The Pediatric Urology Fellowship Experience with the Surgical Ability Milestones

Abstract

Graduates of surgical training programs may not be prepared for independent practice. Given significant patient safety concerns, pediatric urologists must understand the surgical ability of its trainees prior to graduation as well as the programmatic factors that enable the development of surgical skill proficiency during training. The surgical ability of pediatric urology fellows training in North America between 2015-2020 was studied by obtaining the ratings reported to the Accreditation Council for Graduate Medical Education (ACGME) on the four Surgical Ability Milestones. The proportion of fellows not meeting graduation targets on the Surgical Ability Milestones was compared to the self-ratings on the Surgical Ability Milestones submitted by recently graduated fellows via a survey. An explanatory, sequential mixed-methods study design was then used to determine the programmatic factors that foster and prevent surgical skill development during fellowship training. Surveys and semi-structured interviews targeting fellowship program directors and recently graduated fellows generated qualitative data that was analyzed using a thematic analysis approach. Up to 17% of graduating pediatric urology fellows failed to meet the graduation targets in each of the four Surgical Ability Milestones. Programs report that 26% of fellows did not meet graduation targets in all four Surgical Ability Milestones. With a survey response rate of 33%, recently graduated fellows self-reported that 43% did not meet graduation targets in at least one Surgical Ability Milestone by the end of fellowship. Five distinct program factors were determined to be essential for surgical skill development during fellowship including (1) learner-centered faculty instruction, (2) surgical skills practice with faculty coaching, (3) purposeful practice variability, (4) tailored learning experiences, and (5) psychologically safe learning environment. Various solutions to address competency gaps were categorized into 3 themes. Pediatric urology fellowship graduates did not perceive themselves, nor were they deemed by their training programs, to have universally met surgical ability graduation targets prior to entering independent practice. Future efforts to improve surgical training in pediatric urology can target the programmatic factors deemed to be essential for training by trialing the solutions offered by its stakeholders.