- Email: [email protected]
Assessing Resident Surgical Volume Before and After Initiation of a Female Pelvic Medicine and Reconstructive Surgery Fellowship
ORIGINAL REPORTS
Assessing Resident Surgical Volume Before and After Initiation of a Female Pelvic Medicine and Reconstructive Surgery Fellowship$ Zaid Chaudhry, MD,* and Christopher M. Tarnay, MD*,† *
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; and †Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
OBJECTIVES: The effect of fellowship programs on resident training for gynecologic surgery volume has not been clearly defined. The purpose of our study is to assess resident surgical volume for laparoscopic and vaginal hysterectomy before and after initiation of a female pelvic medicine and reconstructive surgery (FPMRS) fellowship.
in the 3 years after the start of the FPMRS fellowship finished with 3.2 more laparoscopic hysterectomies compared with residents who graduated before the fellowship although this was not significant (p ¼ 0.25). CONCLUSIONS: Resident surgical volume was signifi-
for Graduate Medical Education Resident Case Logs of obstetrics and gynecology residents who graduated in the 3 years before and after initiation of a FPMRS fellowship was performed. Mean values of vaginal and laparoscopic hysterectomies were compared using two-tailed t-tests with statistical significance set at p o 0.05.
cantly decreased for vaginal hysterectomy after the initiation of a FPMRS fellowship, whereas laparoscopic hysterectomy volume was not significantly changed. Longer follow-up and a national assessment are necessary to determine the broader effect of fellowship training on resident surgical experience. C 2016 Association of Program ( J Surg Ed ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: Obstetrics and gynecology resident case logs at
KEY WORDS: vaginal hysterectomy, laparoscopic hyster-
the Ronald Reagan University of California Los Angeles (UCLA) Medical Center were assessed. The UCLA Medical Center, located in Los Angeles, CA, is a tertiary referral center with a graduating class of 7 obstetrics and gynecology residents yearly.
ectomy, resident surgical experience, surgical training COMPETENCIES: Patient Care, Medical Knowledge, Systems-Based Practice
PARTICIPANTS: Obstetrics and gynecology residents who graduated from residency 3 years before and after imitation of a FPMRS fellowship were included. In the 3 years before the start of the fellowship, 20 residents graduated, whereas 21 residents graduated after the start of the fellowship.
INTRODUCTION
DESIGN: A retrospective review of Accreditation Council
RESULTS: Residents who graduated in the 3 years after the start of the FPMRS fellowship, finished with 4.6 less vaginal hysterectomies compared with residents who graduated before the fellowship (p ¼ 0.022). Residents who graduated ☆ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Correspondence: Inquiries to Zaid Chaudhry, MD, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue 27-139 CHS, Los Angeles, CA 90095-1740; fax: (310) 206-7168; e-mail: [email protected], [email protected]
Surgical volume is an imperfect but commonly used tool in assessing trainee competency.1-3 This information is recorded by the Accreditation Council for Graduate Medical Education (ACGME) using the Resident Case Log System. Residents are expected to meet minimum procedural numbers and these data are used by the ACGME to determine if residency programs are providing trainees adequate exposure to various procedures. Although residents record cases as both surgeon (performing 450% of the procedure) and assistant on their logs, cases logged as surgeon are primarily used for the purposes of credentialing and assessing experience.
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.11.007
1
TABLE. Comparison of Mean Hysterectomies Performed as Surgeon Before and After Initiation of Fellowship
Number of residents VH (p ¼ 0.022) LH (p ¼ 0.25)
Before Fellowship
After Fellowship
20 28.4 30.3
21 23.8 33.5
The effect of fellowship training on resident experience has been varied in the general surgery and gynecology literature depending on the fellowship in question.4-7 Female pelvic medicine and reconstructive surgery (FPMRS) is a recently accredited subspecialty and the objective effect that fellow training has on the resident surgical experience is limited in the current literature.8 The purpose of our study is to assess resident surgical volume as primary surgeon of vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) before and after initiation of a FPMRS fellowship at a single institution.
