Is surgical training in ob/gyn residency adequate?

Dr Cohen reports receiving consulting fees from Olympus Surgical. Dr Hinchcliff has no conflicts of interest to report in respect to the content of this article.

Much has changed since Howard Kelly established a gynecology residency at Johns Hopkins Hospital in the late 19th century. Though the time available for training is relatively fixed, the amount of information and number of skills that must be learned are increasing.

Not only are residents expected to be competent in key aspects of obstetrics, primary care, and office gynecology, but they also must master a multitude of surgical techniques and be competent with evolving technology.

When asked about the state of ob/gyn training in the Contemporary OB/GYN 2015 Labor Force Reader Survey, one respondent commented, “... we are training poorly prepared ob/gyns who are not capable of handling a variety of clinical problems, and who are not truly surgically independent and competent when they finish residency.”¹

This sentiment, although bleak, underscores an increasingly common concern about the adequacy of surgical training during residency.

The time crunch

The Accreditation Council for Graduate Medical Education (ACGME) began mandating 80-hour limits on weekly resident work hours in 2003. This was in part a response to seminal cases such as that of patient Libby Zion. It was felt that resident fatigue contributed in part to Zion’s death. The goals of work-hour limitations were to improve patient safety, resident wellness, and resident education. However, representatives of multiple surgical subspecialties have debated the effects of work-hour restrictions and argued that the limitations may have a negative impact on surgical training.

A meta-analysis of 57 studies regarding the impact of work-hour restrictions found that while there were some reports of improved resident wellness, there was also a trend toward declining performance on examinations in some specialties and a perception of worsened education. The analysis also found no overall improvement in patient outcomes as a result of duty-hour limitations, and some studies suggest increased complication rates in high-acuity patients.²

These findings are echoed by an analysis of Medicare claims data, which found no changes in mortality, serious complications, or readmission even among the highest intensity teaching hospitals as defined by resident:bed ratio.³

Ready for graduation?

What could explain the lack of benefit to decreasing work hours, which has an associated decrease in trainee fatigue? Possibilities include the increasing complexity of cases which carry steeper learning curves, compounded by a decline in overall case volume. The diminishing amount of surgical experience in ob/gyn residency has been documented via retrospective analysis of ACGME case log reports.⁴ Although there was no significant change in the overall number of hysterectomies logged from 2008 to 2012, there was a marked decrease in the number of both abdominal (4-year cumulative case load: 89, vs 59 in 2008-2009 and 2011-2012, respectively; a 28% decrease) and vaginal hysterectomy cases (4-year cumulative case load: 35, vs 19 in 2008–2009 and 2011–2012; a 40% decrease). This may reflect a shift toward minimally invasive approaches, but raises concern that graduating residents may not have sufficient exposure to all the surgical approaches. Even in the area of laparoscopy, residents self-reported a low level of competency in most advanced procedures upon graduation.⁵

Perhaps in response to the lack of surgical experience in residency, there has been a drive toward sub-specialization and additional training. The proportion of ob/gyn graduates accepted into fellowships rose from 7% in 2000 to 19.5% in 2012.⁶ However, a 2014 survey of fellowship program directors suggested a high level of unpreparedness for fellowship training.⁷ In this survey, professionalism and overall patient care was rated favorably, though only incoming fellows in maternal-fetal medicine were deemed able to practice independently.

A meager 20% of incoming female pelvic medicine and reconstructive surgery fellows were deemed able to independently perform a vaginal hysterectomy, with only 44% of first-year gynecologic oncology fellows able to perform a hysterectomy on their own.

Another survey specific to the field of gynecologic oncology revealed sub-par surgical skills of incoming fellows with a delay in independent functioning in the operating room until later in fellowship training.⁸

Possible solutions

Residency programs may look to affiliations with community hospitals and physicians as a source of additional operative volume for their trainees, but there is a limit to how much that can ameliorate the issue given competing time demands. This is particularly true in light of the observed decrease in national incidence of some major gynecologic procedures. For example, national estimates of annual hysterectomy volume in the United States are steadily declining.^9,10 If the absolute number of cases per resident cannot be increased enough to produce adequate surgical experience,

one option is to extend the duration of training beyond 4 years, as is the norm in many European ob/gyn post-graduate training programs and in other procedural specialties in the United States. This significant change to the nature of ob/gyn training programs may be met with considerable institutional or individual resistance.

