Scholarship, self-directed learning, teaching, EBM and research

Overview

• The RANZCOG Fellowship examination assesses not only clinical knowledge but the capacity to function as a self-directed, critically appraising, evidence-generating specialist.
• The Scholar domain under CanMEDS 2015 (adopted by RANZCOG in its curriculum framework) requires the specialist to maintain and extend knowledge through independent learning, critically appraise evidence, apply research methodology, and contribute to the knowledge base of the discipline.

For the Structured Oral examination, Scholar competencies are most commonly tested through scenarios that require you to:

• Justify a clinical decision by reference to evidence hierarchy and specific RANZCOG guidance
• Explain how you would critically appraise a paper presented to you or a new guideline
• Describe how you keep your practice current between guideline updates
• Articulate the governance pathway for a quality improvement project or audit
• Demonstrate awareness of research ethics, trial registration, and responsible conduct of research

This note covers the conceptual scaffolding, practical application, and exam-specific expectations for FRANZCOG_SCHOLAR_S1: demonstrating engagement in ongoing, independent, self-guided learning.

Key Concepts

1. The CanMEDS Scholar Role in the RANZCOG Context

The CanMEDS 2015 Scholar role encompasses four competencies:

1. Engaging in the continuous enhancement of personal and professional expertise
2. Critically evaluating medical information and its sources
3. Facilitating the learning of patients, families, students, and other health professionals
4. Contributing to the creation, dissemination, application, and translation of new medical knowledge

• RANZCOG maps these directly to its Continuing Professional Development (CPD) program, which is mandated under AHPRA registration standards.
• From 2023, AHPRA's revised CPD registration standard requires all specialists to complete a minimum of 50 hours of CPD per year (25 hours reviewing performance and measuring outcomes, 12.5 hours educational activities, 12.5 hours self-allocated), with a mandatory reflective practice component and a peer review or multi-source feedback element.
• Failure to meet CPD requirements is a registration compliance matter.

RANZCOG's CPD program categorises activities into:

• Category 1: Educational activities (journal clubs, conferences, online modules, RANZCOG e-learning)
• Category 2: Performance review (audit, peer review, case review, morbidity and mortality meetings)
• Category 3: Remediation (only applicable if a performance gap is identified)

Self-directed learning sits primarily in Category 1 but feeds directly into Category 2 when it informs audit or quality improvement activity.

2. Evidence Hierarchy and Critical Appraisal

A senior registrar must be able to articulate the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology, which underpins most contemporary clinical practice guidelines including those published by RANZCOG.

GRADE evidence quality levels:

• GRADE separates the quality of evidence from the strength of recommendation.
• A strong recommendation can be made on low-quality evidence if the balance of benefits and harms is clear (e.g. corticosteroids for fetal lung maturity in extreme prematurity where RCT evidence is sparse for the 22-23 week cohort but the benefit-harm ratio is compelling).
• RANZCOG Statements as living evidence summaries: RANZCOG publishes College Statements, Guidelines, and Consensus Statements.
• These are not static documents.
• The College reviews and updates them on a rolling cycle.
• A candidate must know that a RANZCOG Statement represents the College's synthesis of current evidence at the time of publication and carries institutional authority, but it does not replace individual clinical judgement applied to the specific patient.
• When a Statement is under review or when new high-quality evidence has emerged since its last update, the clinician has a professional obligation to be aware of that gap.

3. Reporting Standards: CONSORT and PRISMA

When appraising primary literature, two reporting standards are essential:

CONSORT (Consolidated Standards of Reporting Trials): The CONSORT 2010 statement provides a 25-item checklist and flow diagram for reporting randomised controlled trials. Key items relevant to O&G appraisal include:

• Sequence generation and allocation concealment (items 8-10): critical for assessing selection bias in trials of intrapartum interventions
• Blinding (item 11): often impossible in surgical trials (e.g. comparing laparoscopic vs open myomectomy) - the absence of blinding must be acknowledged as a limitation
• Intention-to-treat analysis (item 16): important in trials with high crossover rates, common in labour management trials
• Harms reporting (item 19): frequently under-reported in obstetric trials

