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Residency Training in Pediatric and Adolescent Gynecology Across Obstetrics and Gynecology Residency Programs: A Cross-Sectional Study
Original Study Residency Training in Pediatric and Adolescent Gynecology Across Obstetrics and Gynecology Residency Programs: A Cross-Sectional Study Ellen R. Solomon MD 1,*, Tyler M. Muffly MD 2, Carrie Hood MD 1, Marjan Attaran MD 1 1 2
Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH Division of Female Pelvic Medicine and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
a b s t r a c t Study Objective: To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. Design: Prospective, anonymous, cross-sectional study. Participants: United States program directors of Obstetrics and Gynecology residency programs, N 5 242; respondents 104 (43%). Results: 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n 5 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n 5 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P 5 .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P 5 .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P 5 .03). Conclusions: Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training. Key Words: Fellowship, Pediatric and Adolescent Gynecology, Program directors, Residency training
Introduction
Historically, among Obstetrics and Gynecology programs, less focus has been given to Pediatric and Adolescent Gynecology (PAG), perhaps because there is no single specialty that “owns” these patients and their complications. General surgeons, general pediatricians, pediatric surgeons, pediatric urologists, adolescent medicine specialists, and gynecologists have provided care for pediatric and adolescent patients with gynecologic issues in the past. The increase in resident work hour restrictions set by the Accreditation Council for Graduate Medical Education (ACGME) may have made teaching residents to all facets of Obstetrics and Gynecology more difficult. Specifically, the Council on Resident Education in Obstetrics and Gynecology (CREOG) objectives for PAG includes the following: to understand the medical and surgical treatment of pediatric gynecologic disorders, to describe appropriate medical and surgical treatments for patients with Received 24 December 2012; revised 31 January 2013; accepted 2 February 2013. The authors indicate no conflicts of interest. Presented at the 27th Annual Clinical and Research North American Society for Pediatric and Adolescent Gynecology Meeting on April 19, 2013, San Diego, California. * Address correspondence to: Ellen R. Solomon, MD, Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Desk A-81, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195; Phone: (216) 445-6587 E-mail address: [email protected] (E.R. Solomon).
developmental anomalies, and to treat gynecologic disorders medically or surgically.1 While the pathology and breadth of cases in PAG appears to be extremely important, it is unclear to what extent this subject material is and is not covered in United States Obstetrics and Gynecology residencies. Physicians specializing in PAG undergo advanced training in the diagnosis and management of common pediatric gynecology conditions, as well as more complex conditions such as congenital reproductive anomalies, reproductive endocrine function, and sexual development. However, with very few PAG training programs within the United States, specialists in this subspecialty are rare and other practitioners may be needed to diagnose and treat these patients. Research focused primarily on PAG training during Obstetrics and Gynecology residency is limited as revealed upon a review of the literature. A literature search was performed using PubMed and included the search terms “resident education,” “pediatric and adolescent gynecology,” “resident competency,” “teaching formats,” “program director,” and “survey” (January 1996-August 2012). In a recent survey study evaluating resident perceptions of how well equipped they are to practice pediatric and adolescent gynecology, it was demonstrated that residents deem themselves not fully prepared to treat the pediatric and adolescent population.2 Other studies evaluated various methods of teaching the PAG curriculum using novel techniques. For example, one study determined that using
1083-3188/$ - see front matter Ó 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.02.003
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Table 1 Demographic Comparison of Programs with PAG Rotation vs No PAG Rotation
Location (N 5 102) Region 1 Region 2 Region 3 Region 4 Region 5 Other Type of obstetrics and gynecology residency program (N 5 102) Community Military University Other* Affiliated with a children's hospital (N 5 104) Yes No # faculty who practice PAG (N 5 105) 0 faculty 1 faculty 2 faculty 3 faculty 4 to 10 faculty More than 10 faculty PAG fellowship trained faculty (N 5 105) Yes No PAG fellowship at institution (N 5 104) Yes No PAG clinic where residents see patients (N 5 104) Yes No # Residents apply for PAG fellowship (N 5 104) 0 residents 1 resident 2 residents 3 residents 4 to 10 residents More than 10 residents
Total (N 5 105)
PAG Rotation (N 5 18)
No PAG Rotation (N 5 87)
N (%)
N (%)
N (%)
P
21 20 21 27 12 1
(21) (20) (21) (27) (12) (12)
3 3 5 6 0 1
(17) (17) (28) (33) (0) (6)
18 17 16 21 12 0
(21) (20) (19) (25) (14) (0)
.134
27 3 69 3
(27) (3) (68) (3)
3 0 15 0
(17) (0) (83) (0)
24 3 54 3
(29) (4) (64) (4)
.411
45 (52) 41 (48)
.004
24 26 14 10 11 2
(28) (30) (16) (12) (13) (2)
.427
61 (59) 43 (41) 26 32 17 15 13 2
(25) (31) (16) (14) (12) (2)
16 (89) 2 (11) 2 6 3 5 2 0
(11) (33) (17) (28) (11) (0)
18 (17) 87 (83)
6 (33) 12 (67)
12 (14) 75 (86)
.079
7 (7) 97 (92)
6 (33) 12 (67)
1 (1) 85 (99)
!.001
39 (37) 65 (63)
18 (100) 0 (0)
21 (24) 65 (76)
!.001
96 6 0 0 2 0
14 2 0 0 2 0
82 4 0 0 0 0
(92) (6) (0) (0) (2) (0)
(78) (11) (0) (0) (11) (0)
(95) (5) (0) (0) (0) (0)
.004
* Identified as an independent-university affiliated practice.
