- Email: [email protected]
Longitudinal impact of a female pelvic medicine and reconstructive pelvic surgery fellowship on resident education
Longitudinal impact of a female pelvic medicine and reconstructive pelvic surgery fellowship on resident education Geoffrey W. Cundiff, MD, Victoria Handa, MD, and Jessica Bienstock, MD Baltimore, Md OBJECTIVE: The purpose of this study was to assess residents’ perceptions of the impact of a new fellowship on their educational experience. STUDY DESIGN: A voluntary questionnaire was administered to residents in obstetrics and gynecology that assessed how they felt fellowships in female pelvic medicine and reconstructive surgery had an impact on their education. The initial questionnaire was given within 1 month of the beginning a new 3-year fellowship and then annually for 3 years. RESULTS: The mean response rate was 32%. In the initial questionnaire, the fellowships were perceived as detracting from the educational experience. Thereafter, there was a positive increase in the perceived impact of fellowships that was sustained for 3 years. Residents also reported higher self-assessments of the quality of their education during this period. Residents’ surgical volume did not change with the introduction of the fellowship. CONCLUSION: Although at the outset residents anticipated the addition of a fellowship to have a negative impact on their educational experience, they consistently reported a positive impact after the fellowship was instituted. (Am J Obstet Gynecol 2002;187:1487-93.)
Key words: Fellowship in female pelvic medicine and reconstructive surgery, residency education, obstetrics and gynecology
Female pelvic floor dysfunction is a term that reflects a collection of disorders that include urinary incontinence, lower urinary tract symptoms, fecal incontinence, pelvic organ prolapse, defecatory dysfunction, and sexual dysfunction. These are common problems with a significant burden for affected women.1-3 These maladies are related causally,4 yet historically different medical specialties have treated different aspects of pelvic floor dysfunction (including gynecology, urology, colorectal surgery, and gastroenterology). Estimates suggest that the population of women with pelvic floor dysfunction is increasing and that there will be a large population of underserved patients in the near future.5 Recognizing the disorganized care of pelvic floor dysfunction and the future need for additional physicians who are well trained in female pelvic floor dysfunction, the American Board of Obstetrics and Gynecology combined efforts with the American Board of Urology to create the new subspecialty of female pelvic medicine and reconstruc-
From the Johns Hopkins Medical Institutes. Presented at the Twenty-eighth Annual Meeting of the Society of Gynecologic Surgeons, Dallas, Tex, March 4-6, 2002. Reprint requests: Geoffrey Cundiff, MD, Johns Hopkins Medicine, Department of Gynecology and Obstetrics, 600 N Wolfe St/Harvey 319, Baltimore, MD 21287. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002 $35.00 + 0 6/6/129155 doi:10.1067/mob.2002.129155
tive pelvic surgery. This subspecialty follows the approach used previously in creating the subspecialties of maternal fetal medicine, reproductive endocrinology, and gynecologic oncology. Inherent to this approach is the certification of fellowship programs to provide training to future members of the subspecialty. Learning objectives were established, and the American Board of Obstetrics and Gynecology began accrediting training programs in 1996. The learning objectives are extensive and include the diagnosis and treatment of urinary incontinence, irritative voiding, voiding dysfunction, fecal incontinence, defecatory dysfunction, and pelvic organ prolapse.6 Mandated diagnostic techniques include urodynamics, endoscopy, anorectal physiologic testing, imaging, and neurophysiologic testing techniques. Fellows are to receive training in nonsurgical treatment and surgical treatment, which should include both abdominal and vaginal surgical approaches. Although the specialty of female pelvic medicine and reconstructive pelvic surgery promises to improve the care of women with pelvic floor dysfunction, many educators are concerned about the impact of the new fellowship programs on resident education. Recent innovations in surgical techniques have drastically increased the repertoire of gynecologic surgery to be mastered, making learning the full breadth of gynecologic surgery during a 4-year residency challenging. At the same time, shifting indications for gynecologic surgery and the increasing 1487
1488 Cundiff, Handa, and Bienstock
Table I. Areas of knowledge in female pelvic medicine and reconstructive surgery included in self assessment questionnaire Urinary incontinence Genuine stress incontinence Overactive bladder disorders Intrinsic sphincteric deficiency Urinary tract fistula Irritative voiding symptoms Urinary tract infections Urethral diverticula Urethral syndrome Interstitial cystitis Urinary retention Urethral obstruction Neurogenic bladder Detrusor sphincter dyssynergia Fecal incontinence External anal sphincter defect Internal anal sphincter defect Neurogenic anal incontinence Defecatory dysfunction Irritable bowel syndrome Colonic inertia Anismus Outlet obstruction Pelvic organ prolapse Cystocele Rectocele Enterocele Vault prolapse Perineal descent Rectal prolapse Residents assessed the quality of their diagnostic and therapeutic education during the past year for each subheading. Scores were pooled and the analysis performed for the bolded headings.
