Development and Evaluation of a Multi-Institutional Virtual Urology Course for Medical Students.

OBJECTIVE: Urological education has been declining in medical schools, leaving many students without adequate exposure to the fundamentals of the field. We aimed to create a virtual urology course for medical students preparing for subinternships. DESIGN: We created a 4-week curriculum of case-based urology modules with sections on hematuria, bladder cancer, kidney stones, vesicoureteral reflux, prostate cancer, urinary incontinence, and erectile dysfunction. Students completed precourse and postcourse surveys assessing confidence in content knowledge and 4 educational competencies. Faculty completed postcourse surveys. Confidence was scored on a 5-point Likert scale (0-4). SETTING: We offered the course in May 2022 and May 2023. The course was fully virtual and was offered at medical schools across the United States. PARTICIPANTS: The course included 157 medical students from 60 institutions and 44 faculty instructors from 30 institutions. All instructors were urologists representing a range of urological subspecialties. RESULTS: Surveys were completed by 61/157 students (39%) and 33/44 faculty (75%). Median student confidence in content knowledge increased across all disease processes: hematuria (3 vs. 2), bladder cancer (3 vs. 1), kidney stones (3 vs. 2), vesicoureteral reflux (3 vs. 1), prostate cancer (3 vs. 1), urinary incontinence (3 vs. 2), and erectile dysfunction (3 vs. 2) (all p < 0.001). Median confidence scores also increased across all 4 educational competencies: patient evaluation (3 vs. 2), pathophysiology (3 vs. 2), literature appraisal (3 vs. 2), and patient counseling (3 vs. 1) (all p < 0.001). Confidence increases in all areas were maintained at 7-month follow-up. Most students (85%) and faculty (91%) rated the course "excellent" or "very good." CONCLUSIONS: A multi-institutional virtual urology course for medical students led to a durable increase in confidence pertaining to content knowledge and various educational competencies.

The Impact of American Board of Urology Certification on Postoperative Outcomes for Patients in New York State.

INTRODUCTION: Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations. METHODS: We performed a retrospective cohort study of patients aged 65 and over having radical prostatectomy (RP), radical cystectomy (RC), and radical or partial nephrectomy (RPN) by surgeons with New York State licenses from 2015 to 2021 using the Medicare limited dataset. Our primary exposure was surgeon American Board of Urology certification determined by the New York State Physician Profile. All surgeons were in practice for at least 5 years. Our primary outcomes were 90-day mortality, 30-day unplanned readmission, and hospital length of stay (LOS). We used multivariable linear and logistic regression adjusted for surgeon, hospital, and patient characteristics. We performed the analysis in R, and 2-sided P values < .05 were considered statistically significant. RESULTS: We identified 12,601 patients who had a procedure performed. At the time of the procedure, a minority of procedures (1.3%) were performed by nonboard-certified (NBC) urologists. Among the patient cohort, there were 262 and 1419 mortality and readmission events, respectively; median LOS was 2 days (interquartile range 1155). Patients operated on by NBC urologists tended to have lower-volume surgeons who were less likely to be fellowship trained and to have surgery at smaller hospitals. Patients treated by NBC urologists were more likely to have RP, and less likely to have RC and RPN. On multivariate analysis, board certification was protective against readmission for RP (P < .001) and RC (P = .02), longer LOS for RC (P = .001), and mortality for RPN (P = .008). CONCLUSIONS: Urology board certification was associated with fewer readmissions after RP and RC, a shorter LOS after RC, and a lower risk of mortality after RPN. Given low event numbers, these findings require validation with a larger dataset.

Multidisciplinary Development and Implementation of a Trial of Void Algorithm to Standardize and Reduce Indwelling Urethral Catheter Use.

INTRODUCTION: Prolonged indwelling catheter use is a known risk factor for catheter-associated UTIs (CAUTIs). We sought to reduce catheter use by creating and implementing a trial of void (TOV) algorithm to standardize indwelling Foley catheter removal in surgical patients. METHODS: We partnered with the Departments of General Surgery and Nursing to develop an evidence-based TOV algorithm for a step-down unit at a large urban teaching hospital. Our cohort included patients treated with intra-abdominal, thoracic, vascular, urologic, and gynecologic surgeries. The primary outcome was mean cumulative indwelling urethral catheter patient-days. For example, if 2 patients had catheters for 3 and 7 days, respectively, then cumulative catheter days would be 10. We analyzed changes in catheter use 90 days before and after algorithm implementation. RESULTS: The mean number of hospitalized patient-days before and after algorithm introduction did not differ (32.2 vs 32.0, P = .60). After implementation, mean cumulative catheter patient-days decreased (14.8 vs 9.9, P < .01), as did mean daily number of patients with catheters on the unit (3.7 vs 3.1, P = .02). There was 1 CAUTI before and after algorithm implementation, the latter deemed associated with algorithm nonadherence. Catheter use in a surgical floor control group where the algorithm was not implemented did not differ for any outcome over the same time period (P > .05). CONCLUSIONS: A multidisciplinary approach to standardize catheter care with a TOV algorithm is feasible and effective in reducing catheter use. Further research is needed to determine its impact on CAUTI rate.

