- Email: [email protected]
Is there a need for a formal gynecology curriculum in a pediatric surgery training program? A needs assessment
Journal of Pediatric Surgery 55 (2020) 904–907
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Is there a need for a formal gynecology curriculum in a pediatric surgery training program? A needs assessment☆,☆☆,★ Tara D. Justice a,⁎, Robert J. Baird b,c, Nicole J. Todd a,b,d a
Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe St, Vancouver, BC, Canada, V6Z 2K8 BC Children's Hospital, 4480 Oak St, Vancouver, BC, Canada, V6H 3N1 Division of Pediatric Surgery, Department of Surgery, University of British Columbia, 4480 Oak St, Vancouver, BC, Canada, V6H 3V4 d Division of Gynaecologic Specialties, Department of Obstetrics & Gynaecology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 6th floor, 2775 Laurel St, Vancouver, BC, Canada, V5Z 1M9 b c
a r t i c l e
i n f o
Article history: Received 20 January 2020 Accepted 25 January 2020 Key words: Pediatric surgery Pediatric gynecology Adolescent gynecology Postgraduate medical education Curriculum Simulation
a b s t r a c t Purpose: Fellows in Pediatric Surgery need to learn to manage a variety of gynecologic conditions. We completed a needs assessment of Pediatric Surgery training programs to inform development of a standardized gynecology curriculum. Methods: A survey was sent to Program Directors of Canadian Pediatric Surgery training programs with 27 questions that focused on the fellowship program, surgical practice, and trainee exposure to pediatric gynecology, and how the envision a standardized gynecology curriculum. Results: Six of eight Program Directors responded. All respondents had treated ovarian-related conditions and genital injuries in the past 5 years, and most felt trainees received adequate training in managing these conditions. Most respondents felt trainees had minimal or inadequate training in imperforate hymens, Müllerian anomalies, vulvar abscesses, vaginal foreign bodies, and labial adhesions. Program Directors currently allot an average of 3.5 h to delivering the gynecology objectives. All Program Directors expressed interest in a formal gynecology curriculum delivered through some combination of case-based teaching and/or simulation. Conclusion: There is a need for a standardized gynecology curriculum for Pediatric Surgery trainees. Most Pediatric Surgeons will manage gynecological conditions as part of their practice and current Program Directors feel that training is inadequate for a number of gynecological conditions. Type of Study: Observational Cross-Sectional Study. Level of Evidence: Level IV. © 2020 Elsevier Inc. All rights reserved.
The Royal College of Physicians and Surgeons of Canada requires that the training of fellows in Pediatric Surgery include the knowledge and capacity to manage a variety of gynecologic conditions in children and adolescents [1]. As Pediatric and Adolescent Gynecology (PAG) services co-exist at many hospitals where Pediatric Surgery trainees perform their training, it is unclear whether trainees have any clinical exposure to PAG during their fellowship. Based on the experience at our centre, it is likely that these objectives of training are being met through didacAbbreviations: OSCE, Objective Structured Clinical Examination; PAG, Pediatric and Adolescent Gynecology; PBL, Problem-Based Learning. ☆ Funding Source: No external funding for this manuscript. ☆☆ Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. ★ Declarations of Interest: The authors have no potential conflicts of interest to disclose. ⁎ Corresponding author at: University of British Columbia, Department of Obstetrics & Gynecology, Gordon & Leslie Diamond Health Care Centre, 6th floor, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9. Tel.: +1 604 314 9284. E-mail address: [email protected] (T.D. Justice). https://doi.org/10.1016/j.jpedsurg.2020.01.037 0022-3468/© 2020 Elsevier Inc. All rights reserved.