MATERIALS AND METHODS A retrospective review of the ACGME Resident Case Log System of graduated obstetrics and gynecology (OB/GYN) residents at the UCLA David Geffen School of Medicine, Department of Obstetrics and Gynecology was performed. Residents who had graduated within their specific academic cycle were included in the study. Residents who had taken extended leaves and graduated off track were excluded. The time frame spanned the 3 graduating classes of residents before initiation of the fellowship and the 3 years after. At our institution, the FPMRS fellowship was jointly ACGME certified under the departments of Urology and OB/GYN in 2011 and the first fellow started in July of that year. Therefore, we specifically compared the graduating resident case log data for the academic years 2008 to 2011 and then from 2011 to 2014. The ACGME collects case information on 10 gynecologic procedures and provides additional information based on the data of all ACGME-approved residencies including mean/median values along with percentiles. For our purposes, we collected data on VH and LH numbers that could include total or laparoscopic-assisted VH along with any cases of robotic assistance. For the academic year 2013 to 2014, laparoscopic-assisted VH was categorized as a VH per ACGME recommendations. We specifically chose these 2 modes of hysterectomy because they are commonly performed by specialists and generalists alike and are considered procedures that any currently graduating gynecologist should be comfortable performing. The number of VH and LH performed by the primary FPMRS specialist at our institution was also recorded during this period as a proxy of division volume in addition to overall institutional volume. 2
FIGURE 1. Bar graph comparing mean vaginal hysterectomy procedures logged by institutional residents, nationally, and by division proxy.
National ACGME data were also reviewed during this period. Statistical analysis was performed using descriptive statistics and unpaired t-tests with an α ¼ 0.05. Data analysis was performed using SPSS. The UCLA Institutional Review Board deemed this study exempt from review.
RESULTS A total of 20 residents graduated in the 2008 to 2011 period before the start of the fellowship, whereas 21 residents graduated in the 2011 to 2014 time frame. The mean number of VH performed by this group before fellowship initiation was 28.4 (⫾7.1). The mean number of VH performed by this group after the fellowship was 23.8 (⫾4.8). The difference between these 2 groups was significant (Table). During this 6-year period, ACGME national data show a relatively stable number of vaginal hysterectomies being logged by graduating residents except for the 2013 to 2014 year where there was a large spike (Fig. 1). Our division proxy numbers were also generally increasing after initiation of the fellowship, whereas institutionally there was no specific trend in VH (Fig. 2).
FIGURE 2. Bar graph tracking vaginal and laparoscopic hysterectomy rates over a 6-year period. LH, laparoscopic hysterectomy; VH, vaginal hysterectomy. Journal of Surgical Education Volume ]/Number ] ] 2016
With the movement in medical and surgical training toward subspecialization, the trend toward fellowship training has increased. This has led to a unique training environment in many institutions where the needs of both fellows and residents must be balanced to train competent physicians. This “balancing act” has been assessed in the general surgery literature on the potential effect of specific fellowships on resident experience with somewhat conflicting results. For example, certain fellowships such as pediatric surgery appear to reduce resident surgical volume, whereas hepatopancreaticobiliary and minimally invasive surgery fellowships appeared to do the opposite.5,6 Even if surgical volume has been affected, the overall consensus of general surgery program directors has been positive on the overall knowledge/teaching that occurs when a fellowship is present during a resident’s training.4 This attempt at characterizing fellowship training effect on resident training has been lacking in the gynecologic literature. Prior work in the field of gynecologic oncology surveyed residents to assess their interaction with fellows and most residents did feel some sense of competition with fellows on surgical cases although they overall had a positive view of fellows in their training.9 Similarly, a single institutional survey of residents found that they felt that a
