Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017

Complex obstetrical surgery: building a team and defining roles

As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.

Vesicovaginal Fistula Repair Simulation Model and Hierarchical Task Analysis

IMPORTANCE

There is a need for surgeons skilled in vesicovaginal fistula (VVF) repair, yet training opportunities are limited.

OBJECTIVES

This study aimed to create a low-fidelity simulation model for transvaginal VVF repair, identify essential steps of VVF repair, and evaluate the model's ability to replicate essential steps.

STUDY DESIGN

First, a low-fidelity VVF repair simulation model was designed and built by the authors. Next, a hierarchical task analysis was performed by urogynecologic surgeons with expertise in VVF repair. Each expert submitted an outline of tasks required to perform VVF repair. To control for bias, an education specialist de-identified, reviewed, and collated the submitted outlines. The education specialist then led a focus group, and through a modified Delphi process, the experts reached consensus on the essential steps. A separate group of urogynecologic surgeons then tested the model and completed an anonymous questionnaire assessing how well the model replicated the essential steps. Descriptive analyses were performed.

RESULTS

Five experts submitted an outline of steps for transvaginal VVF repair, and 4 experts participated in a focus group to reach consensus on the essential steps. Nine urogynecologic surgeons, with a median of 10 years in practice (interquartile range, 7-12 years), tested the model and completed the postsimulation questionnaire. Most testers thought that tasks involving identification and closure of the fistula were replicated by the model. Testers thought that tasks involving cystoscopy or bladder filling were not replicated by the model.

CONCLUSIONS

We developed a novel, low-fidelity transvaginal VVF repair simulation model that consistently replicated tasks involving identification and closure of the fistula.

Role of simulation-based training and assessment to improve brachytherapy competency among radiation oncology residents

Simulation is a technique used in healthcare to replicate clinical scenarios and improve patient safety, efficacy, and efficiency. Simulation-based medical education facilitates training and assessment in healthcare without increasing risk to patients, supported by ample evidence from surgical/procedural specialties. Simulation in radiation oncology has been leveraged to an extent, with successful examples of both screen-based and hands-on simulators that have improved confidence and performance in trainees. In the current era, evidence substantiates a significant deficit in brachytherapy procedure education, with radiation oncology residents reporting low confidence in this procedural skill, largely attributable to insufficient caseloads at some centers. Simulation-based medical education can facilitate structured training and competency-based assessment in brachytherapy skills. This review discusses existing advances and future directions in brachytherapy simulation, using examples from simulation in surgical specialties.

Procedure-specific simulation for vaginal surgery training: A randomized controlled trial

INTRODUCTION

Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence.

MATERIAL AND METHODS

We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05).

CLINICALTRIALS

gov: Registration no. NCT05887570.

RESULTS

We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups.

CONCLUSIONS

Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Shifting trends and sicker patients: Reassessing hysterectomy performed for benign indications by gynecologic oncologists

OBJECTIVE

To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO).

METHODS

This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends.

RESULTS

Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (β = 0.41, R2 = 0.71,p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (β = -0.47, R2 = 0.90, p < 0.01), but GO did not (β = -0.36, R2 = 0.38, p = 0.10).

CONCLUSIONS

GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG.

Trends in orthopaedic surgery resident case volume and the impact of COVID-19 on resident education

Introduction

COVID-19 had numerous objective and subjective effects on resident physician education. We intended to examine objective changes in orthopedic education that occurred during the COVID pandemic and other trends from 2018 to 2022 by analyzing surgical case logs from Accreditation Counsel for Graduate Medical Education (ACGME) approved American orthopedics programs. We hypothesized that surgical case load during the COVID pandemic would remain similar to pre-pandemic levels and case logs would show a general upward trend.

Methods

We analyzed 3146 resident case-logs from the ACGME national case-log report from academic years (AY) 2018-2022. Surgical cases were classified by their Current Procedural Terminology (CPT) codes and grouped by anatomical location (shoulder, hand, etc.).

Results

From AY 18-19 to "peak pandemic" AY 19-20, resident caseloads either had no change or increased in every orthopedic discipline with few exceptions. Residents performed fewer shoulder (p < 0.0001), wrist (p = 0.0023), knee (p < 0.0001) and leg/ankle (p = .0019) arthroscopies in AY 19-20 than AY 18-19. Hip arthroscopy was notably unchanged. Oncology, Spine, and Foot/Toes did not see any change from AY 18-19 to 21-22 while Microsurgeries decreased (p = .0061). There were substantial differences between high volume (90th percentile) residents, and low volume (10th percentile) residents. All other anatomic areas saw significant increases in caseload over those four academic years.

Discussion/conclusion

COVID had numerous effects on the orthopedic residency experience, however, any decreases in operative load were small, and largely isolated to the 19-20 AY. Microscopic and arthroscopic surgeries decreased during peak pandemic AY 19-20 when elective surgeries experienced cancellations. This illustrates that these areas of orthopedic education may be supplemented outside of the operating room if similar circumstances arise in the future. Otherwise, resident surgical caseloads continue to rise and show no signs of slowing.

