Obstetrics and gynecology (ObGyn) is a surgical specialty, yet the training of ObGyn residents differs significantly from that of residents in other surgical specialties. In addition to attaining competency in both the distinct but related fields of obstetrics and gynecology, ObGyn residents have their training condensed into 4 years rather than the 5 years’ training of many other surgical specialties. This limits the time dedicated to gynecologic surgery, currently 18 to 20 months in most programs, and has been exacerbated by tighter duty-hour restrictions.1
Additionally, with increasing demand for minimally invasive procedures, residents are expected to attain competency in a growing breadth of gynecologic procedures in a patient population with increasing morbidity, and they may have less autonomy to do so in an increasingly litigious environment.2 Furthermore, annual hysterectomy cases are declining, from about 680,000 in 2002 to 430,000 in 2010,3 and these declining rates are seen in the low case numbers of recent graduates.4
Training time, procedure complexity
With less time to master a growing body of increasingly complex procedures, is the profession adequately training gynecologic surgeons? Many gynecologic surgeons are concerned that the answer is no and that significant shifts in resident training are needed to generate safe and competent gynecologic surgeons. These training deficits represent a deficiency in the quality of care for women specifically, and thus the inattention to training gynecologic surgeons should be considered a health care disparity.
The concern over insufficient attention to gynecologic surgical training is not new, nor are proposed solutions, with many physicians citing the above concerns.5-9 In 2018, the Accreditation Council for Graduate Medical Education (ACGME) case minimums for hysterectomy increased to 85 from 70 hysterectomies, with a shift toward minimally invasive hysterectomy.10 Otherwise, minimal national changes have been made in this century to training gynecologic surgeons.
Tracking as an option
Many critics of current ObGyn training argue that obstetrics and gynecology, while related, have significantly different pathologies, surgical approaches, and skill sets and thus warrant the option to track toward obstetrics or gynecology after attaining limited core skill set in residency. In 2010, the Carnegie Foundation for the Advancement of Teaching called for the need for increased individualization opportunities in graduate medical education, citing that minimal changes have been made to medical education since the Flexner Report a century prior.11
Notably, tracking has been implemented with success at Cleveland Clinic, where residents are given 5 to 10 weeks of time allotted to their specific fields of interest, while still meeting minimum ACGME requirements and, in some cases, exceeding hysterectomy minimums by as much as 500%.12 Tracking is viewed positively by a majority of program directors.13 See the box below for Dr. Ferrando’s experience on tracking at the Cleveland Clinic.
Other educators advocate for maximizing preparedness for the operating room by using high-fidelity simulation.14,15 Simulation allows for the acquisition of basic technical skills needed for surgery as well as for repetition not easily achieved in the current surgical environment. Additionally, it provides lower-level learners the opportunity to acquire basic skills in a safe setting, thereby enhancing the ability to participate meaningfully on arrival in the operating room.16
In 2018, the American Board of Obstetrics and Gynecology added the Fundamentals of Laparoscopic Surgery certification as a new requirement for board certification.17 Laparoscopic and robotic surgery simulators allow trainees to develop coordination and specific skills, like knot tying and suturing. Additionally, models are available with varying levels of fidelity for vaginal and abdominal hysterectomy.18-20 See the box below for Dr. Miyazaki’s experience in developing the Miya Model trainer for vaginal surgery simulation.
Finally, if a resident has limited exposure to a specific procedure, maximizing the preparation and feedback for each procedure is paramount. However, surgeons receive minimal formal training in teaching trainees, which leads to inconsistent and underutilized feedback.21 Specific structured feedback models have been implemented with success in the general surgery literature, including the SHARP (Set learning objectives, How did it go, Address concerns, Review learning points, Plan ahead) and BID (Briefing, Intraoperative, Debriefing) models.22,23
While surgical reimbursement is not directly tied to resident education, decreased reimbursement to women’s health pathology and procedures has the downstream effect of decreasing the funds available for ObGyn departments to invest in research and education. Additionally, “suboptimal mastery or maintenance of appropriate surgical skills results in procedural inefficiencies that compound surgical cost.”5 Providers and payors alike should therefore be motivated to improve funding in order to improve adequate training of gynecologic surgeons. Payment reform is necessary to equally value women’s health procedures but also can ensure that gynecologic surgeons have the funds needed to train a competent next generation of ObGyn physicians. ●
- Residents and fellows have significant constraints that limit adequate training in gynecologic surgery. In a panel discussion at the 48th annual meeting of the Society of Gynecologic Surgeons, Drs. Zimmerman, Ferrando, and Miyazaki spoke about potential solutions.
