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Objectives of Training in the Subspecialty of Gynecological Reproductive Endocrinology
and Infertility

2013

EDITORIAL REVISION APRIL 2017
VERSION 1.1

This document applies to those who begin training on or after July 1, 2013.

NOTE: Throughout this document, references to the patient’s family are intended to include all those who are personally significant to the patient and are concerned with his or her care, including, according to the patient’s circumstances, family members, partners, caregivers, legal guardians, and substitute decision-makers.

DEFINITION

Gynecologic Reproductive Endocrinology and Infertility (GREI) is a subspecialty of Obstetrics and Gynecology. It is concerned with the prevention, diagnosis, and treatment of those disorders of the reproductive endocrine system that interfere with reproductive health at any age, and endocrine and other conditions that interfere with the human procreative process.

GOALS

Upon completion of training, a resident is expected to be a competent subspecialist in Gynecologic Reproductive Endocrinology and Infertility, capable of assuming a consultant’s role in the discipline. The resident must acquire a working knowledge of the theoretical basis of the subspecialty, including its foundations in science and research, as it applies to medical/surgical practice.

Only candidates certified by the Royal College of Physicians and Surgeons of Canada in Obstetrics and Gynecology may be eligible for certification in Gynecologic Reproductive Endocrinology and Infertility. A maximum of one year of training in GREI may be undertaken at the third or fourth year residency level during training for certification in Obstetrics and Gynecology.

Residents must demonstrate the requisite knowledge, skills, and behaviours for effective patient-centred care and service to a diverse population. In all aspects of specialist practice, the graduate must be able to address ethical issues and issues of gender, sexual orientation, age, culture, and ethnicity in a professional manner.

GYNECOLOGIC REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY COMPETENCIES

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert

Definition:

As Medical Experts, subspecialists in Gynecologic Reproductive Endocrinology and Infertility integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. Medical Expert is the central physician Role in the CanMEDS framework.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical, and patient-centred medical care
   1. Perform a consultation effectively, including the presentation of well-documented assessments and recommendations in oral, written, and/or electronic format, in response to a request from another health care professional
   2. Demonstrate use of all CanMEDS competencies relevant to GREI
   3. Identify and appropriately respond to relevant ethical issues arising in patient care
   4. Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems
   5. Demonstrate compassionate and patient-centred care
   6. Recognize and respond to the ethical dimensions in medical decision-making
   7. Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed
2. Establish and maintain clinical knowledge, skills, and behaviours appropriate to Gynecologic Reproductive Endocrinology and Infertility
   1. Demonstrate and apply knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to GREI
      1. Embryology, anatomy, histology, physiology, and genetics of the male and female reproductive tracts
      2. Anatomy, histology, and physiology of the hypothalamic-pituitary gonadal axis and related endocrine functions throughout life
      3. Mechanisms of reproductive hormone action and endocrine pharmacology
      4. Endocrinology and immunology of pregnancy and the feto placental unit
      5. Physiology of gametogenesis, gamete transport, fertilization, embryo development, implantation, and early pregnancy development
      6. Principles of epidemiology relevant to disorders of reproduction
      7. Microsurgical principles as they apply to tubal and other reproductive surgery
         1. Principles for selection of patients and technique(s) of tubal reanastomosis after previous tubal sterilization
      8. Principles of assisted reproductive laboratory techniques, including gamete culture and micromanipulation techniques
      9. Prevention and management of complications of assisted reproductive technology (ART), including but not limited to high-order multiple pregnancies, ovarian hyperstimulation syndrome, and ectopic pregnancy
      10. Appropriate preoperative assessment of the patient
      11. Etiology, diagnosis, and management of reproductive endocrinological disorders
          1. Disorders of function and physiology of the hypothalamic-pituitary-gonadal axis
          2. Disorders of menstrual cycle regulation throughout reproductive life
          3. Disorders of ovulation and follicle development
          4. Congenital anomalies of the reproductive system
          5. Primary and secondary amenorrhea
          6. Oligomenorrhea
          7. Anovulatory bleeding
          8. Hyperprolactinemia
          9. Hypogonadotropic hypogonadism
          10. Hypothyroidism
          11. Hyperandrogenic disorders in women and girls, including idiopathic hirsutism, polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing’s syndrome, and androgen-secreting tumour
          12. Disorders of sexual differentiation, anatomic alterations, and congenital anatomical variations, including ambiguous genitalia, ovarian dysgenesis, androgen insensitivity syndrome, testicular failure, and primary and secondary male hypogonadism
          13. Climacteric and menopause, including vasomotor symptoms, and osteopenia or osteoporosis
      12. Management of the following reproductive options
          1. Fertility preservation for medical and social indications
          2. Genetic screening and testing relevant to ART
          3. Third-party reproduction
   2. Describe the CanMEDS framework of competencies relevant to GREI
   3. Apply lifelong learning skills of the Scholar Role to implement a personal program to keep up to date, and enhance areas of professional competence
   4. Integrate the available best evidence and best practices to enhance the quality of care and patient safety in their practice
3. Perform a complete and appropriate assessment of a patient
   1. Identify and effectively explore issues to be addressed in a patient encounter, including the patient’s context and preferences
   2. Elicit a history that is relevant, concise, and accurate to context and preferences for the purposes of diagnosis, management, health promotion, and disease prevention
   3. Perform a focused physical examination that is relevant and accurate for the purposes of diagnosis, management, health promotion, and disease prevention
   4. Select medically appropriate investigative methods in a resource-effective and ethical manner
   5. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans in the following:
      1. The infertile couple, including but not limited to female and male causes, unexplained infertility, genetic abnormalities associated with infertility, assisted reproductive techniques, and the emotional needs of the couple
      2. Recurrent pregnancy loss
      3. Reproductive abnormalities of childhood and adolescence, including but not limited to precocious puberty, delayed puberty, growth disorders, and ambiguous genitalia
      4. Endometriosis
      5. Uterine leiomyomas
      6. Appropriate patient selection for medical and/or surgical management of infertility, including but not limited to treatment of ectopic pregnancy and uterine myoma
      7. Disorders of sexual function in females, males, and couples, including the ability to recognize and refer to the appropriate professional program for ongoing care
4. Use preventive and therapeutic interventions effectively
   1. Implement an effective management plan in collaboration with a patient, the patient’s family, and/or a third party
   2. Demonstrate effective, appropriate, and timely application of preventive and therapeutic interventions relevant to GREI
      1. Promote the prevention of and effectively manage ART complications, including but not limited to high-order multiple pregnancy, ovarian hyperstimulation syndrome (OHSS), and ectopic pregnancy
   3. Obtain appropriate informed consent for therapies
   4. Ensure patients receive appropriate end-of-treatment care
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
   1. Demonstrate effective, appropriate, and timely performance of diagnostic procedures relevant to GREI
      1. Hysterosalpingography (HSG) or sonohysterography (sonoHSG)
      2. Pelvic ultrasonography for diagnostic procedures, and appropriate selection of ancillary imaging techniques
   2. Demonstrate awareness of indications, contraindications, techniques, limitations, sources of error, and interpretation of diagnostic and therapeutic procedures
   3. Demonstrate effective, appropriate, and timely performance of therapeutic procedures relevant to GREI
      1. Pelvic ultrasonography for therapeutic procedures, and appropriate use of ancillary imaging techniques
      2. Appropriate medical and surgical management of ovulatory dysfunction
      3. Minimally invasive surgical procedures, including laparoscopy and hysteroscopy, for pelvic assessment and the surgical treatment of pelvic pathology affecting reproduction
         1. Lysis of adhesions
         2. Treatment of ectopic pregnancy
         3. Treatment of hydrosalpinx, including salpingectomy
         4. Ovarian cystectomy
         5. Treatment of pelvic endometriosis
         6. Myomectomy
         7. Diagnostic and operative hysteroscopy (office or operating room), including but not limited to
            1. Hysteroscopic polypectomy
            2. Hysteroscopic myomectomy
            3. Hysteroscopic lysis of adhesions
            4. Hysteroscopic resection of uterine septum
      4. Assisted reproductive technology procedures
         1. Transvaginal ultrasonography (TVUS) for ovulation induction/ assisted reproduction cycle monitoring
         2. Transvaginal ultrasonography (TVUS) for ovum retrieval under local anesthetic
         3. Embryo transfer (ET), with or without ultrasound guidance
         4. Paracentesis, by TVUS guidance or abdominal
         5. Artificial insemination, with or without ultrasound guidance
      5. Ovulation induction and controlled ovarian hyperstimulation
   4. Obtain appropriate informed consent for procedures
   5. Document and disseminate information related to procedures performed and their outcomes
   6. Ensure adequate followup is arranged for procedures performed
6. Seek appropriate consultation from other health professionals, recognizing the limits of their own expertise
   1. Demonstrate insight into their own limits of expertise
   2. Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal patient care
   3. Arrange appropriate followup care services for a patient and the patient’s family

