Young Urologists Research Articles

Estado actual de la formación en cirugía reconstructiva en España: resultados de una encuesta nacional

Introduction and objectiveAssessment of urethral stricture (US) management in a specific group of professionals, Urology Residents, in a specific region (Spain), seems to be important to determine the quality of the educational program and design educational interventions to improve it. We aim to investigate diagnosis and therapeutics practices among Urology Residents for the US management. Materials and methods20-question on-line survey was conducted among residents and junior consultants registered on the mailing list of residents and young urologists of the Spanish Association of Urology (RAEU) group of the educational period 2018-2023. We evaluated demographic, educational, surgical technics and experience data during the training period. 290 questionnaires were mailed between May-August 2023. Data was collected in a prospective way between May-December 2023, with 29,6% response rate. ResultsThe survey obtained 86 responders, with 29,65% (86/290) response rate. Two first sections were answered by all the responders, however, from the assessment section on, only 57 responders completed the survey, which represents 66,28% of them. ConclusionsEducational program in Reconstructive Urology among Urology Residents in Spain has an improvement margin. We must dedicate our efforts to standardize the educational process and facilitate access to formation to and increasing area of interest among residents.

Sexuality of urologist in training: Does cobbler always wear the worst shoes? Sex AFUF study.

Sexuality is an integral part of well-being. Urologists are a population faced with a significant workload and stress that can affect their sexuality. The purpose of this study is to investigate sexuality in this population and assess factors that may impact it. A cross-sectional study was conducted between May and July 2023 among French urology residents and fellows. Data was collected through an anonymous questionnaire sent by the French Association of Trainee Urologists (AFUF) via email. Out of 445 members of the AFUF, 196 trainee urologists responded. Among them, 130 young urologists, accounting for 66% of respondents, were satisfied with their sexual life, and 123 (63%) respondents reported having one or more sexual encounters per week. In univariate analysis, factors significantly impacting the level of sexual satisfaction were gender (p=0.029), level of job satisfaction/well-being (p<0.01), level of professional burnout (p<0.001), and the existence of a romantic relationship. Young urologists are mostly satisfied with their sexual life. Gender, level of job satisfaction/well-being, and level of professional burnout are significant factors impacting the level of sexual satisfaction.

Trends of European School of Urology (ESU) training and resident education: an overview of 2 decades of EAU education programme.

Over the last 2 decades, various education and training programmes have been launched by the European School of Urology (ESU) on behalf of the European Association of Urology (EAU) Education Office. These include e-learning platforms, in-person meetings, courses, podcasts, webinars, sub-specialisation meetings and the European Urology Resident Education Programme (EUREP), all of which aim to achieve standardisation in urological education (SISE) and training at the highest level. Data from the last 2 decades of all ESU activities were collected by the EAU/ESU office and analyzed for attendance, geographical, gender and age trends. Demographic data on registrations and attendances at EUREP were also monitored and analysed. A descriptive analysis of participation and trends is provided. A total of 4750 participants have completed ESU courses (including guideline courses, specialization courses and webinar courses). Similarly, a total of 5958 trainees attended the EUREP from 2004 to 2022 of which the male: female ratio was 3.75:1. However, the proportion of females increased 3.5-fold from 10.7% in 2004 to 37.1% in 2022(p < 0.001). There is a growing interest in the meeting, with increasing registrations over this time (353 in 2004 to 599 in 2023, p < 0.001). The mean age of participants is constantly decreasing (32.6 years in 2004 to 31.54 in 2022), with a mean yearly decrease of -0.18% (p < 0.001). ESU courses have had increasing interest and participation from young urologists worldwide. During EUREP, while the trainee age has decreased, there has been a surge in the proportion of female trainees. ESU is providing all modes of education and training across the world with both virtual and in-person meetings and courses, which would help in the development and preparation of urologists of the future and provide the best patient care.

Financial and Business Literacy Among Urology Residents: Is this a Problem and How Can We Better Prepare Residents for their Careers?