computer based learning tools can increase overall PAG knowledge and is a reliable method to teach this subject matter.1,3 Another study used a simulation model to teach pediatric gynecology and then residents were retested later, with improved post-training vs pre-training scores.4 While determining the ideal way to teach PAG among obstetrics and gynecology residents is crucial to resident education, perhaps using these novel techniques and increasing the opportunities to see pediatric and adolescent gynecology patients would increase resident preparedness. To our knowledge, there are no studies that measure preparedness to practice PAG from a residency program director standpoint. This study aims to estimate the prevalence of formal training for PAG among Obstetric and Gynecology residency programs in the United States as well as to determine curriculum deficiencies. Materials and Methods
An exemption from Cleveland Clinic institutional review board was obtained prior to the initiation of this study. A total of 242 U.S. Obstetrics and Gynecology residency programs were determined by cross-referencing the Fellowship and Residency Electronic Interactive Database
Access System (FREIDA) and the Association of Professors of Gynecology and Obstetrics (APGO) website.5,6 The deidentified surveys were then sent to the 242 program directors and non-responders were identified by the survey software for follow-up. Initially an introductory letter with the web address of the electronic survey was sent via postal mail. This was then followed by 3 weekly e-mail reminders with a link to the electronic survey. No return e-mails noting a delivery status failure notification were received after sending the survey. Finally during the fourth week of the study period (March 2012) a follow-up letter was sent via postal mail to those non-responders with a paper copy of the survey and a selfaddressed stamped envelope. No incentive was provided for participation. The 22-item questionnaire included 8 domains: residency program characteristics, resident experience, didactics, clinical experience, teaching methods, perceived competence, and respondent demographics (Table 1). Responses were analyzed using the statistical software (JMP 9.0, SAS Institute, Cary, NC). Categorical data was compared using a chi-square test with P ! .05 showing statistical significance. The Wilcoxon rank-sum test was used for ordinal data and the t-test was used for continuous variables. The program directors
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Table 2 Comparison of Clinical Experience (Programs with PAG Fellowship vs No PAG Fellowship) Number of Protected Resident Hours Per Year for:
Total PAG No PAG (N 5 99) Fellowship Fellowship (N 5 6) (N 5 93) N (%)
Pediatric and Adolescent Gynecology (N 5 99) 0-4 h 5-10 h Over 10 h Benign Gynecology (N 5 99) 0-4 h 5-10 h Over 10 h Female Pelvic Medicine and Reconstructive Surgery (N 5 99) 0-4 h 5-10 h Over 10 h General Obstetrics (N 5 98) 0-4 h 5-10 h Over 10 h Genomics (N 5 98) 0-4 h 5-10 h Over 10 h Gynecologic Oncology (N 5 99) 0-4 h 5-10 h Over 10 h Maternal and Fetal Medicine (N 5 98) 0-4 h 5-10 h Over 10 h Primary Care (N 5 99) 0-4 h 5-10 h Over 10 h Reproductive Endocrinology and Infertility (N 5 99) 0-4 h 5-10 h Over 10 h Minimally Invasive Surgery (N 5 98) 0-4 h 5-10 h Over 10 h Interpersonal and Communication Skills (N 5 99) 0-4 h 5-10 h Over 10 h
N (%)
Table 3 Comparison of PAG Educational Experience (Programs with PAG Fellowship vs No PAG Fellowship Total
P
N (%)
57 (58) 33 (33) 9 (9)
3 (50) 2 (33) 1 (17)
54 (58) 31 (33) 8 (9)
1 (1) 5 (5) 92 (93)
1 (17) 1 (17) 4 (67)
0 (0) 5 (5) 88 (95)
.792
!.001*
7 (7) 40 (40) 52 (53)
0 (0) 4 (67) 2 (33)
7 (8) 36 (39) 50 (54)
.370
0 (0) 3 (3) 95 (97)
0 (0) 1 (20) 4 (80)
0 (0) 2 (2) 91 (98)
.024*
56 (57) 32 (33) 10 (10)
3 (50) 3 (50) 0 (0)
53 (58) 29 (32) 10 (11)
.523
2 (2) 30 (30) 67 (68)
0 (0) 2 (33) 4 (67)
2 (2) 28 (30) 63 (68)
.928
1 (1) 18 (18) 79 (81)
0 (0) 1 (17) 5 (83)
1 (1) 17 (19) 74 (80)
.960
19 (19) 38 (38) 42 (42)
2 (33) 1 (17) 3 (50)
4 (4) 29 (29) 66 (67)
1 (17) 2 (33) 3 (50)
3 (3) 27 (27) 63 (63)
.244
11 (11) 41 (42) 46 (47)
2 (33) 2 (33) 2 (33)
9 (10) 39 (42) 44 (48)
.207
34 (34) 41 (41) 24 (24)
3 (50) 2 (33) 1 (17)
31 (33) 39 (42) 23 (25)
.702
17/18 37/40 39/42
.464
* Statistically significant difference at P ! .05.
comments provided at the end of surveys were reviewed for similar themes relating to their PAG curriculum and plans for improvement. Results
We received 104 completed surveys from the 242 residency program directors who were invited to participatedan overall 43% response rate. Nationwide, there was a 57% response rate from university-based residency programs, a 24% response rate from community-based programs and a 57% response rate from military-based programs. Most respondents were from university-
Who teaches PAG to Residents: yes response? (N 5 104) Female Pelvic Medicine and Reconstructive Surgery faculty General Gynecology faculty Pediatric and Adolescent Gynecology faculty Reproductive Endocrinology and Infertility faculty Othery Forms of PAG teaching residents receive: yes response? Case Studies (N 5 102) Journal Clubs (N 5 102) Lectures (N 5 102) Online Learning Modules (N 5 102) Q&A Sessions (N 5 102) Simulator Labs (N 5 102) Small Learning Groups (N 5 102) Otherz No. of PAG operative cases in 4 year residency? (N 5 100) None 1 to 5 operative cases 6 to 10 operative cases 11 to 20 operative cases Over 20 operative cases No. of patients seen by residents in 4 year residency? (N 5 103) None 1-10 patients 11-25 patients 26-50 patients O50 patients
PAG No PAG Fellowship Fellowship (N 5 7) (N 5 96)
P
N (%)
N (%)
N (%)
26 (25)
6 (86)
20 (21)
!.001*
80 (77) 49 (47)
1 (14) 2 (29)
79 (81) 47 (49)
!.001* .309
10 (10)
0 (0)
10 (10)
.372
4 (4)
1 (14)
3 (3)
.137
55 28 94 19
(54) (28) (92) (19)
3 2 4 4
(43) (29) (57) (57)
52 26 90 15
(55) (27) (95) (16)
.543 .945 !.001* .007*
31 (30) 6 (6) 15 (15)
1 (14) 1 (14) 2 (29)
30 (32) 5 (5) 13 (14)
.337 .328 .283
1 (1)
0 (0)
1 (1)
.785
6 48 29 12 5
(6) (48) (29) (12) (5)
0 2 1 2 2
(0) (29) (14) (29) (2)
6 46 28 10 3
(6) (49) (28) (11) (3)
.020
1 26 28 24 24
(1) (25) (27) (23) (23)
0 0 2 1 4
(0) (0) (29) (14) (57)
1 26 26 23 20
(1) (27) (27) (24) (21)
.205
* Statistically significant difference at P ! .05. y Other category includes: Family Medicine, Pediatric, Pediatric Endocrinology, and 'various'. z Other category includes: cadaver and animal surgery labs, operative cases with the subspecialist, and self-directed learning.