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses): The PRISMA 2020 statement provides a 27-item checklist. Key elements:

• PRISMA flow diagram: documents records identified, screened, assessed for eligibility, and included
• Risk of bias assessment: should use validated tools (Cochrane Risk of Bias 2 for RCTs; ROBINS-I for non-randomised studies)
• Certainty of evidence: GRADE should be applied to the body of evidence, not just individual studies
• Registration: systematic reviews should be registered on PROSPERO prior to commencement
• Cochrane methodology: The Cochrane Collaboration produces systematic reviews using a standardised methodology described in the Cochrane Handbook for Systematic Reviews of Interventions.
• Cochrane reviews in O&G (e.g. Cochrane Pregnancy and Childbirth Group) are frequently cited in RANZCOG Statements.
• A candidate should understand that Cochrane reviews are updated as new evidence emerges and that the version date matters when citing them.

4. Research Ethics and Governance

• NHMRC National Statement on Ethical Conduct in Human Research (2007, updated 2018): This is the primary Australian framework governing research involving humans.
• It is published jointly by the NHMRC, Australian Research Council, and Universities Australia.

Key principles:

• Research merit and integrity
• Justice
• Beneficence
• Respect for persons

For O&G research, specific chapters are relevant:

• Chapter 2.3: Research involving pregnant women - requires specific justification for inclusion or exclusion of pregnant participants; exclusion without justification is itself an ethical issue given the historical under-representation of pregnant women in clinical trials
• Chapter 4.2: Research involving Aboriginal and Torres Strait Islander peoples - requires community consultation, community benefit, and respect for cultural protocols; the NHMRC Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities guidelines (2018) provide additional specific guidance

Australian Code for the Responsible Conduct of Research (2018): Published jointly by the NHMRC and Universities Australia, this Code sets out the principles and responsibilities for researchers and institutions. It covers:

• Data management and storage (minimum 5 years for most research; 15 years for clinical trials)
• Authorship: all authors must meet all four ICMJE criteria (conception/design OR data acquisition OR analysis; drafting or critically revising; final approval; accountability)
• Conflicts of interest: must be declared and managed
• Research misconduct: fabrication, falsification, plagiarism - institutions have mandatory investigation obligations
• HREC processes: Human Research Ethics Committees operate under the National Statement.
• In Australia, most public hospitals and universities have their own HRECs or participate in a certified review network.
• For multisite O&G research (e.g. a national trial of induction of labour protocols across multiple maternity units), a single ethical review through a certified HREC can be accepted by all participating sites under the National Mutual Acceptance scheme, avoiding duplicative review.
• ANZCTR (Australian New Zealand Clinical Trials Registry): All interventional clinical trials conducted in Australia and New Zealand must be prospectively registered on the ANZCTR or another WHO-recognised primary registry before the first participant is enrolled.
• Retrospective registration is a research integrity violation.
• The ANZCTR is the WHO primary registry for Australia and New Zealand.
• Registration provides a public record of the trial protocol, primary outcome, and statistical analysis plan, which guards against outcome switching and publication bias.

5. Self-Directed Learning Strategies at Specialist Level

Independent learning at this level is not passive reading. It involves:

Structured journal surveillance: Identifying high-yield journals (BJOG, American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, The Lancet, NEJM for landmark trials) and setting up automated alerts (PubMed My NCBI, journal RSS feeds) for key MeSH terms relevant to your practice.

• Critical appraisal practice: Applying CONSORT or PRISMA checklists to papers before accepting their conclusions.
• For example, a new RCT on cervical pessary for preterm birth prevention should be appraised for: allocation concealment, whether the control group received standard care, whether the primary outcome was patient-important, and whether the trial was powered for the primary outcome.
• Morbidity and mortality (M&M) meetings as learning: M&M meetings are a Category 2 CPD activity but also a primary vehicle for self-directed learning.
• Preparing a case for M&M requires independent literature review, identification of the evidence-practice gap, and formulation of a systems recommendation.
• This is the Scholar role in action.
• Audit and quality improvement: The NSQHS Standards (Australian Commission on Safety and Quality in Health Care, 3rd edition) Standard 1 (Clinical Governance) requires health service organisations to have systems for monitoring and improving clinical performance.
• Participating in departmental audit against RANZCOG benchmarks (e.g. caesarean section rates, third-degree tear rates, oxytocin use in labour) is both a CPD requirement and a Scholar activity.