Although financial wellness is a predictor of physician burnout, we are yet to optimize financial education or wellness of Urology trainees. We assessed existing studies, compared them to those of other specialties, and discussed resources and methods to address this deficiency. Urology residents tend to be less fiscally savvy (carry significant debt, and lack retirement savings or disability insurance), and 90% of trainees and young Urologists do not feel comfortable with the business of practice, including skills like coding and billing, contract negotiation, and self-value assessment. Financial and business literacy are deficiencies of Urology training, as in other specialties. Eventually, the goal should be universal adoption of a formal curriculum that is graded in nature. In the interim, we need to propose and endorse adoption of a formal curriculum, and we should support trainees by promoting a space for easily accessible and transparent information regarding best practices in personal finance and the business of healthcare.

Optimizing Colon Identification by Window Setting Modulation on Noncontrast Computed Tomography Prior to Percutaneous Nephrolithotomy.

Background: Preoperative identification of the bowel on imaging is essential in planning renal access during percutaneous nephrolithotomy (PCNL) and avoiding colonic injury. We aimed this study to assess which noncontrast computed tomography (NCCT) window setting provides the optimal colonic identification for PCNL preoperative planning. Methods: Ten urologic surgeons (four seniors, six residents) reviewed 22 images of NCCT scans in both abdomen and lung window settings in a randomized blinded order. Colonic area delineation in each image was performed using a dedicated, commercially available area calculator software. A comparison of the marked colonic area between the abdomen and lung window settings was performed. Results: Overall, the mean marked colonic area was greater in the lung window compared with the abdomen window (8.82 cm2 vs 7.4 cm2, respectively, p < 0.001). Switching the CT window from abdomen to lung increased the identified colonic area in 50 cases (50%). Intraclass correlation showed good agreement between the senior readers and among all readers (0.92 and 0.87, respectively). Similar measurements of the colonic area in both abdomen and lung windows were observed in 26/44 (60%) of the seniors cases and in 7/66 (10%) of the resident cases (p = 0.002). Conclusion: Lung window solely or in combination with abdomen window appears to provide the most accurate colonic identification for preoperative planning of PCNL access and potentially reduce the risk of colonic injury. This pattern is more evident among young urologists, and we propose to introduce it as a standard sequence in PCNL preplanning.

Current status of robotic training during the urology residency: results from a national survey in Spain

Introduction and objectivesThe increasing number of robotic urological procedures observed in recent years highlights the need to expand training opportunities in robotic surgery. Our objective is to investigate the state of robotic training during urology residency in Spain in order to identify significant deficiencies. Materials and methodsA 20-item online survey was conducted among urology residents in Spain who were registered in the database of the Residents and Young Urologists Group of the Spanish Association of Urology. The survey assessed subjective opinions, institutional aspects, training resources, and experience regarding robotic surgery. A total of 455 email invitations were sent throughout the year 2021. Descriptive analysis of the responses was performed. ResultsThe participation rate reached 30%, with a total of 135 residents. 52% of respondents lacked access to a robotic system in their institution, of which only 48% could compensate for this deficiency through external rotations. Among those with access to a robotic system, 25% and 23% reported having access to theoretical and practical training, respectively. The existence of a formal training program was low (13%). 85% of the respondents considered robotic surgery training in Spain to be deficient. ConclusionsTraining for Spanish residents in robotic urological surgery is perceived as inadequate, emphasizing the crucial need for improvement in training programs in this field.

Estado de la formación robótica en la residencia de urología: resultados de una encuesta nacional en España

Introduction and objectiveThe increasing number of robotic urological procedures observed in recent years highlights the need to expand training opportunities in robotic surgery. Our objective is to investigate the state of robotic training during urology residency in Spain in order to identify significant deficiencies. Materials and methodsA 20-item online survey was conducted among urology residents in Spain who were registered in the database of the Residents and Young Urologists Group of the Spanish Association of Urology. The survey assessed subjective opinions, institutional aspects, training resources, and experience regarding robotic surgery. A total of 455 email invitations were sent throughout the year 2021. Descriptive analysis of the responses was performed. ResultsThe participation rate reached 30%, with a total of 135 residents. The 52% of respondents lacked access to a robotic system in their institution, of which only 48% could compensate for this deficiency through external rotations. Among those with access to a robotic system, 25% and 23% reported having access to theoretical and practical training, respectively. The existence of a formal training program was low (13%) and 85% of the respondents considered robotic surgery training in Spain to be deficient. ConclusionsTraining for Spanish residents in robotic urological surgery is perceived as inadequate, emphasizing the crucial need for improvement in training programs in this field.

