The future of surgical training in the field of urogynecology and female pelvic floor surgery

Excerpt

At a time when our field is undergoing rapid technical developments, based on what we perceive to be a better understanding of surgical anatomy and support, as well as simpler surgical ways to address common pathologic conditions, the issue of how best to train residents, fellows, and practicing physicians interested in this area becomes a timely and relevant topic. At present, when surgical complications arise from the use of new innovations or materials the difficult question to discern is whether these complications are occurring for technical reasons, i.e., because the surgeon did not appropriately perform the procedure, or whether certain complications are inherent to the procedure, meaning they would occur, to a certain degree, in the best of hands. For this reason, there needs to be a somewhat standardized mechanism to appropriately train surgeons who are going to be managing simple and complex pelvic floor disorders. Historically we have utilized an apprentice model in the operating room to teach resident and fellow surgeons appropriate techniques. Now, owing to the rapid advent in popularity of newer surgeries, knowledge is lacking in many of the basic techniques that, in my opinion, are necessary prior to adapting these newer techniques. Couple this with the reduced amount of time that a resident, at least in the USA, spends in training, as well as a decrease in the number of surgical cases that can be utilized for teaching, and one can easily see how educational inefficiencies rapidly arise. Core teaching has historically involved understanding basic knowledge and progressive development of expertise in clinical decision making and technical skills, evaluating the student and taking corrective action as necessary during a period of several years. Also, there must be mechanisms to train those who have completed residency, and are practicing and managing patients with pelvic floor disorders without any formal training in this area. The days have long passed when the education of a surgeon can be at the expense of a patient. Thus, many alternatives are quickly arising, such as simulators and extensive cadaver labs. While I do feel that these will ultimately constitute a very important component of surgical training, they still don’t address simple and basic knowledge about anatomy and techniques in traditional pelvic floor surgery. If the future of pelvic reconstructive surgery is the passage of trocars and needles through blind spaces, it is of the utmost importance to have a clear three-dimensional understanding of pelvic floor anatomy. Unfortunately, many of the surgeons currently performing these procedures do not possess this knowledge. The question that quickly arises is: Who should be expected to create standardized mechanisms for surgical training? Should this be some form of a national health service, should it be our societies, should it be the organizations that credential our various specialties, or should it be something created internally at the various institutions that are involved in educating surgeons? Unfortunately, what is happening is that currently the majority of the teaching is being provided by industry in the hope of selling their various materials and devices. I say this not at all to create the assumption that the training is not appropriate; in fact, many of these training programs utilize very good mechanisms and models with a well-versed faculty. However, they do lack standardization and formal traing in anatomy. The future of our specialty rests on our ability to appropriately train the next generation of pelvic floor surgeons. We, as a group, have to agree what needs to be entailed in this process and how best this should be achieved. …