary devices, such as blood pressure cuffs, remote stethoscopes, as well as the use of health data from Apple Watches and other patient devices. And, as coronavirus or other pandemics and endemics continue, greater acceptance of communication and treatment virtually could reduce the risk of contamination of healthcare professionals.

The use of computerized algorithms to detect, diagnose and treat patients is another of the advances that teachers and students are applying in practice¹³. It is observed with astonishment how, for example, machines equipped with specific software¹⁴ can help in the targeting of genomic diagnoses¹⁵, their pathology, mutations and variants. This will help the medical community to better understand how diseases occur, how to treat them or even eradicate them. This is a key component in the fight against COVID-19, as a person's genetic makeup has a critical impact on how his body responds to the virus.

Will everything be handled by new technology alone?

Medical education of the future will require the inclusion of new technology and artificial intelligence. It is very easy to wish for it, but how to make it effective quickly in a country with limited research and few licenses for technological discoveries?

On the other hand, it will always be necessary to remind our students that decision making is still the exclusive preserve of our minds, knowledge and experience, and should not be totally replaced by new technology. We will emphasize the importance of a good clinical history with ample and understandable writing. This will be the basis for our medical practice, but also -later on- for the conformation of the algorithms of the software used by computers and our defense in case of litigation. The medical record must be entered from the beginning in a computer -electronic medical records-, in order to have the patient's complete information permanently and to use it at any time and place. In addition to personal data and anamnesis, the history includes the clinical examination, reports of auxiliary methods, diagnoses, medical and surgical management, follow-up and many other data, from birth to death¹⁶. The use of evidence derived from collected medical records in patient care has been a long-standing vision of clinicians and informaticists; implementation of this vision is now possible. Researchers have developed an on-demand query service to obtain evidence from patient data to answer clinicians' questions and support their decision making at the bedside. The methods of these services are publicly available to facilitate their widespread adoption by health systems and academic medical centers¹⁷.

But then, should all medical care always be per formed with artificial technology?

A Chinese article addresses this aspect. It points out that medical education must adapt to different healthcare contexts, including digitized healthcare systems and a digital generation of students in a hyper-connected world. To detect these developments, they searched PubMed, Scopus, Web of Science, and EBSCO ERIC for articles between 2011 and 2017. Key search terms were "undergraduate medical education," "future," "twenty-first century," "millennium," "curriculum," "teaching," "learning," and "assessment." Using a modified Hawler evaluation format, among the 7,616 abstracts initially identified, 28 full-text articles were selected to reflect trends in medical education and suggest appropriate educational programs. The integrative themes and subthemes of suggested future medical education are as follows: 1) a humanistic approach to patient safety involving the promotion of humanistic physicians and facilitating collaboration; 2) early experience and longitudinal integration through early exposure to patient-oriented integration and longitudinal integrated practices; 3) moving beyond hospitals into society by responding to changing community needs and showing respect for diversity; and 4) student-driven learning with advanced technology through active learning with individualization, social interaction, and accessibility to resources¹⁸. That is to say, as contemplated above, the formulation of the curricular plans of the new medical education cannot forget the pillars of the interpersonal performance of the health professional, with humanism and ethics, integrated with the other health care actors, knowing and integrating into the community of each place and applying the new knowledge and the new technology envisioned. Further studies will be required on how to adapt the new plans in postgraduate and continuing medical education, as well as to evaluate the results of the application of the new curricular programs in medical schools and the environments in which they will be applied.

Finally, many of the future medical professionals will eventually hold health management positions, and their vision should encompass preventing and managing health crises, and knowing how to rapidly organize health care from the community to the most complex levels.