Stone Specialist,Cancer Surgeon,or Both? Optimizing the Endourology Fellowship Training Model

Introduction

Minimally invasive surgery (MIS) has become the standard of care for treating patients with many benign and malignant urologic diseases. This evolution of urologic care has informed training at both residency and fellowship levels. Minimally invasive procedures for kidney stones or benign disease (e.g., percutaneous nephrolithotomy) as well as oncology (e.g., robotic prostatectomy, partial nephrectomy) have become core elements of residency training for urologists. While becoming an expert in all forms of minimally invasive surgery is still feasible, the breadth and complexity of treatment options has made this increasingly challenging. Subspecialization within academic practices and large physician groups is becoming more common (e.g., becoming the “stone expert” v the “robotic surgeon”). While most residencies intend to produce competent minimally invasive surgeons, trainees graduate from residency with variable skill sets, may desire to augment their training in specific areas, and may desire to build research credentials for an academic career. While the traditional endourology fellowship—with broad instruction in nephrolithiasis, benign prostatic hypertrophy (BPH), upper urinary tract obstruction, and malignant disease and with endoscopic and laparoscopic/robotic training—may be relevant for some trainees, subspecialized tracks within fellowship may be more appropriate depending on practical needs and fellows' career goals.

The Endourological Society (EUS) recently modified its accreditation paradigm to include subspecialized tracks, with accredited 2-year fellowships in endourology/stone disease and laparoscopy/robotics, while maintaining the traditional “combined” fellowship. One-year certificate programs in either endourology/stone disease or laparoscopy/robotics are also offered (www.endourology.org/fellowship/). The intent of these changes has been to recognize the heterogeneity of trainee needs and preferences regarding both clinical and research experience.

We have observed that many formally trained endourologists, particularly in academic settings, have subspecialized practices (stones/benign disease versus minimally invasive oncology). We sought to corroborate this observation, with the intent of informing the design and philosophy of future endourology fellowships.

Methods

Email addresses for the 327 graduates of EUS fellowships between 2001 and 2010 were obtained from the society. These names were then cross-referenced with the American Urological Association (AUA) member database in order to maximize the amount of current addresses. Ultimately 309 active email addresses were obtained and 24 recipients with active email accounts opted out of the survey. A 20-question electronic survey (SurveyMonkey Inc., Palo Alto, CA) was sent to this group. Survey results were analyzed using Microsoft Excel (Microsoft Corp., Redmond, WA), and a univariate analysis was performed.

Results

Responses were received from 120 of 284 former fellows with active email addresses who did not opt out of the survey (42.3%). Those who opted out had preset filters on their email accounts that rejected electronic surveys. Of respondents, 86% had completed fellowships in North America and 71% had completed 1-year fellowships. Among respondents in academic practice (46%), 44% reported a “mixed” benign and oncology-based practice, compared to 68% of nonacademic practitioners (P=0.004). Among academic practitioners, 33% practice predominantly MIS for benign disease and 24% practice predominantly MIS for oncology, versus 23.1% (P=0.3) and 9% (P=0.04), respectively, of nonacademic practitioners (Table 1).

Approximately half of respondents (56%) had mixed interests before their fellowships, while 22% had a primary interest in MIS for oncology and 22% in MIS for stones/benign disease. Of those with a mixed prefellowship interest, 85% had a similar interest after their fellowships (P=0.78) and 66% report their current clinical focus to be mixed. Of those with a prefellowship interest in MIS for stones/benign disease, 88% had a similar interest after their fellowships (P=0.87) and 65% report a current clinical focus in this area. Of those with a prefellowship interest in MIS for oncology, 65% had a similar interest after their fellowships (P=0.61) and 38% report a similar current clinical focus (Table 2).

Trainees who completed a 2-year fellowship were almost twice as likely to be working in what they describe as an academic practice (69% v 35%; P=0.002) but were no more likely to subspecialize when compared to those completing a 1-year fellowship (P=0.23). Almost all of those surveyed were satisfied with their decision to pursue a fellowship (98%) and felt they could comfortably operate autonomously at the completion of their training (97%).

Discussion

While fellowship-trained endourologists have diverse practice patterns, we found that most academic endourologists have a clinical emphasis in stones/benign disease or oncology, and a notable minority of private practice endourologists treats primarily benign disease. This is consistent with our observation that endourologists commonly subspecialize and supports recent changes in endourology fellowship design allowing for focused tracks in addition to a traditional model. Those desiring a subspecialized career path can pursue their clinical and research interests more efficiently, and those desiring broad endourology training have this opportunity. The creation of 2-year accredited fellowships within specialized tracks, rather than exclusively 1-year certificate programs, gives legitimacy to these routes by providing the desired credentials as well as time for substantive research for those desiring an academic career. As there is a defined opportunity cost for time spent in fellowship (i.e., lost wages and savings that are often not recovered during one's career), ¹ it is critical that training is tailored to the individual's goals. Encouragingly, almost all of those surveyed were satisfied with their decision to pursue a fellowship and felt they could comfortably operate autonomously at the completion of their training.

Our data demonstrates the stability of clinical interests before and after fellowship programs. This reinforces the idea that trainees can viably select their niche of training within endourology without missing valuable exposure. Indeed, exposure to endourology is occurring more commonly within residency programs, as advanced minimally invasive surgeries (e.g., percutaneous nephrolithotomy, robotic partial nephrectomy) are increasingly included in residency training. Interestingly, those with an interest in stones/benign disease after fellowship are likely to have a clinical focus in this area (65%), while those with a postfellowship interest in oncology are less likely to have this clinical focus (38%). This may reflect the broad practice of urologic oncology by general urologists and those trained in oncology fellowships, which makes it more difficult for endourologists to have focused oncology practice. Meanwhile, there are fewer surgeons with the skill set needed for advanced kidney stone surgery.

Our questionnaire reflected providers' focus on certain disease states rather than specific technologies. In analogizing our data to the fellowship tracks within endourology, we have made the assumption that most laparoscopy/robotic surgery is done for oncology. We believe this to be the case, specifically for kidney, prostate, and bladder cancer, based on our experience and the prevalence of these conditions. Reconstructive urology is often performed in minimally invasive fashion, however, and this is instructed within these fellowships (e.g., robotic pyeloplasty).

Our study includes a good response rate compared with comparable surveys published in urology literature. ² We attempted to maximize yield of responses by correlating email addresses from the EUS with those from the AUA. Shortcomings of the study include selection bias for respondents, though it is difficult to anticipate who may be more or less likely to respond (academic v nonacademic, subspecialized v broader practice). As this is self-reported data, responses may not reflect actual practice, though we believe that providers have a reasonable sense of their daily practices such that their responses are reliable. Also, our responses were designed to acknowledge that most practices are broadly constructed: Most urologists do have varied practices and do not exclusively treat benign or malignant disease. However, our question was phrased regarding primary rather than exclusive practice in benign or malignant disease, and we believe this captures the flexible job descriptions of many endourologists who still focus on certain procedures.

Conclusion

Increased flexibility in accredited endourology fellowship design should support the heterogeneous needs of trainees seeking advanced minimally invasive training. These changes are critical to ensure the continued relevance and appeal of these fellowships.