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G. Cundiff, V. Handa, J. Bienstock (2002)Longitudinal impact of a female pelvic medicine and reconstructive pelvic surgery fellowship on resident education.
American journal of obstetrics and gynecology, 187 6
A. Lightfoot, H. Rosevear, W. Steers, Chad Tracy (2011)Current and future need for academic urologists in the United States.
The Journal of urology, 185 6
Arab Journal of Urology (2013) 11, 113–116 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com URODYNAMICS/FEMALE UROLOGY REVIEW Establishing the subspecialty of female pelvic medicine and reconstructive surgery in the United States of America William D. Steers Department of Urology, University of Virginia School of Medicine, Charlottesville, VA, USA Received 28 December 2012, Received in revised form 16 January 2013, Accepted 17 January 2013 Available online 15 March 2013 KEYWORDS Abstract Objective: In this review I describe the history leading to the creation of the subspecialty of female pelvic medicine and reconstructive surgery and its fellow- Female urology; ships, the process involved in the current requirements for subspecialty certiﬁcation Female pelvic medicine and fellowship applications, and the implications for urological training. and reconstructive sur- Results and conclusions: The route to subspecialty certiﬁcation and fellowships for gery; female urology in the USA is a lesson in politics, education, medical rivalries and Subspecialty certiﬁca- perseverance, with the goal of improving care for women. This decade-long journey tion; culminated in the recognition of a separate subspecialty by the American Board of Fellowship training Medical Specialties in 2011, accreditation by the American Council for Graduate Medical Education in 2012, and certiﬁcation to be awarded by the Boards of Obstet- ABBREVIATIONS rics and Gynecology and Urology in 2013. It remains to be seen whether this effort FPMRS, female pelvic will improve resident education and patient care, or represent a marketing tool in the medicine and repro- competitive USA healthcare environment. While many of the details and regulatory Address: Department of Urology, Box 800422, Charlottesville, VA 22908, USA. Tel.: +1 1434249107. E-mail address: Wds6t@virginia.edu Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2013.01.003 114 Steers ductive surgery; issues are speciﬁc to the USA, elements of the curriculum and procedures should be ABOG, American relevant to other countries. Board of Obstetrics ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. and Gynecology; ACGME, American Council for Graduate Medical Education; ABMS, American Board of Medical Spe- cialties; ABU, Ameri- can Board of Urology Introduction with relevant courses, topics and procedures that encompassed training for the subspecialty of FPMRS. A speciﬁc amount of time, clinical and non-clinical The ﬁrst documented call for a separate specialty in work was delineated. A year of academic work, female pelvic medicine and reproductive surgery whether clinical or basic, was mandated. Regardless (FPMRS) was at a meeting of the American Urogyne- of whether the programme director and graduates were cological Society in 1979. Within the specialty of urologists or gynecologists, the curriculum needed to obstetrics and gynecology, the subspecialties in mater- be the same to guarantee the consistent training of nal and foetal medicine, gynecological oncology, and graduates with an identical subspecialty certiﬁcate. This reproductive endocrinology and infertility already ex- last point engendered debate because urologists in the isted. The American Board of Obstetrics and Gynecol- subspecialty would most likely be undertaking a broad- ogy (ABOG) is unique in the USA in that it is able to er range of duties, such as male incontinence, neuro- certify its own subspecialties. In urology only paediat- genic bladder and male voiding dysfunction. Such ric urology was a subspecialty accredited by the Amer- additional training is allowed but Fellows must meet ican Council for Graduate Medical Education minimal FPMRS training within the 2-year period. (ACGME) and recognised by the American Board The duration of Residencies in urology and obstet- of Medical Specialties (ABMS). rics and gynecology in the USA differs. Because Res- In 2000, the American Board of Urology (ABU) ap- idency training is longer in urology, a compromise proached the ABOG about working with uro-gynecol- was reached whereby the fellowship would run for ogists to establish a fellowship in female urology with 3 years for urogynecologists, consistent with the other similar criteria to existing subspecialties. The desire to subspecialty fellowships in obstetrics and gynecology, collaborate with urogynecologists resulted in a joint vs. only 2 years in urology because, especially in the committee with appointees nominated by the ABU areas of neurogenic bladder and open surgery, urolo- and approved by the ABOG. Thus began the formal gists have a longer duration of training. Throughout process of approving fellowships. The overhaul and the process of creating this specialty and fellowships, lengthening of female urology fellowships were contro- the overall guiding principle was that the fellowships versial among academic leaders in the subspecialty who should be academically grounded and not merely directed the numerous 1-year non-certiﬁed fellowships apprenticeships, with requirements for programme in the USA, who would have to change the duration directors to demonstrate academic productivity. In and ﬁnancing of their programmes to be compliant addition, research and a thesis were required. Fellow- with ABU/ABOG fellowships. One of the earliest con- ship applications would be reviewed by the committee troversies for these joint fellowships with a common and would either be approved or disapproved. Also curriculum and