Implementation and educational impact of the step ladder system: A structured clinical competency framework for obstetrics and gynecology

OBJECTIVES: While competency-based medical education (CBME) has become globally accepted, especially in postgraduate training, its structured implementation in undergraduate obstetrics and gynecology (OBGYN) education remains limited. The Step Ladder System, developed at Tottori University, addresses this gap through a three-tiered competency framework across obstetrics, gynecology, and general practice. This system was further enhanced with a mobile application to streamline assessments and facilitate real-time feedback. METHODS: This study evaluated the implementation of the Step Ladder System by comparing stepwise competency achievement among 26 final-year medical students and 19 first-year residents during a 4-week OBGYN rotation in 2023. Competency completion was tracked using the mobile app, which allowed instructors to log performance and provide immediate feedback. RESULTS: After the 4-week rotation, both students and residents demonstrated high completion rates for Step 1 tasks (75%-90%) across all domains, while Step 3 completion remained consistently low (<30%), reflecting the advanced complexity of those competencies. In some areas, students outperformed residents at Step 1, indicating strong preparation in basic OBGYN skills. Residents generally outperformed students at Steps 2 and 3, particularly in Obstetrics. The app-based system increased the frequency of real-time feedback and facilitated broader instructor engagement, with all 15 faculty members participating in evaluations. CONCLUSIONS: The Step Ladder System, enhanced by a mobile application, effectively supports basic competency acquisition and feedback in undergraduate and early postgraduate OBGYN training. The persistently low achievement of advanced competencies highlights the need for extended clinical exposure or supplemental simulation training. This structured framework may serve as a scalable model for other specialties pursuing competency-based education.