tic teaching only. With the shift to Competence by Design in Canadian training programs, it is important that Pediatric Surgery trainees develop competency in basic pediatric and adolescent gynecology, particularly when trainees may eventually work in centres where there is no PAG provider. Several studies have demonstrated a difference in the management of gynecological conditions by Pediatric Surgeons compared to Pediatric Gynecologists [2, 3]. A recent single-centre retrospective analysis by Williams et al. documented that young girls were more likely to undergo laparoscopic surgery and ovarian-preserving surgery when under the care of a Pediatric Gynecologist compared to a Pediatric Surgeon [3]. This raises the question of whether a formal PAG curriculum designed by a Pediatric and Adolescent Gynecologist would be of value in a Pediatric Surgery training program. The PAG group at the University of Ottawa recently demonstrated the value of a PAG curriculum that included simulation for their Obstetrics & Gynecology residents [4]. After 3 h of simulation, residents reported increased self-perceived knowledge and increased comfort
T.D. Justice et al. / Journal of Pediatric Surgery 55 (2020) 904–907
with procedures. One of the themes from the qualitative feedback was the value of the hands-on sessions. Furthermore, performance on a PAG OSCE station 2 months after the PAG simulation was significantly improved when compared to an OSCE session that took place 2 months prior to the PAG simulation [5]. These positive results suggest that a PAG curriculum with simulation, tailored to the Pediatric Surgery Objectives of Training, would be of value in meeting the competencies required by the Royal College. Our objective was to perform a needs assessment of Pediatric Surgery Program Directors to assess whether there is interest in a formal gynecology curriculum and, if interest exists, to help inform the design of a curriculum tailored to Pediatric Surgery trainees. 1. Materials and methods 1.1. Questionnaire An electronic questionnaire was designed using the Guidelines for Surveys of the American Pediatric Surgical Association [6]. It was validated for use prior to distribution. The questionnaire was emailed to the Program Directors of the 8 Canadian Pediatric Surgery training programs with an accompanying information sheet in March 2019. Completion of the questionnaire was voluntary. The questionnaire took approximately 10 min to complete. Participants were given 3 weeks to complete the questionnaire. Three follow-up emails were sent throughout the study duration. The survey consisted of 27 questions that focused on the demographics of their training program, their own surgical practice, their trainees' exposure to pediatric gynecology, and how they envision a standardized gynecology curriculum in their training program. Questions were presented in a variety of formats including multiple choice, matrix/rating style, and open-ended.
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adhesions; 17% had managed a vaginal foreign body. All respondents had managed benign ovarian cysts, ovarian torsion, ovarian tumors, and genital injuries. All program directors stated that training in PAG was included in their training program. The length of time spent on PAG objectives of training ranged from 2 to 5 h. 83% of programs reported delivering the content in the form of didactic lectures and clinical exposure on the General Surgery service. There was no exposure to the PAG clinical service in the hospitals where PAG exists. Some programs also delivered the content through cases, with 50% using web-based cases and 33% using PBL cases. Simulation was not used to teach any of the gynecology objectives of training. Most programs had the teaching delivered by a Pediatric Surgeon while 1 program used a combination of Pediatric Surgery and PAG. Most Program Directors felt that the training in management of ovarian conditions (benign cysts, torsion, and tumors) was adequate while training in the management of other gynecological conditions could benefit from more teaching (Table 1). All Program Directors evinced interest in a standardized gynecology curriculum, with 67% in favor of a curriculum and 33% possibly interested. Five of six had experience implementing a new curriculum during their time as Program Director. Responses varied, but overall, they were willing to dedicate approximately 4–10 h to meet the gynecology objectives of training. Similarly, Program Directors had varied opinions about inclusion of the gynecology curriculum in a Pediatric Surgery bootcamp setting, with 33% definitely interested, 50% possibly interested, and 17% not interested. All Program Directors expressed interest in a case-based format, with 67% interested in it being delivered over the web. Only 33% of respondents were interested in simulation as part of their curriculum. Finally, Program Directors cited lack of time and lack of formal curriculum as barriers to the implementation of a PAG curriculum. There was also interest in greater engagement of the local PAG group in providing the teaching.