evaluation process was what to name programmes could be put ‘on probation’. the subspecialty. The terms ‘female urology’ and ‘uro- In the decade after establishing the fellowships a ‘crit- gynecology’ are specialty-speciﬁc, so the boards com- ical mass’ of urogynecology-programme director-based promised and adopted FPMRS as the name. The and urology-programme director-based programmes was concern was raised that this could be misleading for established and a formal application to the ABMS was those who perform reconstructive surgery in urology, made. Initially the application was rejected, not because which often encompasses different specialty training. of arguments against a separate subspecialty, but because Under the leadership of Dr. Andrew Novick, then of the question of the ability of ‘Obstetrics and gynecology’ President of the ABU, and Secretary Dr. Stuart Ho- to certify their own subspecialties. When both boards wards, an environment was created for both urologists acquiesced to having the ACGME oversee the fellowships, and gynecologists to participate in this committee. The in 2011 the ABMS recognised the subspecialty. joint committee developed a list of aspirational goals, Establishing the subspecialty of female pelvic medicine 115 research design. Course listings and grading must be in- Methods cluded. The inpatient and outpatient experience, as well as patient numbers in the hospital and clinics, are noted. The goal in establishing a fellowship in FPMRS was to The diagnostic procedures and endoscopic evaluations improve the healthcare of women. It was recognised that are included. The number of Fellows and whether they residency training in urology and obstetrics and gyne- are gynecologists or urologists, and whether the course cology varies. Although there are common overlapping is for 2 or 3 years, as well as a block diagram of rota- areas of procedures for the care of women, each spe- tions that include personnel and location, must be in- cialty has its own domains. The fellowship in the USA cluded in the application. The fellowship’s ongoing encompasses both elements of gynecology and urology, logs are reviewed for a range of procedures for urinary in addition to having common ground. For example, it incontinence, faecal incontinence, prolapse, obstetrics is recognised that procedures for prolapse and stress uri- exposure and reconstruction of ﬁstulae. Adequate diver- nary incontinence are the same in both specialties. Both sity in pharmacological, behavioural and surgical-device specialties also care for recurring UTIs and painful blad- treatment of these areas is required. The facilities must der/interstitial cystitis syndromes. However, urogynecol- have adequate diagnostic machinery and operating ogists also feel the need to screen for cervical cancer and rooms, and offer endoscopy at the site. take care of more patients with faecal incontinence and A thesis must be completed at the end of the fellow- other anogenital disorders. In the previously named ship that meets journal requirements in terms of patients ‘female urology’, patients were also evaluated for hae- and appropriate subject matter. The thesis must have a maturia and there was a larger focus on neuro-urology, proper statistical analysis and reach appropriate conclu- and bladder outlet and ureteric obstruction. Both sions. The thesis should demonstrate the candidate’s specialties also use urodynamics, although historically knowledge of the ﬁeld. The thesis cannot just be a liter- Valsalva leak-point pressures are used in urology to ature review. measure bladder outlet resistance, as opposed to ure- A list of the procedures for female reconstructive sur- thral pressure proﬁles, which tend to be favoured in gery is given at the ABU website (www.abu.org). For urogynecology. Recognising the differences between those already in clinical practice wishing to certify for the two areas, a common ground of topics and proce- the subspecialty of FPMRS, these procedures should ac- dures was developed to include lower urinary tract and count for 60% of the practice experience in the subspe- pelvic ﬂoor disorders in both. The programme director cialty. The prescribed annual surgical logs should in urogynecology can also focus more on areas speciﬁc include 45 cases in urodynamics, 25 in incontinence, to gynecology, whereas a urology training programme and 40 in the reconstruction/prolapse/ﬁstula and tis- includes male voiding dysfunction and other urological sue-transfer categories. conditions. Challenging the rationale for forming a joint commit- Regardless of whether the proposed programme tee between urology and urogynecology was the need to director is a gynecologist or urologist, both need to be oversee formal training. Forming a subspecialty with Board-certiﬁed and have 5 years of experience after formal fellowships was also the best way to recruit Board certiﬁcation to be considered. Programme direc- young urologists to the discipline. Concerns were ex- tors must have a record of scholarly activity, full-time pressed that subspecialty certiﬁcation could be used employment, and direct responsibility for Fellows. for marketing, to limit the scope of care for general urol- There must also be at least one other faculty in the ogists, which has not happened to date. Subspecialties subspecialty as part of the training programme. The need to proceed with a vigorous oversight of the curric- number of training places and the rationale for inclusion ulum to avoid haphazard training. The quality of pa- must be delineated. The curriculum consists of didactics, tient care, manpower, training and competition seem graduate courses, inpatient and outpatient experience, to be recurring themes with the establishment of fellow- as well as diagnostic evaluation and operative ships in the USA. Finally, the Boards recognised the ef- procedures. fect of the core curriculum, and