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On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada
Commentary
On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada Geoffrey W. Cundiff, MD Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
Abstract Within Canada, the specialty of female pelvic medicine and reconstructive surgery stands on the brink. The needs of Canadian women for pelvic floor services are not presently met. There are inadequate academic programs to train surgeons, and the existing programs are inconsistent in scope. Consequently, the physicians who are interested in the field are drawn to the Board-accredited programs in the United States, and they frequently do not return to Canada. Those who do return will have trouble reversing this trend because of the absence of research and academic funding for urogynaecology in Canada. This will be accomplished only through the collaborative efforts of Canadian urogynaecologists to define the needs of the specialty and the support of health care administrators to build sustainable academic programs in urogynaecology.
Résumé Au Canada, la spécialité de la médecine pelvienne et de la chirurgie reconstructive du bassin de la femme se trouve au bord du gouffre. Nous ne sommes présentement pas en mesure de répondre aux besoins des Canadiennes en services visant le plancher pelvien. Nous ne disposons pas d’un nombre adéquat de programmes universitaires pour former nos chirurgiens et les programmes existants n’offrent pas un curriculum uniformisé. Par conséquent, les médecins qui s’intéressent au domaine sont attirés par les programmes américains agréés par les Conseils qui régissent la discipline aux États-Unis; de plus, il est fréquent de voir ces professionnels ne pas revenir au Canada. Ceux qui reviennent auront de la difficulté à renverser cette tendance, et ce, en raison de l’absence de financement de la recherche et des études supérieures dans le domaine de l’urogynécologie au Canada. En fait, nous n’y parviendrons que par la mise en œuvre d’efforts concertés de la part des urogynécologues canadiens en vue de définir les besoins de la spécialité; le soutien des administrateurs des services de santé pour assurer la mise sur pied de programmes universitaires durables en urogynécologie s’avérera également indispensable.
Key Words: Urogynaecology, female urology, female pelvic medicine and reconstructive surgery Conflict of Interest: None declared. Received on July 5, 2011 Accepted on August 10, 2011
U
rogynaecology, or female pelvic medicine and reconstructive surgery (FPMRS), as it is now known in the United States, forms an increasingly large proportion of gynaecologic surgery. Factors that have increased its role include the aging demography, an increase in effective medical therapy for gynaecologic conditions, and improved procedures for pelvic floor disorders. The roots of urogynaecology date back to the 1950s and 1960s, with the development of retropubic urethropexy for stress urinary incontinence and apical prolapse procedures including sacrospinous fixation and sacral colpopexy. Urogynaecology has always distinguished itself from other forms of benign pelvic surgery through its focus on diagnostics. The Robertson urethroscope is an early example. A precursor to multi-channel urodynamics, it provided both anatomical and functional assessments of the lower urinary tract.1
The Robertson urethroscope was developed by Dr Jack Robertson. This pioneer also started the first fellowship program in urogynaecology. His first fellow was Dr Harold Drutz, a Canadian gynaecologist, and his second was Dr Donald Ostergard. Both started their own fellowship programs, and two of Dr Ostergard’s earliest fellows were Dr Alfred Bent and Dr Scott Farrell, both Canadians. While urogynaecologists have worked within the Canadian health care system since the early days, the subspecialty has evolved quite differently in Canada and in the United States. An important reason for the divergent paths is the emergence of active subspecialty professional organizations in the United States. The American Urogynecologic Society and the Society for Urodynamics and Female Urology were founded in the late 1970s. They are both inclusive organizations that accept researchers, allied health professionals, and physicians of any specialty as members. J Obstet Gynaecol Can 2011;33(12):1253-1255
DECEMBER JOGC DÉCEMBRE 2011 l 1253
Commentary
The birth of subspecialty professional organizations provided important influences on the evolution of the subspecialty in the United States. Most fundamentally, they provided a venue for early investigators to present their work. This role expanded as the subspecialty professional organizations developed subspecialty journals for publication of scientific work in the field. Equally important were early seed grants and research retreats that helped to encourage the growth of basic science, epidemiologic investigations, and multicentre trials. But perhaps the most dramatic influence was the government relations campaign undertaken by the American Urogynecologic Society, whose direct lobbying of members of the United States Congress resulted in Congress passing bills requiring the National Institutes of Health to sponsor research in FPMRS. Thus, in 2000, the National Institutes of Health released requests for applications focused on the epidemiology and basic science of pelvic floor disorders, as well as two multicentre treatment networks dedicated to clinical trials: the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network. The professional organizations also had a significant impact on education. Beyond continuing medical education, which allowed physicians to expand their skills in the new specialty, both the American Urogynecologic Society and the Society for Urodynamics and Female Urology developed standardized curricula for fellowship training. Important elements included broad training in diagnostics, both nonsurgical and surgical therapeutics, and a view of the specialty that included disorders of all pelvic viscera, including the bladder, vagina, and rectum. Training in research methodology and academic productivity was also required, which helped to establish a scholarly base in the subspecialty. Within the United States, the cross-fertilization between the professional societies, coupled with similar views of a training curriculum, brought the urologists and urogynaecologists together to develop a joint subspecialty. Overcoming the strain of cooperation took time, but eventually they sought the support of the American Boards of Urology and Obstetrics & Gynecology, and the field of female pelvic medicine and reconstructive surgery was born. The two boards established a fellowship curriculum and started accrediting fellowship programs in 1994. The goal was to develop sufficient capacity for training subspecialists before pursuing certification. That target is now met, and an examination process towards certification will be offered beginning in 2012. Importantly, fellowship training in an accredited program will be a requirement for certification, and while grandfathering will be available for any gynaecologist or urologist completing training prior to 1254 l DECEMBER JOGC DÉCEMBRE 2011
2010, surgeons beginning training after 2010 will have to do so in an accredited program. Thus, within the United States FPMRS has evolved to become a well-defined, evidence-based subspecialty. Urologists and gynaecologists can seek training at one of 40 accredited fellowship programs that will lead to certification. Following training, they can look forward to rewarding academic careers, as nearly all academic centres with residency training have faculty members in FPMRS, and there is sufficient research funding to support an academic career. This was an arduous path of over 15 years, made possible through the energy, tenacity, and political savvy of dedicated leadership. Within Canada, FPMRS has had a different course. Even though Canada benefited from early pioneers in urogynaecology and the early establishment of fellowship programs, the absence of a strong professional organization has stunted its evolution. The Canadian Society of Pelvic Medicine, formerly known as the Canadian Society of Urogynaecology and Reconstructive Pelvic Surgery, is a satellite of the Society of Obstetricians and Gynaecologists of Canada and has never developed a membership or agenda close to that of the American organizations. This occurred in part because Canadian urogynaecologists gravitated towards the international organizations, but also because the focus of the SOGC on continuing education of the generalist did not provide the environment to encourage a subspecialty agenda. The absence of this agenda combined with membership apathy prevented the Canadian Society of Pelvic Medicine from becoming an advocate for research or education. Other political realities have similarly hampered FPMRS as a subspecialty in Canada. Pelvic floor specialists in gynaecology and urology rarely work cooperatively and are frequently in competition. Responsibility for education, assessment, and a research agenda are parsed among different organizations: the SOGC, the Royal College of Physicians and Surgeons of Canada, and the Association of Academic Professionals in Obstetrics and Gynaecology These organizations may be served by the same individuals but have uncoordinated functions. As a result, Canada lacks a standardized educational curriculum in FPMRS. Canada also has virtually no federal funding for FPMRS research, and the Canadian Institutes for Health Research appears to have overlooked women’s gynaecologic health altogether. The diminished status of urogynaecology in Canada has implications for the subspecialty, as well as for women who suffer from pelvic floor disorders. Recent epidemiologic studies have shown that one quarter of women suffer from
On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada
at least one pelvic floor disorder and have a lifetime risk of undergoing surgery for urinary incontinence or pelvic organ prolapse of between 11% and 25%.2–4 Moreover, the aging demographics of our population will increase the number of affected women seeking care.5 The skills to treat these conditions properly are not part of the CanMEDS required skills for residents in obstetrics and gynaecology or urology, so the provision of a workforce capable of treating these pelvic floor disorders will depend on subspecialty fellowship training.
Within Canada, the specialty stands on the brink. The needs of Canadian women for pelvic floor services are not presently met. There are inadequate academic programs to train surgeons, and the existing programs are inconsistent in scope. Consequently, the physicians who are interested in the field are drawn south to the Board-accredited programs, and frequently do not return to Canada. Those who do return will have trouble reversing this trend because of the absence of research and academic funding for urogynaecology in Canada.
