The fellowship effect: how the establishment of a fellowship in female pelvic medicine and reconstructive surgery affected resident vaginal hysterectomy training




Objective


We report on trends in resident-performed vaginal hysterectomies before and after the establishment of a female pelvic medicine and reconstructive surgery fellowship at Vanderbilt University Medical Center.


Study Design


We examined medical records and resident self-reports concerning all hysterectomies at our institution in an 8-year period: 4 years before fellowship and 4 years after. Route of hysterectomy, resident and fellow involvement, and division of attending surgeon were recorded from the electronic medical record. Resident Accreditation Council for Graduate Medical Education (ACGME) case log data were used to estimate the number of hysterectomies where residents reported themselves as the primary surgeon.


Results


During the 8-year period of this study, 3317 hysterectomies were performed at our institution, 41% (1371) before and 59% (1946) after fellowship. Prior to fellowship, 29% (393) were vaginal, 56% (766) were abdominal, and 15% (212) were laparoscopic/robotic. After addition of fellowship, 23% (449) were vaginal, 31% (597) were abdominal, and 46% (900) were laparoscopic/robotic. Of the total vaginal hysterectomies (TVH), there was resident involvement in 98.0% (385) cases before fellowship and 98.2% (441) cases after fellowship. From the ACGME case log data, the resident identified himself/herself as the primary surgeon in 388 cases before and 393 cases after fellowship. During this time period, medical records indicate a fellow was involved in 42% (189) of TVH, with resident involvement in all but 5 of these procedures.


Conclusion


Frequency of resident involvement in TVH cases, either as primary surgeon or team member, remained constant after the addition of the female pelvic medicine and reconstructive surgery fellowship.


The American College of Obstetrics and Gynecology states that “vaginal hysterectomy is the approach of choice [for hysterectomy] whenever feasible” ; however, feasibility depends on the surgeon’s level of experience. This statement is based on the minimally invasive nature of a vaginal hysterectomy and data showing higher rates of complications, including lower urinary tract injuries, with laparoscopic and abdominal hysterectomies. Current trends show that fewer inpatient procedures, including vaginal and abdominal hysterectomies, are being performed due to the increase in laparoscopic/robotic route. Given this, there is a concern within the field and among residents that trainees may not be adequately proficient performing a vaginal hysterectomy after graduating from residency. The current average number of vaginal hysterectomies performed by an obstetrician/gynecologist resident during his/her 4 years of training is 19 with the minimum number required being 15.


For the majority of residents, their official surgical training ends with residency; thus, maintaining surgical volume during training is a key priority. With the recent board certification of the subspecialty of female pelvic medicine and reconstructive surgery (FPMRS), fellowships have increased in number and the impact of this on resident surgical volume is not known. A common question that medical students ask current residents is how the fellows impact their training, specifically in the role of vaginal hysterectomies. In an attempt to answer this question, we report on trends in resident-performed vaginal hysterectomies before and after the establishment of an FPMRS fellowship at Vanderbilt University Medical Center. The primary objective of our study was to evaluate the number of vaginal hysterectomies performed by obstetric and gynecology residents before and after the establishment of the FPMRS fellowship. Given changes in practice patterns during this time period, secondary objectives included evaluating trends in route of hysterectomy, the presence of a fellow during the hysterectomy, and the specialty of the attending surgeon.


Materials and Methods


This is a retrospective analysis of all hysterectomy cases performed by the Department of Obstetrics and Gynecology at Vanderbilt University Medical Center from July 1, 2004, through June 30, 2012. This time period was chosen as it encompasses the 4 years prior to and 4 years following the establishment of an FPMRS fellowship within the department. This study was institutional review board approved. Data were collected from 2 distinct sources: the electronic medical record (EMR) and Accreditation Council for Graduate Medical Education (ACGME) resident case logs. The EMR provided information on the presence of residents and fellows in the operating room and the total number of hysterectomies performed by the department, but lacked information on the degree of resident involvement in the case. The ACGME resident case logs contain the number of hysterectomies in which the resident felt that s/he performed >50% of the case, but lack patient identifiers and cannot be linked to cases in the EMR.