- Allowing residents to track toward obstetric or gynecologic subspecialties may improve surgical volume of trainees who aim for a future career in gynecologic surgery.
- Simulation has demonstrated efficacy in enabling residents to prepare and improve their technical skills for specific procedures prior to entering the operating room.
Cecile A. Ferrando, MD, MPH
In his 2013 presidential address at the opening ceremony of the 42nd AAGL Global Congress on Minimally Invasive Gynecology, Javier Magrina, MD, asked the audience, “Isn’t it time to separate the O from the G?”7 Since that address, this catchy question has been posed several times, and it continues to be a topic of interest to many ObGyn educators seeking to innovate the curriculum and to better train our next generation’s gynecologic surgeons.
Several concerns have been raised about the current traditional 4-year residency training program, which has been impacted by the reduction of training hours due to duty-hour rules in the setting of decreased surgical volume and new technologies used to perform surgery. While other surgical specialties have begun to innovate their pathways for trainees, ObGyn has been a little slower to make a significant transition in its approach to training.
In 2012, Cleveland Clinic decided to lead the way in innovation regarding residency training. At its inception, the curriculum was designed to allow “tracking blocks” through each academic year to allow residents to gain additional experience in their specialty of choice. The program was carefully designed to assure that residents would achieve all 28 of the core obstetrics and gynecology milestones while still allowing for curricular flexibility.
Currently, residents are given autonomy to design their own tracking blocks with an assigned mentor for the rotation. Allowing residents to spend more time in their specialty of choice permits them to fine-tune skills that a standard curriculum may not have afforded the opportunity to home in on. It also allows residents to gain exposure to specialties that are not part of the core program, such as vulvar health, breast health and surgery, and gender affirmation surgery.
The Cleveland Clinic experience has been successful thus far. Importantly, preliminary data show that the tracking program does not interfere with the overall case number necessary for graduation. Residents also have succeeded in their postgraduation pursuits, including those who chose to specialize in general obstetrics and gynecology.
Cleveland Clinic is no longer the only program to incorporate tracking into its curriculum. This innovation is likely to become more standard as medical education in ObGyn evolves. We have not yet “separated the O from the G” completely in our specialty. However, thought leaders in our field are recognizing the need to better prepare our trainees, and this flexibility in mindset is bound to lead to a paradigm that may become the new standard for our specialty.
Acknowledgments: John E. Jelovsek, MD, the first Program Director of the Cleveland Clinic Residency in Obstetrics & Gynecology, who was responsible for creating the tracking program; and Vicki Reed, MD, the current Program Director, who has continued to innovate the program.
The Miya Model (Miyazaki Enterprises LLC) is a multiprocedural vaginal surgery simulator born from the need for standardized, scalable training in response to reductions in the average surgical case volume per resident. The Miya Model supports various basic procedures, such as pelvic exams and dilation and curettage, as well as full surgical procedures, including anterior and posterior colporrhaphy, midurethral and retropubic slings, cystoscopy, and vaginal hysterectomy. Training with the Miya Model moves resident surgical education from the operating room to any simulation lab or office-based setting. With rapidly declining resident surgical case volumes, there is an even stronger need to provide additional training outside of the operating room theater. Creation and development of the Miya Model were fueled by a desire to create a safer and more efficient method to educate residents without the risk of patient harm.
Miyazaki Enterprises has taken the Miya Model from a vision on paper to a standardized, commercially available product to help support resident and physician education. The Miya Model has undergone numerous rounds of waterfall and agile development, validity testing, and the creation of internal and external processes to achieve this vision. It serves as an example that ideas originating from significant demonstrated market need can be successfully created and deployed by a physician.