Young urologists and kidney transplantation training: A survey designed by the French Transplantation Committee of the French Association of Urology (CTAFU) and the French Association of Urologists in training (AFUF)

ObjectiveIn France, kidney transplantations (KT) are mainly performed by urologist. Young urologists and residents are involved in this activity mostly performed in emergency. How do they feel about KT training? Is KT an attractive part of the urologist activity? MethodsThis survey has been designed in the form of a questionnaire by the French Committee of Kidney Transplantation (CTAFU) and the French Association of Urologists in training (AFUF). It has been sent by e-mail to all the AFUF members. Interest in KT and performance of the training were evaluated. ResultsIn total, 126 members filed the form. Among the residents, 51.5% feel secure to perform KT at the end of their residency. KT is considered as an interesting surgery for 92.1% of the participants: 76.5% are willing to get involved in KT during their residency/fellowship. Among the participants, 44% are willing to continue a long-term involvement. Among the residents, 65.9% consider their practical training insufficient: 56.8% have been supervised for a KT performance during their residency and 86% declare a lack of practical training and had a patient-based learning. Among the residents, 92.1% declare an insufficient theorical training. Among the residents, 33.3% say the schedules of transplantation limit their interest in KT. Among the participants, 34.4% receive a transplant bonus in addition to the usual on-call salary. ConclusionYoung urologists wish to continue their involvement in KT activity, but improved theoretical and practical training are essential. In addition, the conditions under which this activity is performed and remunerated are a matter of concern. Level of evidence3

Prevalent practices and changing trends in the management of vesicovaginal fistula: a cross-sectional study from a nationwide questionnaire-based survey of urologists from a developing country

Vesicovaginal fistula (VVF) management is primarily backed by evidence from retrospective studies and expert opinions and therefore lacks standardization. Newer generations of surgeons are more proactive toward changing clinical practices in domains lacking good-quality evidence. This survey-based cross-sectional study aims to elicit consensus on management practices regarding various domains of VVF management and look for any changes in clinical practice trends. A nationwide survey of urologists was conducted, and responses were grouped into 3 categories (overall response, response from young urologists, and response from experienced urologists) and compared. Based on the level of overall consensus, the responses were categorized as highly preferred, preferred, and somewhat preferred. Consensus was noted in conservative and endoscopic management of VVF, timing of VVF repair, definition of simple/complex VVF, approach for surgical repair for trigonal and supratrigonal VVF, use of interposition tissue for repair, and patient positioning in the postoperative period. A lack of consensus was noted in other domains. Changing trends in clinical practices were noted in attempts at conservative and endoscopic management, investigations considered mandatory for evaluation, surgical approach for complex VVF with bladder neck involvement and radiation-induced fistulas, the use of interposition grafts during surgical repair, the use of cystograms during follow-up, and the definition of a successful repair. There is uniformity in practices regarding many domains of VVF management. Those areas, where discordance in opinions is noted, require further research to bring standardization into practice. Regarding certain aspects of VVF management, there appears to be a change in trends among the younger generation of urologists.

The importance of laparoscopic surgery for young urologists remains unwavering even in the era of robot-assisted surgery.

Robot-assisted surgery (RAS) cannot be achieved without the performance of laparoscopic surgical techniques by a patient-side surgeon (PSS). In many medical institutions in Japan, young urologists often take on the role of a PSS. Participating in RAS as a PSS provides a good opportunity to acquire not only the knowledge necessary for surgery, but also skills in laparoscopic surgical techniques. Learning laparoscopic surgery as a PSS may contribute to improving the quality of RAS. Furthermore, it will lead to skill improvement as an operator in laparoscopic surgery. However, notably, opportunities for young urologists to perform laparoscopic surgery are decreasing in the current era of RAS. Under these circumstances, we believe that cadaver surgical training will become increasingly important in the future. We believe that performance of cadaver surgical training will contribute to increased motivation, enhance the understanding of surgical procedures, and facilitate the acquisition of surgical techniques.