From the EMR, all hysterectomies performed during this time period were identified by Current Procedural Terminology codes (abdominal [58180, 58152, 58180, 58200, 58210], vaginal [58260, 58262, 58263], and laparoscopic [58570, 58571]) and confirmed by manual review of operative notes. For each case the following data were recorded: date of procedure, mode of hysterectomy, presence of resident in the case, presence and type of a fellow in the case (FPMRS, minimally invasive fellow), and departmental division of the attending faculty member (urogynecology/FPMRS, minimally invasive surgery, gynecologic oncology, general obstetrics/gynecology, and gynecology). The mode of hysterectomy was categorized as abdominal, vaginal, or laparoscopic/robotic. Laparoscopic-assisted vaginal hysterectomies (LAVH) were included in the vaginal hysterectomy numbers. These categories were chosen to be consistent with recording via the ACGME case log. Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at Vanderbilt University. REDCap is a secure, World Wide Web–based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.


The ACGME case log data on resident surgical experience were obtained for the same time period. Residents recorded whether they operated for >50% of the case or if they acted as an assistant (performed <50% of the case). Date and mode of hysterectomy (abdominal, vaginal, laparoscopic/robotic) were recorded, as well as the postgraduate year (PGY) of the resident at the time the case was performed (PGY1-4). Per ACGME guidelines, LAVH were coded as vaginal hysterectomies.


Descriptive statistics were computed and graphed for each of the 8 academic years, stratifying the self-reported residency data by hysterectomy type and resident or attending classification. Descriptive statistics were calculated by type of hysterectomies performed at Vanderbilt University Medical Center from Vanderbilt’s EMR. However these data are case based and they could not be linked with aforementioned self-reported data from residents. Trends over time in both data sets are presented in tables and figures. Note that formal hypothesis testing was not conducted and is not warranted, because these data comprise the entire population of residents or cases for a given year. Hence any difference in statistics or patterns observed from year to year, no matter their magnitude, are in fact true differences (whether clinically meaningful or not).




Results


A total of 3464 hysterectomies were identified by Current Procedural Terminology codes, of which 147 cases were excluded after manual review due to coding errors. Of the 3317 hysterectomies performed during this 8-year time period, 842 (25.4%) were total vaginal hysterectomy (TVH), 1112 (33.5%) were laparoscopic/robotic, and 1363 (41.1%) were abdominal. Hysterectomy numbers increased during the time period of this study: 1371 hysterectomies were performed in the 4 years prior to the FPMRS fellowship and 1946 in the 4 years after initiation of the fellowship. At the start of this study, in 2005, the total number of hysterectomies performed was 304. This increased to 559 in 2012 ( Figure ). For TVH numbers, there were 393 (28.7%) performed prior to fellowship and 449 (23.1%) performed afterward. Because the TVH and LAVH cases are grouped as 1 category in the ACGME case logs, the same methodology was used for the EMR data collection. To give an idea of what percentage of our TVH cases were actually LAVH, we extracted that information. When looking at the EMR data: of the 393 TVH performed prior to fellowship, 67 (17%) were LAVH, and of the 449 TVH performed after fellowship, 71 (16%) were LAVH. However, from this point throughout the manuscript, the TVH number refers to the combined number of TVH and LAVH procedures. Resident involvement was similar between the 2 methods of data collection. Through the EMR, a resident was present in 385 (98.0%) of all TVH before fellowship and in 441 (98.2%) after fellowship. In the ACGME resident case logs, residents recorded themselves as the primary surgeon in 388 TVH cases before fellowship and 393 cases after fellowship ( Table 1 ). There is mild discrepancy in these numbers, likely related to coding errors and the use of 2 different data sets. When separated out by PGY, residents PGY1-3 were performing more vaginal hysterectomies after the initiation of fellowship. Interns performed 2 TVH in the 4 years before fellowship compared to 5 afterward; PGY2 residents performed 14 before and 23 after; and in PGY3, residents recorded themselves as primary surgeon in 45 TVH before fellowship and 131 afterward ( Table 2 ).