Trends in Urogynecologic Surgery Among Obstetrics and Gynecology Residents From 2002 to 2022

IMPORTANCE

The number of American women with a pelvic floor disorder is projected to increase from 28.1 million in 2010 to 43.8 million in 2050.

OBJECTIVES

The objective of this study was to evaluate trends in the number of urogynecologic procedures performed by graduating obstetrics and gynecology residents and to compare variability in volume between residents in the 70th and 30th percentiles for logged cases.

STUDY DESIGN

National case log measures for residents who graduated between 2003 and 2022 were reviewed. Mean case numbers and variability in case numbers were analyzed over time.

RESULTS

Data were collected from a median of 1,216.5 residents (range, 1,090 to 1,427) annually. Mean number of vaginal hysterectomies logged per resident decreased by 46.4% from 2002/2003 to 2021/2022 ( P = 0.0007). Mean number of urogynecology procedures increased by 1,165.5% from 2002/2003 to 2007/2008 ( P = 0.0015). Mean number of incontinence and pelvic floor procedures (including cystoscopies) increased by 190.9% from 2002/2003 to 2011/2012 ( P = 0.0002). Mean number of incontinence and pelvic floor procedures (excluding cystoscopies) decreased by 39.7% from 2012/2013 to 2021/2022 ( P < 0.0001). Mean number of cystoscopies increased by 19.7% from 2012/2013 to 2021/2022 ( P < 0.0001). Ratios of cases logged by residents in the 70th percentile to those in the 30th percentile decreased for vaginal hysterectomies and cystoscopies ( P < 0.0001 and P = 0.0040, respectively). The ratio for incontinence and pelvic floor procedures (excluding cystoscopies) was 1.76 in 2012/2013 and 2.35 in 2021/2022 ( P = 0.2878).

CONCLUSION

Resident surgical training in urogynecology is decreasing nationally.

The routes of hysterectomy: A survey of current practices amongst members of the International Society for Gynaecologic Endoscopy (ISGE)

OBJECTIVE

This study aimed to explore the current opinion on the routes of hysterectomy amongst the members of the International Society for Gynaecologic Endoscopy (ISGE), as well as the perceptions of potential barriers that inhibit gynaecologists from offering a minimally invasive hysterectomies (MIHs) to their patients.

STUDY DESIGN

An anonymous, electronic survey was designed, including the questions about the surgeon location and length of gynaecological practice, preferred approach to hysterectomy, approximate number of surgical cases performed during the year preceding the survey (2021), and potential barriers and contraindications to performing MIHs. It was validated by 12 practicing gynaecologists. Subsequently, the survey was sent to all practicing gynaecologists who are the members of the ISGE.

RESULTS

We received a response from 159 members of ISGE (29 % response rate), of which 92 % with ≥ 5 years in practice since the completion of their residency training in Gynaecology and Obstetrics. When asked about the preferred route of hysterectomy for themselves or their relatives, 59 % chose total laparoscopic hysterectomy (TLH), 19 % vaginal hysterectomy (VH), 8 % chose laparoscopically-assisted vaginal hysterectomy (LAVH) and 5 % chose total abdominal hysterectomy (TAH). However, TAH was the most performed hysterectomy procedure undertaken by the respondents in the year preceding the survey. When asked about the main obstacles to performing MIHs, more than half of the respondents highlighted insufficient training during residency and insufficient surgical experience. Only 25 % of the responders acknowledged reading the ISGE guidelines on performing vaginal hysterectomy.

CONCLUSIONS

Contrary to a full understanding of the benefits of MIHs, lack of training, as well as insufficient surgical experience and unawareness of existing evidence-based guidelines were the main reasons for the high rate of TAH among the ISGE members who participated in the study. All efforts should be directed at teaching VH and TLH techniques during residency, continuous acquisition of practical experience, and use of validated patient selection guidelines for MIH in daily clinical practice.

Longitudinal Changes in the Operative Experience for Junior Urology Residents

OBJECTIVE

To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency.

METHODS

Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression.

RESULTS

A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05).

CONCLUSION

There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning

The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.

Beef Tongue Surgical Simulation Model for Posterior Vaginal Repair

BACKGROUND

This surgical simulation model for vaginal posterior repair is designed to enhance vaginal surgical training.

METHODS

A beef tongue simulation model was previously described and validated to practice the repair of obstetric laceration. The model was modified for surgical simulation of vaginal posterior repair. Chicken skin was used to simulate the anal canal. The model was secured in a PVC (polyvinyl chloride) pipe attached to a wooden base to simulate operating within the vaginal canal.

EXPERIENCE

Materials can be obtained from the local supermarket and hardware store. The total cost of the model is $35.47 for initial setup and $7.11 per use. Residents performing on the model felt it was realistic and useful for practicing the steps and skills for this procedure.

CONCLUSION

The beef tongue simulation model of vaginal posterior repair is realistic, easy to construct, and affordable. It can be incorporated into a vaginal surgery curriculum to augment resident surgical education.