The New York Section EMPIRE Collaborative: Piloting a Multi-Institutional, Simulation-Based Surgical Skills Boot Camp for Junior Urology Residents.

INTRODUCTION: Since the integration of the intern year into urology residencies, programs are mandated to introduce fundamental skills to junior residents. Our goal was to assess the impact of one such program: the 2023 New York Section of the AUA (NYS-AUA) EMPIRE (Educational Multi-institutional Program for Instructing REsidents) Boot Camp. METHODS: Junior urology residents from all 10 NYS-AUA institutions attended a free EMPIRE Boot Camp on June 9, 2023. The seminar covered procedural skills including urethral catheterization, cystoscopy, renal and bladder ultrasound, transrectal prostate ultrasound with biopsy, and an introduction to robotics/laparoscopy. Sessions focused on urologic emergencies and postoperative scenarios. Participants completed questionnaires before, immediately after, and 6 months post course, assessing comfort with procedures and overall program quality using a 5-point Likert scale and free text responses. t Tests compared pre and immediate/6-month post scores. RESULTS: Forty junior residents, along with faculty and resident instructors from all 10 NYS-AUA programs, participated. Of the 40 trainees, 35 (87.5%) completed pre- and immediate post-boot camp surveys, while 23 (57.5%) responded to the 6-month follow-up survey. Ratings showed significant improvement in comfort with basic urologic technical skills for 13 out of 14 domains (93%) immediately after the course and at the 6-month mark. Attendees reported notably higher comfort levels in managing obstructive pyelonephritis (P = .003) and postoperative complications (P = .001) following didactic sessions. CONCLUSIONS: A skills-based, free collaborative urology boot camp for junior residents is feasible and can be effective. Trainees reported improved comfort performing certain technical skills and managing urologic emergencies both immediately after the course and at 6 months of follow-up.

A Comparative Review of Oral Board Delivery Across Procedural Disciplines.

OBJECTIVE: Despite its ubiquity in the certification process among surgical specialties, there is little data regarding oral board delivery across various procedural fields. In this study we sought to determine the specifics of oral board exam administration across surgical disciplines with the goal of highlighting common practices, differences, and areas of innovation. This comparative analysis might further serve to identify unifying principles that undergird the oral board examination process across specialties. DESIGN: A standardized questionnaire was developed that included domains of exam structure/administration, content development, exam prerequisites, information about examiners, scoring, pass/failure rates, and emerging technologies. Between December 2022 and February 2023 structured interviews were conducted to discuss specifics of various oral board exams. Interview answers were compared between various specialties to extrapolate themes and to highlight innovative or emerging techniques among individual boards. SETTING: Interviews were conducted virtually. PARTICIPANTS: Executive members of 9 procedural medical boards including anesthesiology, neurosurgery, obstetrics, and gynecology, ophthalmology, orthopaedic surgery, otolaryngology-head and neck surgery, plastic surgery, general surgery, and urology RESULTS: Common themes include assessment of pre-, intra- and postoperative care; all testing involved candidate examination by multiple examiners and psychometricians were used by all organizations. Important differences included virtual versus in person administration (3 out of 9), inclusion and discussion of candidates' case logs as part of the exam (4 out of 9), formal assessment of professionalism (4 out of 9), and inclusion of an objective structured clinical examination (2 out of 9). CONCLUSIONS: While there are common themes and practices in the oral board delivery process between various surgical fields, and important differences continue to exist. Ongoing efforts to standardize exam administration and determine best practices are needed to ensure oral board exams continue to effectively establish that candidates meet the qualifications required for board certification.

An Analysis of American Urological Association Census Trends: Earlier Planned Retirement and Practice Pattern Changes May Exacerbate the Urology Workforce Shortage.