minimally invasive gynecology fellowship did not detract from their training.10 In the field of FPMRS, there is a dearth of objective and subjective data. In 1 study, residents initially felt a FPMRS fellowship negatively affected their education, whereas later reporting a positive effect over the course of 3 years. The study was limited by a mean response rate of 32% at a single institution.11 A retrospective review of resident participation in hysterectomy procedures out of single academic OB/GYN residency indicated no difference in resident involvement on cases before and after the start of their ACGME-accredited fellowship.8 A limitation of this study is its single center nature that does not allow for generalizations to occur as evidenced by our analysis showing conflicting results. We feel this study provides a reasonable starting point for the field of FPMRS to better understand the potential effect that fellowship training may have on the resident experience. We intentionally chose VH and LH as they are foundational procedures for any physician who practices gynecology and are often performed during pelvic reconstructive cases. There may be an apparent trend in reduction in resident surgical experience for VH based on our institutional data but it is difficult to discern an exact reason for this as our division proxy and institutional numbers did not seem to vary with residency numbers. Anecdotally, this could be explained by the fact that in vaginal cases, the operative field is generally shared by the attending and trainees and in difficult cases, it is likely easier for a more senior physician to step in during challenging portions of the surgery. This is in contrast to laparoscopic cases during which the trainees and attending surgeons are physically separated on either side of the patient, making it more difficult for a more senior physician to “take over.” Although the decline in average VH per resident was 4.6, the absolute number of VH residents were graduating with after the fellowship started is concerning. Prior research has indicated that 21 to 27 VH are needed to be performed in order for competence to be achieved although the ACGME minimum has been set at 15.12 Ideally, the number of cases would certainly dictate that this number should be higher to allow for a buffer for variance in volume from year to year. Training programs need to avoid a situation where residents may be graduating from ACGME-accredited residencies without the requisite comfort level to perform a procedure that in essence defines gynecologic surgery. With such low numbers, every VH that is performed by a trainee matters in the course of their training in order for graduating residents to deliver effective patient care. Similarly, if a resident never develops the requisite comfort level with these procedures during training, it is logical to assume they will not perform these procedures as independent physicians, which can have a far reaching effect on overall health care quality and costs as VH and LH are 2 extremely effective and minimally invasive approaches. We also posit that VH enjoys status as one of the few surgical procedures that residents never
Journal of Surgical Education Volume ]/Number ] ] 2016
3
FIGURE 3. Bar graph comparing laparoscopic hysterectomy procedures logged by institutional residents, nationally, and by division proxy.
The mean number of LHs logged as surgeon by a graduating resident before the start of the fellowship was 30.3 (⫾10.8). The mean number of LHs after the start of the fellowship was 33.5 (⫾6.0). The difference between the groups was not statistically significant (Table). Nationally, LH shows a clear year-to-year increase based on the ACGME data (Fig. 3). Our division proxy LH numbers did show year-to-year variation but were generally higher after the fellowship was started, although institutionally, LH numbers were generally higher after the fellowship was initiated (Fig. 2).
