Differences in early career operative experiences among pediatric urologists

Practice Patterns of Surgeons Seeking Board Certification in Urogynecology and Reconstructive Pelvic Surgery

INTRODUCTION

Physician shortages are expected to worsen, especially in subspecialties like Urogynecology and Reconstructive Pelvic Surgery (URPS). To meet increasing demand, our study compares clinic visits and surgeries/procedures in URPS by reviewing clinical logs to understand practice pattern nuances.

METHODS

URPS clinical logs from 2013 to 2021 were obtained from the American Board of Urology. Encounters were organized into URPS diagnostic groups, and the proportion of clinic visits to corresponding procedures was calculated. Multilevel mixed-effects logistic regression evaluated variability between surgeons, accounting for surgeon gender, age, certification status, and patient age.

RESULTS

Three hundred seventy URPS urologists submitted 383 424 clinic and 323 929 procedural encounters, with 49% being URPS-related. Urinary incontinence (UI) was the most common URPS-diagnosis. The overall proportion of clinic visit encounters to procedural/surgical encounters was 3.9:1, ranging from 1.5:1 to 111:1, depending on the diagnosis. The proportion decreases to 1.1:1 when diagnostic procedures are included in surgeries. Multilevel regression identified that 14% of the variance in our proportion was explained by variation between physicians' practice (interclass correlation, clustering of patients under a physician). In regression models we found that female surgeons had greater than 20% increased odds of evaluating patients in the clinic (vs. procedure) for the diagnoses of overactive bladder (OAB; OR = 1.27, 95% CI = 1.09-1.48, p = 0.002), stress UI (OR = 1.29, 95% CI = 1.07-1.56, p = 0.008), UI (OR = 1.32, 95% CI = 1.15-1.54, p < 0.001), and pelvic organ prolapse (POP; OR = 1.94, 95% CI = 1.56-2.41, p < 0.001).

CONCLUSION

Urologists applying for URPS certification perform 3.9 clinic visits for every 1 surgery, and 1.1:1 clinic visits for every procedure. We found variation was attributed to clustering under physicians (practice patterns) but also found physician gender to influence the odds of performing surgeries with women surgeons seeing more clinic patients and performing less surgeries for OAB, UI, and POP. Taken together our findings show that clinic encounters and diagnostic procedures represent a substantial portion of URPS practice.

CLINICAL TRIALS

This article is not presenting data from a clinical trial nor does it use human subjects. The data set is a deidentified retrospective log of cases.

The development of surgical ability during pediatric urology fellowship and its evolution in the early years of practice

BACKGROUND

North American Pediatric Urology fellowship programs underwent a structural change in 2021 that allows more flexibility in training. Given this opportunity as well as widespread concern about the development of contemporary surgical trainees, it is prudent to understand in detail the current state of preparedness of pediatric urology fellowship graduates for independent practice.

OBJECTIVE

The study aimed to determine recent pediatric urology graduates' reported levels of comfort both at graduation and following the start of clinical practice in performing select index procedures. We also queried the aspects of training and clinical practice perceived to be the most valuable for the development of surgical confidence.

STUDY DESIGN

Graduates of ACGME approved pediatric urology fellowships from 2016 to 2021 were surveyed. Index procedures were described via brief case vignettes. Respondents were asked to indicate their comfort level with each index procedure following fellowship graduation and at the current time point. Comfort levels were defined by the degree of support that respondents would seek from senior colleagues in preparation for case booking. Respondents were also asked about the most helpful operative settings during training and factors contributing to high and low comfort.

RESULTS

Fifty-three pediatric urologists (49%) completed the survey out of 109 invited. Most respondents practiced at an academic center. Perceived comfort was very high for low complexity procedures. The responses varied more widely for procedures of moderate and significant complexity (Figure). Across the cohort, there was a substantial increase in comfort between graduation and the current time point for all procedures queried. The most highly valued operative settings in fellowship were those offering real or simulated independence. Respondents most often attributed high comfort to robust case volumes and overall surgical skill gained in fellowship.

DISCUSSION

New pediatric urology faculty differ widely in surgical confidence, particularly for more complex procedures. There is meaningful growth in the confidence and self-perceived independence of pediatric urologists during their initial years of practice. The early years are a critical time of continuing maturation and development that should be supported with structured systems of mentorship. Future challenges include low case volumes for rare conditions and the centralization of complex care.

CONCLUSION

These findings will provide valuable context for pediatric urology fellowship directors as they evaluate and redesign their programs under the new, more flexible structure. There are opportunities to formalize early practice mentorship to support the growth of new faculty.

The ladder of learning in exstrophy closure - A 5 year initial faculty experience

PURPOSE

Closure of bladder exstrophy is one of the most complex reconstructive procedures. Basic concepts of these operations, as well as their subtle nuances, require years of experience. However, the volume of these cases is low. The authors describe the experience of a junior surgeon learning the details of exstrophy closure during fellowship and her initial career.

METHODS

Fellows graduating in 2014 were surveyed for their exstrophy experience during fellowship and the following four years. Operative logs of the junior faculty member were reviewed during the same time. Average operative times were calculated for each year.

RESULTS

Seventeen of the 25 fellows responded to the survey. Eight surgeons did one or fewer exstrophy closures during fellowship; 14 did one or fewer closures as an attending. The junior faculty member assisted in 18 closures as a fellow and 48 exstrophy closures during the next four years. Average operative time decreased from 485 to 309 min from attendingship year one to four.

CONCLUSIONS

There are subtle details inside and outside of the operating room required to ensure a successful outcome in this important step of exstrophy reconstruction. Working alongside senior colleagues is essential to allow the junior surgeon to ascend this ladder of mastering exstrophy closure.

TYPE OF STUDY

Diagnostic.

LEVEL OF EVIDENCE

V.

Proportion of female recipients of resident-selected awards across Canada from 2000 to 2018: a retrospective observational study

BACKGROUND

Female physicians have been shown to receive fewer awards from medical societies than their male colleagues. We examined the sex distribution of recipients of Canadian residency association awards.

METHODS

We conducted a retrospective observational study of the sex of staff and resident physician recipients of resident-selected awards from provincial and national residency associations using data from 2000-2018. We classified awards into professionalism, advocacy and wellness awards, and education and teaching awards based on award names and descriptions, and compared the proportion of male and female recipients in these categories.

RESULTS

We identified 314 recipients of staff physician awards and 129 recipients of resident physician awards. Male staff and resident physicians had higher odds of receiving awards than their female counterparts (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.13-1.89 and OR 1.70, 95% CI 1.18-2.46, respectively). There was a reduction in the odds of male residents' receiving an award over the study period (OR 0.94, 95% CI 0.90-0.98). Male physicians had higher odds of receiving education and teaching awards than female physicians as staff but not as residents (OR 3.21, 95% CI 1.72-5.95 and OR 1.96, 95% CI 0.84-4.60, respectively).

INTERPRETATION

Male staff and resident physicians in Canada had higher odds of receiving awards from provincial and national residency associations between 2000 and 2018 than their female counterparts. Given this disparity, it would be prudent for organizations that distribute awards to physicians, residents and medical students to examine their nomination criteria and processes for potential bias.