Current status of residency training

At present, the potential number of board-certified urologists is limited by the number of available positions in Accreditation Council for Graduate Medical Education (ACGME)–accredited residency training programs in urology. The Residency Review Committee (RRC) for urology is not limited in the number of training programs it may approve. The RRC only judges the quality of the program and its ability to train residents who are competent to practice the specialty of urology independently. Theoretically, and in practice, urologic services can be provided by practitioners who are neither board-certified nor a graduate of an accredited training program. How is this possible? As long as the state medical boards are willing to provide medical licenses and hospitals are given the authority of credentialing their staff members, the desperate need for urologic practitioners is likely to lead hospitals to structure their bylaws to permit individuals without board certification or a certificate from an accredited training program to practice urology. It is this author’s opinion that in an information age that promotes consumerism, the demand for physicians with board certification and documentation of maintenance of certification (MOC) is only going to increase and exacerbate the shortage of urologic specialty care. A second, equally powerful, driving force behind the current diminished urologic service availability is money. The reimbursement of professional service has undergone steady erosion since the last quarter of the twentieth century, and the diminution in value of surgical fees has been striking. The response has not been surprising as surgeons (not just urologic) abandon the hospitals and their operating rooms for ambulatory surgery centers (ASCs) or office-based practices and procedures. This change in modus operandi provides the additional gratuitous benefit of increasing throughput, improving case mix, capturing facility fees, and limiting emergency room call and medical malpractice liability. Proof of this principle is confirmed in the case logs of urologists who are recertifying at 10- and 20-year intervals after the first attainment of board certification. The experiences reported by these practitioners are heavily weighted toward low-acuity cases that can be performed rapidly and with minimal risk.

The case for a change in residency training

The American Urologic Association (AUA) Board of Directors appointed a task force in October of 2005 to assess the current status of residency training and to explore the potential for modification of training. The constituencies represented in these meetings included the AUA, the American Board of Urology (ABU), the RRC for urology, private practice urologists, and residency program directors. What follows is a recapitulation of the white paper authored by John McConnell and published first in the AUA news.

The objectives of the strategic planning group were to (1) define the strengths and weaknesses of urology graduate medical education at this time; (2) define the potential threats to the current training model, including subspecialization, and external competitive threats involving other branches of medicine; (3) define the likely future state of urologic practice; (4) define the urologic training required to prepare urologists for the future state of urologic practice; (5) make specific recommendations to the AUA Board of Directors, the ABU, the Urology Residency Committee, the Society of University Urologists, the Society of University Chairs and Program Directors, and AUA subspecialty societies to close the gap between the current and future state of training and; (6) develop strategies to communicate the planning group’s recommendations to all stakeholders.

The need for change in residency training has been illustrated by recertification operative logs submitted to the ABU. These data indicate that the average urologist at the time of certification and at the time of recertification performs a relatively low number of major urologic operations. A urologist who performs one radical prostatectomy per year or 0.5 radical cystectomy per year is in the top percentile of case volume. Office-based procedures now constitute more than one half of total urologic procedures (eg, cystoscopies, prostate biopsies). This discrepancy between the reported surgical logs of practitioners and the surgical case logs of residents in training promoted a healthy discussion as to whether the current residency program structure prepared urologists well for what they would actually be doing in practice. As we assess the needs of the population for urologic services, it is clear that changes in training should be considered to address future need for urologic service. The current state of urologic practice is a changing landscape. Thirty-five years ago, solo practitioners and small groups of urologists predominated in the marketplace. Perceived economic advantage has led to consolidation in larger markets, and these megagroups often recruit fellowship-trained urologists who cover subspecialty areas. Even in these large groups, however, the leaders of practices desire broad training for their urologist members because they are often required to cover common urologic emergencies and care issues for the group when on call. This increased specialization has seen a parallel increasing role for midlevel providers, such as physician’s assistants and nurse practitioners. Although these midlevel practitioners may provide an opportunity for a urologist to focus on a surgical practice, others view them as a potential threat to the specialty. In addition, urogyncology, radiation oncology, medical oncology, interventional radiology, and reproductive endocrinology compete with urology in many markets across numerous disease states. The panel agreed that although a fellowship-trained urologic specialist may be the ideal way to meet the competitive threat successfully, it is impractical to think that urology can train sufficient subspecialists to meet the volume demands. The broadly trained urologist in most practice settings must be able to provide adequate urologic care to a wide range of patients and disease processes, with the probable exception of major pediatric urologic surgery cases.