DISCUSSION
complain about performing too often during their training based on our observations. The effect of resident surgical experience can also have a rippling effect specifically if newly entering fellows are not comfortable with basic procedures such as VH or LH. For example, at our institution, fellows who have entered the FPMRS fellowship had previously graduated with anywhere from 28 to 38 VH performed as surgeon during their residency training. This allows for the fellow to act as a supervisor to the resident, which enhances the education of both trainees. In this way, the fellow can start to refine their teaching ability, which is an important skill we feel they should develop, whereas the resident still gets the benefit of performing the actual VH. If this were not the case, then this type of supervision would not be possible and fellows would have to spend more time mastering these basic skills that would in turn detract from the resident surgical experience. This would exacerbate the training issue at hand and limit the surgical training of residents, many of whom go onto general practice where this knowledge of VH or LH is vital. Our study does have several limitations though; the first is that this study is conducted at a single institution that is similar to prior studies. It is difficult to infer that the findings noted at our institution would be present at other residency programs with FPMRS fellowship that is evident when comparing our data with the only other published data set.8 Based on the conflicting data, it is prudent to assess this issue on a larger scale. In addition, this retrospective review does not attempt to show or prove causation as it is well outside of the scope of the data presented. We do feel that this trend deserves further examination in a quantitative and qualitative manner. Finally, there will be some inherent issues with the self-reported data in the ACGME case log system. Although this is a legitimate concern, this type of data is used by the ACGME for the purposes of residency review on a regular basis. As this study provides a starting point on the potential effect of a FPMRS fellowship on residency training, there are several additional steps we feel must be undertaken. A multicenter review of programs with ACGME-approved FPMRS fellowships would be a reasonable next step to see if the tendencies we have noticed are occurring nationwide. In addition, a qualitative assessment of resident perception of the effect of FPMRS fellows should be undertaken to see if they are less likely to log cases, specifically VH, if a fellow is also scrubbed in on a case. This information would be beneficial in assisting attending surgeons in how to better delineate expectations and even formally designate trainee roles during surgical cases.
CONCLUSION After the initiation of a FPMRS fellowship, resident surgical volume for VH was significantly lower, whereas LH surgical volume was nonsignificantly increased. Additional research is 4
needed to determine whether this is a widespread trend and to assess the true effect of fellowships on resident training.
REFERENCES 1. Ciotti M. Minimum Thresholds for Obstetric and
Gynecology Procedures. Available at: 〈https://www. acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRe sources/220_Ob_Gyn%20Minimum_Numbers_An nouncment.pdf〉; 2012 Accessed 01.08.14.
2. Selvasekar CR, Holubar SD, Pendlimari R, et al.
Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience. J Surg Res. 2012;174(1):e17-e23. 3. Fronza JS, Prystowsky JP, DaRosa D, Fryer JP.
Surgical residents’ perception of competence and relevance of the clinical curriculum to future practice. J Surg Educ. 2012;69(6):792-797. 4. Perler BA, Zuidema GD. The effect of vascular
fellowships on general surgical residency training. Ann Surg. 1984;200(3):247-254. 5. Snyder RA, Phillips SE, Terhune KP. Impact of
implementation of a pediatric surgery fellowship on general surgery resident operative volume. J Surg Educ. 2012;69(6):753-758. 6. Zyromski NJ, Torbeck L, Canal DF, Lillemoe KD,
Pitt HA. Incorporating an HPB fellowship does not diminish surgical residents’ HPB experience in a highvolume training centre. HPB (Oxford). 2010;12(2): 123-128. 7. Kothari SN, Cogbill TH, O’Heron CT, Mathiason MA.
Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience. J Surg Educ. 2008;65(6): 393-396. 8. Danford JM, White NC, New M, Fletcher S, Blume JD,
Ward RM. The fellowship effect: how the establishment of a fellowship in female pelvic medicine and reconstructive surgery affected resident vaginal hysterectomy training. Am J Obstet Gynecol. 2014;211(5):559 e1–e6. 9. Cohn DE, Roney JD, O’Malley DM, Valmadre S.
Residents’ perspectives on surgical training and the resident-fellow relationship: comparing residency programs with and without gynecological oncology fellowships. Int J Gynecol Cancer. 2008;18(1):199-204. 10. Einarsson JI, Timmins A, Young AE, Zurawin RK.
Does a minimally invasive surgery fellowship impact surgical experience among gynecology residents? J Am Assoc Gynecol Laparosc. 2004;11(4):464-466. Journal of Surgical Education Volume ]/Number ] ] 2016
11. Cundiff GW, Handa V, Bienstock J. Longitudinal
12. Jelovsek JE, Walters MD, Korn A, et al. Establishing
impact of a female pelvic medicine and reconstructive pelvic surgery fellowship on resident education. Am J Obstet Gynecol. 2002;187(6):1487-1492.
cutoff scores on assessments of surgical skills to determine surgical competence. Am J Obstet Gynecol. 2010;203(1):81 e1–e6.