primary care curriculum requirements have decreased the volume of surgical experience in many residency programs. Under these circumstances, concerned program directors view fellows in a surgical subspecialty as competitors for a dwindling number of surgical cases. Contrary to this sentiment, we hypothesized that the introduction of a fellowship in female pelvic medicine and reconstructive pelvic surgery would actually enhance resident education rather than diminish it. This belief was based on several assumptions. First, the fellowship would actually increase overall clinical and surgical volume. Second, a fellowship would enhance education, by increasing the number of teaching faculty, specifically with fellows who are not distracted by heavy clinical and administrative responsibilities. Third, fellows would further the research endeavors of the department, which would translate to a richer educational environment. We designed and undertook this project to investigate this hypothesis. Material and methods The Department of Gynecology and Obstetrics at the Johns Hopkins Medical Institutions started a fellowship in
December 2002 Am J Obstet Gynecol
female pelvic medicine and reconstructive pelvic surgery in July 1998. This is a 3-year program that follows the guidelines of the American Board of Obstetrics and Gynecology. Two fellows began the program in July 1998, and an additional fellow was added for each of the subsequent years, 1999 and 2000. The fellows’ clinical responsibilities for the first and third years are fulfilled at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. During the second year, they rotate off service for a total of 4 months on urology, colorectal surgery, and plastic surgery. They also spend 4 months on the female pelvic medicine and reconstructive surgery service at Greater Baltimore Medical Center (GBMC). The GBMC also has a fellowship in female pelvic medicine and reconstructive surgery with which our program collaborates. When fellows from Johns Hopkins rotate through GBMC, their GBMC counterparts rotate through Johns Hopkins so that the residents interact with four Johns Hopkins fellows and five GBMC fellows during the course of this study. Although fellows have 20% dedicated research time and requirements for research productivity, the program has a strong clinical curriculum. Fellows operate as junior attending physicians and are expected to participate in the educational responsibilities, that include attending physician of the week and gynecology call. The fellows’ weekly schedule includes supervised sessions 1 day per week in the clinic, 1 day a week in diagnostic testing, and 2 days a week in surgery. Residents also attend these activities. Johns Hopkins and GBMC have a combined residency program in obstetrics and gynecology. The residents’ primary exposure to female pelvic medicine and reconstructive pelvic surgery is during the fourth year, at which time they have two 4-week rotations on the female pelvic medicine and reconstructive surgery services, one rotation at Johns Hopkins Hospital, and one rotation at GBMC. During the Johns Hopkins Hospital rotation, they attend all urogynecologic operations and attend the clinic and diagnostic testing sessions, if surgical cases are not scheduled. Fellows are present for and actively participate in teaching in all of these venues. Third-year residents run the gynecology service at Johns Hopkins Bayview Medical Center, where they attend the urogynecology operations, operating with the attending physician and fellow. Fellows also interact with residents of all levels as the instructor of the Gynecologic Endoscopy Education Laboratory, a dry laboratory that is dedicated to teaching laparoscopy, hysteroscopy, and cystoscopy. This weekly 3hour laborotory is taught by the first-year fellow and is attended by residents on the Johns Hopkins Bayview Medical Center gynecology service on a voluntary basis. Data for this investigation include surgical productivity that are based on information that is collected from S forms and data that are collected by a voluntary survey that is completed by the residents. The survey used a 100mm visual analog scale in which 100 equals excellent, 50
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Fig 1. Mean scores from visual analog scales for fellowship impact by year of survey. Asterisk, P ≤ .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
equals average, and 0 equals poor. The survey had two sections: one section asked residents to describe their educational experience in specific aspects of six broad areas of female pelvic medicine and reconstructive surgery during the past year (Table I). They were asked to differentiate between diagnostic and therapeutic aspects of their education, with separate visual analog scales for each in all categories listed in Table I. The specific wording was: The following questions are aimed at documenting your own assessment of the quality of education that you have received in Urogynecology during the past year. The questions refer to broad categories in Urogynecology. Each question has a visual analog scale for both diagnosis and management. Please answer by placing a single vertical line through the visual analog scale at the location that describes your experience. Management includes both surgical and non-surgical management. If you are not familiar with the sub-category, place your mark at the poor extreme. For analysis, the data were pooled within each of the six main categories and are listed as diagnostic and therapeutic means. The second section asked them to assess how they felt that fellowships in female pelvic medicine and reconstructive surgery had an impact on their education in six specific areas: general gynecology, gynecologic surgery, laparoscopic surgery, urogynecology, urogynecologic surgery, and overall educational experience. The precise wording was “How has the presence of the Urogynecol-
ogy Fellows impacted your knowledge of . . .” There was also space for residents to provide additional comments. The survey was given to all 28 residents in obstetrics and gynecology during the first month of the beginning of the fellowship in female pelvic medicine and reconstructive surgery and then annually for 3 years. The survey was completed on a voluntary basis, but residents were encouraged to use the survey as an opportunity to express their opinions about how the fellowship had an impact on their education. In conformity with institutional practice and the recommendations of the Department of Health and Human Services, which exempts research on educational practices from institutional review, this study was not submitted for review by the institutional review board. Statistical analysis of changes in the fellowship impact scores between different years was conducted with the Mann-Whitney U test for nonparametric comparison of unpaired groups and compared the initial (before) year to pooled data for years 2 to 4 (after) years. Regression analysis to examine linear and logarithmic relationships was used to compare diagnostic and therapeutic scores as a function of the year of the test. The same statistics were used to compare the diagnostic and therapeutic scores by year. Changes in surgical productivity were evaluated with regression analysis. Results The mean response rate to the survey was 32%, with 36% on the initial survey, 32% at the 1-year survey, 22% at
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December 2002 Am J Obstet Gynecol
Fig 2. Mean scores from visual analog scales for diagnostic knowledge by year of survey. Asterisk, P < .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
Table II. Resident surgical experience, expressed as a mean of individual annual cases Surgery type Vaginal hysterectomy (No.) Urinary incontinence (No.)