Urology has typically attracted the best and the brightest medical students to the specialty. We generally fill all available urology positions in residency programs, and the specialty continues to be attractive because of the mix between surgical and medical management approaches. The planning group, however, concluded that surgery is the key element in attractiveness of the specialty. It was thought that a two-tiered training approach would make urology a much less attractive specialty to medical students if there was a suggestion that some would perform far fewer surgical procedures. The planning group took note that many medical school graduates face educational debts of more than $100,000, and $150,000 in some cases, when they begin residency training. They pragmatically recognized that a 5- to 6-year training program may pose a barrier to students when they compare urology with fields that only require 3 years of training. The planning group expressed a strong desire to keep urology more attractive by potentially limiting the length of training and to promote diversity in the specialty by appealing to and recruiting women and underrepresented minorities.

The planning group also reviewed the issue of certificates of added qualification (CAQs), and they did not reach a consensus. The ABU continues to review and consider CAQs based on their merit. Although the planning group did not reach a consensus, they did unanimously support the importance of fellowship training to the future of urology. They recognized that fellowships enhanced the overall quality of a training program and aided in faculty recruitment and retention. The future of academic urology depends on the fellowship pipeline. Acknowledging the value and importance of fellowship training led the group to consider the possibility of shortening the overall time requirement to achieve specialization. It was thought that urology could develop a clearly defined core curriculum and advance those interested in specialization and differentiation toward that area before completion of residency. The RRC and program directors have articulated a clear willingness to consider a flexible curriculum that would give advanced placement credit for a portion of fellowship training to those individuals who focused their penultimate and ultimate years of training on that particular discipline.

In an effort to assist core curriculum planning and revision, the RRC leadership has re-evaluated the residency program’s index cases percentile requirements. After grouping certain types of cases into several categories, the RRC has suggested minimums of surgical experience for accreditation. This effort has already undergone several discussions, and a presentation for clarification of these changes was made at the June 2007 meeting of the RRC. The planning group also thought that there was an opportunity for better coordination of the early residency experience. Defining more precisely the requirements and expectations of the preliminary urology experience may create an opportunity for more elective time in later years. The panel concluded with a series of specific recommendations:

• 1.
  

  Communicate that a two-tiered model in the United States is not in the best interest of patients or the specialty.

  
  
• 2.
  

  Develop a national core curriculum to include cognitive and manipulative skills.

  
  
• 3.
  

  Begin to define the knowledge and skills that should be acquired during core versus fellowship training.

  
  
• 4.
  

  Put urology program directors in charge of the first postgraduate year.

  
  
• 5.
  

  Make the last 2 years of residency flexible after core competencies are developed.

  
  
• 6.
  

  Move away from all residents needing equal surgical logs.

  
  
• 7.
  

  Integrate the chief residency year into fellowship training for those who wish to pursue subspecialization.

  
  
• 8.
  

  Develop a fellowship program directors’ organization.

  
  
• 9.
  

  Define who controls the quality of the fellowships.

  
  
• 10.
  

  Reinforce the importance of the research experience.

  
  
• 11.
  

  Develop electives for residents headed for academic careers to develop skills in teaching, research, writing, and grantsmanship.

  
  
• 12.
  

  Put ongoing assessment of urologic training into a continuous quality improvement model and repeat national assessments periodically.