Identification of essential surgical competencies to be imparted in urological residency: A survey-based study.

INTRODUCTION: There are variations in surgical procedures included in urology residency curricula across various programs. We conducted a survey of practicing urologists to determine which procedures are considered essential to a core urology residency curriculum.
MATERIALS AND METHODS: A web-based survey was conducted between October 2016 and February 2017 using SurveyMonkey. The questionnaire, comprising a set of 5-questions, was sent to the members of the Urological Society of India. Respondents were requested to grade 37 of the most common urological procedures (competencies) into three groups. Group A, were those that the respondent believed were vital for the trainee to learn (must know). Group B, were those that the respondent thought were essential to acquire (good to know). Group C procedures were labeled as desirable to know by respondents.
RESULTS: A total of 485 (15.75%) responses were received out of 3018 members contacted. 67% respondents were working in the private-sector. Out of the 37 listed procedures, 20 procedures received a median weightage of 1 indicating vital clinical competency for urology curriculum, 15 were identified as "essential to know" while two procedures were identified as "desirable to know."
CONCLUSIONS: Twenty surgical procedures were identified as'must-know' for a urology trainee. The choice of procedures was not affected by the region of the responder or his practice type, suggesting a wide consensus.

INTRODUCTION

India has a robust 3-year residency program for urology culminating in board-certification.[1] The resident is typically involved in patient care, acquiring theoretical knowledge, and performing some research activity usually in the form of a thesis. Additionally, the student has to acquire surgical skills under supervision. However, expansion of knowledge with the addition of more and more surgical procedures that require special training (with definite learning curves) has made the curriculum “obese” and it has become difficult to acquire “all” these skills. It is becoming apparent that it is difficult to train the residents in the limited period of 3 years.[2]

India is a heterogeneous country with the economic status varying from the very rich to the very poor. Similarly, the medical facilities vary from the most advanced to the very basic. Therefore what surgical skills are to be taught during the residency becomes a difficult question.

Urology is primarily a surgical branch, where the students have to acquire psychomotor skills. The important surgical skills that a student needs to acquire usually include the various endourological procedures (such as transurethral surgery, ureterorenoscopy, percutaneous renal surgery), laparoscopy, urethroplasty, and various extirpative oncologic surgeries. It is difficult for both the trainees and the trainers to acquire all these skills in a short-time span of 3 years. Therefore, there is a need to make a uniform policy and identify “must know” procedures that the trainee has to learn.

Issues such as what should constitute the core of the training program and how to objectify procedural competency remain a matter of ongoing debate. Many countries have addressed this complex issue.[3456] A Canadian study executed a survey of urologists from their country to identify the competencies that they believed were essential.[7] We conducted a similar survey with the aim to answer the basic question: what are the core urological procedures identified across the nation, that should be a part of the curriculum and also to understand the regional variations in it.

MATERIALS AND METHODS

A web-based survey using SurveyMonkey was conducted between October 2016 and February 2017. The survey questionnaire was E-mailed to all the members of the Urological Society of India (USI). The questionnaire broadly comprised of a set of 5 questions [Annexure 1]. Demographic information of the respondents was gathered and the respondents were requested to grade 37 common urological procedures, based on current urological practice, into three groups: Group-A competencies that the respondent believed were essential for the trainee to learn (must know; vital); Group-B competencies that the respondent thought were good to acquire (good to know; essential); and Group-C procedures were labeled as nice to know by the respondents (desirable to know).

We did not include many office procedures and basic urology procedures such as diagnostic cystoscopy, orchiectomy, pyelolithotomy, ureterolithotomy, etc., in the questionnaire. This omission was made with the belief that these were mandatory skills and were often learned during surgical residency and also for the sake of making the questionnaire brief. An option was given in the end to suggest additional procedures that were not included in the list, if the respondents deemed them necessary. Before mailing the questionnaire, it was reviewed within the department (expert opinion) to suggest any modifications.

Statistical analysis

The statistical analysis was carried out using the IBM SPSS Statistics V21.0. and the SurveyMonkey® logical survey analysis tool. The responses to “a procedure being in Group A, B, or C” after being scaled on a Likert scale were presented as weighted means rounded up to the closest integer value. The individual responses were then stratified by possible variables in the form of zone-wise demographic data and sector-wise data. The descriptive data was analyzed using nonparametric tests, and multivariate analysis was carried for stratified data. P = 0 05 was considered statistically significant, and Bonferroni correction was applied for stratified dataset analysis.

RESULTS

The survey was emailed to 3018 members of USI; 485 (15.75%) responses were received. Nearly 69% of the respondents were from the private sector (43.22% in corporate structure and 25.42% working at an individual hospital). Of the 148 respondents from the government-sector, 95 (64%) were from various medical colleges with an ongoing recognized urology training program.

The USI zone-wise demographic representation of those who answered (444/485) is shown in Table 1. This data corresponds to 27.4% representation from the North, 10.4% from East, 24.6% from West, and 37.6% from South zone of the country. However, there was no effect of this regional variation on the results. Univariate analysis, based on this regional variation, did not reveal a statistically significant difference in the procedure preference. Multivariate analysis failed to show a difference of opinion amongst urologists working in different sectors that included 5 options (1) Urology departments with MCh/DNB training, (2) Urology departments without MCh/DNB training, (3) Government centres with Urologist without a department of Urology, (4) Private Sector - -corporate hospital, and (5) Private Sector -individual hospital.

