Michael Nimaroff, MD - Training the Next Generation of Endosurgeons
Endometriosis Foundation of America
Medical Conference 2019
From Biomarkers to Precision Surgery
March 8-9, 2019 - Lenox Hill Hospital, NYC
Thank you very much. I really want to thank the EFA as well as Dr. [Sachin 00:00:22] for inviting me to speak here this weekend and especially with this incredible team of renowned colleagues and experts in this very complex field. Following that last talk in the video, which was spectacular, it's very fit to follow up to say, "Now, how do we go about training our next generation of surgical experts?" because the world today is very different than the world that many of those experts that are on this screen here. And, of course, we don't have to name who they are. We all know very well our respected experts and leaders in the field of minimally invasive surgery and also endometriosis surgery. But how do we go about training our next experts?
So, I think we can all agree endometriosis is a very complex disease. It's a process that requires a focused, multi-disciplinary approach. Again, in our last surgery, are working together along with our general surgical colleagues. Endometriosis surgery, again, is complex and often the most difficult procedures to perform, even at times, and I apologize to the Gyn Oncologists in the room, but even at times, clearly more difficult than some very complex gynecologic cancer surgery. But as well, it's definitely, I think we can agree, it's probably not in the scope of the general Ob Gyn and it requires extensive surgical experience, especially when using minimally invasive robotic techniques, which I think we all agree is now the standard for treating our patients who have several disease.
So, what do we do now? So, we have a four-year diverse resident education in Ob Gyn, which, as I think, many of us will agree and there's much literature on this, I'll touch on a few, but which really is maybe very insufficient. We also now have fellowship training in minimally invasive surgery, pelvic surgery. Some of them one year fellowships, but it's an improvement that we do have some advanced training.
We have mentorship again. It's been in the path with our surgical experts, but there's no specific volume requirements. It's very difficult to measure outcomes and we have no specific, really defined path except self-proclaimed experts, and that's certainly not the world that we live in today. The see one, do one, teach one is not really ... I don't think we can say that that's an appropriate approach for a patient who has complex endometriosis. Unfortunately, even though we have a wide range of simulators, both artificial with virtual reality and such, still they're tremendously underutilized because they're extremely expensive and are really, again, underutilized by our trainees.
So, in the past, again, many of the surgical experts are actually general Ob Gyns. I didn't even know this until very recently, but Dr. Sachin used to delivery babies. I, myself, still, occasionally, will deliver a baby. This is my fellowship co-director, Dr. Goldman, who still does deliver babies. But, again, the experts who are recognized leaders of today, mostly came out of the fields of just general Ob Gyn and developed the expertise, except for, again, the few who came out of the reproductive endocrinology fellowships. But today, that's not been generally the path. So how are we going to go ahead and train this next generation of experts?
What we have in our Ob Gyn residencies and the trends, there's increasing subspecialization, there is a stable or declining birth rates, decreasing rates of hysterectomy. We still have work restriction duties, although that has been changed somewhat, but we still have some duty-hour restrictions in residency programs. And there's increasing data transparency. There's informed consumers. There's an increased focus on patient safety and quality oversight. A majority of gynecologists in practice do less than one hysterectomy per month. I've tried desperately hard to find data on, actually, on endometriosis, and it's not in existence. I couldn't find it.
I apologize, the picture was of our current fourth-year residents. I'll go back for one second. But interesting, of our fourth-year residents, a few were going into REI, one into minimally invasive surgery. A few went to urogynecology, a couple into maternal-fetal medicine, and a few just going into general Ob Gyn. But the story is among our general Ob Gyn graduates, I think very few are going to be comfortable with doing advanced minimally invasive surgery, much less doing advanced complex endometriosis surgery.
If I go back to this, this is again a small study. But looking at it, it was a survey of graduates of Canadian programs. Very low volume of total laparoscopic hysterectomy during their training. Majority were only comfortable with abdominal approach, and only 26% felt competent in TLH procedures.
Again, this is from Journal of Graduate Medical Education, a slightly more recent study, and done in the United States at University of Michigan. Different numbers, but still, 65% of the graduates felt comfortable to perform TLHs. This is, again, a program that is really a large-volume program. It's very interesting, and we're still ... Our current education of our general Ob Gyns in particular certainly comes up short for training our graduates to perform complex procedures.
Again, this is from Belgium. Only 28% of Gyn respondents felt proficient to perform advanced MIS procedures. 69% had access to skill labs and other opportunities for improvement outside of the operating room, but very few actually use them.
If you look at the current ... This is actually current ACGME case minimums for Ob Gyn programs. Only really a total of 85 hysterectomies, and that's all types are required, are minimum standards for 2019. What's interesting here, there's nothing about disease-specific management. That's where we have a little bit, again, there's an issue.
At least I'm happy to say this is our current ... This is an updated version of the case minimum requirements for the FMIGS for our fellowship programs. At least here, we actually have a case minimum of advanced endometriosis, so disease-specific management, not only case numbers for surgical procedures. Here, actually, on the bottom, is a picture of just the most recent graduation of the fellows.