Clinical Application

Scenario 1: New Evidence Challenges Current Practice

• You are the on-call consultant.
• A registrar presents a newly published RCT suggesting that routine continuous electronic fetal monitoring (CTG) in low-risk labour increases caesarean section rates without improving neonatal outcomes, and asks whether your unit should change its protocol.

Scholar response:

• Acknowledge the question is legitimate and reflects good self-directed learning behaviour
• Apply GRADE: what is the quality of this single trial? Is it consistent with the existing body of evidence? Has it been incorporated into a systematic review?
• Check whether RANZCOG has a current Statement on intrapartum fetal surveillance (it does - the RANZCOG Intrapartum Fetal Surveillance Clinical Guideline, currently in its 4th edition) and whether this new trial changes the evidence base sufficiently to deviate from it
• Explain that a single trial, even a well-conducted RCT, does not immediately change institutional protocol. The pathway is: appraise the paper, present at journal club or M&M, escalate to the Clinical Director if a practice change is warranted, and await RANZCOG Statement update or seek College guidance
• Document your appraisal and the decision not to change practice pending further evidence

Scenario 2: Preparing a Quality Improvement Project

• You identify that your unit's rate of postpartum haemorrhage (PPH) following vaginal birth is above the AIHW national benchmark.
• You want to conduct a quality improvement project.

Scholar pathway:

1. Define the problem using AIHW data (Australia's Mothers and Babies report, published annually) as the benchmark comparator
2. Conduct a retrospective audit of your unit's PPH cases against RANZCOG's PPH prevention and management guidelines
3. Identify the evidence-practice gap (e.g. delayed oxytocin administration, inconsistent use of active management of third stage)
4. Design the intervention (education, protocol revision, simulation training)
5. Determine whether the project requires HREC review: quality improvement projects that use de-identified existing data and do not involve additional interventions on patients are generally exempt from full HREC review under the National Statement (Chapter 2.2, low and negligible risk research), but institutional governance approval is still required
6. Register the project with the hospital's quality and safety unit (NSQHS Standard 1 requirement)
7. Measure outcomes using a Plan-Do-Study-Act (PDSA) cycle
8. Present findings at M&M and submit to a peer-reviewed journal if results are generalisable

Scenario 3: Critically Appraising a Meta-Analysis at Journal Club

You are presenting a Cochrane systematic review on magnesium sulphate for neuroprotection in preterm birth.

Key appraisal points using PRISMA and Cochrane methodology:

• Was the review registered on PROSPERO? (Cochrane reviews are registered in the Cochrane Register)
• What was the PICO question and was it clearly defined?
• What databases were searched and were grey literature and trial registries (including ANZCTR) included?
• What risk of bias tool was used for included trials? (Cochrane Risk of Bias 2 for RCTs)
• Was GRADE applied to the certainty of evidence for each outcome?
• Are the outcomes patient-important? (neonatal death, cerebral palsy, not just surrogate outcomes)
• Is there heterogeneity (I-squared statistic) and how was it explored?
• Does the review conclusion align with the RANZCOG Statement on magnesium sulphate for neuroprotection?

Pitfalls

1. Confusing evidence quality with recommendation strength.

• A common error is stating that a strong recommendation requires high-quality evidence.
• Under GRADE, a strong recommendation can be made on low-quality evidence when the benefit-harm balance is clear, values and preferences are consistent, and resource implications are acceptable.
• Conversely, high-quality evidence may yield only a conditional recommendation if harms are significant or values vary.

2. Treating RANZCOG Statements as infallible or immutable.

• Statements are evidence summaries at a point in time.
• A candidate who says "the RANZCOG guideline says X therefore I do X" without being able to articulate the evidence behind X, or acknowledge when new evidence has emerged, will not satisfy the Scholar domain.