Six of the 16 Canadian medical schools offer fellowship training in urogynaecology; these include seven gynaecology programs, one urology program, and one combined program. The programs differ significantly in length of training and focus. Some focus on surgical instruction with minimal instruction in diagnostics or non-surgical management of pelvic floor disorders. Only two programs provide formal instruction in research design and education. There is an overall lack of consistency that speaks to the lack of a common vision for the specialty. Yet obstetrics and gynaecology departments recognize the need for expertise. The Association of Academic Professionals in Obstetrics and Gynaecology estimates that presently there are three positions advertised for academic urogynaecologists and an anticipated eight more positions to be filled in the next three years. Will these positions be filled by urogynaecologists trained in Canada? This seems unlikely. Of the 50 trainees who have completed Canadian training programs, 28 have been international trainees who returned to their countries of origin following training, and five of the Canadian trainees immigrated to the United States. Moreover, of the 17 Canadian physicians who sought training in the United States, 60% have remained there following training. This brain drain will no doubt intensify following the initiation of board certification in the United States as trainees seek out well-defined programs that offer board certification. The lack of Royal College certification exacerbates the brain drain, as the absence of postgraduate educational funding forces Canadian fellowship programs to fund trainees through a combination of hospital, departmental, corporate, and self-funding. The self-funded programs primarily draw international trainees; none of the accredited programs in the United States are self-funded, a fact that makes them significantly more attractive.
Ensuring the future of the specialty will require a campaign to pursue Royal College certification for urogynaecology in the long run, but, before this is a realistic goal, there are smaller obstacles to overcome. These include developing a model of care for delivering care to women with pelvic floor disorders that will meet the unique needs of the Canadian population and its health care system, a common vision for the specialty within Canada, a consistent educational curriculum for fellowship training, and a meaningful research agenda to maximize the quality of care. Existing training programs may benefit in the short term from seeking accreditation with the American boards as a means to ensure adequate numbers of fellowship candidates, but this will not ultimately provide the workforce needed for Canadian women. This will be accomplished only through the collaborative efforts of Canadian urogynaecologists to define the needs of the specialty and the support of health care administrators to build sustainable academic programs in urogynaecology. REFERENCES 1. Robertson JR. Gynecologic urethroscopy. Am J Obstet Gynecol 1973;115:986 2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6. 3. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6. 4. Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 2010;116:1096–100. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496–501.
DECEMBER JOGC DÉCEMBRE 2011 l 1255
On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada Geoffrey W. Cundiff, MD Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
Abstract Within Canada, the specialty of female pelvic medicine and reconstructive surgery stands on the brink. The needs of Canadian women for pelvic floor services are not presently met. There are inadequate academic programs to train surgeons, and the existing programs are inconsistent in scope. Consequently, the physicians who are interested in the field are drawn to the Board-accredited programs in the United States, and they frequently do not return to Canada. Those who do return will have trouble reversing this trend because of the absence of research and academic funding for urogynaecology in Canada. This will be accomplished only through the collaborative efforts of Canadian urogynaecologists to define the needs of the specialty and the support of health care administrators to build sustainable academic programs in urogynaecology.
Résumé Au Canada, la spécialité de la médecine pelvienne et de la chirurgie reconstructive du bassin de la femme se trouve au bord du gouffre. Nous ne sommes présentement pas en mesure de répondre aux besoins des Canadiennes en services visant le plancher pelvien. Nous ne disposons pas d’un nombre adéquat de programmes universitaires pour former nos chirurgiens et les programmes existants n’offrent pas un curriculum uniformisé. Par conséquent, les médecins qui s’intéressent au domaine sont attirés par les programmes américains agréés par les Conseils qui régissent la discipline aux États-Unis; de plus, il est fréquent de voir ces professionnels ne pas revenir au Canada. Ceux qui reviennent auront de la difficulté à renverser cette tendance, et ce, en raison de l’absence de financement de la recherche et des études supérieures dans le domaine de l’urogynécologie au Canada. En fait, nous n’y parviendrons que par la mise en œuvre d’efforts concertés de la part des urogynécologues canadiens en vue de définir les besoins de la spécialité; le soutien des administrateurs des services de santé pour assurer la mise sur pied de programmes universitaires durables en urogynécologie s’avérera également indispensable.
