Current Challenges in Urology Resident Training Lance Hampton, MD Chief, Division of Urology Virginia Commonwealth University Richmond, Virginia 1
Disclosures I have nothing to disclose 2
Appreciation Thanks to City of Hope and invitation to speak City of Hope fellow class of 2008 Ken Jacobsohn, MD Director of Robotic Surgery, Medical College of Wisconsin, Milwaukee, Minnesota Brian Link, MD Director of Robotic Surgery, Mercy Hospital, Oklahoma City, Oklahoma Lance Hampton, MD 3
Class of 2008 4
City of Hope 2007-2008 5
My Background University of New Mexico 1997-1999 Surgery Resident Identical schedule as surgery categorical residents 1999-2002 Urology Resident 3 year urology program including kidney transplant training. 6
My Background Private practice 2002-2007 Flagstaff, Arizona 7
My Background 2008: Director of Robotic Urology at VCU New program, new robot, urology residency program on probation 2009-2016: Urology MS3 Clerkship Director 2009- current: Urology MS4 Acting Internship Director 2010: Director of Robotic Surgery 2011: Interim Chair, Division of Urology 2012- current: Chair, Division of Urology 8
So, who cares? Current urology residency looks completely different than even 20 years ago. 9
Objectives Compare and contrast current urology residency training with what you may have experienced Current requirements for academic urology faculty involved in teaching residents A focus on current methods of teaching robotic surgery in urology Try to be optimistic about future urologists 10
Current VCU Urology Program 2 residents per year/5 yr program 1 year preliminary, 3 ½ year urology, 6 months research Mixture of residents primarily from Mid- Atlantic medical schools One of the most diverse groups of residents nationwide. 11
Current Urology Residents 12
Pre-urology PGY1 6 months of surgical subspecialties (transplant, ICU, surg onc, trauma, and general surgery) 3 months of urology 1 month each of pathology, radiology, urogynecology 13
Pre-urology PGY1 Virtually no operative experience other than urology rotations Expansion of APP (Advanced Practice Provider: NP and PAs) providing inpatient care Duty Hour Restrictions! Never more than 24 hrs of clinical duties (used to be 18 for interns) 14 hrs off after 24 hours on 14
PGY1 Challenges New PGY2 have almost no operative skills Short rotations lead to no continuity of care Hospital care increasingly being performed by APPs in direct coordination with attending Has been compared to a 5 th year of medical school. (4 th year medical school basically a year off now also) 15
Urology Resident Expectations Work-life balance (anecdotal, of course) Immediate feedback Participation in national and international meetings Ability to give feedback (evaluate the evaluators) 16
Millennials 17
Millennials Disagreement for start and end years Often children of baby boomers Time magazine in 2013, Millennials: The Me Me Me Generation 18
Generation X Mid 60s to mid 80s birth years Current age 54-33 Average age of practicing urologist is 55 Traits: middle child Individualistic, flexible, technologically adept Work/life balance Nihilistic, cynical 19
Traits of Millennials (not all negative) Strong sense of community, both local and global Seven basic traits: Special, sheltered, confident, team-oriented, conventional, pressured, achieving. Generation Me: Entitlement, narcissism Elevated scores on Narcissistic Personality Inventory (16% more narcissism than older adults) 20
Workplace Attitudes of Millennials Producing meaningful work Finding a creative outlet Preference for immediate feedback. Career paths more dynamic and less predictable Social media has created a preference for team-oriented environment 21
Expansion of Social Media Virtually all residents have multiple accounts (Facebook, Instagram, Twitter, Snapchat, Tinder) Concerns about privacy and appropriateness of information shared online Prospective residents/fellows use online footprint of programs for information 22
Urology for Millennials Work/Life Balance Incorporation of technology Simulation, smartphone apps (guidelines, training, handoffs, etc.) Improving feedback and providing more immediate and specific feedback Immediate postoperative feedback 23
Feedback Requirements End of rotation evaluations Immediate feedback after every OR case CCC Clinical Competency Committee Twice yearly Evaluates Milestones At VCU, to review 8 residents takes at least 3 hourly meetings of majority of faculty 24
Urology Milestone Project Joint initiative of ACGME and ABU Started in August 2016 The Milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. 5 levels 25
Urology Milestones Level 1: The resident demonstrates milestones expected of an incoming resident. Level 2: The resident is advancing and demonstrates additional milestones. Level 3: The resident continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target. Level5: The resident has advanced beyond performance targets set for residency, and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level. 26
New Requirements for Urology Academic Faculty Increased supervision All notes cosigned (inpatient and outpatient) No resident clinics OR supervision Pre-op briefing (in holding area) with attending In room briefing Time-out Present during all critical portions Post-procedure time-out 27
Robotic Surgery Training Push from ACGME, hospitals, and RRC for standardized curriculum Every specialty has its own program Online modules Hands-on bedside training with robotic coordinators and faculty Simulations Nonstandardized credentialing Type of training, proctored cases, etc. 28
Urology Resident Expectations ACGME requirements for urology: must develop competence in the following core techniques including laparoscopy and robotics All residents expect full competency in robotic surgery Anecdotally, residents expect console experience by at least PGY4 and doing complete cases by residency completion. 29
Robotic Surgery for Millenials Graduated responsibility Outpatient evaluation and indications for robotic surgery Pre and post operative care of patients Docking and bedside assisting Console surgeon Dividing common procedures into portions depending on complexity and possibility of harm Immediate Feedback and documentation 30
#MeToo 31
#MeToo Increased focus on inclusivity and diversity Culture change in surgery, especially in the OR 1995 study found 52% of all women in academic medicine said they had been sexually harassed. 2017: Majority of entering medical students are women 32
Challenges for the future Increased supervision of residents Increased demands on teaching faculty Generational differences in trainers and trainees Lack of standardization of training, specifically for robotic surgery Changing demographics of residents (more women, more diversity) 33
Discussion In your role, how have you seen changes in the way urology residents are trained? Going forward, will graduating residents be better trained or worse? How has MeToo and the changing demographic of surgery residents and medical students changed residency training? 34
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