1998
1999
2001
2002
P value
27 23
20 17
17 20
24 20
.647 .683
the 2-year survey, and 39% on the final survey. In the initial questionnaire, the fellowships were perceived as detracting from the educational experience because mean scores for all categories were <50 mm (average). Thereafter, there was a positive increase in the perceived impact of fellowships in all educational categories that was sustained at 2 and 3 years (Fig 1). The change in scores between the initial survey and the subsequent surveys was statistically significant for all categories except urogynecologic surgery. Scores for years 1, 2, and 3 were not significantly different from one another. The residents’ self-assessment of their diagnostic knowledge was below average (50 mm) in all categories on the initial survey (Fig 2). Scores on subsequent surveys were above average for urinary incontinence, lower urinary tract symptoms, voiding dysfunction, and pelvic organ prolapse, although the change in pelvic organ prolapse was not statistically significant. There was a statistically significant rise in scores for fecal incontinence; scores remained below average (50 mm) for years 1 and 3. Defecatory dysfunction scores increased, but not statistically, and remained below average (50 mm), except in year 2. The self-assessment scores for therapeutic knowledge on the initial survey were also all below average (50 mm, Fig 3). There was a statistically significant rise in scores for all categories for years 1, 2, and 3. Although scores fell in year 3 in all categories, this was not a statistically signif-
icant change. Scores for fecal incontinence and defecatory dysfunction rose but remained below average (50 mm) in all years. There was no statistically significant change in the mean number of vaginal hysterectomies, surgeries for urinary incontinence, or laparoscopy after the introduction of the fellowship (Table II). Comment A negative impact of fellowship programs on residency education has been a concern in obstetrics and gynecology since the creation of the original subspecialties of maternal fetal medicine, reproductive endocrinology and infertility, and gynecologic oncology. Several studies that were performed in the mid 1980s addressed this concern. The results of a postal questionnaire that was sent to leaders in obstetrics and gynecology were reported in 1988.7 This survey was sent to department chair persons, residency directors at nonuniversity residency programs, and members of the American Gynecologic and Obstetrics Society. There was near-unanimous consensus (90%) that the development of subspecialties had helped in the development of the specialty of obstetrics and gynecology. Most respondents also agreed that the development of subspecialties enhanced the education of medical students (76%) and residents (86%). The survey identified “reproductive urology” as the preferred area for development of a future subspecialty.
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Fig 3. Mean scores from visual analog scales for therapeutic knowledge by year of survey. Asterisk, P < .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
A similar postal survey that was sent to administrative chief residents revealed that, overall, subspecialty fellowships were viewed as an improvement in the quality of training, although this was dependent on the degree to which fellows functioned as junior faculty who were involved in teaching.8 Moreover, competition for surgical cases, especially difficult or nonroutine cases, and the degree of surgical priority that were afforded to fellows over residents were identified as detractors from the residentfellow training relationship. These potential detractors varied by subspecialty and the particular content areas of the fellowship program. A direct comparison of the surveys of department chair persons and residency program directors to administrative chief residents at the same institution revealed that both groups viewed subspecialty fellowships programs as beneficial to residency training, although the residents’ views were less favorable.9 Moreover, directors underestimated the degree of regret expressed by residents at the loss of surgical experience, particularly in laser surgery, infertility surgery, and radical pelvic surgery. Additionally, within a given program, the residents’ views and program directors’ views were often contradictory and unrelated. Our study suggests that residents view a fellowship in female pelvic medicine and reconstructive surgery similarly to previous subspecialty fellowships. Initially, there was a perception that the introduction of the fellowship would have a negative impact on residency training. Instead, residents reported that the fellowships had a beneficial effect in all areas except urogynecologic surgery, for which the increase in scores was not statistically significant. This enhancement in education was also supported by increased self-assessment scores in multiple aspects of
pelvic floor dysfunction knowledge, and importantly, the improvements were sustained over time. Although mean surgical volumes for residents did not change, loss of surgical experience remains concerning to residents. This is suggested by the smaller rise in the urogynecologic surgery scores but is also supported by specific comments on the survey by the residents. Previous studies have indicated that residents are less concerned about losing surgical experience to fellows at institutions that grant fellows junior faculty status and emphasize research over clinical duties.10 These are principles that we have invoked in our fellowship program, and this may enhance resident acceptance and account for the noted benefits to resident education. We view fellowships as training programs for academic physicians and consider one of our responsibilities to be teaching fellows how to be teachers. Fellows are therefore encouraged to take the educators’ role in all interactions with residents, including in the operating room. This helps to prevent conflict between fellows and residents by defining complimentary roles. We feel that this approach is justified by the study. The residents’ self-assessment of their knowledge of female pelvic medicine and reconstructive surgery helped to support the beneficial impact of the fellowship on resident education in this area. It also identified a perception among residents that they were inadequately trained in female pelvic medicine and reconstructive surgery at the outset of the study. Although scores for many areas improved, the self-assessed knowledge of defecatory dysfunction and fecal incontinence remained below average (50 mm), even after 3 years. This information has provided the basis for programmatic changes and suggests