Figure


Total hysterectomies performed at Vanderbilt University from 2005 through 2012

Total number of hysterectomies performed in 8-year time period at Vanderbilt University Medical Center. These are also separated between route of hysterectomy (total vaginal hysterectomy [TVH], laparoscopic hysterectomy [LH], total abdominal hysterectomy [TAH]).

Danford. FPMRS fellowship effect on resident vaginal hysterectomy training. Am J Obstet Gynecol 2014 .


Table 1

Total number of hysterectomies compared with resident hysterectomies


































































































































































Variable Total (EMR) Resident (EMR) Resident (Self reported)
TVH AH LH All TVH AH LH All TVH AH LH All
Pre-fellowship
2005 105 193 6 304 103 182 5 290 90 139 25 254
2006 95 209 19 323 91 200 18 309 102 218 39 359
2007 91 199 69 359 91 185 60 336 58 219 41 318
2008 102 165 118 385 100 158 95 353 138 213 22 373
Post-fellowship
2009 104 157 150 411 104 155 139 398 88 173 119 380
2010 110 168 189 467 108 167 172 447 95 173 161 429
2011 108 145 256 509 102 138 240 480 93 155 187 435
2012 127 127 305 559 127 126 254 507 117 134 210 461

AH , abdominal hysterectomy; EMR , electronic medical record; LH , laparoscopic hysterectomy; TVH , total vaginal hysterectomy.

Danford. FPMRS fellowship effect on resident vaginal hysterectomy training. Am J Obstet Gynecol 2014 .


Table 2

Mode of hysterectomy separated by postgraduate year



























































































































































































































































Variable PGY 1 PGY 2 PGY 3 PGY 4
n TVH AH LH All n TVH AH LH All n TVH AH LH All n TVH AH LH All
Pre-fellowship
2005 6 0 3 0 3 6 5 22 0 27 6 10 18 3 31 6 75 96 22 193
2006 6 0 2 0 2 6 3 9 0 12 6 6 21 0 27 6 93 186 39 318
2007 4 2 11 5 18 7 3 33 7 43 6 0 18 0 18 6 53 157 29 239
2008 6 0 2 0 2 5 3 20 1 24 7 19 49 8 76 6 116 142 13 271
Post-fellowship
2009 6 5 3 12 20 6 3 28 21 52 5 0 11 0 11 7 80 131 86 297
2010 6 0 1 5 6 6 2 22 31 55 6 41 50 52 143 5 52 100 73 225
2011 6 0 2 11 13 5 5 11 33 49 6 43 49 52 144 6 45 93 91 229
2012 6 0 3 15 18 6 13 18 61 92 6 47 40 40 127 6 57 73 94 224

AH , abdominal hysterectomy; LH , laparoscopic hysterectomy; PGY , postgraduate year; TVH , total vaginal hysterectomy.

Danford. FPMRS fellowship effect on resident vaginal hysterectomy training. Am J Obstet Gynecol 2014 .


Fellow presence at TVH increased over the 4 years after initiation of the fellowship. There was a fellow present in the operating room for 21 of the 105 TVH in the first year of fellowship and in 77 of 127 of the cases in the fourth year. The total fellow involvement over the 4 years was 197 of 449 cases (43.9%). When looking at cases that had both a resident and a fellow present, there were 192 of the total 449 cases. Therefore, of the 197 cases with a fellow present, there were 5 that did not have a resident present ( Table 3 ).


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May 10, 2017 | Posted by in GYNECOLOGY | Comments Off on The fellowship effect: how the establishment of a fellowship in female pelvic medicine and reconstructive surgery affected resident vaginal hysterectomy training

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