affiliated residency programs (68%) and they were distributed across the 5 ACOG regions. Over half of the responding departments had a program affiliated with a children's hospital (61/104), about one quarter did not employ a faculty practicing PAG (26/105), while 17% of the respondents (18/ 105) reported having a fellowship trained Pediatric and Adolescent Gynecologist involved in resident education at their program. All 7 residency programs with an associated PAG fellowship responded to the survey. A comparison of programs with and without a PAG rotation showed differences in the number or residents applying for PAG fellowship, presence of a PAG clinic, and affiliation with a children's hospital (P 5 .004, !.001, and .004 respectively). During each academic year, 93% of residents spent far greater than 10 hours in dedicated didactics learning benign gynecology and general obstetrics. In contrast, PAG was a subject that was taught more than 10 hours each year in only 9% of respondent's residencies, while less than 4 hours each year were dedicated to PAG in 58% of respondent's residencies (57/100). Subjects that were also taught less than 4 hours per academic year included genetics and
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Table 4 Comparison of General Ob/Gyn Clinical Experience (Programs with PAG Fellowship vs No PAG Fellowship) Weeks Spent on the Following Rotations in 4 Year Residency
Pediatric and Adolescent Gynecology (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Benign Gynecology (N 5 100) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Female Pelvic Medicine and Reconstructive Surgery (N 5 99) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk General Obstetrics (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Genomics (N 5 98) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Gynecologic Oncology (N 5 99) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Maternal and Fetal Medicine (N 5 100) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Primary Care (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Reproductive Endocrinology and Infertility (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk
Total (N 5 101)
PAG Fellowship (N 5 7)
No PAG Fellowship (N 5 94)
N (%)
N (%)
N (%)
P
88 12 1 0
(87) (12) (1) (0)
5 2 0 0
(71) (29) (0) (0)
83 10 1 0
(88) (8) (1) (0)
.359
1 15 38 46
(1) (15) (38) (46)
0 1 5 1
(0) (14) (71) (14)
1 14 33 45
(1) (15) (33) (48)
.268
15 75 4 5
(15) (76) (4) (5)
2 5 0 0
(29) (71) (0) (0)
13 70 4 5
(14) (76) (4) (5)
.660
1 11 35 54
(1) (11) (35) (53)
0 0 5 2
(0) (0) (71) (29)
1 11 30 52
(1) (12) (32) (55)
.195
84 13 1 0
(86) (13) (1) (0)
7 0 0 0
(100) (0) (0) (0)
77 13 1 0
(85) (14) (1) (0)
.534
2 51 37 9
(2) (52) (37) (9)
0 4 2 1
(0) (57) (29) (14)
2 47 35 8
(2) (51) (38) (9)
.901
1 61 27 11
(1) (61) (27) (11)
0 5 1 1
(0) (71) (14) (14)
1 56 26 10
(1) (60) (28) (10)
.865
35 53 9 4
(35) (52) (9) (4)
3 2 1 1
(43) (29) (14) (14)
32 51 8 3
(34) (54) (9) (3)
.357
4 90 5 2
(4) (89) (5) (2)
1 5 1 0
(14) (71) (14) (0)
3 85 4 2
(3) (90) (4) (2)
.288
interpersonal skills (Table 2). The topic of PAG is taught by general gynecology faculty in 77% (80/104) of programs, with the second most frequent instructors being Pediatric and Adolescent Gynecology faculty in 47% (49/104). During dedicated teaching time, residents are most likely to be taught PAG via lectures, which were used in 92% (94/102) of residencies, followed by case studies in 54% (55/102), and interactive question and answer sessions 30%, (31/102, Table 3). The number of lectures given among programs without PAG fellowships is statistically greater than those with PAG fellowships (P ! .0001), thus programs with PAG fellowships include less lecture time on PAG compared to other programs. In terms of trainee exposure to PAG rotations, the majority, 83% (87/105), of respondents did not have a formal, dedicated PAG rotation and 63% (65/104) had no outpatient clinic for pediatric and adolescent gynecology where residents see patients as part of their residency program. Eighty-seven percent of (88/101) residents spent less than 4 weeks on a PAG service during a 4-year
residency compared to over 40 weeks on other subjects. However, there is no significant difference in the amount of time spent on a PAG rotation among residents from institutions with or without a PAG fellowship (P 5 .36, Table 4). During that time period on a PAG rotation, 77% of responding program directors (79/103) stated that residents saw 50 or fewer pediatric patients in an ambulatory setting over 4 years of training. Over a 4-year residency, 53% of all resident directors (54/101) said that their residents completed 5 or fewer PAG operative cases. One factor associated with a higher number of operative cases included the presence of a PAG fellowship (P 5 .020, Table 3). Residents' competency levels were assessed by their program director for office and surgical procedures. Residents were thought to be capable of independently performing only 3 out of 11 recommended competencies based on the APGO criteria, namely: diagnostic laparoscopy, elicit a pertinent medical and sexual history, and perform a focused physical examination (Table 5). Also, residents
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Table 5 Ability of Residents to Perform Pediatric Adolescent Gynecology Office Procedures (Programs with PAG Fellowship vs No PAG Fellowship) Total (N 5 100)
PAG Fellowship (N 5 6)
No PAG Fellowship (N 5 94)
N (%)
N (%)
N (%)
2 (2) 13 (13) 84 (85)
0 (0) 2 (33) 4 (67)
2 (2) 11 (12) 80 (86)
.307
1 (1) 16 (16) 82 (83)
0 (0) 1 (17) 5 (83)
1 (1) 15 (16) 77 (83)
.968
3 (3) 59 (60) 37 (37)
0 (0) 3 (50) 3 (50)
3 (3) 56 (60) 34 (37)
.754
25 (25) 52 (52) 23 (23)
3 (50) 3 (50) 0 (0)
22 (23) 49 (35) 23 (25)
.216
2 (2) 67 (67) 31 (31)