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December 2002 Am J Obstet Gynecol
that this type of survey may have a role in the assessment of residency program weaknesses. REFERENCES
1. Abrams P, Kelleher CJ, Kerr LA, Rogers RD. Overactive bladder significantly affects quality of life. Am J Manage Care 2000; 6(Suppl):S580-90. 2. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a thirty-year retrospective cohort study. Obstet Gynecol 1997;89:896-901. 3. Ellerkmann RM, Cundiff GW, Bent AE, Nihira MA, Melnick C. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332-8. 4. Bump RC, Norton P. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:72341. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496-503. 6. Committee of Urogynecology/Reconstructive Pelvic Surgery, American Board of Obstetrics and Gynecology. Guide to learning in urogynecology/reconstructive pelvic surgery. American Board of Obstetrics and Gynecology; 1996. 7. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. Am J Obstet Gynecol 1988;158:747-53. 8. Metheny WP, Sherline DM. The resident and fellow relationship on obstetrics and gynecology. Am J Obstet Gynecol 1988; 158:618-24. 9. Sherline DM, Metheny WP. A comparison of resident and program directors’ views on the effects of subspecialty fellowships on residency training in obstetrics and gynecology. Am J Obstet Gynecol, 1988;158:625-8. 10. Metheny WP, Sherline DM. The effects of fellowships on residency training in obstetrics and gynecology. Obstet Gynecol 1987;69:825-9.
Discussion DR RALPH P. CHESSON, New Orleans, La. Dr Cundiff has shown, through a voluntary questionnaire, that the longitudinal impact of a female pelvic medicine and reconstructive surgery fellowship was perceived to be positive for their program. His findings are similar to a series of studies from 1987 through 1988 that regarded the impact of oncology, maternal fetal medicine, and endocrine/reproductive fellowships on residency training.1-4 He has shown that the anticipated negative impact was replaced
by a positive experience of the residents to the fellowship. He has shown that there was no significant loss of surgical experience by the residents. As both the Residency Program Director and the Fellowship Director in Female Pelvic Medicine and Reconstructive Pelvic Surgery, I have a conflict of interest regarding the impact of the fellowship on resident education. As a Residency Program Director, I am interested in the surgical experience of our residents. In reviewing the surgical experience at Louisiana State University Health Sciences Center, there was a change in the number of procedures performed by the residents (Table). The year of the arrival of a urogynecologist (Dr Tom Elkins, 1993) before the fellowship was started is compared with our last year. These numbers from the residency S-Forms for the annual report for the Residency Review Committee are dependent on the reliability of self-reporting by our residents, known by all Residency Program Directors to have questionable reliability. The increased prolapse/incontinence numbers are associated with the addition of a pelvic surgeon to the staff before the fellowship was started. I was not able to document the changes in the number of surgeries in which the residents assisted, which is probably decreased. We feel that an important part of our fellowship program is to teach young surgeons how to be surgical teachers, and this frequently involves both the faculty and fellow assisting the resident. This necessitates some loss of experience for the residents in assisting at surgical procedures. Our fellows rarely do the procedures when the residents are present and receive most of their personal surgical experience with the faculties’ private referral practice (Table). Our fellows have consistently been recognized by the residents for their teaching contributions and their leadership in the research projects. The previous subspecialties of oncology, maternal fetal medicine, and reproductive medicine have added greatly to the development of our field. We believe that female pelvic medicine and reconstructive surgery fellowship will likewise advance science in our field.
Table. Average procedures per graduating resident t Test 1992 Procedure* Abdominal hysterectomy Vaginal hysterectomy Prolapse/incontinence Adnexal surgery Laparoscopic surgery Ectopic pregnancy Endocrine Residents (No.) *Data are given as median (range).
61 (31-104) 24 (6-46) 11 (1-6) 38 (12-86) 29 (116-53) 21 (12-33) 10 (3-27) 12
1993
2000-2001
81 (37-125) 30 (17-43) 18 (9-26) 40 (17-67) 34 (20-56) 19 (9-33) 32 (10-68) 9
0.037 0.18 0.00095 0.68 0.016 0.70 0.0039
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I have two questions for Dr Cundiff. One of your assumptions was that the addition of a fellowship program would increase surgical procedures for the program, but you had no data to prove this assumption. Where did the program find the extra procedures that were necessary to train the fellows? From the community? Were you able to document any change in the number of surgical procedures in which residents assisted during their training?
REFERENCES
1. Metheny WP, Sherline DM. The effects of fellowships on residency training in obstetrics and gynecology. Obstet Gynecol 1987;69:825-9. 2. Metheny WP, Sherline DM. The resident and fellow relationship on obstetrics and gynecology. Am J Obstet Gynecol 1988; 158: 618-24. 3. Sherline DM, Metheny WP. A comparison of resident and program directors’ views on the effects of subspecialty fellowships
Cundiff, Handa, and Bienstock 1493
on residency training in obstetrics and gynecology. Am J Obstet Gynecol 1988;158:625-8. 4. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. Am J Obstet Gynecol 1988;158:747-53.