Adequate Mentorship Program for Holmium Laser Enucleation of the Prostate (HoLEP) Leads to Satisfactory Short-Term Outcomes in the Early Learning Curve of Young Urologists: First-Year Outcomes of a Newly Established Mentorship Training in Mexico.

Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate (HoLEP) has been recommended by international guidelines as an alternative to transurethral resection of the prostate (TURP). HoLEP's learning curve and the lack of adequate mentorship remains an obstacle for the worldwide adoption of this technique. Objective To report the first-year learning curve of a newly established mentorship program in young urologists without any previous HoLEPexperience. Methods We report a cohort of patients with BPH, with prostate size ≥70 grams, treated with HoLEP, analyzed for perioperative data and complications, and short-term postoperative complications and functional outcomes, at three and six months after surgery. Results A total of 47 patients were managed with HoLEP. Mean total operative time was 149.8 ± 42.9 minutes. We experienced five (10.6%) intraoperative complications, including one intravesical resection of the prostate with bipolar energy, three conversions to TURP and one conversion to open prostatectomy. We experienced four postoperative complications, all of them Clavien-Dindo ≤2. Median International Prostate Symptom Score (IPSS) decrease at six months was -17 points from baseline. Mean post-void residual volume and prostate-specific antigen significantlydecreased by the third postoperative month. Multiple linear regression showed that prostate size is directly related to increased surgical time during the early learning curve. Discussion Our experience adequately reflects the importance of HoLEP mentorship in young urologists seeking training in this technique. Both surgeons had perioperative and postoperative outcomes deemed satisfactory based on previously published learning curves. Conclusions HoLEP is a technically difficult procedure, however, adequate mentorship leads to satisfying short-term outcomes since the early stages of the learning curve in young urologists with no previous training on this technique.

Women in urology: what is their current situation in Spain?

ObjectiveTo analyze the current state of women in urology in Spain. Material and methodsDescriptive study based on the results of an online survey sent between February and April 2020 through the database of the Residents and Young Urologists group (RAEU) of the Spanish Association of Urology (AEU). Characteristics of the survey and its results were analyzed. ResultsIn total, 257 responses were obtained from 210 women (81.71%) and 47 men (18.29%) belonging to 111 hospitals. Statistically significant differences were observed (p < 0.001) with a higher proportion of men in all categories except for the group of young female and male attendings (29−39 years, p = 0.789), and the group of female residents against male residents (p = 0.814). The number of men was higher in hospitals with subspecialty units except for the Pelvic Floor Unit, where no statistically significant difference was observed (p = 0.06). Regarding positions of responsibility, only 7 out of 111 hospitals had female Department Chiefs. ConclusionsWomen's representation in urology is increasing, mainly due to the younger generations. However, the access of these women to relevant positions is anecdotal.

Perceived influence of medical school sexual health education on specialty selection in young urologists specializing in sexual dysfunction.

To determine effects of sexual health curriculum (SHC) in medical school and mentorship on future specialty/subspecialty selection, we sought to evaluate the experiences of urology trainees and practicing urologists. Residents, fellows, and practicing urologists completed a 15-question survey regarding their exposure to a SHC during medical school, topics covered, and the influence of mentors in their career choice. Summary statistics were used to identify trends based on survey responses. Ninety-four respondents, primarily post-graduate training year 4 and 5 (46%), completed the survey. Approximately 50% recalled a dedicated SHC during medical school with 46% planning to pursue fellowship training in sexual medicine/reconstruction. Topics commonly covered included reproductive anatomy/physiology and sexual history-taking, while respondents rarely recalled topics such as sexual aids/toys and pornography. Only 25% felt their SHC provided an adequate fund of knowledge to address sexual health concerns in patients, and only 14% felt that exposure to a SHC influenced their decision to pursue urology. Individuals intending to pursue fellowship were more likely to have an attending mentor, a mentor with expertise in sexual dysfunction, and considered their mentor as important or very important in their decision to subspecialize (P<0.05). Most urology trainees do not have strong exposure to a SHC during medical school and cite mentorship as a more important role in the decision to pursue subspecialty training. These data support the need for a standardized formal SHC and continued exposure to sexual health experts during training to ensure continued interest in sexual medicine/reconstruction fellowship.