Again, comparison to surgical techniques among fellowship- and non-fellowship-trained members of AAGL. Just look at volumes. We all know this. Case volumes for FMIG grads, 63% had over eight majors per month, versus 38% of non-fellowship-trained, even though these were, again, these are AAGL members, so people who are interested in the field. Again, in suturing, our fellowship graduates were comfortable, 32% versus 13%. Again, and again, I think these are all valid, even though we don't have specific data regarding complex endometriosis, but certainly there are advanced MIS skills at the very least, we need to be comfortable with before we can attack, obviously, a complex endometriosis procedure.
Again, what about attending experience? Again, I love this quote from Einstein, "The only source of knowledge is experience." I don't think my children believe that, but I think many of us believe experience is very key, especially in the realm of medicine.
So what about the volume and outcomes? We can go on for hours about this, as far as what's the standard volume of complex surgery that our members, our physicians should have. As a hospital administrator, I will tell you that this is something that we struggle with. In the robotic world, we've actually set some standards as far as what case minimums should be at the very least, but we haven't done the same with really the remainder of the complex procedures, and we probably need to mimic that. We are certainly looking and considering looking at some, at least, case metrics.
Here, this was a meta-analysis. There were 14 studies included. Low-volume surgeons performed the procedure less than 12 times per year, so the low-volume surgeons had increased intra-op, post-op, and also mortality. It's not a surprise. The outcomes have been found in many studies that have looked at low-volume surgeons. But if you think about that, one procedure per month in the procedures they looked at, it's not an uncommon thing. I would tell you that if we looked at our hospital staffs, I would say that's probably 75% of surgeons fall into that category.
Again, another study here, this from JMIG. General surgery focuses on surgical training for five years. Ob Gyn it's actually 18 months if we total all the amount of time spent on the surgical aspects of gynecology. Majority of Ob Gyns, only 15% of practice is devoted to surgery. Again, low-volume surgeries, less than one hysterectomy per month. That's at least 80% of our Gyn colleagues. The learning curve, it's been shown that for robotic, this is for robotic TLH, FMIG fellows needed 50 cases and 15 cases for hysterectomy and 15 cases for complex retroperitoneal dissections. So again, higher-volume surgeons and fellows had lower complication rates. And again, I don't think it's any surprise.
So what is the ideal to train our next generation of future surgeons? One thing that's obviously it's been up for discussion and looking at moving to the track system in Ob Gyn residencies. This is something that is currently in progress in some programs, and it's under consideration. But certainly to direct after an initial focus on a sort of a general-type education, that at least half the residency is spent devoted to a specific tract. So the surgical, non-surgical, or high-risk Ob tract. And then again, we think, certainly, a fellowship in FMIGS, pelvic surgery, with significant endometriosis focus. And then mentorship with an endometriosis expert is certainly a advantage and certainly a path for many. But then the question is do we need even more, because even in our fellowship programs, okay, there's a wide range of a slight disparity as far as what is actually taught during fellowship programs. Again, an endometriosis-focused fellowship is something that we've been thinking about considering, and certainly I think would be beneficial for our female patients.
And again, so Center of Excellence. What about Center of Excellence? We need to establish guidelines. I mean, that's really what it comes down to, training, volume, and outcome data collection. Similar to the growing number of other disease-specific COE programs, and these are growing. Yes, insurance carriers are looking for this and sort of funneling patients to programs that are recognized Centers of Excellence. Certainly in Europe, it appears that they are leading the charge on this and developing criteria for developing Centers of Excellence regarding endometriosis. I think we certainly need, and should, follow that lead and really consider developing formal guidelines for what it would take to become a Center of Excellence in endometriosis. But there's very sparse data on surgical experience in endometriosis treatment outcomes, but we all know there's certainly is a difference in volume, and experience matters.
Again, there's just quickly definition of an endometriosis center. An expert. But what is the objective? It's to improve the diagnosis, the management, and the outcomes, trained health professionals, disease-specific management, develop research and data collection, and coordinate access with an expert multidisciplinary team. And that's really, I think, the key for providing really excellent care.
So again, heading into the right direction with inclusion of FLS training in our current curriculum. I don't know if you all know this, but finally, we are now, it's mandated for our residents to complete FLS program before graduation. Fortunately, our fourth-year residents don't have this requirement, but the third-years and below all have to take the FLS and pass the FLS program, so at least to have some standard for minimally invasive surgical technique and skill.
Residents and fellows must spend more time in the sim lab. They just don't, even when we have expensive robotic simulators, robotic computer simulators, and honestly, it doesn't take an expensive ... You can have a lovely, cheap, box trainer that is affordable. You just need to practice. Working with trainers to improve dexterity, understanding pelvic anatomy. Curriculum must include formal training in endometriosis management, both the medical and the surgical side, obviously, because there is, certainly, multiple components to really skilled treatment. Again, a Center of Excellence should be developed. We really need to move on this.
But the summary, what do we do? How do we train those future experts? So first, we have to recognize the significant expertise required, which, I think, we do in this room, and certainly the Endometriosis Foundation sponsoring this event certainly is well aware. Surgery and management requires a multidisciplinary team. In the past, our surgical experts were born through individual experience and learning. But that, in today's complex environment, is becoming more and more difficult and is a problem, so we really need to develop a clear path just to train our experts in the future, much like many of our other subspecialties. So. Thank you very much.