DR CUNDIFF (Closing). With respect to surgical volume, that actually is the hardest part of this study to address really well. We did ask the residents to complete, as part of their survey, how many cases they had done, specifying how many they had assisted in, second assisted in, and actually been primary surgeon on. Those data were even more unreliable than their S forms because they were doing it from memory. So we really do not have any way of documenting a change in how they were functioning in the operating room. My personal philosophy is that the goal in teaching fellows is to train surgical teachers. Towards that end, our fellows usually first assist the resident who operates as the primary surgeon, and I act as a second assistant, to make sure the case proceeds appropriately.
Key words: Fellowship in female pelvic medicine and reconstructive surgery, residency education, obstetrics and gynecology
Female pelvic floor dysfunction is a term that reflects a collection of disorders that include urinary incontinence, lower urinary tract symptoms, fecal incontinence, pelvic organ prolapse, defecatory dysfunction, and sexual dysfunction. These are common problems with a significant burden for affected women.1-3 These maladies are related causally,4 yet historically different medical specialties have treated different aspects of pelvic floor dysfunction (including gynecology, urology, colorectal surgery, and gastroenterology). Estimates suggest that the population of women with pelvic floor dysfunction is increasing and that there will be a large population of underserved patients in the near future.5 Recognizing the disorganized care of pelvic floor dysfunction and the future need for additional physicians who are well trained in female pelvic floor dysfunction, the American Board of Obstetrics and Gynecology combined efforts with the American Board of Urology to create the new subspecialty of female pelvic medicine and reconstruc-
From the Johns Hopkins Medical Institutes. Presented at the Twenty-eighth Annual Meeting of the Society of Gynecologic Surgeons, Dallas, Tex, March 4-6, 2002. Reprint requests: Geoffrey Cundiff, MD, Johns Hopkins Medicine, Department of Gynecology and Obstetrics, 600 N Wolfe St/Harvey 319, Baltimore, MD 21287. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002 $35.00 + 0 6/6/129155 doi:10.1067/mob.2002.129155
tive pelvic surgery. This subspecialty follows the approach used previously in creating the subspecialties of maternal fetal medicine, reproductive endocrinology, and gynecologic oncology. Inherent to this approach is the certification of fellowship programs to provide training to future members of the subspecialty. Learning objectives were established, and the American Board of Obstetrics and Gynecology began accrediting training programs in 1996. The learning objectives are extensive and include the diagnosis and treatment of urinary incontinence, irritative voiding, voiding dysfunction, fecal incontinence, defecatory dysfunction, and pelvic organ prolapse.6 Mandated diagnostic techniques include urodynamics, endoscopy, anorectal physiologic testing, imaging, and neurophysiologic testing techniques. Fellows are to receive training in nonsurgical treatment and surgical treatment, which should include both abdominal and vaginal surgical approaches. Although the specialty of female pelvic medicine and reconstructive pelvic surgery promises to improve the care of women with pelvic floor dysfunction, many educators are concerned about the impact of the new fellowship programs on resident education. Recent innovations in surgical techniques have drastically increased the repertoire of gynecologic surgery to be mastered, making learning the full breadth of gynecologic surgery during a 4-year residency challenging. At the same time, shifting indications for gynecologic surgery and the increasing 1487
1488 Cundiff, Handa, and Bienstock
Table I. Areas of knowledge in female pelvic medicine and reconstructive surgery included in self assessment questionnaire Urinary incontinence Genuine stress incontinence Overactive bladder disorders Intrinsic sphincteric deficiency Urinary tract fistula Irritative voiding symptoms Urinary tract infections Urethral diverticula Urethral syndrome Interstitial cystitis Urinary retention Urethral obstruction Neurogenic bladder Detrusor sphincter dyssynergia Fecal incontinence External anal sphincter defect Internal anal sphincter defect Neurogenic anal incontinence Defecatory dysfunction Irritable bowel syndrome Colonic inertia Anismus Outlet obstruction Pelvic organ prolapse Cystocele Rectocele Enterocele Vault prolapse Perineal descent Rectal prolapse Residents assessed the quality of their diagnostic and therapeutic education during the past year for each subheading. Scores were pooled and the analysis performed for the bolded headings.
