Gynecologic Surgical Training: Current and Future Perspectives

Pelvic anatomy and pelvic surgery are complex and sophisticated. The head and neck comprise the only other anatomical region where so many specialties have become so interrelated. ¹ It is noted clearly that the expectation for gynecologic surgical training has suffered greatly for various reasons. ² This issue is not new, as multiple authors had suggested changes in gynecologic surgical training as early as Brunschwig did in 1968 who called for certification in gynecologic surgery. ³ In this special topic issue of the Journal of Gynecologic Surgery, we present the current and future perspectives of gynecologic surgical training. The span of the discussion starts within residency programs and extends to all subspecialty fellowships and beyond.

Wright et al. (pp. 375–378) not only discuss the current status of surgical training in obstetrics and gynecology (OB/GYN) residency programs, including the reasons behind decreased preparedness of graduates to operate independently, ⁴ but also some challenges that face new graduates including decreased surgical volume to maintain skills. ⁵ Wright et al. also offer some solutions, including residency tracking and expansion of fellowship training.

Magrina in his 2014 presidential address at the American Association of Gynecologic Laparoscopists (AAGL) called for separating OB/GYN residency training into different residencies. ⁶ Since then, much discussion has occurred regarding how to optimize gynecologic surgical training. However, less frequently, discussions have included surgical training for the practicing obstetrician. Recently, obstetric hospitalists have become more prevalent, and more OB/GYN graduates are practicing only obstetrics. Sawangkum et al. (pp. 379–382) discuss the importance of gynecologic surgical training for obstetrics practice.

The depth and complexity of gynecologic surgery are continually increasing due to surgical innovation and a trend toward minimally invasive surgery (MIS) approaches. ⁷ In 2001, the AAGL and the Society of Reproductive Surgeons collaborated to establish the first fellowship in minimally invasive gynecologic surgery (FMIGS). The stated goal of FMIGS was to provide standardized training for graduating OB/GYN residents so they could acquire additional skills in minimally invasive gynecologic surgery (MIGS) and serve as scholarly and surgical resources for the communities in which these residents would practice. ⁸

In 2019, The American Board of Obstetrics and Gynecology announced a designated focused practice for MIGS. ⁹ Fellowship training in MIGS is not a prerequisite to obtain this designation. This announcement was opposed by some individuals (writing a letter on behalf of the Board of Directors of the American Urogynecologic Society, stating that the designation was insufficiently specific and described a route of surgical access rather than a field of medicine. ¹⁰ While some individuals oppose the MIGS designation, MIGS training represents a potential answer to the conundrum of gynecologic surgical training. Graduates of the program are filling the roles of complex gynecologic surgeons in academic departments, integrated hospital systems, and community practices, ¹¹ not only in MIS but in all complex gynecologic cases. Horwood et al. (pp. 383–386) discuss how expertise that MIGS-trained individuals develop over time in anatomical understanding and technical skills allows them to serve patients' needs better for complex open surgeries.

The role of reproductive surgeons in advancing MIS cannot be argued, as pioneer minimally invasive reproductive surgeons (MIRS) had a significant role in advancing the field. ¹² Some authors make a clear distinction between MIRS and MIGS, defining a MIRS as a reproductive endocrinologist who focuses on the surgical aspects of this field, while calling a surgeon who performs MIGS as a general gynecologist with special training in laparoscopy. ¹³ MIGS is not and should not be a technology-centered specialty, ¹¹ nor should it be focused on route of surgery. Rather, MIGS must own a certain domain and demonstrable expertise in gynecologic surgery. MIGS is no longer a niche skill but is well on its way to becoming the standard of care even among non–fellowship-trained surgeons. ¹¹ Some authors have expressed concern that the surgical expertise of infertility specialists is diminishing, stating that there is a delicate balance between the increasing use of assisted reproductive technology and the loss of surgical skills. ¹⁴ Pavlovic et al. (pp. 387–389) article discuss not only the integration between MIRS and MIGS and how collaboration between them might improve patient care, but also how MIRS can maintain their important role in surgical care of infertile patients.

Although vaginal hysterectomy has been the signature operation for the gynecologic surgeon, the national trend of the vaginal route for hysterectomy is decreasing. ¹⁵ Emphasis on the vaginal route during training is needed, but who is more suited for that role more than the female pelvic medicine and reconstructive surgery (FPMRS) specialist? FMPRS was recognized by American Board of Medical Specialties in 2011, and FPMRS Fellowship was accredited by the Accreditation Council for Graduate Medical Education for the first time in 2013. ¹⁶ Ross et al. (pp. 390–392) describe the variation in surgical training in FPMRS and how emphasis on vaginal surgery should be implemented in an era in which laparoscopic and robotic surgery are utilized widely.

The challenges in gynecologic surgical training have affected all subspecialties, including gynecologic oncology (GYN/ONC). Since the inception of this subspecialty 50 years ago, major changes have occurred. ¹⁷ Neoadjuvant chemotherapy, introduction of MIS, and extent of radical surgery are a few of the major changes. In addition, the Laparoscopic Approach to Cervical Cancer trial has changed the standard treatment for cervical cancer. ¹⁸ Roque et al. (pp. 393–396) discuss how surgical training in GYN/ONC fellowship is evolving.

In the final special topic article in this issue, King (pp. 397–399) places emphasis on the concept that, if society at large is concerned about improving health care for women, including optimization of gynecologic surgical training, then society should be also concerned about improving the double discrimination that female gynecologic surgeons experience.