Key Words: Urogynaecology, female urology, female pelvic medicine and reconstructive surgery Conflict of Interest: None declared. Received on July 5, 2011 Accepted on August 10, 2011
U
rogynaecology, or female pelvic medicine and reconstructive surgery (FPMRS), as it is now known in the United States, forms an increasingly large proportion of gynaecologic surgery. Factors that have increased its role include the aging demography, an increase in effective medical therapy for gynaecologic conditions, and improved procedures for pelvic floor disorders. The roots of urogynaecology date back to the 1950s and 1960s, with the development of retropubic urethropexy for stress urinary incontinence and apical prolapse procedures including sacrospinous fixation and sacral colpopexy. Urogynaecology has always distinguished itself from other forms of benign pelvic surgery through its focus on diagnostics. The Robertson urethroscope is an early example. A precursor to multi-channel urodynamics, it provided both anatomical and functional assessments of the lower urinary tract.1
The Robertson urethroscope was developed by Dr Jack Robertson. This pioneer also started the first fellowship program in urogynaecology. His first fellow was Dr Harold Drutz, a Canadian gynaecologist, and his second was Dr Donald Ostergard. Both started their own fellowship programs, and two of Dr Ostergard’s earliest fellows were Dr Alfred Bent and Dr Scott Farrell, both Canadians. While urogynaecologists have worked within the Canadian health care system since the early days, the subspecialty has evolved quite differently in Canada and in the United States. An important reason for the divergent paths is the emergence of active subspecialty professional organizations in the United States. The American Urogynecologic Society and the Society for Urodynamics and Female Urology were founded in the late 1970s. They are both inclusive organizations that accept researchers, allied health professionals, and physicians of any specialty as members. J Obstet Gynaecol Can 2011;33(12):1253-1255
DECEMBER JOGC DÉCEMBRE 2011 l 1253
Commentary
The birth of subspecialty professional organizations provided important influences on the evolution of the subspecialty in the United States. Most fundamentally, they provided a venue for early investigators to present their work. This role expanded as the subspecialty professional organizations developed subspecialty journals for publication of scientific work in the field. Equally important were early seed grants and research retreats that helped to encourage the growth of basic science, epidemiologic investigations, and multicentre trials. But perhaps the most dramatic influence was the government relations campaign undertaken by the American Urogynecologic Society, whose direct lobbying of members of the United States Congress resulted in Congress passing bills requiring the National Institutes of Health to sponsor research in FPMRS. Thus, in 2000, the National Institutes of Health released requests for applications focused on the epidemiology and basic science of pelvic floor disorders, as well as two multicentre treatment networks dedicated to clinical trials: the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network. The professional organizations also had a significant impact on education. Beyond continuing medical education, which allowed physicians to expand their skills in the new specialty, both the American Urogynecologic Society and the Society for Urodynamics and Female Urology developed standardized curricula for fellowship training. Important elements included broad training in diagnostics, both nonsurgical and surgical therapeutics, and a view of the specialty that included disorders of all pelvic viscera, including the bladder, vagina, and rectum. Training in research methodology and academic productivity was also required, which helped to establish a scholarly base in the subspecialty. Within the United States, the cross-fertilization between the professional societies, coupled with similar views of a training curriculum, brought the urologists and urogynaecologists together to develop a joint subspecialty. Overcoming the strain of cooperation took time, but eventually they sought the support of the American Boards of Urology and Obstetrics & Gynecology, and the field of female pelvic medicine and reconstructive surgery was born. The two boards established a fellowship curriculum and started accrediting fellowship programs in 1994. The goal was to develop sufficient capacity for training subspecialists before pursuing certification. That target is now met, and an examination process towards certification will be offered beginning in 2012. Importantly, fellowship training in an accredited program will be a requirement for certification, and while grandfathering will be available for any gynaecologist or urologist completing training prior to 1254 l DECEMBER JOGC DÉCEMBRE 2011
2010, surgeons beginning training after 2010 will have to do so in an accredited program. Thus, within the United States FPMRS has evolved to become a well-defined, evidence-based subspecialty. Urologists and gynaecologists can seek training at one of 40 accredited fellowship programs that will lead to certification. Following training, they can look forward to rewarding academic careers, as nearly all academic centres with residency training have faculty members in FPMRS, and there is sufficient research funding to support an academic career. This was an arduous path of over 15 years, made possible through the energy, tenacity, and political savvy of dedicated leadership. Within Canada, FPMRS has had a different course. Even though Canada benefited from early pioneers in urogynaecology and the early establishment of fellowship programs, the absence of a strong professional organization has stunted its evolution. The Canadian Society of Pelvic Medicine, formerly known as the Canadian Society of Urogynaecology and Reconstructive Pelvic Surgery, is a satellite of the Society of Obstetricians and