The Fellowship Effect: How Establishment of an FPMRS Fellowship Affected Resident Vaginal Hysterectomy Training

Abstract

The FPMRS fellowship was established in 2008, providing a natural experiment in which to examine potential impact of the fellowship on resident training. Materials and methods: While the number of residents remained approximately constant during this time period, faculty in the department of OB/GYN and the division of Urogynecology doubled in size. Cases were identified by CPT codes and route of hysterectomy (vaginal, abdominal, or laparoscopic; with or without robotic assistance), resident and fellow involvement, division of attending surgeon (general obstetrics and gynecology generalist, gynecology generalist, gynecology oncology, urogynecology, minimally invasive) were recorded from the electronic medical record. Resident American College of Graduate Medical Education (ACGME) case log data was used to estimate the number of hysterectomies where residents reported themselves as the primary surgeon. These logs are deidentified with respect to cases, so these data could not be combined with case record data. Results: During the 8-year period of this study, 3317 hysterectomies were performed at our institution, 41% (1371) in the 4 years before and 59% (1946) in the 4 years after fellowship. Prior to fellowship, 27% (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 TVHs, there was resident involvement in 98.0% (385) of the cases before fellowship and 98.2% (441) of the 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. The higher number of vaginal hysterectomies from ACGME case log data than recorded in medical records suggests some misclassification in either case log or CPT obtained data logs. During this time period, medical records indicate a fellow was involved in 42% (189) of TVHs, with resident involvement in all but 5 of these procedures. Of the vaginal hysterectomies with resident involvement, 58.7% (226) were performed by surgeons in the division of urogynecology before initiation of a fellowship. After the fellowship, 70.7% (312) of vaginal hysterectomies were performed by this group of surgeons. Conclusion: Nationally, there has been a decline in TVHs, prompting concern regarding resident training. At our institution, the decline in TVHs performed by non-urogynecology faculty was offset by an increase in TVHs by urogynecology. Frequency of resident involvement in TVH cases, either as primary surgeon or team member, remained constant after the addition of the FPMRS fellowship. Thus, prospective residents need not be concerned about a fellowship diminishing their surgical experience.