Abstract
Training in general surgery at the University of the West Indies commenced in Jamaica in 1972 and urology training followed just over a decade later. Since then, the ‘Doctor of Medicine’ diploma offered by the university has also expanded to include the Trinidadian campus. Most urologists in the English-speaking Caribbean are, in fact, graduates of this programme. Residents follow a two-part training plan and two years of core surgical training are followed by four years of urology training. Despite the tremendous regional impact of this training programme, there is a lack of awareness of its existence among the wider urology community. This article reviews the history, development and structure of urology training in the English-speaking Caribbean.
Introduction
The University of the West Indies (UWI) was founded in 1948 with its first campus located in Mona, Jamaica. 1 Originally developed as a branch of the University of London, called the University College of the West Indies, it was subsequently renamed and received independent university status in 1962. The St Augustine campus was opened in 1960 and the Cave Hill Campus in Barbados followed in 1963. The most recent Open Campus, which focuses on online learning, was developed in 2008. The University has served as the premier institution of higher learning for the 17 territories of the English-speaking Caribbean. It is currently listed among the top 5% of universities worldwide. 2
Medical training at UWI commenced at Mona from its inception. Training in Trinidad and Tobago followed in 1989 and Barbados in 2008, although it was possible to undertake clinical clerkships in these territories much earlier. The medical programme consists of five years of training divided into three pre-clinical years and two clinical years. Postgraduate training began at the university with the Diploma in Anaesthesia in 1966 3 and has since expanded to include residency training programmes in many disciplines, both surgical and medical.
At the end of training, residents who complete the prescribed exit examinations are conferred with the title of ‘Doctor of Medicine’ (DM) in their respective disciplines. Surgical training commenced in 1972 at the Mona Campus in Jamaica and was established by Professors Harry Annamunthodo and Errol Walrond. The development of training in Urology at UWI in Jamaica followed that of General Surgery. Some years later, training commenced in Trinidad and Tobago, mirroring its evolution in Jamaica.
The aim of all the DM training programmes has been to produce surgeons who exhibit maturity of surgical training and surgical judgement with the requisite experience to be suitably appointed as a surgical consultant. Graduates should function as leaders within the health sector, be able to communicate well and have a good moral compass.
Although the DM in Urology has been crucial to the provision of urology training and staffing of the Caribbean region, there does not seem, anecdotally, to be awareness outside of the region that urology training may be undertaken locally.
Development of urology training
Jamaica
The development of urology training in Jamaica was the brainchild of Dr. Lawson Douglas and was borne out of necessity as the high patient-to-provider ratio in the 1970s was untenable. 4 Several trainees were sent to Canada but only one returned, the rest being lured by lucrative opportunities elsewhere. Following the model of General Surgery, which was at the time already being offered by The University of the West Indies, Dr. Douglas developed both a Diploma as well as a Master’s Degree in Urology. The Diploma programme consisted of an intensive year in urology following the completion of general surgery training; the Master’s programme involved three-monthly rotations in nephrology, plastic surgery and vascular surgery, two years of urology training and a one-year overseas elective. Owing to the perceived rigours of the Master’s programme, no candidates applied, opting instead for the shorter Diploma in Urology. This programme eventually produced three graduates, the first in 1988, of whom two are still in practice on the island. Both programmes were subsequently discontinued in July 1995 and replaced with the DM as it exists today. The first graduate of the DM in Urology in Jamaica in 1998 was Dr. William Aiken, who went on to head the Urology Division following Dr. Douglas’ retirement in 1999. At the time of writing, 20 urologists have completed training at the Mona Campus.
Trinidad and Tobago
In Trinidad and Tobago, Dr. Lester Goetz noted similar issues with patient-to-provider ratios as well as an ageing pool of urologists. A DM in General Surgery was approved by the St. Augustine Campus of UWI and commenced in 2004. With a structure in place to facilitate core surgical training, approval of the DM in Urology followed in 2006, with the programme being based at the San Fernando General Hospital (SFGH), the major tertiary referral centre in the South of Trinidad. Dr Goetz served as programme director from the inception of the programme to his retirement from public service in 2018.
Previously, the Department of Urology was established as an independent department in 2005. This followed the establishment of a 25-bed urology ward in 2002 and dedicated twin urology operating theatres in 2004. Having this infrastructure in place allowed sufficient volume to accommodate residency training. Subsequently, the Eric Williams Medical Sciences Complex in the North of Trinidad was approved for training and residents now rotate between both centres on a six-monthly basis. The Department of Urology at San Fernando General Hospital was approved as a Société Internationale d’Urologie (SIU)-approved teaching facility in 2011 and has benefitted from several international workshops through its relationship with IVUmed, a volunteer organisation that works closely with the SIU. In particular, these workshops have led to a transfer of skills in minimally invasive and reconstructive urology.
