Variability in Operative Experience Among US Gynecologic Oncology Fellows (030)

Abstract

<b>Objectives:</b> The Accreditation Council for Graduate Medical Education (ACGME) case log system provides a mechanism to assess the breadth and depth of the clinical experience provided by gynecologic oncology fellowships. Logging has been required since 2017; however, the required minimum number of procedures has not yet been determined. We aimed to evaluate the range of operative experience across gynecologic oncology fellowship programs in relation to proposed procedure-specific minimum numbers. <b>Methods:</b> ACGME surgical case logs of graduating gynecologic oncology fellows from 2019 to 2020 were analyzed for case volume trends. <b>Results:</b> Data were collected from 64 graduating gynecologic oncology fellows enrolled in 50 US programs. The median number of intestinal surgeries performed by graduating fellows was 42 (19 performed by those in the 10^th percentile to 89 performed by those in the 90^th percentile); a minimum of 20 has been proposed by the ACGME. By contrast, ACGME requires general surgery residents to complete a minimum of 25 small and 40 large intestinal surgeries during training. Gynecologic oncology fellows who performed more than ten intestinal procedures in training were more likely to feel prepared to perform these surgeries independently, however, only 58% reported feeling prepared to do so within three years of graduation. The median number of urologic procedures performed by graduating fellows was one (0 to 4); a minimum of 2 has been proposed by the ACGME. However, ACGME requires urology residents to complete a minimum of eight urinary diversion procedures during training, with the stipulation that this minimum "does not signify the achievement of competence." The median number of radical hysterectomies performed by graduating fellows was 17 (8 to 32). A minimum of ten has been proposed by the ACGME. A single-institution study of gynecologic oncology fellow productivity reported 17 radical hysterectomies completed per fellow per year since 2005. The median number of exenterations performed by graduating fellows was three (1 to 8); a minimum of two has been proposed by the ACGME. A single-institution study of exenterations over 20 years showed an average of six procedures per surgeon and no association of operative experience with complications or survival. The median number of inguinal dissections performed by graduating fellows was 11 (4 to 18). As this is considered a rare procedure, no minimum has been proposed by the ACGME. A minimum of ten was proposed to overcome the surgeon learning curve for inclusion in GROINSS-V-I. <b>Conclusions:</b> In the US, gynecologic oncology fellows experience significant variability in their surgical training. Based on our extrapolation of ACGME data, approximately half of the fellows fall below the proposed case minimums for urologic procedures. All but those in the bottom 10^th percentile met proposed minimums for radical hysterectomies, exenterations, and intestinal procedures. However, ACGME-proposed case minimums may be inadequate to achieve competence. Understanding the scope and variability of gynecologic oncology surgical training is needed to continue to improve and address gaps in fellow education.