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A web-exclusive discussion on the complexities and the current landscape of gynecologic surgery.
Drs. Einarsson, Ascher-Walsh, Moawad, and Munro continue their conversation in a web-exclusive roundtable focused on the challenges associated with certification for today’s surgeons and how they differed from what surgeons faced in the past. The discussion also delves into the evaluation of surgical skills and how the surgical volume that today’s residents are graduating with impacts the specialty.
Ms. Wetzel: What challenges are associated with certification in gynecologic surgery today and how do they differ from what surgeons faced in the past?
Dr. Einarsson: One of the main challenges is that there is no objective evaluation of surgical skills built into the current system. We have excellent, well-monitored training programs. But when surgeons complete training and go into practice, they may not necessarily be able to maintain their skills. There is also no way of testing to determine if surgeons are maintaining as least the lowest acceptable standard of skills. I think objective evaluation is really needed. Surgery also has become much more complicated-more options, technology, and knowledge that surgeons have to acquire, adapt to, and maintain proficiency with.
Dr. Munro: But I’m not sure that gynecologic surgeons are getting excellent training. The training an individual gets has more to do with who the instructor is in the particular medical center than with any specific standards. The Council on Resident Education in Obstetrics and Gynecology (CREOG) does set standards for certification, but many residents don’t even get to see many of the procedures that they’re asked to be competent in performing. When I was in training, we did five vaginal hysterectomies a day, most of them on normal uteri. Now hysterectomy is far more likely to be performed in very complicated circumstances because of the focus on alternatives to surgery. The public today also is far more likely to look up surgeons to see how many procedures they’ve done and what experience they’ve had.
Dr. Moawad: I think that most of the problems arise from increasing of working hours. Conversely, reducing hands-on time would have important ramifications for surgical training because it relies on development of fine-motor skills, dexterity, and coordination. The root of the problem is lack of standardization of training because in many places, surgeons still train in apprenticeships. Branding of physicians in the eyes of public, to which Dr. Munro alluded, places pressure on hospitals and also makes it even more challenging for newer learners.
Dr. Einarsson: One challenge of ob/gyn residency training is that our residents have to master not only gynecologic surgery but also obstetrics. So, they don’t get as much time training in the operating room as general surgeons, urologists, or physicians in other surgical specialties. I think in surgery, residents graduating today may outperform ob/gyns who have been in practice for 5 years. That is because residents have a fairly decent volume of surgical cases during their training but actual ob/gyn practices often are obstetrics heavy. So a clinician’s surgical skills actually may go regress a little bit, which is bit concerning to me.
Dr. Munro: I always remember shaking the hand of my outgoing senior resident, who had just done his 600th vaginal hysterectomy. Current residents perform a tiny fraction of that number. The notion that we’re graduating people who still need to get experience while they’re practicing on patients is embarrassing, suboptimal, and possibly dangerous. Juxtapose that with all of the data available about numbers and types of cases and the spectrum of procedures gynecologic surgeons need to perform and put that in context of a litigiousness society and you’ve got a pretty problematic situation.
I really think the elephant in the room is that we aren’t training gynecologic surgeons properly. It’s really a specialty and obstetrics and gynecology residents can’t be adequately trained to do all the operations that are listed in the CREOG/ABOG guidelines during a 4-year program when they’re spending about 14 months in a surgical environment. We have a short training process and, in addition nationally, the training environment is diluted. In the United States, ob/gyn training is typically 4 years and there is one gynecologist for every 6,000 patients. Training is 5.7 years in Canada, 7 years in the UK, and 6 years in Australia, all of which have a ratio of approximately 1 gynecologist for every 25,000 individuals in the population.
Dr. Moawad: I completely agree with you but there are workload restrictions in Europe, and sometimes residents cannot work more than 48 hours a week. So, training is longer partially because of those restraints.
Dr. Munro: In a lot of countries, an ob/gyn cannot operate without doing an additional surgical fellowship. In Germany, for example, those without additional training are limited to becoming a community gynecologist – it would generally take at least another couple of years in an apprenticeship-type program before they can operate.
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Dr. Einarsson: That may actually be happening in the United States as well, slowly but surely. We’re graduating 30 fellows per year in minimally invasive surgery, which I would really just call gynecologic surgery, and I think they’re gradually taking up more of the volume, which makes it harder for generalists to compete. We may see an evolution similar to what happened in gynecologic oncology, which became a subspecialty in the 1970s after volume had moved gradually away from generalists to gynecologic oncologists. Outcomes are better in the hands of high-volume surgeons and in my opinion, I think the same is probably going to hold true for advanced benign surgery.
Dr. Munro: I totally agree with that.
Dr. Ascher-Walsh: I agree with Dr. Einarsson that we are naturally moving to a field where the majority of surgeries are being done by more high-volume surgeons. It is happening because patients are better educated and seeking out these surgeons. It is also happening because surgery is stressful in the best of hands but doing a dozen cases a year leaves the less experienced surgeons with greater anxiety when they do operate, and they therefore self-select to not do it. Also, dedicated OR time is difficult to come by at the larger institutions and the surgeons that rarely operate find it difficult to get OR time and it requires that they take off an entire day to do one or two cases. It isn’t financially worth it. All this said, though, we should not be letting this happen naturally but we should be driving this for the reason the others have been stating. Surgeries are safer in the hands of those with the experience. We should be tracking our residencies to generate surgeons by design, not by default.
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Dr. Moawad: The complexity and the landscape of gynecologic surgery also is completely different today. Before ultrasound and other treatments became available, vaginal hysterectomy was performed for abnormal uterine bleeding and sometimes even as a method of sterilization. Removal of completely normal uteri was not unusual. We have a moral imperative to ensure that our patients get the highest quality of care and they should not be treated by clinicians who have not demonstrated that they can operate safely and reliably.