1 (17) 3 (50) 2 (33)
1 (1) 64 (68) 29 (31)
.028*
4 (4) 71 (71) 25 (25)
0 (0) 6 (100) 0 (0)
4 (4) 65 (69) 25 (27)
.272
3 (3) 50 (50) 47 (47)
0 (0) 3 (50) 3 (50)
3 (3) 47 (50) 44 (47)
.903
6 (6) 61 (61) 33 (33)
0 (0) 2 (33) 4 (67)
6 (6) 59 (63) 29 (31)
.185
8 (8) 72 (72) 20 (20)
0 (0) 5 (83) 1 (17)
8 (9) 67 (71) 19 (20)
.719
6 (6) 62 (63) 31 (31)
0 (0) 3 (60) 2 (40)
6 (6) 59 (63) 29 (31)
.798
1 (1) 17 (17) 82 (82)
0 (0) 1 (17) 5 (83)
1 (1) 16 (17) 77 (82)
.968
Elicit a pertinent medical and sexual history (N 5 99) Not at all With assistance On their own Perform focused physical examination (N 5 99) Not at all With assistance On their own Counsel pt./family about long-term prognosis/reproductive effects (N 5 99) Not at all With assistance On their own Perform forensic exam to evaluate sexual abuse (N 5 100) Not at all With assistance On their own Interpret results of tests to evaluate precocious puberty (N 5 100) Not at all With assistance On their own Describe major developmental anomalies (N 5 100) Not at all With assistance On their own Describe the principal causes of delayed puberty (N 5 100) Not at all With assistance On their own Perform a vaginoscopy (N 5 100) Not at all With assistance On their own Perform a hysteroscopic uterine septoplasty (N 5 100) Not at all With assistance On their own Perform a release of labial fusion (N 5 99) Not at all With assistance On their own Perform a diagnostic laparoscopy (N 5 100) Not at all With assistance On their own
P
* Statistically significant difference at P ! .05.
who were trained in a program with a fellowship-trained PAG faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P 5 .03). In the open comments section of our survey, many program directors indicated that the majority of the resident PAG education comes in the last 2 years of training. Many program directors noted interest in expanding the pediatric and adolescent curriculum; however, they felt limited by work hour restrictions. Residency directors in programs with PAG fellowships documented complaints that residents are second or third operating room assistants while fellows gain greater operative experience. Discussion
The field of PAG is an important subject in Obstetrics and Gynecology and there is a clear need for increased training in this area, although recent studies are sparse regarding
this area.7 Our results show that despite the many CREOG educational objectives listed for PAG, there is still a lack of PAG training in residency programs without affiliated PAG fellowships. This information is consistent with the previously mentioned resident based survey studies. Based on this knowledge, it is crucial that residency training programs identify models of resident teaching that contribute to high yield learning and retention. The strength of this study lies in the fact it was able to reach all 242 United States Obstetrics and Gynecology residency programs via email addresses publicly made available through ABOG and that the survey was completely de-identified , and thus was blinded. The survey population was diverse and included respondents from each region and from all program affiliations (university, community, and military). However, the response rate of 43% is a major weakness of the study. In addition, this is a survey study, which introduces recall bias; moreover, the questionnaire was not validated. Furthermore, selection bias may not be
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overcome with survey studies since people who chose to fill out surveys self-select themselves to complete the survey. Conditions such as premature adrenarche and vaginal agglutination are prepubertal disorders that are likely to present to the gynecologist.8,9 Urgent situations when a gynecologist would be consulted on a PAG patient include straddle injuries, sexual abuse, and vaginal bleeding related to a foreign body. With these challenges it is ideal that Obstetrics and Gynecology residents feel comfortable caring for the gynecologic needs of patients under 18 years of age. Although the medical problems experienced by adolescent gynecology patients are similar to what adults encounter, the perception and experience of the pediatric or adolescent gynecology patient may be vastly different compared to that of an adult. Care for these patients may be limited due to physician discomfort treating these patients and/or by lack of access to care by the patients. Our survey results show a notable gap in knowledge about the special circumstances that should be recognized when treating adolescent patients. To remedy the identified problems, residents may be directed towards learning resources provided by national organizations focused on resident education. One such resource is the Clinical Cases in Pediatric and Adolescent Gynecology to improve their mastery of the topic. This joint educational venture between and the American College of Obstetrics and The North American Society for Pediatric and Adolescent Gynecology (NASPAG) includes 32 clinical cases and is available for purchase at a low cost on the NASPAG website.10 Free resources include the ACOG Committee Opinions addressing adolescent issues. ACOG also provides a “tool kit” regarding a woman's first examination and offers 2 publications focused on adolescent gynecology: “Guidelines for Adolescent Healthcare, second edition” and “Reproductive Health Care for Adolescents with Disabilities.”11,12
185
We recommend the above works and development of a PAG curriculum as an educational strategy to teach residents. Without proper objectives regarding education on this topic, we are concerned that the adolescent and pediatric female population will experience a delay in diagnosis and untimely referral to centers that are more experienced with diagnosis and treatment.