primary care curriculum requirements have decreased the volume of surgical experience in many residency programs. Under these circumstances, concerned program directors view fellows in a surgical subspecialty as competitors for a dwindling number of surgical cases. Contrary to this sentiment, we hypothesized that the introduction of a fellowship in female pelvic medicine and reconstructive pelvic surgery would actually enhance resident education rather than diminish it. This belief was based on several assumptions. First, the fellowship would actually increase overall clinical and surgical volume. Second, a fellowship would enhance education, by increasing the number of teaching faculty, specifically with fellows who are not distracted by heavy clinical and administrative responsibilities. Third, fellows would further the research endeavors of the department, which would translate to a richer educational environment. We designed and undertook this project to investigate this hypothesis. Material and methods The Department of Gynecology and Obstetrics at the Johns Hopkins Medical Institutions started a fellowship in
December 2002 Am J Obstet Gynecol
female pelvic medicine and reconstructive pelvic surgery in July 1998. This is a 3-year program that follows the guidelines of the American Board of Obstetrics and Gynecology. Two fellows began the program in July 1998, and an additional fellow was added for each of the subsequent years, 1999 and 2000. The fellows’ clinical responsibilities for the first and third years are fulfilled at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. During the second year, they rotate off service for a total of 4 months on urology, colorectal surgery, and plastic surgery. They also spend 4 months on the female pelvic medicine and reconstructive surgery service at Greater Baltimore Medical Center (GBMC). The GBMC also has a fellowship in female pelvic medicine and reconstructive surgery with which our program collaborates. When fellows from Johns Hopkins rotate through GBMC, their GBMC counterparts rotate through Johns Hopkins so that the residents interact with four Johns Hopkins fellows and five GBMC fellows during the course of this study. Although fellows have 20% dedicated research time and requirements for research productivity, the program has a strong clinical curriculum. Fellows operate as junior attending physicians and are expected to participate in the educational responsibilities, that include attending physician of the week and gynecology call. The fellows’ weekly schedule includes supervised sessions 1 day per week in the clinic, 1 day a week in diagnostic testing, and 2 days a week in surgery. Residents also attend these activities. Johns Hopkins and GBMC have a combined residency program in obstetrics and gynecology. The residents’ primary exposure to female pelvic medicine and reconstructive pelvic surgery is during the fourth year, at which time they have two 4-week rotations on the female pelvic medicine and reconstructive surgery services, one rotation at Johns Hopkins Hospital, and one rotation at GBMC. During the Johns Hopkins Hospital rotation, they attend all urogynecologic operations and attend the clinic and diagnostic testing sessions, if surgical cases are not scheduled. Fellows are present for and actively participate in teaching in all of these venues. Third-year residents run the gynecology service at Johns Hopkins Bayview Medical Center, where they attend the urogynecology operations, operating with the attending physician and fellow. Fellows also interact with residents of all levels as the instructor of the Gynecologic Endoscopy Education Laboratory, a dry laboratory that is dedicated to teaching laparoscopy, hysteroscopy, and cystoscopy. This weekly 3hour laborotory is taught by the first-year fellow and is attended by residents on the Johns Hopkins Bayview Medical Center gynecology service on a voluntary basis. Data for this investigation include surgical productivity that are based on information that is collected from S forms and data that are collected by a voluntary survey that is completed by the residents. The survey used a 100mm visual analog scale in which 100 equals excellent, 50
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Fig 1. Mean scores from visual analog scales for fellowship impact by year of survey. Asterisk, P ≤ .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
equals average, and 0 equals poor. The survey had two sections: one section asked residents to describe their educational experience in specific aspects of six broad areas of female pelvic medicine and reconstructive surgery during the past year (Table I). They were asked to differentiate between diagnostic and therapeutic aspects of their education, with separate visual analog scales for each in all categories listed in Table I. The specific wording was: The following questions are aimed at documenting your own assessment of the quality of education that you have received in Urogynecology during the past year. The questions refer to broad categories in Urogynecology. Each question has a visual analog scale for both diagnosis and management. Please answer by placing a single vertical line through the visual analog scale at the location that describes your experience. Management includes both surgical and non-surgical management. If you are not familiar with the sub-category, place your mark at the poor extreme. For analysis, the data were pooled within each of the six main categories and are listed as diagnostic and therapeutic means. The second section asked them to assess how they felt that fellowships in female pelvic medicine and reconstructive surgery had an impact on their education in six specific areas: general gynecology, gynecologic surgery, laparoscopic surgery, urogynecology, urogynecologic surgery, and overall educational experience. The precise wording was “How has the presence of the Urogynecol-
ogy Fellows impacted your knowledge of . . .” There was also space for residents to provide additional comments. The survey was given to all 28 residents in obstetrics and gynecology during the first month of the beginning of the fellowship in female pelvic medicine and reconstructive surgery and then annually for 3 years. The survey was completed on a voluntary basis, but residents were encouraged to use the survey as an opportunity to express their opinions about how the fellowship had an impact on their education. In conformity with institutional practice and the recommendations of the Department of Health and Human Services, which exempts research on educational practices from institutional review, this study was not submitted for review by the institutional review board. Statistical analysis of changes in the fellowship impact scores between different years was conducted with the Mann-Whitney U test for nonparametric comparison of unpaired groups and compared the initial (before) year to pooled data for years 2 to 4 (after) years. Regression analysis to examine linear and logarithmic relationships was used to compare diagnostic and therapeutic scores as a function of the year of the test. The same statistics were used to compare the diagnostic and therapeutic scores by year. Changes in surgical productivity were evaluated with regression analysis. Results The mean response rate to the survey was 32%, with 36% on the initial survey, 32% at the 1-year survey, 22% at
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December 2002 Am J Obstet Gynecol
Fig 2. Mean scores from visual analog scales for diagnostic knowledge by year of survey. Asterisk, P < .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
Table II. Resident surgical experience, expressed as a mean of individual annual cases Surgery type Vaginal hysterectomy (No.) Urinary incontinence (No.)
