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Canadian urology residency programs generate approximately 33 urologists annually,1 serving 5.6 million children age 14 and younger among a total population of 35 000 000.2 Given the widely dispersed population over a vast geographic area and the fact that the majority of pediatric urologists are concentrated in urban centres, community urologists must manage some pediatric urologic issues locally. Determining which operations and conditions general urologists can deal with presents a challenge for creating requirements for clinical training and for competency.
It has been suggested that Canadian urology residents have insufficient exposure to pediatric urology with suboptimal competency even in low to moderately complex procedures, such as inguinalscrotal surgery and pyeloplasties. Interestingly, >80% senior residents and >75% urology program directors felt graduating residents were competent in those cases.3 Currently, there exist no required number of cases to determine Canadian urology trainee competency. In a recent review of six Canadian programs, on average, residents participated in 149 minor cases and nine major cases.4
In contrast, for urology trainees in the U.S., the Accreditation Council for Graduate Medical Education (ACGME) has set a minimum requirement of procedures residents must to be involved in to qualify for board certification. For pediatric urology, these include 30 minor cases (endoscopy, hernia/hydrocele, orchidopexy) and 15 major cases (hypospadias, ureter).5 Published national averages for pediatric cases of all graduating U.S. urology residents from 2015–2016 were 121 minor and 63 major cases.6 They have also implemented six milestones residents must complete in order to achieve clinical competence, making physician training more accountable to the public.
As current fellows who are U.S. residency-trained and who matched to SickKids for subspecialty training, we compare our residency experiences from that we observed of our local counterparts.
I spent eight months rotating on the pediatric urology service during my six-year residency. For six of those months during my third and fourth year, I rotated at my home institution, with two fellowship-trained pediatric urologists, no pediatric urology fellows, and one dedicated pediatric inpatient floor. I was responsible for participating in staff clinics, covering all consults and the emergency room, and fielding parent calls, but primarily operating as first assist or primary surgeon in all cases.
Two additional months during my fourth year were spent rotating at a major free-standing children’s hospital where there were eight fellowship-trained pediatric urologists, one clinical pediatric urology fellow, and at least 3–4 other urology residents. Despite the fellow and increased resident presence compared to Toronto, I continued to do all I had done at my home institution. All of us trainees felt capable of managing basic pediatric problems and performing circumcisions, orchidopexies, and even pyeloplasties by the completion of our training.
After six months in Toronto, it appears that the University of Toronto residents rotate through SickKids for only 2–3 months, as required by the Royal College of Physicians and Surgeons of Canada (RCPSC). Regardless of milestones set by the RCPSC, local residents spend very little time in the operating room (OR) compared to my U.S. contemporaries, reducing the likelihood that they will feel competent and confident to practice basic pediatric urology independently. Should they spend more time in pediatrics with an emphasis on OR rather than clinic (education trumping service) knowing that simulated surgeries and case-based teaching scenarios are not a substitute (yet)? Should they be exposed to the rare and exceptional, not just “bread-and-butter” cases, if we are to spark their interest in pediatrics?
Fellowship training in Toronto was appealing because of the high volume of complex cases consolidated into one tertiary institution and also to learn about the Canadian healthcare system. After 1.5 years, it is increasingly evident that residents have minimal exposure to pediatric urology here. Residents rotate on service for only three months total. Coming from a five-year program with one fellowship-trained pediatric urologist, I rotated for six consecutive months on the pediatric service in my fourth year. This intensive time, solely dedicated to pediatrics, allowed for continuity of care, provided a solid foundation of basic concepts, and fostered my interest in the field.
Two months as a junior resident and one month during a senior year, in my opinion, would not have made me feel competent performing surgery on children. In the U.S., residents may only rotate at a maximum of four hospitals and it is required that at least two residents are stationed at any time, which is not the case in Toronto. In the U.S., much of the everyday service is performed by physician extenders (pediatric nurse practitioner and physician assistants), who are overtly absent in this environment, forcing trainees to provide service over education.
As pediatric urology is so subspecialized, it is difficult to determine what general urologists should feel comfortable managing. Even if trainees do not feel confident in operating independently after residency, one should still have adequate exposure to pediatric urology to at least recognize and manage common problems in a community/general urology setting.
Now with specific ACGME milestones set in the U.S., the need for defining competency and determining an adequate case number, it becomes ever more important for residents to have the strongest experiences in every subspecialty. This issue shouldn’t be overlooked, as competency-based training matures in Canada.