1.2. Outcomes 3. Discussion Our needs assessment aimed to explore a number of different areas. Outcomes of interest included the frequency with which Program Directors see gynecological conditions in their practice, the current format of the PAG training in their program, their perception of whether their trainees are meeting the Royal College Objectives of Training, and their interest and ideas about a possible future PAG curriculum. As our questionnaire was serving as a needs assessment of Pediatric Surgery training programs, no statistics were carried out. 1.3. Ethics The ARECCI Ethics Screening Tool was used prior to commencement of this study [7]. As the questionnaire is a Needs Assessment for Quality Improvement and Program Evaluation, it is not considered to be research by the Tri-Council Policy 2 (TCPS 2) for ethics purposes. As such, it did not require Research Ethics Board review. 2. Results Six of eight Canadian Pediatric Surgery Program Directors completed the survey. The majority had been in the role of Program Director for 2+ years. All respondents practiced at the same hospital as their Pediatric Surgery training program. Only one training program was based at a hospital that did not have a PAG service. All programs had 1–2 fellows, with 4 programs reporting 2 fellows. Two thirds of respondents felt that their trainees would practice in an Academic hospital upon graduation while 33% felt their trainees would work in a community practice with university affiliation. All of the respondents had managed gynecological conditions in children and adolescents in the last 5 years. Two thirds had managed an imperforate hymen, Mullerian anomaly, vulvar abscess, or labial
This needs assessment is the first to describe the current state of PAG training in Pediatric Surgery training programs and highlight areas for improvement. The general theme throughout the survey results was that PAG skills are required in practice as a Pediatric Surgeon, but that the current PAG training provided may not be adequately addressing these educational needs prior to entering independent practice. With the upcoming transition to a Competence by Design training program designed to graduate trainees without knowledge gaps and who feel prepared for independent practice [8], it is likely that trainees will require competence in the diagnosis and management of select PAG conditions. As such, it is imperative that Pediatric Surgery trainees receive PAG training that is tailored to their career in Pediatric Surgery and that develops competence in the management of the conditions that will be most likely encountered in practice. The importance of competence in the management of PAG conditions is highlighted by the frequency with which Pediatric Surgeons encounter PAG in their practice. All Program Directors reported managing ovarian cysts, ovarian torsion, ovarian tumors, and genital injuries multiple times over the past 5 years. Several Program Directors also reported managing imperforate hymens and Mullerian anomalies, which are less frequently encountered compared to ovarian pathology. These practice patterns are in spite of the fact that all but one of these clinicians' practice in a tertiary hospital with a PAG service. Although it is not documented in the literature, one could infer that Pediatric Surgeons based in community hospitals without PAG manage a greater number of PAG cases in their pediatric surgery practice. With the personal experience of managing PAG cases as a Pediatric Surgeon, all Program Directors felt that there was room for improvement in the PAG training provided to their trainees. Upon review of the current Royal College Objectives of Training [1], most Program
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T.D. Justice et al. / Journal of Pediatric Surgery 55 (2020) 904–907
Table 1 Program directors' perception of level of training provided to their trainees in the management of the pediatric and adolescent gynecology conditions required by the Royal College Objectives of Training. Gynecological condition
Level of training No Minimal training training
Adequate Excellent I feel more training is needed
Imperforate hymen Mullerian anomalies PID Vulvar abscess Labial adhesions Vaginal foreign bodies Benign ovarian cysts Ovarian torsion Ovarian tumors Genital injuries
0 2 3 2 0 4 0 0 0 0
1 0 1 1 2 0 2 3 2 4
4 1 0 0 2 0 1 1 0 1
0 0 0 0 0 0 1 1 2 0
1 2 2 3 2 2 2 1 2 1
Directors highlighted the current level of training in the management of imperforate hymens, Mullerian anomalies, PID, vulvar abscesses, and vaginal foreign bodies to be non-existent or minimal, highlighting an educational gap that needs to be filled. All Program Directors felt that the current level of training provided in the management of benign ovarian cysts, ovarian torsion, and ovarian tumors was adequate. However, a recent study has shown that young girls were more likely to undergo laparoscopic surgery and ovarian-preserving surgery when under the care of a Pediatric Gynecologist compared to a Pediatric Surgeon [3]. This raises the question of whether further training in the management of ovarian pathologies by a Pediatric and Adolescent Gynecologist could fine-tune the management of ovarian pathologies and improve the rate of ovarian-preservation and time to recovery from surgery. Canadian Pediatric Surgery training programs have made a concerted effort to include PAG training in their fellowship program. PAG content is currently delivered through a combination of didactic teaching, case-based learning, and clinical exposure on the Pediatric Surgery service. The teaching is largely delivered by Pediatric Surgeons, with the exception of one program that has developed a collaboration between Pediatric Surgery and Pediatric & Adolescent Gynecology. Currently, no programs are using simulation to meet the PAG Objectives of Training. This is despite the well documented benefits of simulation training on the acquisition and transfer of skills to the operating room [9–12]. Given that Pediatric Surgeons do not frequently manage PAG conditions, simulation training is likely even more valuable as a learning tool for education in low-frequency events or procedures. Facilitation of simulation sessions by a Pediatric and Adolescent Gynecologist with greater experience in the management of PAG conditions may help Pediatric Surgery trainees develop further competence in the PAG conditions