Mujer y urología: ¿cuál es la situación en España?

ObjectiveTo analyze the current state of women in urology in Spain. Material and methodsDescriptive study based on the results of an online survey sent between February and April 2020 through the database of the Residents and Young Urologists group (RAEU) of the Spanish Association of Urology (AEU). Demographic characteristics of the survey and its results were analyzed. ResultsIn total, 257 responses were obtained from 210 women (81.71%) and 47 men (18.29%) belonging to 111 hospitals. Statistically significant differences were observed (P<.001) with a higher proportion of men in all categories except for the group of young female and male attendings (29-39 years, P=.789), and the group of female residents against male residents (P=.814). The number of men was higher in hospitals with subspecialty units except for the Pelvic Floor Unit, where no statistically significant difference was observed (P=.06). Regarding positions of responsibility, only 7 out of 111 hospitals had female department chiefs. ConclusionsWomen's representation in urology is increasing, mainly due to the younger generations. However, the access of these women to relevant positions is anecdotal.

The Impact of the COVID-19 Pandemic and Associated Lockdowns on the Mental and Physical Health of Urologists

The COVID-19 pandemic and subsequent lockdowns have posed unprecedented challenges to healthcare professionals world- wide, including urologists. This study sought to evaluate the mental and physical health outcomes among urologists during this period. The study encompassed a sample of 150 urologists of varying ages and genders, using standardized scales to measure men- tal and physical health, activity levels, relationships, work-related stress, and preventive measures. Our findings underscored that urologists of both genders experienced significant psychological distress, with younger urologists (25-45 years) reporting higher levels of depression and anxiety. Doctors with higher hospital visit frequency exhibited more psychiatric morbidity, likely due to the heightened fear of virus exposure and subsequent risk to family members. The lockdown period was also marked by a decline in structured exercise and increased consumption of ultra-processed foods, leading to weight gain among participants. In light of these findings, we advocate for mental health outreach within the urology community, with a focus on younger professionals. Furthermore, we emphasize the importance of adequate protective measures in hospitals, promoting healthier lifestyles, and social support systems to bolster mental and physical health in such crises. Future research is recommended to explore the long-term consequences of the pandemic on urologists’ health and to devise effective strategies to mitigate adverse effects.

MP25-07 HOW SURGICAL TRAINING IS PERCEIVED BY YOUNG EUROPEAN UROLOGISTS: RESULTS FROM A ESRU-ESU-YAU UROTEC COLLABORATIVE SURVEY

MP25-07 HOW SURGICAL TRAINING IS PERCEIVED BY YOUNG EUROPEAN UROLOGISTS: RESULTS FROM A ESRU-ESU-YAU UROTEC COLLABORATIVE SURVEY