References 1. Educational Objectives: Core Curriculum in Obstetrics and Gynecology, (9th ed). New York, Professional Publishing Group, 2009 2. Korczak DJ, MacArthur C, Katzman DK: Canadian pediatric residents' experience and level of comfort with adolescent gynecological health care. J Adolesc Health 2006; 38:57 3. Dietrich JE, De Silva NK, Young AE: Reliability study for pediatric and adolescent gynecology case-based learning in resident education. J Pediatr Adolesc Gynecol 2010; 23:102 4. Loveless MB, Finkenzeller D, Ibrahim S, et al: A simulation program for teaching obstetrics and gynecology residents the pediatric gynecology examination and procedures. J Pediatr Adolesc Gynecol 2011; 24:127 5. FREIDA Online: Fellowship and residency electronic interactive database access. Available: http://www.ama-assn.org/ama/pub/education-careers/graduatemedical-education/freida-online.page. Accessed January 26, 2012 6. APGO (Association of Professors of Gynecology and Obstetrics): Available: http://www.apgo.org/component/residencedirectory 5 residency%20director. Accessed January 26, 2012 7. Wagner EA, Schroeder B, Kowalczyk C: Pediatric and Adolescent Gynecology experience in academic and community OB/GYN residency programs in Michigan. J Pediatr Adolesc Gynecol 1999; 12:215 8. Williams RM, Ward CE, Hughes IA: Premature adrenarche. Arch Dis Child 2012; 97:250 9. Berenson AB, Heger AH, Hayes JM, et al: Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89:387 10. Clinical Cases in Pediatric & Adolescent Gynecology (2008): An educational program from the American College of Obstetricians and Gynecologists and the North American Society for Pediatric and Adolescent Gynecology. Available: www.naspag.org/index.php/pagestore. Accessed August 20, 2012 11. Guidelines for Adolescent Health Care, 2nd ed: Washington, DC, American College of Obstetrics and Gynecology, 2011 12. Committee on Adolescent Health Care, Toolkit for Teen Care, 2nd ed: Atlanta, GA, American College of Obstetrics and Gynecology, Committee on Adolescent Healthcare, 2009
Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH Division of Female Pelvic Medicine and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
a b s t r a c t Study Objective: To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. Design: Prospective, anonymous, cross-sectional study. Participants: United States program directors of Obstetrics and Gynecology residency programs, N 5 242; respondents 104 (43%). Results: 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n 5 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n 5 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P 5 .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P 5 .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P 5 .03). Conclusions: Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training. Key Words: Fellowship, Pediatric and Adolescent Gynecology, Program directors, Residency training
Introduction
Historically, among Obstetrics and Gynecology programs, less focus has been given to Pediatric and Adolescent Gynecology (PAG), perhaps because there is no single specialty that “owns” these patients and their complications. General surgeons, general pediatricians, pediatric surgeons, pediatric urologists, adolescent medicine specialists, and gynecologists have provided care for pediatric and adolescent patients with gynecologic issues in the past. The increase in resident work hour restrictions set by the Accreditation Council for Graduate Medical Education (ACGME) may have made teaching residents to all facets of Obstetrics and Gynecology more difficult. Specifically, the Council on Resident Education in Obstetrics and Gynecology (CREOG) objectives for PAG includes the following: to understand the medical and surgical treatment of pediatric gynecologic disorders, to describe appropriate medical and surgical treatments for patients with Received 24 December 2012; revised 31 January 2013; accepted 2 February 2013. The authors indicate no conflicts of interest. Presented at the 27th Annual Clinical and Research North American Society for Pediatric and Adolescent Gynecology Meeting on April 19, 2013, San Diego, California. * Address correspondence to: Ellen R. Solomon, MD, Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Desk A-81, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195; Phone: (216) 445-6587 E-mail address: [email protected] (E.R. Solomon).
developmental anomalies, and to treat gynecologic disorders medically or surgically.1 While the pathology and breadth of cases in PAG appears to be extremely important, it is unclear to what extent this subject material is and is not covered in United States Obstetrics and Gynecology residencies. Physicians specializing in PAG undergo advanced training in the diagnosis and management of common pediatric gynecology conditions, as well as more complex conditions such as congenital reproductive anomalies, reproductive endocrine function, and sexual development. However, with very few PAG training programs within the United States, specialists in this subspecialty are rare and other practitioners may be needed to diagnose and treat these patients. Research focused primarily on PAG training during Obstetrics and Gynecology residency is limited as revealed upon a review of the literature. A literature search was performed using PubMed and included the search terms “resident education,” “pediatric and adolescent gynecology,” “resident competency,” “teaching formats,” “program director,” and “survey” (January 1996-August 2012). In a recent survey study evaluating resident perceptions of how well equipped they are to practice pediatric and adolescent gynecology, it was demonstrated that residents deem themselves not fully prepared to treat the pediatric and adolescent population.2 Other studies evaluated various methods of teaching the PAG curriculum using novel techniques. For example, one study determined that using
1083-3188/$ - see front matter Ó 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.02.003
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Table 1 Demographic Comparison of Programs with PAG Rotation vs No PAG Rotation
Location (N 5 102) Region 1 Region 2 Region 3 Region 4 Region 5 Other Type of obstetrics and gynecology residency program (N 5 102) Community Military University Other* Affiliated with a children's hospital (N 5 104) Yes No # faculty who practice PAG (N 5 105) 0 faculty 1 faculty 2 faculty 3 faculty 4 to 10 faculty More than 10 faculty PAG fellowship trained faculty (N 5 105) Yes No PAG fellowship at institution (N 5 104) Yes No PAG clinic where residents see patients (N 5 104) Yes No # Residents apply for PAG fellowship (N 5 104) 0 residents 1 resident 2 residents 3 residents 4 to 10 residents More than 10 residents
Total (N 5 105)
PAG Rotation (N 5 18)
No PAG Rotation (N 5 87)
N (%)
N (%)
N (%)
P
21 20 21 27 12 1
(21) (20) (21) (27) (12) (12)
3 3 5 6 0 1
(17) (17) (28) (33) (0) (6)
18 17 16 21 12 0
(21) (20) (19) (25) (14) (0)
.134
27 3 69 3
(27) (3) (68) (3)
3 0 15 0
(17) (0) (83) (0)
24 3 54 3
(29) (4) (64) (4)
.411
45 (52) 41 (48)
.004
24 26 14 10 11 2
(28) (30) (16) (12) (13) (2)
.427
61 (59) 43 (41) 26 32 17 15 13 2
(25) (31) (16) (14) (12) (2)
16 (89) 2 (11) 2 6 3 5 2 0
(11) (33) (17) (28) (11) (0)
18 (17) 87 (83)
6 (33) 12 (67)
12 (14) 75 (86)
.079
7 (7) 97 (92)
6 (33) 12 (67)
1 (1) 85 (99)
!.001
39 (37) 65 (63)
18 (100) 0 (0)
21 (24) 65 (76)
!.001
96 6 0 0 2 0
14 2 0 0 2 0
82 4 0 0 0 0
(92) (6) (0) (0) (2) (0)
(78) (11) (0) (0) (11) (0)
(95) (5) (0) (0) (0) (0)
.004
* Identified as an independent-university affiliated practice.
