Changes in Training and Education

Changes in Training and Education HISTORICALLY urology training programs, like other surgical disciplines, followed the Halstedian apprenticeship model characterized by a progressive increase in responsibility during the duration of training. While this training model certainly has its merits and still clearly exists, educational programs must now be curriculum based and each must document that residents have become proficient in certain core competencies by the end of their training. As a result of the Accreditation Council for Graduate Medical Education Milestones Project, programs will soon be asked to judge whether residents meet certain competency based milestones during the course of their training, adding an additional layer of resident evaluation. There has been some discussion about a 2-tiered training system in which some residents would be trained to assume office based practices while others would be trained in preparation for primarily surgical practices. While this idea appears to have been put to rest in this country, it is well recognized that there are significant differences between the complex surgery focused experience of residents during training and the office based practices that a majority will assume after graduation. Resident work hours continue to become shorter and the majority of residency training programs have transitioned from a 6 to a 5-year training duration, presenting further challenges in the creation of the optimal residency experience. When the American Urological Association sanctioned a urological education strategic planning meeting in April 2006 to plot the future of urological education, it was recognized that a more flexible training experience was needed. Training flexibility allows program directors the opportunity to tailor residents’ experience, to shore up weaknesses in their training or better prepare them for the practice they will assume after the completion of training. This flexibility would also allow those residents interested in an academic career to begin their subspecialty focus before starting a fellowship. The Urology Residency Review Committee (RRC) has now established minimum surgical case requirements for residents and will no longer cite programs for unequal distribution of case mix between residents as long as the minimum 0022-5347/11/1864-1185/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION

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case numbers are achieved. These changes should allow programs to provide greater flexibility in training and give innovative program directors the opportunity to individualize the training experience if they so choose. The Northwestern University residency program was the first to explore a more flexible training curriculum and an update on the first 3 years of their experience with this training model is reported by Greiman et al in this issue of The Journal (page 1422). Their training curriculum, which was approved by the RRC in 2006, allows residents 8 months of elective rotations in postgraduate years 2 and 4 as well as a broader urology experience in the pre-urology years. The article highlights some of the challenges in the implementation of this kind of program, but shows convincingly that it has been well received by residents and faculty, and does not result in less surgical experience or lower in-service examination scores. Although new to urology, individualized residency programs with elective experiences are not uncommon in other specialties. The success of the Northwestern experience coupled with the changes in RRC requirements on case number and mix should prompt other programs to consider a more flexible training experience. Medical students are our future residents who are often inspired to pursue careers in urology after initial exposure to our specialty during a medical school clerkship. Unfortunately there has been a well documented decline in exposure to urology during medical school. A survey of resident applicants revealed that the percentage of medical schools with a required clinical urology rotation decreased from 99% in 1956 to only 17% in 2004.1 Another survey of urology residency program directors in 2007 found that almost a third of medical schools had no urology lectures in the preclinical years and only 20% had a required urology rotation.2 These numbers are concerning, especially given the graying of the United States population. Graduating medical students entering primary care practices will be asked to serve an increasing population of elderly patients who will need urological care. While the impact of this trend has yet to be determined, there is a clear need for Vol. 186, 1185-1186, October 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.07.045

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CHANGES IN TRAINING AND EDUCATION

increased exposure to urology in medical school and a structured curriculum in urology is essential to ensure a consistent educational experience among students. Fortunately a national medical student core curriculum was recently developed, and is currently available to medical students and program directors via the American Urological Association web site. This curriculum is based on core learning objectives identified after a national survey of graduating medical students and residency directors of primary care disciplines.3 The results of this survey helped to define the 10 most important urological topics medical students should know. Also in this issue Slaughenhoupt et al (page 1417) report their experience with the implementation of a new curriculum for their 2-week urology clerkship based on these 10 core learning objectives. The authors hypothesized that an improved curriculum with clearly stated core learning objectives would increase student learning, enhance the fund of knowledge and make the clerkship more satisfying

to students. While improved student satisfaction was not proven, there was evidence that learning improved in this more structured educational format. Other medical student curricula based on core learning objectives have also been implemented successfully.4 The authors of both of these studies are to be congratulated for promoting innovative educational changes in their respective programs. In most cases these kinds of changes are successful because of the dedication of individual program directors or medical school faculty, as too often mandates for change in training and education are unfunded. Yet it is clear that to be successful educators of the next generation of urologists and medical students, our training techniques and teaching strategies must evolve, and these changes should be welcomed. Christopher L. Amling Division of Urology Oregon Health and Science University Portland, Oregon

REFERENCES 1. Kerfoot BP, Masser BA and DeWolf WC: The continued decline of formal urological education of medical students in the United States: does it matter? J Urol 2006; 175: 2243.

2. Loughlin KR: The current status of medical student education in the United States. J Urol 2008; 179: 1087. 3. Kerfoot BP and Turek PJ: What every graduating medical student should know about urology: the stakeholder viewpoint. Urology 2008; 71: 549.

4. Rapp DE, Gong EM, Reynolds WS et al: Assessment of the core learning objectives curriculum for the urology clerkship. J Urol 2007; 178: 2114.