MP57-02 AN UPDATE ON PROFESSIONAL BURNOUT AND CONFLICT-WORK FROM THE AUA WORKFORCE WORKGROUP

You have accessJournal of UrologyCME1 Apr 2023MP57-02 AN UPDATE ON PROFESSIONAL BURNOUT AND CONFLICT-WORK FROM THE AUA WORKFORCE WORKGROUP Seth Teplitsky, Amanda North, Raymond Fang, William Meeks, Kate Kraft, and Andrew Harris Seth TeplitskySeth Teplitsky More articles by this author , Amanda NorthAmanda North More articles by this author , Raymond FangRaymond Fang More articles by this author , William MeeksWilliam Meeks More articles by this author , Kate KraftKate Kraft More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003310.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urologists are experiencing burnout at an alarming rate. With this, the American urologic Association (AUA) has continued to collect various pertinent workforce metrics in the annual census. Here the AUA Workforce Workgroup compares the latest data collected in the census related to burnout, comparing these metrics over time. METHODS: The AUA Workforce Workgroup examined the annual census results since 2016. The AUA sends out an annual census to all practicing urologists. The census works to collect demographic and geographic data, in addition to collecting answers to other pertinent questions from practicing urologists. Particular to this study, burnout related data was examined from the past 5 years. Examined metrics included burnout assess across age and gender, effect of COVID on burnout, work-personal life conflict across demographic groups. RESULTS: In 2021, 36.7% of urologists report burnout compared to 36.2% in 2016. When assessing by gender, burnout in men decreased from 36.3% to 35.2%, but increased in women from 35.3% to 49.2%. When examined by age, the largest increases in burnout were seen in the<45 years old group, increasing from 37.9% to 44.8%, followed by 45-54 years old, 43.4% to 44.6%. Those over age 55 either had a decrease or stable burnout. When asked about the effect of COVID-19 on burnout, 54% of urologists didn’t feel COVID-19 impacted burnout. When considering work-life conflicts, 25.0% of men and 4.6% of women reported no conflict between work and personal responsibilities, while 25.7% of men and 44.7% of women resolved conflicts in favor of work or were unable to resolve them. Respondents were then asked how satisfied they were with work-life balance, where 22.5% of men, and 37.1% of women responded dissatisfied. Similarly, 33.6% of males reported their work schedule does not leave enough time for personal/family life, compared to 57.5% of females. CONCLUSIONS: Overall, urologists have higher burnout now when compared to 2016. The gender discrepancy has vastly widened with women experiencing burnout at an increased rate compared to 2016, while burnout in men decreased. Burnout has increased the most in younger urologists, with the highest increase seen in those<45 years old. Further action is needed to substantiate the causes of burnout. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e784 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seth Teplitsky More articles by this author Amanda North More articles by this author Raymond Fang More articles by this author William Meeks More articles by this author Kate Kraft More articles by this author Andrew Harris More articles by this author Expand All Advertisement PDF downloadLoading ...

Novel Methods of Social Media Dissemination in Urology

Social Media (SoMe) platforms are widely used by urologists with over 99% using SoMe and 63% of young urologists rating the influence of SoMe on knowledge acquisition as moderate to high. The urology community is abreast with the SoMe revolution in many ways but several new methods of SoMe dissemination remain to be explored. These provide an exciting future for SoMe enthusiasts in urology and beyond. In this article, the European Association of Urology Dissemination Committee explores these novel methods of SoMe dissemination while discussing the importance of maintaining quality, ethics, and reliability in SoMe and the role EAU plays in it.

Burnout: A Call to Action From the AUA Workforce Workgroup.

We hypothesize burnout has failed to improve and certain demographics may be disproportionately affected. The AUA Workforce Workgroup examined work from the annual AUA Census over the past several years. Particular to this study, relevant burnout-related data were examined from the past 5 years. In 2021, 36.7% of urologists reported burnout compared to 36.2% in 2016. Burnout in men decreased from 36.3% to 35.2%, but increased in women from 35.3% to 49.2%. When examined by age, the largest increases in burnout were seen in those <45 years old, increasing from 37.9% to 44.8%, followed by 45-54 years old, increasing from 43.4% to 44.6%. When asked about the effect of COVID-19 on burnout, 54% of urologists didn't feel COVID-19 impacted burnout. Beyond burnout, only 25.0% of men and 4.6% of women reported no conflict between work and personal responsibilities, while 25.7% of men and 44.7% of women resolved these conflicts in favor of work or were unable to resolve them. Of respondents, 22.5% of men and 37.1% of women were "dissatisfied" with work-life balance. Similarly, 33.6% of men reported their work schedule does not leave enough time for personal/family life, compared to 57.5% of women. Overall, urologists have higher burnout now when compared to 2016. The gender discrepancy has vastly widened with women experiencing burnout at an increased rate of 14% compared to 2016, while burnout in men decreased by 1%. Burnout has increased the most in those <45 years old. Further action is needed to substantiate the causes of burnout.

Promotion of next generation urologists-Construct urology of the future

In view of the growing demand for urological care and the simultaneous demographic change, the need for urologists in Germany is increasing. Therefore, young professionals are urgently needed to ensure urological care in the future. This objective can be achieved by fascinating medical students for urology and by implementing satisfactory residency programs in clinical departments and outpatient offices. Perspectives and possible career paths should be shown to junior colleagues at an early stage. Structured research funding is needed to reconcile academic with clinical work. The German Society for Residents in Urology (GeSRU) offers young urologists aplatform for networking, for representation of interests as well as for education and training.