Communicator

Definition:

As Communicators, subspecialists in Gynecologic Reproductive Endocrinology and Infertility effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
   1. Recognize that being a good communicator is a core clinical skill for GREI specialists, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence, and improved clinical outcomes
   2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, support, honesty, and empathy
   3. Respect patient privacy, confidentiality, and autonomy
   4. Listen effectively
   5. Be aware of and responsive to nonverbal cues
   6. Facilitate a structured clinical encounter effectively
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
   1. Gather information about a disease and about a patient’s beliefs, concerns, expectations, and illness experience
   2. Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers, and other professionals, while respecting individual privacy and confidentiality
3. Convey relevant information and explanations accurately to patients and families, colleagues, and other professionals
   1. Deliver information to a patient and family, colleagues, and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making
      1. Recognize that patients with endocrine dysfunction and infertility are faced with complex diagnoses and treatments that they may find difficult to understand and explain to others
      2. Recognize that those seeking infertility investigations often feel isolated and may prefer not to confide in friends and family
      3. Demonstrate expertise in explaining diagnoses, rationale for treatment, and treatment protocols clearly, avoiding highly technical language
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
   1. Identify and effectively explore problems to be addressed from a patient encounter, including the patient’s context, responses, concerns, and preferences
   2. Respect diversity and difference, including but not limited to the impact of gender, sexual orientation, religion, and cultural beliefs on decision-making
   3. Encourage discussion, questions, and interaction in the encounter
      1. Demonstrate an understanding that patients may believe that past decisions adversely affect the current situation
   4. Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care
      1. Offer referral for professional support
      2. Provide information and links to peer support groups
      3. Demonstrate empathy with a patient’s concerns and preferences; assist a patient in making the best personal choice
   5. Address challenging communication issues effectively, including but not limited to obtaining informed consent, delivering bad news, and addressing anger, confusion, and misunderstanding
5. Convey oral, written, and/or electronic information effectively about a medical encounter
   1. Maintain clear, concise, accurate, and appropriate records of clinical encounters and plans
   2. Present oral reports of clinical encounters and plans
   3. Convey medical information appropriately to ensure safe transfer of care
6. Present medical information to the public or media about a medical issue

Collaborator

Definition:

As Collaborators, subspecialists in Gynecologic Reproductive Endocrinology and Infertility work effectively within a health care team to achieve optimal patient care.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Participate effectively and appropriately in an interprofessional health care team
   1. Describe the GREI consultant’s roles and responsibilities to other professionals
   2. Describe the roles and responsibilities of other professionals within the health care team
   3. Describe the role of an interprofessional and multidisciplinary team in assisted reproduction programs
   4. Describe the role of an interprofessional and a multidisciplinary team involved in the activity of minimally invasive GREI-relevant surgical procedures
   5. Recognize and respect the diverse of roles, responsibilities, and competencies of other professionals in relation to their own, including but not limited to
      1. Urologists, endocrinologists, generalist obstetricians and gynecologists, and other health care professionals, in the management of complex reproductive disorders
   6. Work with others to assess, plan, provide, and integrate care for individuals and groups of patients
      1. Demonstrate active participation with the urologist, endocrinologist, and other health care professionals in the management of complex reproductive disorders
      2. Synchronize and coordinate the clinical component of ART procedures with the laboratory component, including but not limited to gamete and embryo treatment in the assisted reproduction laboratory
   7. Work collaboratively in other activities and tasks; examples include research, educational work, program review, and/or administrative responsibilities
   8. Participate in interprofessional team meetings
   9. Enter into interdependent relationships with other professions for the provision of quality care
   10. Describe the principles of team dynamics
   11. Respect team ethics, including confidentiality, resource allocation, and professionalism
   12. Demonstrate leadership in a health care team, as appropriate
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict
   1. Demonstrate a respectful attitude towards colleagues and members of an interprofessional team
   2. Work with other professionals to prevent conflicts
   3. Respect differences and the scopes of practice of other professionals
   4. Reflect on their own differences, misunderstandings, and limitations that may contribute to interprofessional tension
   5. Reflect on interprofessional team function
   6. Employ collaborative negotiation to resolve conflicts and address misunderstandings