OBJECTIVE: To explore how changes in planned retirement age, practice setting, and physician productivity may impact the workforce shortage in urology. METHODS: We compared data between the 2015 and 2022 American Urological Association census, a specialty-wide annual survey which collects data on demographics, practice patterns, and procedures from a representative sample of U.S. urologists. Workforce productivity was measured by the self-reported number of hours worked per week and patients seen per week. A novel formula was developed to demonstrate how planned retirement age and productivity impact the workforce's production capacity. RESULTS: The total number of practicing urologists increased during the period from 2015 to 2022 (11,990 to 13,976), while the mean age of practicing urologists decreased slightly (55.0 to 54.5years; P < .002). During this period, the mean planned age of retirement for all urologists decreased from 68.9years to 67.7 (P < .001). Urologists in solo practice had a significantly higher planned age of retirement at 71.9years (P < .001) as compared to all other practice models. The number of patients seen per week for all urologists decreased from 78.7 to 72.9 (P < .001). The amount of hours worked per week remained relatively constant between the study periods. The maximum possible number of patients seen by the workforce prior to retirement increased by only 2.4% during the study interval. CONCLUSION: Though the U.S. urology workforce is growing and the mean age is decreasing, decreases in planned retirement age and productivity may offset these gains and intensify the physician shortage for U.S. urologists.

Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Resident Remediation: A National Survey of Urology Program Directors.

OBJECTIVES: To describe formal remediation rates and processes in urology training programs nationally. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional study by surveying program directors (PDs) through the Society of Academic Urologists. Formal remediation was defined as the process initiated when resident competency deficiencies were significant enough to necessitate documentation and notification of the Graduate Medical Education (GME) office. The primary outcome was the prevalence of urology programs that initiated formal remediation over the past 5 years. Secondary outcomes included reported competency deficiencies and formal remediation processes. RESULTS: Across 148 institutions, 73 (49%) PDs responded to the survey. The majority of PDs (67%, 49/73) stated that at least 1 resident underwent formal remediation over the last 5 years (median 1). "Professionalism" and "Interpersonal and Communication Skills" were the most common competency deficiencies that prompted formal remediation, whereas "Technical Skill" was the least common. While the majority of respondents notified the GME office of residents undergoing remediation, formal remediation plans varied from faculty coaching and mentorship (80%, 39/49) to simulation training (10%, 5/49). Absence of documented faculty feedback on poor performance was the most commonly cited barrier to formal remediation. The majority of PDs reported documentation in a resident's file (81%, 59/73); however, remediation processes differed with only half of PDs reporting that GME offices were routinely involved in creating and overseeing corrective action plans (56%, 41/73). Over the study period, 15% (11/73) of PDs did not promote a resident to the next year of training, and 23% (17/73) of PDs stated "Yes" to graduating a resident who they would not trust to care for a loved one. CONCLUSIONS: Formal remediation among urology residency programs is common, and processes vary across institutions. The most common competency areas prompting remediation were "Professionalism" and "Interpersonal and Communication Skills." Future research should address developing resources to facilitate resident remediation.

Practice Readiness? Trends in Chief Resident Year Training Experience Across 13 Residency Programs.

INTRODUCTION: Urology residency prepares trainees for independent practice. The optimal operative chief resident year experience to prepare for practice is undefined. We analyzed the temporal arc of cases residents complete during their residency compared to their chief year in a multi-institutional cohort. METHODS: Accreditation Council for Graduate Medical Education case logs of graduating residents from 2010 to 2022 from participating urology residency programs were aggregated. Resident data for 5 categorized index procedures were recorded: (1) general urology, (2) endourology, (3) reconstructive urology, (4) urologic oncology, and (5) pediatric urology. Interactions were tested between the trends for total case exposure in residency training relative to the chief resident year. RESULTS: From a sample of 479 resident graduates, a total of 1,287,433 total cases were logged, including 375,703 during the chief year (29%). Urologic oncology cases had the highest median percentage completed during chief year (56%) followed by reconstructive urology (27%), general urology (24%), endourology (17%), and pediatric urology (2%). Across the study period, all categories of cases had a downward trend in median percentage completed during chief year except for urologic oncology. However, only trends in general urology (slope of -0.68, P = .013) and endourology (slope of -1.71, P ≤ .001) were significant. CONCLUSIONS: Over 50% of cases completed by chief residents are urologic oncology procedures. Current declining trends indicate that residents are being exposed to proportionally fewer general urology and endourology cases during their chief year prior to entering independent practice.

The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons.