the challenge of billing With regard to didactics, the scientiﬁc foundations of and ﬁnancing Fellows, and the need to obtain a critical FPMRS are listed among the requirements and the pro- mass of Fellows in the subspecialty, especially in aca- gramme must cover anatomy, physiology, pharmacol- demics, to train the next generation of urologists. ogy and pathophysiology of the pelvic ﬂoor, as well as urinary and faecal incontinence. The clinical domains Published material on training in FPMRS, and workforce would include urinary incontinence, rectal issues, needs inﬂammation of the lower urinary tract and pelvis, geri- atric conditions, neurogenic bladder and urogenital Cundiff et al.  assessed the effect of FPMRS on resi- ﬁstula. dent education using a survey instrument. Fellowships Graduate courses must be included in the fellowship, were initially perceived as detracting from education, at which usually focus on statistics, epidemiology and 116 Steers least in oncological fellowships, but after establishing the fellowships have been successful by any measure in the programme there was a positive effect sustained for at USA, with high-calibre graduates going into specialty least 3 years, as noted by Residents and interviewers. practice. These fellowships have generated tremendous Cundiff et al. also assessed the responses from 250 volumes of research in FPMRS. It will probably be dec- obstetrics and gynecology residents, showing that 46% ades before enough Fellows have graduated and their were dissatisﬁed with urogynecology residency education patient outcomes and academic productivity assessed and wanted improvements in fellowships, thus establish- to know whether establishing a formal subspecialty in ing the need for formal fellowships, rotations and train- FPMRS has improved the healthcare of women or res- ing. Only 24% of Residents surveyed actually had idency training beyond the former status quo. The adop- exposure to Fellows. Work force needs by peers and oth- tion of new procedures and additions to the curriculum ers show that there will be a 20% larger female popula- requires a dynamic process. Currently the fellowships tion by 2020 in the USA that needs care. A survey of are evaluated by the ABOG review committee with ad Urology chairs in the USA showed that the main area hoc members from urology to help review the urology of recruitment needed was in female urology and recon- programmes. The joint fellowship committee exists for structive surgery . Thus there is a tremendous need for guidance and to write questions for the certifying exam- fellowships in this under-served area in the USA. ination. In the USA subspecialty certiﬁcation will also be given through the ‘grand-fathering’ process, whereby urologists with adequate clinical logs in the discipline Changing subspecialty certiﬁcation by the ABMS and the proper clinical focus can be certiﬁed by passing the examination, showing appropriate Continuing Med- The ﬁrst reading of the application for recognition of the ical Education credits, and meeting the criteria estab- subspecialty was in July 2010. At that time the applica- lished by the ABU, despite not having completed a tion included a justiﬁcation for the certiﬁcation of the formal fellowship. subspecialty and a delineation of how the fellowships would be organised, including the curriculum, block dia- Conclusion grams, and basic requirements. The documentation pro- vided showed that there were six standard textbooks on gynecology and urology, with chapters devoted to uro- It is envisioned that these fellowship programmes will gynecology and female urology, and reconstructive sur- continue to expand over time. The entire process, gery and female pelvic medicine. It also noted that the although challenging, has led to the improved care joint fellowships between the ABU and ABOG had ex- of women in the USA, through rigorous advance train- isted for 11 years, and at the time of the application ing of both urologists and urogynecologists beyond there were 38 fellowships and 41 Fellows per year. There residency. were 3000 positions in the USA for urogynecologists or female urologists as the primary focus of their clinical Source of funding practice. The subspecialty had national societies and international meetings devoted to this specialty. There None. were 38 programmes; six had urology programme direc- tors, two had combined gynecology and urology train- Conﬂict of interest ing, and 30 had urogynecology programme directors. Two programmes actually had two separate fellowships, None. one led by urologists and the other by gynecologists. A justiﬁcation was given for the difference in training peri- References ods for urologists and gynecologists based on the differ- ences in subject material and exposure during residency  Cundiff GW, Handa V, Bienstock J. Longitudinal impact of a female pelvic medicine and reconstructive surgery fellowship on training. The method of evaluation of Fellows consists resident education. Am J Obstect Gynecol 2002;187:1487–92. of a secure written examination of 200 questions, a the-  Lightfoot AJ, Rosevear HM, Steers WD, Tracy CR. Current and sis, and successful completion of the fellowship. future needs for academic urologists in the United States. J Urol 2011;185:2283–7. Future directions In the 13 years since the formal fellowships were started, the specialty has changed to include robotics. The
Arab Journal of Urology – Taylor & Francis
Published: Jun 1, 2013
Keywords: Female urology; Female pelvic medicine and reconstructive surgery; Subspecialty certification; Fellowship training; FPMRS, female pelvic medicine and reproductive surgery; ABOG, American Board of Obstetrics and Gynecology; ACGME, American Council for Graduate Medical Education; ABMS, American Board of Medical Specialties; ABU, American Board of Urology
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