Journal of Surgical Education Volume ]/Number ] ] 2016
5
Assessing Resident Surgical Volume Before and After Initiation of a Female Pelvic Medicine and Reconstructive Surgery Fellowship$ Zaid Chaudhry, MD,* and Christopher M. Tarnay, MD*,† *
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; and †Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
OBJECTIVES: The effect of fellowship programs on resident training for gynecologic surgery volume has not been clearly defined. The purpose of our study is to assess resident surgical volume for laparoscopic and vaginal hysterectomy before and after initiation of a female pelvic medicine and reconstructive surgery (FPMRS) fellowship.
in the 3 years after the start of the FPMRS fellowship finished with 3.2 more laparoscopic hysterectomies compared with residents who graduated before the fellowship although this was not significant (p ¼ 0.25). CONCLUSIONS: Resident surgical volume was signifi-
for Graduate Medical Education Resident Case Logs of obstetrics and gynecology residents who graduated in the 3 years before and after initiation of a FPMRS fellowship was performed. Mean values of vaginal and laparoscopic hysterectomies were compared using two-tailed t-tests with statistical significance set at p o 0.05.
cantly decreased for vaginal hysterectomy after the initiation of a FPMRS fellowship, whereas laparoscopic hysterectomy volume was not significantly changed. Longer follow-up and a national assessment are necessary to determine the broader effect of fellowship training on resident surgical experience. C 2016 Association of Program ( J Surg Ed ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: Obstetrics and gynecology resident case logs at
KEY WORDS: vaginal hysterectomy, laparoscopic hyster-
the Ronald Reagan University of California Los Angeles (UCLA) Medical Center were assessed. The UCLA Medical Center, located in Los Angeles, CA, is a tertiary referral center with a graduating class of 7 obstetrics and gynecology residents yearly.
ectomy, resident surgical experience, surgical training COMPETENCIES: Patient Care, Medical Knowledge, Systems-Based Practice
PARTICIPANTS: Obstetrics and gynecology residents who graduated from residency 3 years before and after imitation of a FPMRS fellowship were included. In the 3 years before the start of the fellowship, 20 residents graduated, whereas 21 residents graduated after the start of the fellowship.
INTRODUCTION
DESIGN: A retrospective review of Accreditation Council
RESULTS: Residents who graduated in the 3 years after the start of the FPMRS fellowship, finished with 4.6 less vaginal hysterectomies compared with residents who graduated before the fellowship (p ¼ 0.022). Residents who graduated ☆ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Correspondence: Inquiries to Zaid Chaudhry, MD, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue 27-139 CHS, Los Angeles, CA 90095-1740; fax: (310) 206-7168; e-mail: [email protected], [email protected]
Surgical volume is an imperfect but commonly used tool in assessing trainee competency.1-3 This information is recorded by the Accreditation Council for Graduate Medical Education (ACGME) using the Resident Case Log System. Residents are expected to meet minimum procedural numbers and these data are used by the ACGME to determine if residency programs are providing trainees adequate exposure to various procedures. Although residents record cases as both surgeon (performing 450% of the procedure) and assistant on their logs, cases logged as surgeon are primarily used for the purposes of credentialing and assessing experience.
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.11.007
1
TABLE. Comparison of Mean Hysterectomies Performed as Surgeon Before and After Initiation of Fellowship
Number of residents VH (p ¼ 0.022) LH (p ¼ 0.25)
Before Fellowship
After Fellowship
20 28.4 30.3
21 23.8 33.5
The effect of fellowship training on resident experience has been varied in the general surgery and gynecology literature depending on the fellowship in question.4-7 Female pelvic medicine and reconstructive surgery (FPMRS) is a recently accredited subspecialty and the objective effect that fellow training has on the resident surgical experience is limited in the current literature.8 The purpose of our study is to assess resident surgical volume as primary surgeon of vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) before and after initiation of a FPMRS fellowship at a single institution.