3. Conflating audit with research.

• Audit measures current practice against a standard.
• Research generates new knowledge.
• The distinction matters for HREC requirements.
• Presenting audit as research (or vice versa) has governance and ethical implications.
• Under the National Statement, quality improvement activities using existing de-identified data are generally low or negligible risk and may not require full HREC review, but this must be confirmed with the institutional HREC or ethics office.

4. Ignoring the ANZCTR registration requirement. Candidates who describe designing a clinical trial without mentioning prospective registration on the ANZCTR (or another WHO primary registry) will be marked down on research governance knowledge.

5. Passive CPD.

• Listing conference attendance as the entirety of CPD does not satisfy AHPRA's revised CPD standard, which requires reflective practice and performance review components.
• A candidate who cannot describe how they have identified and addressed a personal learning gap will not demonstrate the Scholar role.

6. Overlooking Aboriginal and Torres Strait Islander research ethics.

• Any research or quality improvement project involving Aboriginal and Torres Strait Islander communities requires specific ethical consideration under the NHMRC Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities guidelines (2018).
• Community consultation, community benefit, and data sovereignty are non-negotiable elements.
• Failing to mention these in a scenario involving remote antenatal outreach or Indigenous health data is a significant omission.

7. Misapplying intention-to-treat analysis.

• ITT analysis preserves randomisation and prevents attrition bias.
• A candidate who accepts a per-protocol analysis as the primary result without questioning why ITT was not used (or was not possible) is not demonstrating critical appraisal.

Examiner Expectations (Structured Oral)

In a Structured Oral station testing Scholar competencies, the examiner is looking for evidence that you function as an independent, critically appraising clinician who keeps knowledge current through structured, reflective activity - not someone who passively receives information.

What a high-scoring candidate does:

• Names specific frameworks by their correct titles: "the NHMRC National Statement on Ethical Conduct in Human Research", "the Australian Code for the Responsible Conduct of Research", "the RANZCOG Intrapartum Fetal Surveillance Clinical Guideline", "the CONSORT 2010 checklist"
• Applies GRADE terminology correctly: distinguishes quality of evidence from strength of recommendation, uses the four levels (high, moderate, low, very low), and explains how GRADE informs clinical decision-making
• Describes a concrete, structured approach to keeping current: journal alerts, journal club, M&M, audit cycles, RANZCOG CPD portal
• Articulates the governance pathway for a quality improvement project: institutional approval, HREC determination (low/negligible risk vs full review), NSQHS Standard 1 compliance, PDSA methodology, dissemination
• Mentions ANZCTR registration when discussing clinical trials without being prompted
• Acknowledges the limits of individual studies and explains why a single new trial does not immediately change institutional protocol
• Demonstrates awareness of the AHPRA CPD registration standard and its three-category structure
• When a scenario involves Aboriginal and Torres Strait Islander patients or communities, proactively raises the NHMRC 2018 guidelines on research with Aboriginal and Torres Strait Islander peoples and the principle of community data sovereignty

What a failing candidate does:

• Cites "the literature" or "evidence-based medicine" without naming specific frameworks or documents
• States that a RANZCOG guideline is the final word without being able to discuss the evidence behind it or acknowledge its limitations
• Describes CPD as conference attendance only
• Cannot distinguish audit from research when asked directly
• Does not mention HREC processes or ANZCTR registration in a research governance question
• Applies GRADE incorrectly (e.g. states that low-quality evidence cannot support a strong recommendation)
• Fails to mention cultural safety or Indigenous research ethics in a scenario with an obvious Indigenous health component

Likely examiner prompts and expected responses:

• The Scholar domain is not a soft domain.
• Examiners expect the same precision and specificity that they expect in clinical management questions.
• A candidate who can name the CONSORT item number for allocation concealment, explain why ITT analysis matters in an intrapartum trial, and describe the ANZCTR registration requirement without prompting will consistently score in the upper range on Scholar stations.