they may encounter in practice. Lastly, feedback from participants in the Canadian Pediatric Surgery Bootcamp was that a focus on case-based learning with assigned pre-reading allowed them to optimize their learning during hands-on sessions, suggesting that a combination of web-based cases combined with simulation might be well received by Pediatric Surgery trainees [13]. The results of this needs assessment have highlighted the need for a standardized formal curriculum in PAG for Pediatric Surgery trainees and will help in the development of the curriculum. Several Program Directors cite time constraints as a limitation in delivering the PAG content, but respondents were willing to allocate 4–10 h to meet the PAG Objectives of Training. A study done by the PAG Group at the University of Ottawa demonstrated that an advanced 3-h pelvic simulation curriculum significantly increased residents' knowledge in the management of PAG conditions [5]. This suggests that the PAG Objectives of Training for Pediatric Surgery trainees can likely be met within the time constraints of a 2-year Pediatric Surgery fellowship. Additionally, interest
was gauged regarding the delivery of a centralized PAG curriculum during the new Pediatric Surgery Bootcamp at the beginning of fellowship, however responses were mixed. Although this could overcome the barriers of having the content delivered by a Pediatric & Adolescent Gynecologist and the delivery of higher fidelity simulations, it is acknowledged that a basis in PAG is not a critical skill needed during the transition to fellowship [13]. Once a curriculum is developed, further consideration can be given to the mode of delivery. This study was limited by the small sample size of 8 Canadian Program Directors. A decision was made to survey the Canadian Program Directors alone since the codified Objectives of Training for Pediatric Surgery may vary from country to country. On the other hand, our decision to limit the survey to Canadian Program Directors may mean that the results are not externally generalizable to training contexts outside of Canada (American or other). Although 6/8 Program Directors completed our survey, the 2 non-responders could represent a potential source of bias given the small sample size. In addition, the delivery of the needs assessment as an electronic survey is considered a limitation of the study. The length of the survey was heavily influenced by the desire for a high response rate, resulting in a survey that did not capture some of the factors that would influence rollout of a formal curriculum, such as available funding. Furthermore, refinement of the terminology used in the rating scales in our survey may have more accurately answered our questions. Some of the terminology (e.g. minimal training) refers to volume alone while other terminology (e.g. adequate training) refers to fulfilling a need. Lastly, this needs assessment did not capture the interest of PAG colleagues in other Canadian centres in helping to facilitate a formal gynecology curriculum for their local Pediatric Surgery trainees. Nonetheless, participation in the needs assessment demonstrated engagement of the Program Directors in the improvement of training for their Pediatric Surgery trainees, which increases the likelihood of successful implementation of a formal pediatric gynecology curriculum. Furthermore, the high response rate resulted in a variety of feedback that will be helpful in the design of the curriculum.
4. Conclusions Pediatric surgeons encounter Pediatric & Adolescent Gynecology in their clinical practice. Current Program Directors feel that the training provided to their Pediatric Surgery trainees is inadequate for the management of a number of gynecological conditions. With the upcoming transition to Competence by Design training, it is important that Pediatric Surgery trainees receive training that ensures the development of competence in the management of selected PAG conditions. This needs assessment has highlighted the need for a formal gynecology curriculum for Pediatric Surgery trainees. These results will inform the development of a standardized gynecology curriculum for Canadian Pediatric Surgery trainees. Following implementation of the curriculum, we plan to compare the perceived levels of readiness for PAG cases in practice between trainees who underwent the old and new curriculums. This will explore the increase in knowledge, skills, and competence of Pediatric Surgery trainees in the management of PAG conditions that is essential for practice in Pediatric Surgery.
References [1] Royal College of Physicians and Surgeons of Canada. Objectives of training in the specialty of pediatric surgery. http://www.royalcollege.ca/rcsite/ibd-search-e?N= 10000033+10000034+4294967086, Accessed date: 26 July 2019. [2] Berger-Chen S, Herzog T, Lewin S, et al. Access to conservative surgical therapy for adolescents with benign ovarian masses. Obstet Gynecol 2012;119(2):270–5. https://doi.org/10.1097/AOG.0b013e318242637a. [3] Peeraully R, Henderson K, Fairbrother K, et al. Effect of surgical specialty on management of adnexal masses in children and adolescents: An 8-year single centre review. J Pediatr Adolesc Gynecol 2019. https://doi.org/10.1016/j.jpag.2019.06.007 in press.
T.D. Justice et al. / Journal of Pediatric Surgery 55 (2020) 904–907 [4] Dumont T, Hakim J, Black A, et al. Enhancing postgraduate training in pediatric and adolescent gynecology: evaluation of an advanced pelvic simulation session. J Pediatr Adolesc Gynecol 2014;27:360–70. https://doi.org/10.1016/j.jpag.2014.01. 105. [5] Dumont T, Hakim J, Black A, et al. Does an advanced pelvic simulation curriculum improve resident performance on a pediatric and adolescent gynecology focused objective structured clinical examination? A cohort study. J Pediatr Adolesc Gynecol 2016;29:276–9. https://doi.org/10.1016/j.jpag.2015.10.015. [6] Goldin A, LaRiviere C, Arca M, et al. Guidelines for surveys of the American pediatric surgical association. J Pediatr Surg 2011;46:2012–7. https://doi.org/10.1016/j. jpedsurg.2011.05.016. [7] Alberta Innovates. ARECCI Ethics Screening Tool. http://aihealthsolutions.ca/arecci/ screening/437080/7a1c9ed4a3d8feba2bd8a361afa9ab32, Accessed date: 4 March 2019. [8] Royal College of Physicians and Surgeons of Canada. Competence by Design. http:// www.royalcollege.ca/rcsite/cbd/rationale-why-cbd-e, Accessed date: 23 July 2019.
