From the Journals

Resident experience with hysterectomy is on the decline

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Study reaffirms need to ‘separate the O and G’

This excellent paper by Dr. Gressel and coauthors shows decreasing numbers of hysterectomies – especially open and vaginal approaches – being performed by ob.gyn. residents. Considering also the 2015 publication by Guntupalli et al. showing the low numbers of incoming fellows able to perform hysterectomy, as well as Dr. Guntupalli’s editorial on this new research, we all must question how our patients will be able to undergo safe and effective surgery in the future.

Dr. Charles E. Miller, a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

Dr. Charles E. Miller

In his editorial, Dr. Guntupalli mentions the Cleveland Clinic’s model of allowing residents to track per their desires and future plans. We believe this approach only offers a band-aid to remedy the concern of shrinking hysterectomy numbers, and for that matter all gynecologic surgical procedure numbers. While the ability to choose a major field of interest during residency certainly has been proven to be effective at the Cleveland Clinic, we believe this would be difficult to achieve in smaller programs or programs where there is a huge burden in obstetrics coverage.

Furthermore, it would truly be disheartening and disconcerting for a young physician to choose a residency with the desire of a specific track, only to lose that choice to a coresident.

In his presidential address to the AAGL some years ago, Javier Magrina, MD, of the Mayo Clinic in Phoenix, discussed separating the “O from the G” (J Minim Invasive Gynecol. 2014;21[4]:501-3). Among his points: From 1979 to 2006, there was a 46% decrease in the number of gynecologic operations (2,852,000 vs. 1,309,000), a 54% increase in the number of American College of Obstetricians and Gynecologists’ fellows (21,364 vs. 51,123), and an 81% decrease in the number of gynecologic operations performed per ACOG fellow (132 vs. 25).

In 1980, he pointed out, the total number of hysterectomy procedures performed in the United States was 647,000. In 2007, this total was 517,000. The total number of ACOG fellows in 1980 was 22,516, compared with 52,385 in 2007. And the total number of hysterectomies performed per ACOG fellow was 28, compared with 9.8 hysterectomies per fellow in 2007.

Dr. Magrina’s data goes hand in hand with Dr. Gressel’s new study. The surgical experience of the gynecologic surgeon certainly is on the wane. The result of this lack of experience is noted by Dr. Guntupalli in his 2015 publication. To us, it is readily apparent that Dr. Magrina is right: The only true solution is to finally realize that we must separate the O from the G.

Charles E. Miller, MD, is director of minimally invasive gynecologic surgery, and director of the AAGL fellowship in minimally invasive gynecologic surgery, at Advocate Lutheran General Hospital, Park Ridge, Ill. Kirsten Sasaki, MD, is associate director of the AAGL fellowship in minimally invasive gynecologic surgery at Advocate Lutheran. They have no other conflicts of interest.



The total number of hysterectomies performed during residency training has declined significantly since 2008, despite an increase in laparoscopic hysterectomies performed, according to a new analysis of data from graduating ob.gyn. residents that has implications for the structure of resident education.

laparoscopic surgery being performed U.S. Air Force photo by Staff Sgt. Ciara Gosier

The investigators abstracted case log data from the Accreditation Council for Graduate Medical Education (ACGME) database to assess trends in residents’ operative experience and found decreases in abdominal and vaginal cases but an increase in experience with laparoscopic hysterectomy.

The median number of abdominal hysterectomies performed per resident over 4 years of training decreased by 57% between 2002-2003 and 2017-2018 (from 85 cases to 37), and the median number of vaginal hysterectomies decreased by 36% (from 31 to 20 cases).

Laparoscopic hysterectomy increased by 115% from a median of 20 procedures in 2008-2009 to 43 in 2017-2018. Even so, the median total number of hysterectomies per resident decreased by 6%, from 112 to 105 procedures during those two time periods. (Data on total hysterectomy and laparoscopic hysterectomy were not collected by ACGME until 2008.)

While the absolute decrease in the total number of hysterectomies is “relatively small,” the trend “raises questions about what the appropriate number of hysterectomies per graduating resident should be,” Gregory M. Gressel, MD, MSc, of the Montefiore Medical Center, New York, and coauthors wrote in Obstetrics & Gynecology.

“These data point,” they wrote, “to the necessity of maximizing surgical exposure in the face of a declining availability of procedures and the importance of reflecting on which (and how many) procedures an obstetrics and gynecology resident needs to complete before entering clinical practice.”

The training numbers parallel an increased use of laparoscopic hysterectomy in the United States and other countries, as well as a well-documented decline in the total number of hysterectomies performed in the United States, the latter of which is driven largely by the availability and increasing use of alternatives to the procedure (such as hormone therapy, endometrial ablation, and uterine artery embolization).

Hysterectomy still is a “core procedure of gynecologic surgery,” however, and is “at the heart of surgical training in obstetrics and gynecology,” as surgical techniques developed from learning hysterectomy “are applied broadly in the pelvis,” Saketh R. Guntupalli, MD, wrote in an accompanying editorial.

Dr. Guntupalli, of the University of Colorado at Aurora, Denver, was involved in a survey of fellowship program directors, published in 2015, that found only 20% of first-year fellows were able to independently perform a vaginal hysterectomy and 46% to independently perform an abdominal hysterectomy (Obstet Gynecol. 2015;126:559-68).

This and other research suggest that fellowship training is “used to address deficiencies in residency training rather than to develop new, specialized surgical skills,” he wrote. Given a dearth of fellowship positions in ob.gyn., “it is impossible to adequately use those avenues to train the number of competent surgeons necessary to address the surgical needs of women’s health in the United States.”

To address such concerns, some residency programs have instituted resident tracking to direct more hysterectomy cases toward those residents who plan to pursue surgical subspecialties. The Cleveland Clinic, Dr. Guntupalli noted, has tried the latter approach “with success.”

An increase in the number of accredited training programs and a decrease in the number of residents per program also might help to improve surgical exposure for residents, Dr. Gressel and associates wrote. Over the 16-year study period, the number of graduating residents increased significantly (by 12 per year) and the number of residency programs decreased significantly (0.52 fewer programs per year).

Additionally, Dr. Guntupalli wrote, regulatory bodies may need to reevaluate how competencies are assessed, and whether minimal numbers of cases “continue to carry the same weight as they did in previous generations.”

In the study, one coauthor is a full-time employee of ACGME, and another receives funds as a director for the American Board of Obstetrics and Gynecology. The remaining authors had no relevant financial disclosures. There was no outside funding for the study. Dr. Guntupalli said he had no conflicts of interest.

SOURCES: Gressel GM et al. Obstet Gynecol. 2020 Feb;135(2):268-73; Guntupalli SR. Obstet Gynecol 2020 Feb;135(2):266-7.

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