Another possible solution is introduction of career tracking, wherein residents can focus a portion of their training years specifically toward skills most useful for their intended post-graduation practice.

This model may provide opportunities to increase resident case volume more effectively, allowing residents to self-select earlier and thus maximize valuable experience throughout their training. Unfortunately the literature on the experience with such a tracking model is limited.

Assessment, screening

In addition to consideration of altering the structure of ob/gyn residency training, emphasis has been placed on more accurate assessment of trainee competency. The ACGME has encouraged a shift toward outcome-based medical education with the introduction of the Milestones project.¹¹ The 28 ob/gyn Milestones represent key competencies in obstetrics, gynecology, office practice, and professionalism that can be used to score an individual’s progress as well as the effectiveness of a training program.

The ultimate goal of the Milestones project is to “ensure that each graduate from an ACGME-accredited program receives the educational experiences needed to safely and independently practice in their specialty upon graduation.”¹¹

Finally, it is worth considering upstream interventions in the trainee selection process. Other high-risk professions, such as the aerospace industry, utilize a rigorous and validated candidate selection methodology that has been shown to predict future success in the field.¹² Surgical simulation exercises can reveal tiers of aptitude, indicating students or residents who have higher baseline skill level, and more importantly those who attain proficiency at a task with fewer repetitions.

Identifying these trainees would therefore identify people who can succeed in an environment of decreased case volume and work hours. In addition, it may be possible to predict tiers of skill even prior to simulation exercises. A systematic review of the possible predictors of performance, including visual-spatial perception testing, psychomotor aptitude, and academic achievement, indicated that each of these tests may help predict a resident’s future competence.¹³ Of note, this literature remains in its infancy and requires significant further study prior to implementation on a broader scale.

Summary

The adequacy of surgical training in ob/gyn is a real concern. This is in part related to the increasing breadth of required education, which accompanies medical and technological advances in the field. In addition, clinical experience is on the decline with work-hour limitations and concerns regarding limited surgical case volume. As a result, more residents are choosing to pursue fellowship training after graduating. If left unchecked, it is foreseeable that these changes could lead to the decline of the generalist ob/gyn practice model.

Residency programs face difficult challenges in training competent and independent practitioners. A continued focus on innovation in residency training is key in order for the continued evolution of our specialty.

References

1.     Contemporary OB/GYN Labor Force Survey, January issue.

2.     Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014; 259(6):1041–1053.

3.     Scally CP, Ryan AM, Thumma JR, Gauger PG, Dimick JB. Early impact of the 2011 ACGME duty hour regulations on surgical outcomes. Surgery. 2015;158(6):1453–1461.

4.     Washburn EE, Cohen SL, Manoucheri E, Zurawin RK, Einarsson JI. Trends in reported resident surgical experience in hysterectomy. J Minim Invasive Gynecol. 2014;21(6):1067–1070.

5.      Einarsson JI, Young A, Tsien L, Sangi-Haghpeykar H. Perceived proficiency in endoscopic techniques among senior obstetrics and gynecology residents. J Am Assoc Gynecol Laparosc. 2002;9(2):158–164.

6.     Rayburn WF, Gant NF, Gilstrap LC, Elwell EC, Williams SB. Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology, 2000-2012. Obstet Gynecol. 2012;120(3):619–625.

7.     Guntupalli SR, Doo DW, Guy M, et al. Preparedness of Obstetrics and Gynecology Residents for Fellowship Training. Obstet Gynecol. 2015;126(3):559–568.

8.     Doo DW, Powell M, Novetsky A, Sheeder J, Guntupalli SR. Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology. Gynecol Oncol Rep. 2015;(12):55–60.

9.     Cohen SL, Vitonis AF, Einarsson JI. Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy. JSLS. 2014;18(3).

10.  Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013;122(2 Pt 1):233–241.

11.  Bienstock JL, Edgar L, McAlister R. Obstetrics and Gynecology Milestones. J Grad Med Educ. 2014 6(1 Suppl 1): 126–128.

12.  Bailey M. Evolution of aptitude testing in the RAF. RTO MP-55, 1999; http://ftp.rta.nato.int/public// PubFulltext/RTO/MP/RTO-MP-055///MP-055-25.pdf. Accessed May 27, 2016.

13. Maan ZN, Maan IN, Darzi AW, Aggarwal R. Systematic review of predictors of surgical performance. Br J Surg. 2012;99(12):1610–1621.