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[9] Cheng A, Lang T, Starr S, et al. Technology-enhanced simulation and pediatric education: a meta-analysis. J Pediatr 2014;133:e1313–23. https://doi.org/10.1542/peds. 2013-2139. [10] Dawe S, Pena G, Windsor J, et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg 2014;101:1063–76. https://doi.org/10.1002/ bjs.9482. [11] Matsumoto E, Hamstra S, Radomski S, et al. The effect of bench model fidelity on endourological skills: a randomized controlled trial. J Urol 2002;167:1243–7. https://doi.org/10.1016/S0022-5347(05)65274-3. [12] Sturm L, Windsor J, Cosman P, et al. A systematic review of skills transfer after surgical simulation training. Ann Surg 2008;248(2):166–79. https://doi.org/10.1097/ SLA.0b013e318176bf24. [13] Blackmore C, Puligandla P, Emil S, et al. A transition to discipline curriculum for pediatric surgery trainees: evaluation of a pediatric surgery bootcamp from 2017 to 2018. J Pediatr Surg 2019;54:1024–8. https://doi.org/10.1016/j.jpedsurg.2019.01. 047.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Is there a need for a formal gynecology curriculum in a pediatric surgery training program? A needs assessment☆,☆☆,★ Tara D. Justice a,⁎, Robert J. Baird b,c, Nicole J. Todd a,b,d a
Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe St, Vancouver, BC, Canada, V6Z 2K8 BC Children's Hospital, 4480 Oak St, Vancouver, BC, Canada, V6H 3N1 Division of Pediatric Surgery, Department of Surgery, University of British Columbia, 4480 Oak St, Vancouver, BC, Canada, V6H 3V4 d Division of Gynaecologic Specialties, Department of Obstetrics & Gynaecology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 6th floor, 2775 Laurel St, Vancouver, BC, Canada, V5Z 1M9 b c
a r t i c l e
i n f o
Article history: Received 20 January 2020 Accepted 25 January 2020 Key words: Pediatric surgery Pediatric gynecology Adolescent gynecology Postgraduate medical education Curriculum Simulation
a b s t r a c t Purpose: Fellows in Pediatric Surgery need to learn to manage a variety of gynecologic conditions. We completed a needs assessment of Pediatric Surgery training programs to inform development of a standardized gynecology curriculum. Methods: A survey was sent to Program Directors of Canadian Pediatric Surgery training programs with 27 questions that focused on the fellowship program, surgical practice, and trainee exposure to pediatric gynecology, and how the envision a standardized gynecology curriculum. Results: Six of eight Program Directors responded. All respondents had treated ovarian-related conditions and genital injuries in the past 5 years, and most felt trainees received adequate training in managing these conditions. Most respondents felt trainees had minimal or inadequate training in imperforate hymens, Müllerian anomalies, vulvar abscesses, vaginal foreign bodies, and labial adhesions. Program Directors currently allot an average of 3.5 h to delivering the gynecology objectives. All Program Directors expressed interest in a formal gynecology curriculum delivered through some combination of case-based teaching and/or simulation. Conclusion: There is a need for a standardized gynecology curriculum for Pediatric Surgery trainees. Most Pediatric Surgeons will manage gynecological conditions as part of their practice and current Program Directors feel that training is inadequate for a number of gynecological conditions. Type of Study: Observational Cross-Sectional Study. Level of Evidence: Level IV. © 2020 Elsevier Inc. All rights reserved.