MATERIALS AND METHODS A retrospective review of the ACGME Resident Case Log System of graduated obstetrics and gynecology (OB/GYN) residents at the UCLA David Geffen School of Medicine, Department of Obstetrics and Gynecology was performed. Residents who had graduated within their specific academic cycle were included in the study. Residents who had taken extended leaves and graduated off track were excluded. The time frame spanned the 3 graduating classes of residents before initiation of the fellowship and the 3 years after. At our institution, the FPMRS fellowship was jointly ACGME certified under the departments of Urology and OB/GYN in 2011 and the first fellow started in July of that year. Therefore, we specifically compared the graduating resident case log data for the academic years 2008 to 2011 and then from 2011 to 2014. The ACGME collects case information on 10 gynecologic procedures and provides additional information based on the data of all ACGME-approved residencies including mean/median values along with percentiles. For our purposes, we collected data on VH and LH numbers that could include total or laparoscopic-assisted VH along with any cases of robotic assistance. For the academic year 2013 to 2014, laparoscopic-assisted VH was categorized as a VH per ACGME recommendations. We specifically chose these 2 modes of hysterectomy because they are commonly performed by specialists and generalists alike and are considered procedures that any currently graduating gynecologist should be comfortable performing. The number of VH and LH performed by the primary FPMRS specialist at our institution was also recorded during this period as a proxy of division volume in addition to overall institutional volume. 2
FIGURE 1. Bar graph comparing mean vaginal hysterectomy procedures logged by institutional residents, nationally, and by division proxy.
National ACGME data were also reviewed during this period. Statistical analysis was performed using descriptive statistics and unpaired t-tests with an α ¼ 0.05. Data analysis was performed using SPSS. The UCLA Institutional Review Board deemed this study exempt from review.
RESULTS A total of 20 residents graduated in the 2008 to 2011 period before the start of the fellowship, whereas 21 residents graduated in the 2011 to 2014 time frame. The mean number of VH performed by this group before fellowship initiation was 28.4 (⫾7.1). The mean number of VH performed by this group after the fellowship was 23.8 (⫾4.8). The difference between these 2 groups was significant (Table). During this 6-year period, ACGME national data show a relatively stable number of vaginal hysterectomies being logged by graduating residents except for the 2013 to 2014 year where there was a large spike (Fig. 1). Our division proxy numbers were also generally increasing after initiation of the fellowship, whereas institutionally there was no specific trend in VH (Fig. 2).
FIGURE 2. Bar graph tracking vaginal and laparoscopic hysterectomy rates over a 6-year period. LH, laparoscopic hysterectomy; VH, vaginal hysterectomy. Journal of Surgical Education Volume ]/Number ] ] 2016
With the movement in medical and surgical training toward subspecialization, the trend toward fellowship training has increased. This has led to a unique training environment in many institutions where the needs of both fellows and residents must be balanced to train competent physicians. This “balancing act” has been assessed in the general surgery literature on the potential effect of specific fellowships on resident experience with somewhat conflicting results. For example, certain fellowships such as pediatric surgery appear to reduce resident surgical volume, whereas hepatopancreaticobiliary and minimally invasive surgery fellowships appeared to do the opposite.5,6 Even if surgical volume has been affected, the overall consensus of general surgery program directors has been positive on the overall knowledge/teaching that occurs when a fellowship is present during a resident’s training.4 This attempt at characterizing fellowship training effect on resident training has been lacking in the gynecologic literature. Prior work in the field of gynecologic oncology surveyed residents to assess their interaction with fellows and most residents did feel some sense of competition with fellows on surgical cases although they overall had a positive view of fellows in their training.9 Similarly, a single institutional survey of residents found that they felt that a