computer based learning tools can increase overall PAG knowledge and is a reliable method to teach this subject matter.1,3 Another study used a simulation model to teach pediatric gynecology and then residents were retested later, with improved post-training vs pre-training scores.4 While determining the ideal way to teach PAG among obstetrics and gynecology residents is crucial to resident education, perhaps using these novel techniques and increasing the opportunities to see pediatric and adolescent gynecology patients would increase resident preparedness. To our knowledge, there are no studies that measure preparedness to practice PAG from a residency program director standpoint. This study aims to estimate the prevalence of formal training for PAG among Obstetric and Gynecology residency programs in the United States as well as to determine curriculum deficiencies. Materials and Methods
An exemption from Cleveland Clinic institutional review board was obtained prior to the initiation of this study. A total of 242 U.S. Obstetrics and Gynecology residency programs were determined by cross-referencing the Fellowship and Residency Electronic Interactive Database
Access System (FREIDA) and the Association of Professors of Gynecology and Obstetrics (APGO) website.5,6 The deidentified surveys were then sent to the 242 program directors and non-responders were identified by the survey software for follow-up. Initially an introductory letter with the web address of the electronic survey was sent via postal mail. This was then followed by 3 weekly e-mail reminders with a link to the electronic survey. No return e-mails noting a delivery status failure notification were received after sending the survey. Finally during the fourth week of the study period (March 2012) a follow-up letter was sent via postal mail to those non-responders with a paper copy of the survey and a selfaddressed stamped envelope. No incentive was provided for participation. The 22-item questionnaire included 8 domains: residency program characteristics, resident experience, didactics, clinical experience, teaching methods, perceived competence, and respondent demographics (Table 1). Responses were analyzed using the statistical software (JMP 9.0, SAS Institute, Cary, NC). Categorical data was compared using a chi-square test with P ! .05 showing statistical significance. The Wilcoxon rank-sum test was used for ordinal data and the t-test was used for continuous variables. The program directors
182
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Table 2 Comparison of Clinical Experience (Programs with PAG Fellowship vs No PAG Fellowship) Number of Protected Resident Hours Per Year for:
Total PAG No PAG (N 5 99) Fellowship Fellowship (N 5 6) (N 5 93) N (%)
Pediatric and Adolescent Gynecology (N 5 99) 0-4 h 5-10 h Over 10 h Benign Gynecology (N 5 99) 0-4 h 5-10 h Over 10 h Female Pelvic Medicine and Reconstructive Surgery (N 5 99) 0-4 h 5-10 h Over 10 h General Obstetrics (N 5 98) 0-4 h 5-10 h Over 10 h Genomics (N 5 98) 0-4 h 5-10 h Over 10 h Gynecologic Oncology (N 5 99) 0-4 h 5-10 h Over 10 h Maternal and Fetal Medicine (N 5 98) 0-4 h 5-10 h Over 10 h Primary Care (N 5 99) 0-4 h 5-10 h Over 10 h Reproductive Endocrinology and Infertility (N 5 99) 0-4 h 5-10 h Over 10 h Minimally Invasive Surgery (N 5 98) 0-4 h 5-10 h Over 10 h Interpersonal and Communication Skills (N 5 99) 0-4 h 5-10 h Over 10 h
N (%)
Table 3 Comparison of PAG Educational Experience (Programs with PAG Fellowship vs No PAG Fellowship Total
P
N (%)
57 (58) 33 (33) 9 (9)
3 (50) 2 (33) 1 (17)
54 (58) 31 (33) 8 (9)
1 (1) 5 (5) 92 (93)
1 (17) 1 (17) 4 (67)
0 (0) 5 (5) 88 (95)
.792
!.001*
7 (7) 40 (40) 52 (53)
0 (0) 4 (67) 2 (33)
7 (8) 36 (39) 50 (54)
.370
0 (0) 3 (3) 95 (97)
0 (0) 1 (20) 4 (80)
0 (0) 2 (2) 91 (98)
.024*
56 (57) 32 (33) 10 (10)
3 (50) 3 (50) 0 (0)
53 (58) 29 (32) 10 (11)
.523
2 (2) 30 (30) 67 (68)
0 (0) 2 (33) 4 (67)
2 (2) 28 (30) 63 (68)
.928
1 (1) 18 (18) 79 (81)
0 (0) 1 (17) 5 (83)
1 (1) 17 (19) 74 (80)
.960
19 (19) 38 (38) 42 (42)
2 (33) 1 (17) 3 (50)
4 (4) 29 (29) 66 (67)
1 (17) 2 (33) 3 (50)
3 (3) 27 (27) 63 (63)
.244
11 (11) 41 (42) 46 (47)
2 (33) 2 (33) 2 (33)
9 (10) 39 (42) 44 (48)
.207
34 (34) 41 (41) 24 (24)
3 (50) 2 (33) 1 (17)
31 (33) 39 (42) 23 (25)
.702
17/18 37/40 39/42
.464
* Statistically significant difference at P ! .05.