Gynaecologists of Canada and has never developed a membership or agenda close to that of the American organizations. This occurred in part because Canadian urogynaecologists gravitated towards the international organizations, but also because the focus of the SOGC on continuing education of the generalist did not provide the environment to encourage a subspecialty agenda. The absence of this agenda combined with membership apathy prevented the Canadian Society of Pelvic Medicine from becoming an advocate for research or education. Other political realities have similarly hampered FPMRS as a subspecialty in Canada. Pelvic floor specialists in gynaecology and urology rarely work cooperatively and are frequently in competition. Responsibility for education, assessment, and a research agenda are parsed among different organizations: the SOGC, the Royal College of Physicians and Surgeons of Canada, and the Association of Academic Professionals in Obstetrics and Gynaecology These organizations may be served by the same individuals but have uncoordinated functions. As a result, Canada lacks a standardized educational curriculum in FPMRS. Canada also has virtually no federal funding for FPMRS research, and the Canadian Institutes for Health Research appears to have overlooked women’s gynaecologic health altogether. The diminished status of urogynaecology in Canada has implications for the subspecialty, as well as for women who suffer from pelvic floor disorders. Recent epidemiologic studies have shown that one quarter of women suffer from
On the Brink: The Future of Female Pelvic Medicine and Reconstructive Surgery in Canada
at least one pelvic floor disorder and have a lifetime risk of undergoing surgery for urinary incontinence or pelvic organ prolapse of between 11% and 25%.2–4 Moreover, the aging demographics of our population will increase the number of affected women seeking care.5 The skills to treat these conditions properly are not part of the CanMEDS required skills for residents in obstetrics and gynaecology or urology, so the provision of a workforce capable of treating these pelvic floor disorders will depend on subspecialty fellowship training.
Within Canada, the specialty stands on the brink. The needs of Canadian women for pelvic floor services are not presently met. There are inadequate academic programs to train surgeons, and the existing programs are inconsistent in scope. Consequently, the physicians who are interested in the field are drawn south to the Board-accredited programs, and frequently do not return to Canada. Those who do return will have trouble reversing this trend because of the absence of research and academic funding for urogynaecology in Canada.
Six of the 16 Canadian medical schools offer fellowship training in urogynaecology; these include seven gynaecology programs, one urology program, and one combined program. The programs differ significantly in length of training and focus. Some focus on surgical instruction with minimal instruction in diagnostics or non-surgical management of pelvic floor disorders. Only two programs provide formal instruction in research design and education. There is an overall lack of consistency that speaks to the lack of a common vision for the specialty. Yet obstetrics and gynaecology departments recognize the need for expertise. The Association of Academic Professionals in Obstetrics and Gynaecology estimates that presently there are three positions advertised for academic urogynaecologists and an anticipated eight more positions to be filled in the next three years. Will these positions be filled by urogynaecologists trained in Canada? This seems unlikely. Of the 50 trainees who have completed Canadian training programs, 28 have been international trainees who returned to their countries of origin following training, and five of the Canadian trainees immigrated to the United States. Moreover, of the 17 Canadian physicians who sought training in the United States, 60% have remained there following training. This brain drain will no doubt intensify following the initiation of board certification in the United States as trainees seek out well-defined programs that offer board certification. The lack of Royal College certification exacerbates the brain drain, as the absence of postgraduate educational funding forces Canadian fellowship programs to fund trainees through a combination of hospital, departmental, corporate, and self-funding. The self-funded programs primarily draw international trainees; none of the accredited programs in the United States are self-funded, a fact that makes them significantly more attractive.
Ensuring the future of the specialty will require a campaign to pursue Royal College certification for urogynaecology in the long run, but, before this is a realistic goal, there are smaller obstacles to overcome. These include developing a model of care for delivering care to women with pelvic floor disorders that will meet the unique needs of the Canadian population and its health care system, a common vision for the specialty within Canada, a consistent educational curriculum for fellowship training, and a meaningful research agenda to maximize the quality of care. Existing training programs may benefit in the short term from seeking accreditation with the American boards as a means to ensure adequate numbers of fellowship candidates, but this will not ultimately provide the workforce needed for Canadian women. This will be accomplished only through the collaborative efforts of Canadian urogynaecologists to define the needs of the specialty and the support of health care administrators to build sustainable academic programs in urogynaecology. REFERENCES 1. Robertson JR. Gynecologic urethroscopy. Am J Obstet Gynecol 1973;115:986 2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6. 3. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6. 4. Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 2010;116:1096–100. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496–501.
DECEMBER JOGC DÉCEMBRE 2011 l 1255