The Royal College of Physicians and Surgeons of Canada requires that the training of fellows in Pediatric Surgery include the knowledge and capacity to manage a variety of gynecologic conditions in children and adolescents [1]. As Pediatric and Adolescent Gynecology (PAG) services co-exist at many hospitals where Pediatric Surgery trainees perform their training, it is unclear whether trainees have any clinical exposure to PAG during their fellowship. Based on the experience at our centre, it is likely that these objectives of training are being met through didacAbbreviations: OSCE, Objective Structured Clinical Examination; PAG, Pediatric and Adolescent Gynecology; PBL, Problem-Based Learning. ☆ Funding Source: No external funding for this manuscript. ☆☆ Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. ★ Declarations of Interest: The authors have no potential conflicts of interest to disclose. ⁎ Corresponding author at: University of British Columbia, Department of Obstetrics & Gynecology, Gordon & Leslie Diamond Health Care Centre, 6th floor, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9. Tel.: +1 604 314 9284. E-mail address: [email protected] (T.D. Justice). https://doi.org/10.1016/j.jpedsurg.2020.01.037 0022-3468/© 2020 Elsevier Inc. All rights reserved.
tic teaching only. With the shift to Competence by Design in Canadian training programs, it is important that Pediatric Surgery trainees develop competency in basic pediatric and adolescent gynecology, particularly when trainees may eventually work in centres where there is no PAG provider. Several studies have demonstrated a difference in the management of gynecological conditions by Pediatric Surgeons compared to Pediatric Gynecologists [2, 3]. A recent single-centre retrospective analysis by Williams et al. documented that young girls were more likely to undergo laparoscopic surgery and ovarian-preserving surgery when under the care of a Pediatric Gynecologist compared to a Pediatric Surgeon [3]. This raises the question of whether a formal PAG curriculum designed by a Pediatric and Adolescent Gynecologist would be of value in a Pediatric Surgery training program. The PAG group at the University of Ottawa recently demonstrated the value of a PAG curriculum that included simulation for their Obstetrics & Gynecology residents [4]. After 3 h of simulation, residents reported increased self-perceived knowledge and increased comfort
T.D. Justice et al. / Journal of Pediatric Surgery 55 (2020) 904–907
with procedures. One of the themes from the qualitative feedback was the value of the hands-on sessions. Furthermore, performance on a PAG OSCE station 2 months after the PAG simulation was significantly improved when compared to an OSCE session that took place 2 months prior to the PAG simulation [5]. These positive results suggest that a PAG curriculum with simulation, tailored to the Pediatric Surgery Objectives of Training, would be of value in meeting the competencies required by the Royal College. Our objective was to perform a needs assessment of Pediatric Surgery Program Directors to assess whether there is interest in a formal gynecology curriculum and, if interest exists, to help inform the design of a curriculum tailored to Pediatric Surgery trainees. 1. Materials and methods 1.1. Questionnaire An electronic questionnaire was designed using the Guidelines for Surveys of the American Pediatric Surgical Association [6]. It was validated for use prior to distribution. The questionnaire was emailed to the Program Directors of the 8 Canadian Pediatric Surgery training programs with an accompanying information sheet in March 2019. Completion of the questionnaire was voluntary. The questionnaire took approximately 10 min to complete. Participants were given 3 weeks to complete the questionnaire. Three follow-up emails were sent throughout the study duration. The survey consisted of 27 questions that focused on the demographics of their training program, their own surgical practice, their trainees' exposure to pediatric gynecology, and how they envision a standardized gynecology curriculum in their training program. Questions were presented in a variety of formats including multiple choice, matrix/rating style, and open-ended.
905
adhesions; 17% had managed a vaginal foreign body. All respondents had managed benign ovarian cysts, ovarian torsion, ovarian tumors, and genital injuries. All program directors stated that training in PAG was included in their training program. The length of time spent on PAG objectives of training ranged from 2 to 5 h. 83% of programs reported delivering the content in the form of didactic lectures and clinical exposure on the General Surgery service. There was no exposure to the PAG clinical service in the hospitals where PAG exists. Some programs also delivered the content through cases, with 50% using web-based cases and 33% using PBL cases. Simulation was not used to teach any of the gynecology objectives of training. Most programs had the teaching delivered by a Pediatric Surgeon while 1 program used a combination of Pediatric Surgery and PAG. Most Program Directors felt that the training in management of ovarian conditions (benign cysts, torsion, and tumors) was adequate while training in the management of other gynecological conditions could benefit from more teaching (Table 1). All Program Directors evinced interest in a standardized gynecology curriculum, with 67% in favor of a curriculum and 33% possibly interested. Five of six had experience implementing a new curriculum during their time as Program Director. Responses varied, but overall, they were willing to dedicate approximately 4–10 h to meet the gynecology objectives of training. Similarly, Program Directors had varied opinions about inclusion of the gynecology curriculum in a Pediatric Surgery bootcamp setting, with 33% definitely interested, 50% possibly interested, and 17% not interested. All Program Directors expressed interest in a case-based format, with 67% interested in it being delivered over the web. Only 33% of respondents were interested in simulation as part of their curriculum. Finally, Program Directors cited lack of time and lack of formal curriculum as barriers to the implementation of a PAG curriculum. There was also interest in greater engagement of the local PAG group in providing the teaching.