comments provided at the end of surveys were reviewed for similar themes relating to their PAG curriculum and plans for improvement. Results
We received 104 completed surveys from the 242 residency program directors who were invited to participatedan overall 43% response rate. Nationwide, there was a 57% response rate from university-based residency programs, a 24% response rate from community-based programs and a 57% response rate from military-based programs. Most respondents were from university-
Who teaches PAG to Residents: yes response? (N 5 104) Female Pelvic Medicine and Reconstructive Surgery faculty General Gynecology faculty Pediatric and Adolescent Gynecology faculty Reproductive Endocrinology and Infertility faculty Othery Forms of PAG teaching residents receive: yes response? Case Studies (N 5 102) Journal Clubs (N 5 102) Lectures (N 5 102) Online Learning Modules (N 5 102) Q&A Sessions (N 5 102) Simulator Labs (N 5 102) Small Learning Groups (N 5 102) Otherz No. of PAG operative cases in 4 year residency? (N 5 100) None 1 to 5 operative cases 6 to 10 operative cases 11 to 20 operative cases Over 20 operative cases No. of patients seen by residents in 4 year residency? (N 5 103) None 1-10 patients 11-25 patients 26-50 patients O50 patients
PAG No PAG Fellowship Fellowship (N 5 7) (N 5 96)
P
N (%)
N (%)
N (%)
26 (25)
6 (86)
20 (21)
!.001*
80 (77) 49 (47)
1 (14) 2 (29)
79 (81) 47 (49)
!.001* .309
10 (10)
0 (0)
10 (10)
.372
4 (4)
1 (14)
3 (3)
.137
55 28 94 19
(54) (28) (92) (19)
3 2 4 4
(43) (29) (57) (57)
52 26 90 15
(55) (27) (95) (16)
.543 .945 !.001* .007*
31 (30) 6 (6) 15 (15)
1 (14) 1 (14) 2 (29)
30 (32) 5 (5) 13 (14)
.337 .328 .283
1 (1)
0 (0)
1 (1)
.785
6 48 29 12 5
(6) (48) (29) (12) (5)
0 2 1 2 2
(0) (29) (14) (29) (2)
6 46 28 10 3
(6) (49) (28) (11) (3)
.020
1 26 28 24 24
(1) (25) (27) (23) (23)
0 0 2 1 4
(0) (0) (29) (14) (57)
1 26 26 23 20
(1) (27) (27) (24) (21)
.205
* Statistically significant difference at P ! .05. y Other category includes: Family Medicine, Pediatric, Pediatric Endocrinology, and 'various'. z Other category includes: cadaver and animal surgery labs, operative cases with the subspecialist, and self-directed learning.
affiliated residency programs (68%) and they were distributed across the 5 ACOG regions. Over half of the responding departments had a program affiliated with a children's hospital (61/104), about one quarter did not employ a faculty practicing PAG (26/105), while 17% of the respondents (18/ 105) reported having a fellowship trained Pediatric and Adolescent Gynecologist involved in resident education at their program. All 7 residency programs with an associated PAG fellowship responded to the survey. A comparison of programs with and without a PAG rotation showed differences in the number or residents applying for PAG fellowship, presence of a PAG clinic, and affiliation with a children's hospital (P 5 .004, !.001, and .004 respectively). During each academic year, 93% of residents spent far greater than 10 hours in dedicated didactics learning benign gynecology and general obstetrics. In contrast, PAG was a subject that was taught more than 10 hours each year in only 9% of respondent's residencies, while less than 4 hours each year were dedicated to PAG in 58% of respondent's residencies (57/100). Subjects that were also taught less than 4 hours per academic year included genetics and
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183
Table 4 Comparison of General Ob/Gyn Clinical Experience (Programs with PAG Fellowship vs No PAG Fellowship) Weeks Spent on the Following Rotations in 4 Year Residency
Pediatric and Adolescent Gynecology (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Benign Gynecology (N 5 100) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Female Pelvic Medicine and Reconstructive Surgery (N 5 99) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk General Obstetrics (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Genomics (N 5 98) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Gynecologic Oncology (N 5 99) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Maternal and Fetal Medicine (N 5 100) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Primary Care (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk Reproductive Endocrinology and Infertility (N 5 101) 0 to 4 wk 5 to 20 wk 21 to 40 wk Over 40 wk
Total (N 5 101)
PAG Fellowship (N 5 7)
No PAG Fellowship (N 5 94)
N (%)
N (%)
N (%)
P
88 12 1 0
(87) (12) (1) (0)
5 2 0 0
(71) (29) (0) (0)
83 10 1 0
(88) (8) (1) (0)
.359
1 15 38 46
(1) (15) (38) (46)
0 1 5 1
(0) (14) (71) (14)
1 14 33 45
(1) (15) (33) (48)
.268
15 75 4 5
(15) (76) (4) (5)
2 5 0 0
(29) (71) (0) (0)
13 70 4 5
(14) (76) (4) (5)
.660
1 11 35 54
(1) (11) (35) (53)
0 0 5 2
(0) (0) (71) (29)
1 11 30 52
(1) (12) (32) (55)
.195
84 13 1 0
(86) (13) (1) (0)
7 0 0 0
(100) (0) (0) (0)
77 13 1 0
(85) (14) (1) (0)
.534
2 51 37 9
(2) (52) (37) (9)
0 4 2 1
(0) (57) (29) (14)
2 47 35 8
(2) (51) (38) (9)
.901
1 61 27 11
(1) (61) (27) (11)
0 5 1 1
(0) (71) (14) (14)
1 56 26 10
(1) (60) (28) (10)
.865
35 53 9 4
(35) (52) (9) (4)
3 2 1 1
(43) (29) (14) (14)
32 51 8 3
(34) (54) (9) (3)
.357
4 90 5 2
(4) (89) (5) (2)
1 5 1 0
(14) (71) (14) (0)
3 85 4 2
(3) (90) (4) (2)
.288
interpersonal skills (Table 2). The topic of PAG is taught by general gynecology faculty in 77% (80/104) of programs, with the second most frequent instructors being Pediatric and Adolescent Gynecology faculty in 47% (49/104). During dedicated teaching time, residents are most likely to be taught PAG via lectures, which were used in 92% (94/102) of residencies, followed by case studies in 54% (55/102), and interactive question and answer sessions 30%, (31/102, Table 3). The number of lectures given among programs without PAG fellowships is statistically greater than those with PAG fellowships (P ! .0001), thus programs with PAG fellowships include less lecture time on PAG compared to other programs. In terms of trainee exposure to PAG rotations, the majority, 83% (87/105), of respondents did not have a formal, dedicated PAG rotation and 63% (65/104) had no outpatient clinic for pediatric and adolescent gynecology where residents see patients as part of their residency program. Eighty-seven percent of (88/101) residents spent less than 4 weeks on a PAG service during a 4-year
residency compared to over 40 weeks on other subjects. However, there is no significant difference in the amount of time spent on a PAG rotation among residents from institutions with or without a PAG fellowship (P 5 .36, Table 4). During that time period on a PAG rotation, 77% of responding program directors (79/103) stated that residents saw 50 or fewer pediatric patients in an ambulatory setting over 4 years of training. Over a 4-year residency, 53% of all resident directors (54/101) said that their residents completed 5 or fewer PAG operative cases. One factor associated with a higher number of operative cases included the presence of a PAG fellowship (P 5 .020, Table 3). Residents' competency levels were assessed by their program director for office and surgical procedures. Residents were thought to be capable of independently performing only 3 out of 11 recommended competencies based on the APGO criteria, namely: diagnostic laparoscopy, elicit a pertinent medical and sexual history, and perform a focused physical examination (Table 5). Also, residents
