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 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 team members was forged serendipitously.

The predetermined guiding theme 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 discussion between EP and these trainees and gynecologists yielded insights into how postgraduate trainees perceive their assessment methods and how does this impact the advancement toward higher competency. These reflective sessions were either audiotaped or noted.

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. 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 care, 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 postgraduate 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 the test results. The low-stakes formative assessments 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 director 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.

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 Canada. A new curriculum, called Competency by Design, was introduced in 2019 (16).⁴ The curriculum is framed around 36 EPAs (Table 3).⁵ These EPAs represent essential specialist 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 Canada⁶: “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 observation 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 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.

Postgraduate medical education in Canada and the 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, development 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 the training period. Comparing the content of the EPAs informs us that there are no big differences in the end terms of the 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 perform a cesarean section, 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 Netherlands 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 status. In contrast, in Canada, 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 the 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 through 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 level: “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 reason 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 prescribing 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, the 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 they have met a certain standard and that this will allow them 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 postgraduate trainees regard all the feedback moments as small summative assessments and feel continuously judged about their performance.