1.2. Outcomes 3. Discussion Our needs assessment aimed to explore a number of different areas. Outcomes of interest included the frequency with which Program Directors see gynecological conditions in their practice, the current format of the PAG training in their program, their perception of whether their trainees are meeting the Royal College Objectives of Training, and their interest and ideas about a possible future PAG curriculum. As our questionnaire was serving as a needs assessment of Pediatric Surgery training programs, no statistics were carried out. 1.3. Ethics The ARECCI Ethics Screening Tool was used prior to commencement of this study [7]. As the questionnaire is a Needs Assessment for Quality Improvement and Program Evaluation, it is not considered to be research by the Tri-Council Policy 2 (TCPS 2) for ethics purposes. As such, it did not require Research Ethics Board review. 2. Results Six of eight Canadian Pediatric Surgery Program Directors completed the survey. The majority had been in the role of Program Director for 2+ years. All respondents practiced at the same hospital as their Pediatric Surgery training program. Only one training program was based at a hospital that did not have a PAG service. All programs had 1–2 fellows, with 4 programs reporting 2 fellows. Two thirds of respondents felt that their trainees would practice in an Academic hospital upon graduation while 33% felt their trainees would work in a community practice with university affiliation. All of the respondents had managed gynecological conditions in children and adolescents in the last 5 years. Two thirds had managed an imperforate hymen, Mullerian anomaly, vulvar abscess, or labial
This needs assessment is the first to describe the current state of PAG training in Pediatric Surgery training programs and highlight areas for improvement. The general theme throughout the survey results was that PAG skills are required in practice as a Pediatric Surgeon, but that the current PAG training provided may not be adequately addressing these educational needs prior to entering independent practice. With the upcoming transition to a Competence by Design training program designed to graduate trainees without knowledge gaps and who feel prepared for independent practice [8], it is likely that trainees will require competence in the diagnosis and management of select PAG conditions. As such, it is imperative that Pediatric Surgery trainees receive PAG training that is tailored to their career in Pediatric Surgery and that develops competence in the management of the conditions that will be most likely encountered in practice. The importance of competence in the management of PAG conditions is highlighted by the frequency with which Pediatric Surgeons encounter PAG in their practice. All Program Directors reported managing ovarian cysts, ovarian torsion, ovarian tumors, and genital injuries multiple times over the past 5 years. Several Program Directors also reported managing imperforate hymens and Mullerian anomalies, which are less frequently encountered compared to ovarian pathology. These practice patterns are in spite of the fact that all but one of these clinicians' practice in a tertiary hospital with a PAG service. Although it is not documented in the literature, one could infer that Pediatric Surgeons based in community hospitals without PAG manage a greater number of PAG cases in their pediatric surgery practice. With the personal experience of managing PAG cases as a Pediatric Surgeon, all Program Directors felt that there was room for improvement in the PAG training provided to their trainees. Upon review of the current Royal College Objectives of Training [1], most Program
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T.D. Justice et al. / Journal of Pediatric Surgery 55 (2020) 904–907
Table 1 Program directors' perception of level of training provided to their trainees in the management of the pediatric and adolescent gynecology conditions required by the Royal College Objectives of Training. Gynecological condition
Level of training No Minimal training training
Adequate Excellent I feel more training is needed
Imperforate hymen Mullerian anomalies PID Vulvar abscess Labial adhesions Vaginal foreign bodies Benign ovarian cysts Ovarian torsion Ovarian tumors Genital injuries
0 2 3 2 0 4 0 0 0 0
1 0 1 1 2 0 2 3 2 4
4 1 0 0 2 0 1 1 0 1
0 0 0 0 0 0 1 1 2 0
1 2 2 3 2 2 2 1 2 1
Directors highlighted the current level of training in the management of imperforate hymens, Mullerian anomalies, PID, vulvar abscesses, and vaginal foreign bodies to be non-existent or minimal, highlighting an educational gap that needs to be filled. All Program Directors felt that the current level of training provided in the management of benign ovarian cysts, ovarian torsion, and ovarian tumors was adequate. However, a recent study has shown that young girls were more likely to undergo laparoscopic surgery and ovarian-preserving surgery when under the care of a Pediatric Gynecologist compared to a Pediatric Surgeon [3]. This raises the question of whether further training in the management of ovarian pathologies by a Pediatric and Adolescent Gynecologist could fine-tune the management of ovarian pathologies and improve the rate of ovarian-preservation and time to recovery from surgery. Canadian Pediatric Surgery training programs have made a concerted effort to include PAG training in their fellowship program. PAG content is currently delivered through a combination of didactic teaching, case-based