Reported case numbers and variability in delivery route and volume by obstetrics and gynecology residents from 2003 to 2019

BACKGROUND

The obstetrical landscape in the United States has changed over the past several decades, during which there has been a decline in the number of operative vaginal deliveries performed. Procedural cases of obstetrics and gynecology residents are tracked in the Accreditation Council for Graduate Medical Education database, with a minimum requirement of 15 operative vaginal deliveries before graduation. Nowadays, it is unknown whether the decreasing numbers of operative vaginal deliveries are affecting the delivery case volume and experience of obstetrics and gynecology residents.

OBJECTIVE

This study aimed to analyze the trends in the number and route of obstetrical deliveries, including operative vaginal deliveries, performed by graduating obstetrics and gynecology residents in the United States as logged within the Accreditation Council for Graduate Medical Education database.

STUDY DESIGN

The Accreditation Council for Graduate Medical Education case log data were examined for graduating obstetrics and gynecology residents between 2003 and 2019. Delivery case volume numbers for spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery were extracted and analyzed over time using linear regression. To compare the variability in logged cases, residents at the 70th percentile for number of cases logged were compared with residents at the 30th percentile for number of cases logged for each delivery type (spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery).

RESULTS

Overall, obstetrical delivery data for 20,268 obstetrics and gynecology residents were collected from 2003 to 2019. Over this period, the mean number of spontaneous vaginal deliveries significantly decreased over time by 20% from 320.8±138.7 to 256.1±75.6 (slope, -2.6; P<.001); however, no significant difference was noted in the reported cesarean delivery cases, with an 8% increase from 191.8±80.1 to 206.8±69.7 per graduating resident (slope, 0.136; P=.873). Notably, the mean reported cases of forceps-assisted vaginal deliveries decreased by 75% from 23.8±21.9 to 6±6.8 per graduating resident (slope, -0.851; P<.001). Similarly, the mean logs of vacuum-assisted vaginal delivery decreased by 37% from 23.8±17.1 to 15±9.5 (slope, -0.542; P<.001). The ratio of reported resident case logs comparing the volume at the 70th percentile with the volume at the 30th percentile demonstrated a significant decrease over time for spontaneous vaginal delivery (slope, -0.015; P<.001), cesarean delivery (slope, -0.015; P<.001), and vacuum-assisted vaginal delivery (slope, -0.033; P<.001) but was significantly increased for forceps-assisted vaginal delivery (slope, 0.07, P=.0065).

CONCLUSION

In the reported Accreditation Council for Graduate Medical Education case logs, we identified that the reported number of obstetrical deliveries performed by obstetrics and gynecology residents in the United States is changing, with a significant decline recognized from 2003 to 2019 in logged numbers of spontaneous vaginal deliveries, vacuum-assisted vaginal deliveries, and forceps-assisted vaginal deliveries, without a difference in reported cesarean delivery cases per graduating resident. Furthermore, substantial variation is seen among resident volume nationwide, with the difference in high- and low-volume resident forceps-assisted vaginal delivery experience increasing over time. Awareness of these data should notify the Accreditation Council for Graduate Medical Education and educators about reasonable targets, increased need for simulation, and new ways to teach all modes of deliveries effectively in all residency programs.

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital

Study Objective

The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital.

Design

Retrospective cohort study.

Setting

Tertiary care academic medical center in New York City.

Patients

Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020.

Interventions

March 16 institutional moratorium on elective surgeries.

Measurements and Main Results

The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre–COVID-19 time frame (February 1–March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16–April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant.

Conclusion

This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question “Where have all the emergencies gone?” Although the moratorium on elective procedures was necessary, “elective” GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

Ready for the robot? A cross-sectional survey of OB/GYN fellowship directors' experience and expectations of their incoming fellow's robotic surgical skills

To describe OB/GYN fellowship directors' (FDs) observations, expectations, and preferences of incoming fellow's robotic surgery preparedness. Cross-sectional study. OB/GYN FDs in gynecologic oncology, minimally invasive gynecologic surgery, female pelvic medicine and reconstructive surgery, and reproductive endocrinology and infertility in the United States. 60 FDs answered the questionnaire. Participants completed an online questionnaire about their preferences and expectations of robotic surgery experience for incoming fellows. FDs observed that many incoming first-year fellows had a baseline understanding of robotic technology (60%) and robotic bedside assist experience (53%). However, few could perform more advanced robotic tasks; with FDs indicating fellows could infrequently robotically suture (18%), or perform the entire hysterectomy (15%). FDs reported higher composite observation than expectation scores (34.3 versus 22.2, p < 0.0001), and higher preference than expectation scores (34.0 versus 22.2, p < 0.0001). The composite expectation score of high-volume divisions was greater than of low-volume divisions (23.7 versus 14.0, p = 0.04). Among the domains identified, FDs most strongly preferred their fellows be able to bedside assist, have a basic understanding of robotic technology, and have basic robotic operative skills. While incoming fellows have more robotic skill than their FDs expect, few are deemed competent to independently operate the robot. Higher volume robotic surgery divisions have higher expectations of the robotic skills of their incoming fellows compared to low-volume divisions; however, FDs neither expected nor preferred their incoming fellows to be fully competent in all aspects of robotic surgery.