1998
1999
2001
2002
P value
27 23
20 17
17 20
24 20
.647 .683
the 2-year survey, and 39% on the final survey. In the initial questionnaire, the fellowships were perceived as detracting from the educational experience because mean scores for all categories were <50 mm (average). Thereafter, there was a positive increase in the perceived impact of fellowships in all educational categories that was sustained at 2 and 3 years (Fig 1). The change in scores between the initial survey and the subsequent surveys was statistically significant for all categories except urogynecologic surgery. Scores for years 1, 2, and 3 were not significantly different from one another. The residents’ self-assessment of their diagnostic knowledge was below average (50 mm) in all categories on the initial survey (Fig 2). Scores on subsequent surveys were above average for urinary incontinence, lower urinary tract symptoms, voiding dysfunction, and pelvic organ prolapse, although the change in pelvic organ prolapse was not statistically significant. There was a statistically significant rise in scores for fecal incontinence; scores remained below average (50 mm) for years 1 and 3. Defecatory dysfunction scores increased, but not statistically, and remained below average (50 mm), except in year 2. The self-assessment scores for therapeutic knowledge on the initial survey were also all below average (50 mm, Fig 3). There was a statistically significant rise in scores for all categories for years 1, 2, and 3. Although scores fell in year 3 in all categories, this was not a statistically signif-
icant change. Scores for fecal incontinence and defecatory dysfunction rose but remained below average (50 mm) in all years. There was no statistically significant change in the mean number of vaginal hysterectomies, surgeries for urinary incontinence, or laparoscopy after the introduction of the fellowship (Table II). Comment A negative impact of fellowship programs on residency education has been a concern in obstetrics and gynecology since the creation of the original subspecialties of maternal fetal medicine, reproductive endocrinology and infertility, and gynecologic oncology. Several studies that were performed in the mid 1980s addressed this concern. The results of a postal questionnaire that was sent to leaders in obstetrics and gynecology were reported in 1988.7 This survey was sent to department chair persons, residency directors at nonuniversity residency programs, and members of the American Gynecologic and Obstetrics Society. There was near-unanimous consensus (90%) that the development of subspecialties had helped in the development of the specialty of obstetrics and gynecology. Most respondents also agreed that the development of subspecialties enhanced the education of medical students (76%) and residents (86%). The survey identified “reproductive urology” as the preferred area for development of a future subspecialty.
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Fig 3. Mean scores from visual analog scales for therapeutic knowledge by year of survey. Asterisk, P < .05.The lightly dotted bars represent the initial surveys; the light gray bars represent the 1-year surveys; the dark gray bars represent the 2-year surveys; the closed bars represent the 3-year surveys.
A similar postal survey that was sent to administrative chief residents revealed that, overall, subspecialty fellowships were viewed as an improvement in the quality of training, although this was dependent on the degree to which fellows functioned as junior faculty who were involved in teaching.8 Moreover, competition for surgical cases, especially difficult or nonroutine cases, and the degree of surgical priority that were afforded to fellows over residents were identified as detractors from the residentfellow training relationship. These potential detractors varied by subspecialty and the particular content areas of the fellowship program. A direct comparison of the surveys of department chair persons and residency program directors to administrative chief residents at the same institution revealed that both groups viewed subspecialty fellowships programs as beneficial to residency training, although the residents’ views were less favorable.9 Moreover, directors underestimated the degree of regret expressed by residents at the loss of surgical experience, particularly in laser surgery, infertility surgery, and radical pelvic surgery. Additionally, within a given program, the residents’ views and program directors’ views were often contradictory and unrelated. Our study suggests that residents view a fellowship in female pelvic medicine and reconstructive surgery similarly to previous subspecialty fellowships. Initially, there was a perception that the introduction of the fellowship would have a negative impact on residency training. Instead, residents reported that the fellowships had a beneficial effect in all areas except urogynecologic surgery, for which the increase in scores was not statistically significant. This enhancement in education was also supported by increased self-assessment scores in multiple aspects of
pelvic floor dysfunction knowledge, and importantly, the improvements were sustained over time. Although mean surgical volumes for residents did not change, loss of surgical experience remains concerning to residents. This is suggested by the smaller rise in the urogynecologic surgery scores but is also supported by specific comments on the survey by the residents. Previous studies have indicated that residents are less concerned about losing surgical experience to fellows at institutions that grant fellows junior faculty status and emphasize research over clinical duties.10 These are principles that we have invoked in our fellowship program, and this may enhance resident acceptance and account for the noted benefits to resident education. We view fellowships as training programs for academic physicians and consider one of our responsibilities to be teaching fellows how to be teachers. Fellows are therefore encouraged to take the educators’ role in all interactions with residents, including in the operating room. This helps to prevent conflict between fellows and residents by defining complimentary roles. We feel that this approach is justified by the study. The residents’ self-assessment of their knowledge of female pelvic medicine and reconstructive surgery helped to support the beneficial impact of the fellowship on resident education in this area. It also identified a perception among residents that they were inadequately trained in female pelvic medicine and reconstructive surgery at the outset of the study. Although scores for many areas improved, the self-assessed knowledge of defecatory dysfunction and fecal incontinence remained below average (50 mm), even after 3 years. This information has provided the basis for programmatic changes and suggests
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that this type of survey may have a role in the assessment of residency program weaknesses. REFERENCES
1. Abrams P, Kelleher CJ, Kerr LA, Rogers RD. Overactive bladder significantly affects quality of life. Am J Manage Care 2000; 6(Suppl):S580-90. 2. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a thirty-year retrospective cohort study. Obstet Gynecol 1997;89:896-901. 3. Ellerkmann RM, Cundiff GW, Bent AE, Nihira MA, Melnick C. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332-8. 4. Bump RC, Norton P. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:72341. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496-503. 6. Committee of Urogynecology/Reconstructive Pelvic Surgery, American Board of Obstetrics and Gynecology. Guide to learning in urogynecology/reconstructive pelvic surgery. American Board of Obstetrics and Gynecology; 1996. 7. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. Am J Obstet Gynecol 1988;158:747-53. 8. Metheny WP, Sherline DM. The resident and fellow relationship on obstetrics and gynecology. Am J Obstet Gynecol 1988; 158:618-24. 9. Sherline DM, Metheny WP. A comparison of resident and program directors’ views on the effects of subspecialty fellowships on residency training in obstetrics and gynecology. Am J Obstet Gynecol, 1988;158:625-8. 10. Metheny WP, Sherline DM. The effects of fellowships on residency training in obstetrics and gynecology. Obstet Gynecol 1987;69:825-9.