minimally invasive gynecology fellowship did not detract from their training.10 In the field of FPMRS, there is a dearth of objective and subjective data. In 1 study, residents initially felt a FPMRS fellowship negatively affected their education, whereas later reporting a positive effect over the course of 3 years. The study was limited by a mean response rate of 32% at a single institution.11 A retrospective review of resident participation in hysterectomy procedures out of single academic OB/GYN residency indicated no difference in resident involvement on cases before and after the start of their ACGME-accredited fellowship.8 A limitation of this study is its single center nature that does not allow for generalizations to occur as evidenced by our analysis showing conflicting results. We feel this study provides a reasonable starting point for the field of FPMRS to better understand the potential effect that fellowship training may have on the resident experience. We intentionally chose VH and LH as they are foundational procedures for any physician who practices gynecology and are often performed during pelvic reconstructive cases. There may be an apparent trend in reduction in resident surgical experience for VH based on our institutional data but it is difficult to discern an exact reason for this as our division proxy and institutional numbers did not seem to vary with residency numbers. Anecdotally, this could be explained by the fact that in vaginal cases, the operative field is generally shared by the attending and trainees and in difficult cases, it is likely easier for a more senior physician to step in during challenging portions of the surgery. This is in contrast to laparoscopic cases during which the trainees and attending surgeons are physically separated on either side of the patient, making it more difficult for a more senior physician to “take over.” Although the decline in average VH per resident was 4.6, the absolute number of VH residents were graduating with after the fellowship started is concerning. Prior research has indicated that 21 to 27 VH are needed to be performed in order for competence to be achieved although the ACGME minimum has been set at 15.12 Ideally, the number of cases would certainly dictate that this number should be higher to allow for a buffer for variance in volume from year to year. Training programs need to avoid a situation where residents may be graduating from ACGME-accredited residencies without the requisite comfort level to perform a procedure that in essence defines gynecologic surgery. With such low numbers, every VH that is performed by a trainee matters in the course of their training in order for graduating residents to deliver effective patient care. Similarly, if a resident never develops the requisite comfort level with these procedures during training, it is logical to assume they will not perform these procedures as independent physicians, which can have a far reaching effect on overall health care quality and costs as VH and LH are 2 extremely effective and minimally invasive approaches. We also posit that VH enjoys status as one of the few surgical procedures that residents never
Journal of Surgical Education Volume ]/Number ] ] 2016
3
FIGURE 3. Bar graph comparing laparoscopic hysterectomy procedures logged by institutional residents, nationally, and by division proxy.
The mean number of LHs logged as surgeon by a graduating resident before the start of the fellowship was 30.3 (⫾10.8). The mean number of LHs after the start of the fellowship was 33.5 (⫾6.0). The difference between the groups was not statistically significant (Table). Nationally, LH shows a clear year-to-year increase based on the ACGME data (Fig. 3). Our division proxy LH numbers did show year-to-year variation but were generally higher after the fellowship was started, although institutionally, LH numbers were generally higher after the fellowship was initiated (Fig. 2).