Manager

Definition:

As Managers, subspecialists in Gynecologic Reproductive Endocrinology and Infertility are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
   1. Work collaboratively with others in their organizations
      1. Demonstrate administrative and organizational skills in various clinical settings, particularly interprofessional teams
   2. Participate in systemic quality process evaluation and improvement, including patient safety initiatives
      1. Prepare and participate in quality improvement presentation rounds and initiatives
      2. Demonstrate an understanding of the principles of quality assurance and quality improvement systems in ART programs
      3. Demonstrate an understanding of the principles of quality and infection control of gamete handling, culture, and cryopreservation in ART
   3. Describe the structure and function of the health care system as it relates to GREI, including the roles of physicians
   4. Describe the principles of health care financing, including physician remuneration, budgeting, and organizational funding
   5. Describe the principles of developing an interprofessional and multidisciplinary team in a reproductive clinic
2. Manage their practice and career effectively
   1. Set priorities and manage time to balance patient care, practice requirements, outside activities, and personal life
   2. Manage a practice, including finances and human resources
   3. Implement processes to ensure personal practice improvement
   4. Employ information technology appropriately for patient care
3. Allocate finite health care resources appropriately
   1. Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care
   2. Apply evidence and management processes for cost-appropriate care
   3. Demonstrate an understanding of public and private funding for ART
4. Serve in administration and leadership roles
   1. Participate effectively in committees and meetings
   2. Lead or implement change in health care
   3. Plan relevant elements of health care delivery, such as work schedules

Health Advocate

Definition:

As Health Advocates, subspecialists in Gynecologic Reproductive Endocrinology and Infertility use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Respond to individual patient health needs and issues as part of patient care
   1. Identify the health needs of an individual patient
   2. Identify opportunities for advocacy, health promotion, and disease prevention with individuals to whom they provide care
   3. Identify opportunities for patient education on prevention, timely intervention, and available resources for management of GREI-relevant conditions
   4. Identify opportunities for the emotional support of patients presenting with infertility or other GREI-relevant conditions
   5. Demonstrate an appreciation of the possibility of competing interests between individual advocacy issues and the community at large
2. Respond to the health needs of the communities that they serve
   1. Describe the practice communities that they serve
   2. Identify opportunities for advocacy, health promotion, and disease prevention in the communities that they serve, and respond appropriately
   3. Provide information and suggest strategies for timely approach to infertility management
   4. Demonstrate effective teaching to educate patients about the impact of reproductive age on fertility
   5. Demonstrate effective teaching to educate patients about strategies for minimizing the probability of multiple pregnancies associated with infertility treatment
   6. Communicate effectively to the general public and media about issues of local concern
      1. Respond to patients who inquire about media reports or other public information related to evolving technology in infertility management
      2. Advocate on behalf of patients whose concerns about privacy may limit their ability to advocate for themselves
   7. Demonstrate an appreciation of the possibility of competing interests between the communities served and other populations
3. Identify the determinants of health for the populations that they serve
   1. Identify the determinants of health of the population, including barriers to access to care and resources
   2. Identify vulnerable or marginalized populations within those served and respond appropriately
   3. Identify opportunities for short- and long-term analysis of outcomes of commonly used treatments for GREI-relevant conditions
   4. Identify public and private funding for ART
4. Promote the health of individual patients, communities, and populations
   1. Describe an approach to implementing a change in a determinant of health of the populations they serve
   2. Describe how public policy impacts on the health of the populations served
   3. Identify points of influence in the health care system and its structure
   4. Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity, and idealism
   5. Demonstrates an appreciation of the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper
   6. Describe the role of the medical profession in advocating collectively for health and patient safety

Scholar

Definition:

As Scholars, subspecialists in Gynecologic Reproductive Endocrinology and Infertility demonstrate a lifelong commitment to reflective learning, and the creation, dissemination, application, and translation of medical knowledge.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Maintain and enhance professional activities through ongoing learning
   1. Describe the principles of maintenance of competence
   2. Describe the principles and strategies for implementing a personal knowledge management system
   3. Recognize and reflect on learning issues in practice
   4. Conduct a personal practice audit
   5. Pose an appropriate learning question
   6. Access and interpret the relevant evidence
   7. Integrate new learning into practice
   8. Evaluate the impact of any change in practice
   9. Document the learning process
2. Critically evaluate medical information and its sources and apply this appropriately to practice decisions
   1. Describe the principles of critical appraisal
      1. Demonstrate the ability to recognize and identify gaps in knowledge and expertise around the clinical question
      2. Develop a plan for finding relevant information in the literature for a clinical question
   2. Critically appraise retrieved evidence in order to address a clinical question
      1. Demonstrate competence in critical appraisal of therapies, diagnostic tests, prognosis, and integrative literature including but not limited to meta-analysis, practice guidelines, and decision and economic analyses
      2. Develop, with the assisted reproduction team, a proposed solution for a clinical question
      3. Demonstrate an understanding of clinical trials methodology and biostatistics
   3. Integrate critical appraisal conclusions into clinical care
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public, and others, as appropriate
   1. Describe principles of learning relevant to medical education
      1. Demonstrate knowledge of ongoing developments in reproductive endocrinology and infertility, including treatment, technologies, and diagnostics
   2. Identify collaboratively the learning needs and desired learning outcomes of others
   3. Select effective teaching strategies and content to facilitate others’ learning
   4. Deliver effective lectures or presentations
      1. Present an update on or research relevant to GREI at the local, national, or international level
   5. Assess and reflect on teaching encounters
   6. Provide effective feedback
   7. Describe the principles of ethics with respect to teaching
4. Contribute to the development, dissemination, and translation of new knowledge and practices
   1. Describe the principles of research and scholarly inquiry
      1. Explain the fundamental elements of biostatistics, research ethics, study design, protocol writing, and manuscript preparation
   2. Describe the principles of research ethics
   3. Pose a scholarly question
   4. Obtain the approval of the local bioethics review board for a research proposal, if applicable
   5. Conduct a systematic search for evidence
   6. Select and apply appropriate methods to address the question
   7. Disseminate the findings of research and scholarly inquiry
   8. Complete a scholarly research, quality assurance, or educational project relevant to GREI that is suitable for peer-reviewed publication or presentation at an academic meeting

Professional

Definition:

As Professionals, subspecialists in Gynecologic Reproductive Endocrinology and Infertility are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

Key and Enabling Competencies: Subspecialists in Gynecologic Reproductive Endocrinology and Infertility are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
   1. Demonstrate the ability to meet deadlines and be punctual
   2. Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect, and altruism
   3. Demonstrate a commitment to delivering the highest quality care and maintenance of competence
   4. Recognize and appropriately respond to ethical issues encountered in practice, including impact of new reproductive technologies on bioethics and health economics
   5. Identify, declare, and manage perceived, potential, and actual conflicts of interest
   6. Recognize the principles and limits of patient privacy and confidentiality, as defined by professional practice standards and the law
   7. Maintain appropriate boundaries with patients
2. Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation
   1. Demonstrate knowledge and understanding of the professional, legal, and ethical codes of practice
   2. Fulfil the regulatory and legal obligations required of current practice
   3. Demonstrate accountability to professional regulatory bodies
   4. Recognize and respond appropriately to others’ unprofessional behaviours in practice
   5. Participate in peer review
3. Demonstrate a commitment to physician health and sustainable practice
   1. Balance personal and professional priorities to ensure personal health and a sustainable practice
   2. Strive to heighten personal and professional awareness and insight
   3. Recognize other professionals in need and respond appropriately

This document is to be reviewed by the Specialty Committee in Gynecologic Reproductive Endocrinology and Infertility by December 31, 2018.

• Revised – Specialty Committee – October 2012
• Approved – Specialty Standards Review Committee – April 2013
• Revised – Specialty Committee – September 2016
• Editorial revision approved – Office of Specialty Education – April 2017

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