learning, and clinical exposure on the Pediatric Surgery service. The teaching is largely delivered by Pediatric Surgeons, with the exception of one program that has developed a collaboration between Pediatric Surgery and Pediatric & Adolescent Gynecology. Currently, no programs are using simulation to meet the PAG Objectives of Training. This is despite the well documented benefits of simulation training on the acquisition and transfer of skills to the operating room [9–12]. Given that Pediatric Surgeons do not frequently manage PAG conditions, simulation training is likely even more valuable as a learning tool for education in low-frequency events or procedures. Facilitation of simulation sessions by a Pediatric and Adolescent Gynecologist with greater experience in the management of PAG conditions may help Pediatric Surgery trainees develop further competence in the PAG conditions they may encounter in practice. Lastly, feedback from participants in the Canadian Pediatric Surgery Bootcamp was that a focus on case-based learning with assigned pre-reading allowed them to optimize their learning during hands-on sessions, suggesting that a combination of web-based cases combined with simulation might be well received by Pediatric Surgery trainees [13]. The results of this needs assessment have highlighted the need for a standardized formal curriculum in PAG for Pediatric Surgery trainees and will help in the development of the curriculum. Several Program Directors cite time constraints as a limitation in delivering the PAG content, but respondents were willing to allocate 4–10 h to meet the PAG Objectives of Training. A study done by the PAG Group at the University of Ottawa demonstrated that an advanced 3-h pelvic simulation curriculum significantly increased residents' knowledge in the management of PAG conditions [5]. This suggests that the PAG Objectives of Training for Pediatric Surgery trainees can likely be met within the time constraints of a 2-year Pediatric Surgery fellowship. Additionally, interest
was gauged regarding the delivery of a centralized PAG curriculum during the new Pediatric Surgery Bootcamp at the beginning of fellowship, however responses were mixed. Although this could overcome the barriers of having the content delivered by a Pediatric & Adolescent Gynecologist and the delivery of higher fidelity simulations, it is acknowledged that a basis in PAG is not a critical skill needed during the transition to fellowship [13]. Once a curriculum is developed, further consideration can be given to the mode of delivery. This study was limited by the small sample size of 8 Canadian Program Directors. A decision was made to survey the Canadian Program Directors alone since the codified Objectives of Training for Pediatric Surgery may vary from country to country. On the other hand, our decision to limit the survey to Canadian Program Directors may mean that the results are not externally generalizable to training contexts outside of Canada (American or other). Although 6/8 Program Directors completed our survey, the 2 non-responders could represent a potential source of bias given the small sample size. In addition, the delivery of the needs assessment as an electronic survey is considered a limitation of the study. The length of the survey was heavily influenced by the desire for a high response rate, resulting in a survey that did not capture some of the factors that would influence rollout of a formal curriculum, such as available funding. Furthermore, refinement of the terminology used in the rating scales in our survey may have more accurately answered our questions. Some of the terminology (e.g. minimal training) refers to volume alone while other terminology (e.g. adequate training) refers to fulfilling a need. Lastly, this needs assessment did not capture the interest of PAG colleagues in other Canadian centres in helping to facilitate a formal gynecology curriculum for their local Pediatric Surgery trainees. Nonetheless, participation in the needs assessment demonstrated engagement of the Program Directors in the improvement of training for their Pediatric Surgery trainees, which increases the likelihood of successful implementation of a formal pediatric gynecology curriculum. Furthermore, the high response rate resulted in a variety of feedback that will be helpful in the design of the curriculum.
4. Conclusions Pediatric surgeons encounter Pediatric & Adolescent Gynecology in their clinical practice. Current Program Directors feel that the training provided to their Pediatric Surgery trainees is inadequate for the management of a number of gynecological conditions. With the upcoming transition to Competence by Design training, it is important that Pediatric Surgery trainees receive training that ensures the development of competence in the management of selected PAG conditions. This needs assessment has highlighted the need for a formal gynecology curriculum for Pediatric Surgery trainees. These results will inform the development of a standardized gynecology curriculum for Canadian Pediatric Surgery trainees. Following implementation of the curriculum, we plan to compare the perceived levels of readiness for PAG cases in practice between trainees who underwent the old and new curriculums. This will explore the increase in knowledge, skills, and competence of Pediatric Surgery trainees in the management of PAG conditions that is essential for practice in Pediatric Surgery.
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