DISCUSSION
complain about performing too often during their training based on our observations. The effect of resident surgical experience can also have a rippling effect specifically if newly entering fellows are not comfortable with basic procedures such as VH or LH. For example, at our institution, fellows who have entered the FPMRS fellowship had previously graduated with anywhere from 28 to 38 VH performed as surgeon during their residency training. This allows for the fellow to act as a supervisor to the resident, which enhances the education of both trainees. In this way, the fellow can start to refine their teaching ability, which is an important skill we feel they should develop, whereas the resident still gets the benefit of performing the actual VH. If this were not the case, then this type of supervision would not be possible and fellows would have to spend more time mastering these basic skills that would in turn detract from the resident surgical experience. This would exacerbate the training issue at hand and limit the surgical training of residents, many of whom go onto general practice where this knowledge of VH or LH is vital. Our study does have several limitations though; the first is that this study is conducted at a single institution that is similar to prior studies. It is difficult to infer that the findings noted at our institution would be present at other residency programs with FPMRS fellowship that is evident when comparing our data with the only other published data set.8 Based on the conflicting data, it is prudent to assess this issue on a larger scale. In addition, this retrospective review does not attempt to show or prove causation as it is well outside of the scope of the data presented. We do feel that this trend deserves further examination in a quantitative and qualitative manner. Finally, there will be some inherent issues with the self-reported data in the ACGME case log system. Although this is a legitimate concern, this type of data is used by the ACGME for the purposes of residency review on a regular basis. As this study provides a starting point on the potential effect of a FPMRS fellowship on residency training, there are several additional steps we feel must be undertaken. A multicenter review of programs with ACGME-approved FPMRS fellowships would be a reasonable next step to see if the tendencies we have noticed are occurring nationwide. In addition, a qualitative assessment of resident perception of the effect of FPMRS fellows should be undertaken to see if they are less likely to log cases, specifically VH, if a fellow is also scrubbed in on a case. This information would be beneficial in assisting attending surgeons in how to better delineate expectations and even formally designate trainee roles during surgical cases.
CONCLUSION After the initiation of a FPMRS fellowship, resident surgical volume for VH was significantly lower, whereas LH surgical volume was nonsignificantly increased. Additional research is 4
needed to determine whether this is a widespread trend and to assess the true effect of fellowships on resident training.
REFERENCES 1. Ciotti M. Minimum Thresholds for Obstetric and
Gynecology Procedures. Available at: 〈https://www. acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRe sources/220_Ob_Gyn%20Minimum_Numbers_An nouncment.pdf〉; 2012 Accessed 01.08.14.
2. Selvasekar CR, Holubar SD, Pendlimari R, et al.
Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience. J Surg Res. 2012;174(1):e17-e23. 3. Fronza JS, Prystowsky JP, DaRosa D, Fryer JP.
Surgical residents’ perception of competence and relevance of the clinical curriculum to future practice. J Surg Educ. 2012;69(6):792-797. 4. Perler BA, Zuidema GD. The effect of vascular
fellowships on general surgical residency training. Ann Surg. 1984;200(3):247-254. 5. Snyder RA, Phillips SE, Terhune KP. Impact of
implementation of a pediatric surgery fellowship on general surgery resident operative volume. J Surg Educ. 2012;69(6):753-758. 6. Zyromski NJ, Torbeck L, Canal DF, Lillemoe KD,
Pitt HA. Incorporating an HPB fellowship does not diminish surgical residents’ HPB experience in a highvolume training centre. HPB (Oxford). 2010;12(2): 123-128. 7. Kothari SN, Cogbill TH, O’Heron CT, Mathiason MA.
Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience. J Surg Educ. 2008;65(6): 393-396. 8. Danford JM, White NC, New M, Fletcher S, Blume JD,
Ward RM. The fellowship effect: how the establishment of a fellowship in female pelvic medicine and reconstructive surgery affected resident vaginal hysterectomy training. Am J Obstet Gynecol. 2014;211(5):559 e1–e6. 9. Cohn DE, Roney JD, O’Malley DM, Valmadre S.
Residents’ perspectives on surgical training and the resident-fellow relationship: comparing residency programs with and without gynecological oncology fellowships. Int J Gynecol Cancer. 2008;18(1):199-204. 10. Einarsson JI, Timmins A, Young AE, Zurawin RK.
Does a minimally invasive surgery fellowship impact surgical experience among gynecology residents? J Am Assoc Gynecol Laparosc. 2004;11(4):464-466. Journal of Surgical Education Volume ]/Number ] ] 2016
11. Cundiff GW, Handa V, Bienstock J. Longitudinal
12. Jelovsek JE, Walters MD, Korn A, et al. Establishing
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Journal of Surgical Education Volume ]/Number ] ] 2016
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