Discussion DR RALPH P. CHESSON, New Orleans, La. Dr Cundiff has shown, through a voluntary questionnaire, that the longitudinal impact of a female pelvic medicine and reconstructive surgery fellowship was perceived to be positive for their program. His findings are similar to a series of studies from 1987 through 1988 that regarded the impact of oncology, maternal fetal medicine, and endocrine/reproductive fellowships on residency training.1-4 He has shown that the anticipated negative impact was replaced
by a positive experience of the residents to the fellowship. He has shown that there was no significant loss of surgical experience by the residents. As both the Residency Program Director and the Fellowship Director in Female Pelvic Medicine and Reconstructive Pelvic Surgery, I have a conflict of interest regarding the impact of the fellowship on resident education. As a Residency Program Director, I am interested in the surgical experience of our residents. In reviewing the surgical experience at Louisiana State University Health Sciences Center, there was a change in the number of procedures performed by the residents (Table). The year of the arrival of a urogynecologist (Dr Tom Elkins, 1993) before the fellowship was started is compared with our last year. These numbers from the residency S-Forms for the annual report for the Residency Review Committee are dependent on the reliability of self-reporting by our residents, known by all Residency Program Directors to have questionable reliability. The increased prolapse/incontinence numbers are associated with the addition of a pelvic surgeon to the staff before the fellowship was started. I was not able to document the changes in the number of surgeries in which the residents assisted, which is probably decreased. We feel that an important part of our fellowship program is to teach young surgeons how to be surgical teachers, and this frequently involves both the faculty and fellow assisting the resident. This necessitates some loss of experience for the residents in assisting at surgical procedures. Our fellows rarely do the procedures when the residents are present and receive most of their personal surgical experience with the faculties’ private referral practice (Table). Our fellows have consistently been recognized by the residents for their teaching contributions and their leadership in the research projects. The previous subspecialties of oncology, maternal fetal medicine, and reproductive medicine have added greatly to the development of our field. We believe that female pelvic medicine and reconstructive surgery fellowship will likewise advance science in our field.
Table. Average procedures per graduating resident t Test 1992 Procedure* Abdominal hysterectomy Vaginal hysterectomy Prolapse/incontinence Adnexal surgery Laparoscopic surgery Ectopic pregnancy Endocrine Residents (No.) *Data are given as median (range).
61 (31-104) 24 (6-46) 11 (1-6) 38 (12-86) 29 (116-53) 21 (12-33) 10 (3-27) 12
1993
2000-2001
81 (37-125) 30 (17-43) 18 (9-26) 40 (17-67) 34 (20-56) 19 (9-33) 32 (10-68) 9
0.037 0.18 0.00095 0.68 0.016 0.70 0.0039
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I have two questions for Dr Cundiff. One of your assumptions was that the addition of a fellowship program would increase surgical procedures for the program, but you had no data to prove this assumption. Where did the program find the extra procedures that were necessary to train the fellows? From the community? Were you able to document any change in the number of surgical procedures in which residents assisted during their training?
REFERENCES
1. Metheny WP, Sherline DM. The effects of fellowships on residency training in obstetrics and gynecology. Obstet Gynecol 1987;69:825-9. 2. Metheny WP, Sherline DM. The resident and fellow relationship on obstetrics and gynecology. Am J Obstet Gynecol 1988; 158: 618-24. 3. Sherline DM, Metheny WP. A comparison of resident and program directors’ views on the effects of subspecialty fellowships
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on residency training in obstetrics and gynecology. Am J Obstet Gynecol 1988;158:625-8. 4. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. Am J Obstet Gynecol 1988;158:747-53.
DR CUNDIFF (Closing). With respect to surgical volume, that actually is the hardest part of this study to address really well. We did ask the residents to complete, as part of their survey, how many cases they had done, specifying how many they had assisted in, second assisted in, and actually been primary surgeon on. Those data were even more unreliable than their S forms because they were doing it from memory. So we really do not have any way of documenting a change in how they were functioning in the operating room. My personal philosophy is that the goal in teaching fellows is to train surgical teachers. Towards that end, our fellows usually first assist the resident who operates as the primary surgeon, and I act as a second assistant, to make sure the case proceeds appropriately.