The training programme in Trinidad and Tobago has produced nine urologists with the first graduating in 2015. At present, there are seven residents in various stages of training.
Structure of urology training
The DM in Urology is divided into two parts, the first consisting of core surgical rotations, and the second dedicated to urology training. During the first part, residents complete basic surgical rotations including three-monthly rotations in General Surgery, Anaesthesia and Intensive Care, Urology, Paediatric Surgery, Orthopaedic Surgery, Neurosurgery and Pathology. From its inception, it was always felt that residents should have a firm foundation in the basic sciences and following these core rotations, candidates sit an examination comprising written and oral components covering the subject areas of applied Anatomy, Physiology, Pathology and Principles of Surgery. Following successful completion of core training, trainees then complete four years of urology training including a one- or two-year elective period, during which they are encouraged to seek placements overseas at a University-affiliated hospital. The aim of this overseas experience is to expose trainees to technology and subspecialty training not readily available in the region. Long-lasting professional friendships are often forged during this period. In the past, residents have visited tertiary centres in the Unites States, Canada and the United Kingdom, and are encouraged to prepare for their elective rotation by completing the required licensing examinations well in advance of placements overseas.
Throughout residency, residents are required to maintain a logbook of their surgical cases. They are also expected to compile either a casebook of 20 case reports with accompanying commentaries or 10 case reports along with a research project. Following acceptance of the casebook by the university, trainees then sit an exit examination, again consisting of written and oral components. At present, this consists of two written papers which take the format of essays as well as a 90-min viva examination with two regional and one external examiner each examining the candidate for 30 min. External examiners are appointed by the university and are, by necessity, urologists of high academic standing, usually having the academic rank of professor. Examinations take place twice-yearly and residents are permitted two sittings to complete their examinations. Two unsuccessful attempts oblige residents to withdraw from the programme. Verbal and written feedback from external examiners have been praiseworthy of the candidates’ level of knowledge and application of urological principles in managing patients. In addition, it has been repeatedly noted by them that the candidates are on par with examination candidates at the same level in the USA.
During training, residents are strongly encouraged to participate actively in research projects and to present at local and regional scientific meetings. Research, while encouraged, is as yet not a mandatory requirement apart from their final casebook research project.
Since 2014, residents have also sat the American Urological Association In-Service Examination at the end of every calendar year and have undergone formal in-training assessments every six months in order to identify individual areas of concern.
The academic schedule during residency training involves teaching ward rounds, interactive resident and faculty classes, monthly journal clubs, weekly morbidity and mortality conferences and multidisciplinary team meetings. In addition, residents based in Jamaica benefit from uro-radiology and neuro-urology meetings, the latter conducted on a monthly basis at the local rehabilitation unit.
Staffing
In Jamaica, most DM graduates in urology have remained in the city of Kingston with the remainder in Montego Bay, leading to a skewed urban distribution of services within the island. This has largely been the result of the lack of consultant posts at outlying hospitals. Similarly, six of the nine graduates of the programme in Trinidad and Tobago have remained on staff at the San Fernando General Hospital, leaving sections of the islands greatly underserved, not dissimilar to the situation in Jamaica.
A few graduates of the Mona programme have undertaken fellowship training overseas: three have gone on to complete Endourology fellowships and one has completed a Female Urology fellowship. In Trinidad and Tobago, one graduate has pursued fellowship training in Endourology. It is hoped that more graduates will consider subspecialty training in order to enrich the skillset throughout the region. Several graduates of both programmes have gone on to serve in other territories of the Caribbean including Barbados, Bahamas, Bermuda, Antigua and Guyana.
Future directions of training
Trainers have recognised the need to conduct high-impact research and are considering making research a mandatory component of residency training. There is a need also to institute objective measures of surgical competence such as indicative numbers while bearing in mind the limitations of our small population. There has also been a call to abandon the essay format of the examination in favour of the less subjective multiple-choice format. Essays test not only recollection of facts but cognitive function. However, multiple-choice questions, on the other hand, are used increasingly owing to their ease of scoring and reliability 5 ; the debate continues at the faculty level and likely will for some time on whether the essay format should be replaced.
As it stands, most graduates of the Jamaican and Trinidadian programmes are local and have remained in their respective countries. There is, therefore, a need to train urologists from smaller, underserved territories. While there is a will for this to happen, it will prove challenging as university training is inextricably linked to the trainee’s ability to secure a post at the training hospital and these are now at a premium. It is hoped that regional governments will fund these students via scholarships; having a trainee’s government pay for their training obviates the need to secure a paid spot in the training territory.
Conclusion
Since its inception, the DM in Urology, offered by UWI, has provided the Caribbean region with the majority of its urologists. Most have remained in the islands of Jamaica and Trinidad and Tobago where they trained, and it is hoped that incentives could be put in place to supply trained personnel to underserved territories within the Caribbean region.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