184
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Table 5 Ability of Residents to Perform Pediatric Adolescent Gynecology Office Procedures (Programs with PAG Fellowship vs No PAG Fellowship) Total (N 5 100)
PAG Fellowship (N 5 6)
No PAG Fellowship (N 5 94)
N (%)
N (%)
N (%)
2 (2) 13 (13) 84 (85)
0 (0) 2 (33) 4 (67)
2 (2) 11 (12) 80 (86)
.307
1 (1) 16 (16) 82 (83)
0 (0) 1 (17) 5 (83)
1 (1) 15 (16) 77 (83)
.968
3 (3) 59 (60) 37 (37)
0 (0) 3 (50) 3 (50)
3 (3) 56 (60) 34 (37)
.754
25 (25) 52 (52) 23 (23)
3 (50) 3 (50) 0 (0)
22 (23) 49 (35) 23 (25)
.216
2 (2) 67 (67) 31 (31)
1 (17) 3 (50) 2 (33)
1 (1) 64 (68) 29 (31)
.028*
4 (4) 71 (71) 25 (25)
0 (0) 6 (100) 0 (0)
4 (4) 65 (69) 25 (27)
.272
3 (3) 50 (50) 47 (47)
0 (0) 3 (50) 3 (50)
3 (3) 47 (50) 44 (47)
.903
6 (6) 61 (61) 33 (33)
0 (0) 2 (33) 4 (67)
6 (6) 59 (63) 29 (31)
.185
8 (8) 72 (72) 20 (20)
0 (0) 5 (83) 1 (17)
8 (9) 67 (71) 19 (20)
.719
6 (6) 62 (63) 31 (31)
0 (0) 3 (60) 2 (40)
6 (6) 59 (63) 29 (31)
.798
1 (1) 17 (17) 82 (82)
0 (0) 1 (17) 5 (83)
1 (1) 16 (17) 77 (82)
.968
Elicit a pertinent medical and sexual history (N 5 99) Not at all With assistance On their own Perform focused physical examination (N 5 99) Not at all With assistance On their own Counsel pt./family about long-term prognosis/reproductive effects (N 5 99) Not at all With assistance On their own Perform forensic exam to evaluate sexual abuse (N 5 100) Not at all With assistance On their own Interpret results of tests to evaluate precocious puberty (N 5 100) Not at all With assistance On their own Describe major developmental anomalies (N 5 100) Not at all With assistance On their own Describe the principal causes of delayed puberty (N 5 100) Not at all With assistance On their own Perform a vaginoscopy (N 5 100) Not at all With assistance On their own Perform a hysteroscopic uterine septoplasty (N 5 100) Not at all With assistance On their own Perform a release of labial fusion (N 5 99) Not at all With assistance On their own Perform a diagnostic laparoscopy (N 5 100) Not at all With assistance On their own
P
* Statistically significant difference at P ! .05.
who were trained in a program with a fellowship-trained PAG faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P 5 .03). In the open comments section of our survey, many program directors indicated that the majority of the resident PAG education comes in the last 2 years of training. Many program directors noted interest in expanding the pediatric and adolescent curriculum; however, they felt limited by work hour restrictions. Residency directors in programs with PAG fellowships documented complaints that residents are second or third operating room assistants while fellows gain greater operative experience. Discussion
The field of PAG is an important subject in Obstetrics and Gynecology and there is a clear need for increased training in this area, although recent studies are sparse regarding
this area.7 Our results show that despite the many CREOG educational objectives listed for PAG, there is still a lack of PAG training in residency programs without affiliated PAG fellowships. This information is consistent with the previously mentioned resident based survey studies. Based on this knowledge, it is crucial that residency training programs identify models of resident teaching that contribute to high yield learning and retention. The strength of this study lies in the fact it was able to reach all 242 United States Obstetrics and Gynecology residency programs via email addresses publicly made available through ABOG and that the survey was completely de-identified , and thus was blinded. The survey population was diverse and included respondents from each region and from all program affiliations (university, community, and military). However, the response rate of 43% is a major weakness of the study. In addition, this is a survey study, which introduces recall bias; moreover, the questionnaire was not validated. Furthermore, selection bias may not be
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overcome with survey studies since people who chose to fill out surveys self-select themselves to complete the survey. Conditions such as premature adrenarche and vaginal agglutination are prepubertal disorders that are likely to present to the gynecologist.8,9 Urgent situations when a gynecologist would be consulted on a PAG patient include straddle injuries, sexual abuse, and vaginal bleeding related to a foreign body. With these challenges it is ideal that Obstetrics and Gynecology residents feel comfortable caring for the gynecologic needs of patients under 18 years of age. Although the medical problems experienced by adolescent gynecology patients are similar to what adults encounter, the perception and experience of the pediatric or adolescent gynecology patient may be vastly different compared to that of an adult. Care for these patients may be limited due to physician discomfort treating these patients and/or by lack of access to care by the patients. Our survey results show a notable gap in knowledge about the special circumstances that should be recognized when treating adolescent patients. To remedy the identified problems, residents may be directed towards learning resources provided by national organizations focused on resident education. One such resource is the Clinical Cases in Pediatric and Adolescent Gynecology to improve their mastery of the topic. This joint educational venture between and the American College of Obstetrics and The North American Society for Pediatric and Adolescent Gynecology (NASPAG) includes 32 clinical cases and is available for purchase at a low cost on the NASPAG website.10 Free resources include the ACOG Committee Opinions addressing adolescent issues. ACOG also provides a “tool kit” regarding a woman's first examination and offers 2 publications focused on adolescent gynecology: “Guidelines for Adolescent Healthcare, second edition” and “Reproductive Health Care for Adolescents with Disabilities.”11,12
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We recommend the above works and development of a PAG curriculum as an educational strategy to teach residents. Without proper objectives regarding education on this topic, we are concerned that the adolescent and pediatric female population will experience a delay in diagnosis and untimely referral to centers that are more experienced with diagnosis and treatment.
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