Table 1

Zone-wise distribution of respondents

The results of 37-procedures with weightage 1–3 with 1 being must to know (vital), 2 good to know (essential), and 3 desirables to know are shown in Table 2.

Table 2

List of procedures with Likert scale presented as weighted means, median and standard deviation

Out of 37 procedures, 20 procedures were classified into Group-A identifying them as the core clinical competencies; 15 were classified into Group-B while 2 procedures were considered in Group-C [Table 3].

Table 3

Categorization of procedures as per survey response

An option was given to each respondent to suggest other possible procedures which they thought were necessary to learn during residency. One hundred and eighty-three comments were received that are listed in Table 4.

Table 4

List of procedures that can be added into the training program

DISCUSSION

Education and training curriculum is shifting from a time-based model to a competency-based model. The Royal College of Physicians and Surgeons of Canada proposed a model of Competency-by design, where learning and skills acquired during the residency will be reflected in lifelong practice.[8] Similarly, in the United States of America, the Accreditation Council for Graduate Medical Education projected Urology Milestones Project.[3] Experiments in the direction of competency-based model are being instituted in medical graduate education and in other areas in regions of Europe and Australia.[56]

India accommodates approximately 17% of the world's population, leading to high burden on the health-care system. India produces a large number of medical professionals, including graduate, postgraduate, and super-specialists. Currently, the training module in India is time-bound, irrespective of the competency and the skill acquired. Acquisition of knowledge and surgical skill by a resident varies among different institutes all of which provide an equivalent academic degree. This depends on the institutional infrastructure, equipment, surgical interest and expertise of the mentors, geographical patient distribution, and socioeconomic status of the patients making the training heterogeneous.

There has been an explosion of information in the field of medical science. The urology trainee is expected to learn not only the cognitive knowledge but more importantly has to acquire psychomotor competencies. Acquiring psychomotor competencies requires time as all surgical skills have a definite learning curve.[910] Moreover, there are other duties that are expected from a trainee resident,. There is, in some programs, an additional expectation of doing a project to be submitted as a research thesis. As the duration of training is 3 years, it is difficult to train the students in all competencies within this time span. There is, therefore, a need to identify important competencies.

There is lack of data about the educational needs of the country. This study is a “needs assessment”. We believe that the existing curriculum has been made by experts based merely on experience as there is no scientific data from India regarding the optimal curricula. Our data will help in making an evidence-based uniform curriculum. There are many levels of competencies: Knows, knows how, shows, shows how, and performs. Our data is a simple compilation of a list of procedures without defining the level of competency that the student has to achieve for any given skill.

The field of urology has undergone a tremendous change from being a subdivision of general surgery to a definitive integrated course world-over. Competence-based curriculum (CBC) is a relatively new concept in medical education that may help to overcome the regional variations in practice and define core clinical competencies that may ultimately unify the academic structure. CBC represents a multitude of events (as exemplified in Millar's pyramid) that take place during the residents’ training, including the theoretical knowledge base, practical skills, soft skills for patient interaction, and most importantly the final stage of preparing the residents to acquire necessary skills for clinical practice.[11] The current Halstedian principles fail to address the needs of today's residents and thus a need arises to fill these deficiencies with CBC.[12]

We created this survey to identify the core urological procedures that should be a part of the curriculum and to understand the regional variations in it. This list of 37-procedures is not all-inclusive but tries to identify the procedures that must be classified into three categories, namely, Group A-Must know (vital), Group B-good to know (essential), and Group C-desirable to know. This survey is an attempt to classify most of the urological procedures and opens an opportunity to add others in these categories to finally develop a more comprehensive urological curriculum.

This is the first ever attempt of such a classification in India, however, similar studies have been carried out in other countries.[7] The 3-point classification system can be seen in the UK system of surgical training which tries to classify all possible procedures in the surgical curriculum with an aim to have a common core competency across all the trainees’ and also helps in assessing various programs with high internal validity as it provides a common ground for comparison. All surgical procedures are classified as: (1) Essential – common: Frequently performed operations where specific procedural competency should be attainable through case volume alone by the end of training. (2) Essential – uncommon: rare-urgent operations in a general surgery practice and not typically done in significant numbers by trainees; specific procedure competency cannot be attained by case volume alone. (3) Complex-nonspecific experience in complex procedures in residency is required, but not competence in individual procedures.[13] It makes sense to adopt this 3-point scoring system in India, as it will provide external validity to our attempts on developing a sound urological curriculum that is sculptured to the national needs and also accounts for the regional variations.

The web-based survey was sent to 3018 members of the USI, out of which 485 (16%) responded. This response rate is much higher than that documented by a similar study by Rourke and MacNeily.[7] The highest number of respondents in our study belonged to the private sector contributing 67% of the total responses. Amongst the government sector respondents out of the 148 responses, 95 (64%) were from medical colleges with an ongoing urology training program. These figures may, however, be indicative of the greater number of urologists working in the private sector as compared to the government sector rather than the willingness to respond. Moreover, >60% of the respondents had regular interaction with residents.

We also received a few suggestions regarding involving the residents in answering this questionnaire which we may take up as the second part of the ongoing project. There were many suggestions by the respondents including the need to incorporate radiological procedures as a part of the core curriculum.

CONCLUSIONS

Based on our survey, it can be concluded that there is a broad-based consensus among Urologists in India about the need to teach urology residents competency in 20 common procedures. This consensus is devoid of any regional or practice-situation bias and can be used as a basis for further research in the area of Urological education.