BACKGROUND: Two-thirds of surgeons report work-related musculoskeletal disorders (WRMD). There is limited data on WRMD symptoms experienced by pregnant surgeons. METHODS: We distributed an electronic survey via personal contacts to attending and trainee surgeons across six academic institutions to assess the impact of procedural activities and surgical ergonomics (SE) on WRMD symptoms during pregnancy. RESULTS: Fifty-three respondents were currently or had been pregnant while clinically active, representing 93 total pregnancies. 94.7% reported that symptoms were exacerbated by workplace activities during pregnancy and 13.2% took unplanned time off work as a result. Beyond 24 weeks of pregnancy, 89.2% of respondents continued to operate/perform procedures, 81.7% worked >24-h shifts and 69.9% performed repetitive lifting >50 pounds. No respondents were aware of any institutional pregnancy-specific SE policies. CONCLUSIONS: Procedural activities can exacerbate pain symptoms for the pregnant surgeon. SE best practices during pregnancy warrant further attention.

The State of Urotrauma Education Among Residency Programs in the United States: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: Management of urotrauma is a crucial part of a urologist's knowledge and training. We therefore sought to understand the state of urotrauma education in the United States. RECENT FINDINGS: Using themes of "Urotrauma" and "Education," we performed a systematic review and meta-analysis by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, BIOSIS, Scopus, and Web of Science through May 2023. The primary outcome was the pooled rate of urology trainee and program director attitudes toward urotrauma education. Secondary outcomes involved a descriptive summary of existing urotrauma curricula and an assessment of factors affecting urotrauma exposure. Of 12,230 unique records, 11 studies met the final eligibility criteria, and we included 2 in the meta-analysis. The majority of trainees and program directors reported having level 1 trauma center rotations (range 88-89%) and considered urotrauma exposure as an important aspect of residency education (83%, 95% CI 76-88%). Despite possible increases in trainee exposure to Society of Genitourinary Reconstructive Surgeons (GURS) faculty over the preceding decade, nearly a third of trainees and program directors currently felt there remained inadequate exposure to urotrauma during training (32%, 95% CI 19-46%). Factors affecting urotrauma education include the limited exposure to GURS-trained faculty and clinical factors such as case infrequency and non-operative trauma management. Urology resident exposure to urotrauma is inadequate in many training programs, underscoring the potential value of developing a standardized curriculum to improve urotrauma education for trainees. Further investigation is needed to characterize this issue and to understand how it impacts trainee practice readiness.

Perceived Barriers Among Underrepresented and Historically Marginalized Medical Students Pursuing a Career in Urology.

OBJECTIVE: To assess perceived barriers to pursuing urology among medical students and to determine if marginalized groups identified greater challenges to entry. METHODS: The Deans of all New York medical schools were asked to disseminate a survey to their students. The survey collected demographic information to identify underrepresented minorities, students of low socioeconomic background, and lesbian, gay, bisexual, transgender, queer, intersex, and asexual individuals. Students were asked to rate various survey items on a five-point Likert scale to determine which factors were perceived as barriers to applying to urology residency. Student t tests and ANOVA were used to compare mean Likert ratings between groups. RESULTS: A total of 256 students responded to the survey from 47% of medical institutions. Underrepresented minorities students cited lack of evident diversity within the field as a more significant barrier than counterparts (3.2 vs 2.7, P= .025). Lesbian, gay, bisexual, transgender, queer, intersex, and asexual students perceived the lack of evident diversity within urology (3.1 vs 2.65, P = .01), exclusivity of the field (3.73 vs 3.29, P = .04), and fear that residency programs would have negative perceptions of them as students (3.0 vs 2.1, P < .0001) as substantial obstacles compared to peers. Students with childhood household incomes less than $40,000 cited socioeconomic concerns as a higher barrier compared to students with household incomes greater than $40,000 (3.2 vs 2.3, P = .001). CONCLUSION: Underrepresented and historically marginalized students perceive more significant barriers to pursuing urology than their peers. Urology training programs must continue to foster an inclusive environment to recruit prospective students from already marginalized groups.

Engaging and Empowering Female Urologists in Academic Publishing and Peer Review.

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Current exposure to Female Pelvic Medicine and Reconstructive Surgery faculty during urology residency.

INTRODUCTION: Contemporary US resident exposure to Female Pelvic Medicine and Reconstructive Surgery (FPMRS) faculty during urology residency is unknown. METHODS: Accredited US urology residencies were identified through the American Urological Association (AUA). Accredited, urology-based FPMRS fellowships were identified through the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The number of faculty and residency positions were obtained from program AUA profiles if they were last modified within the current application cycle; this information was obtained from program websites if AUA profiles were outdated. Data on faculty fellowship training was manually extracted from program websites. A quality control cross-check of program and faculty training characteristics was performed through direct communication with 5% of programs. RESULTS: Of 139 accredited residency programs assessed, 10.8% were affiliated with an accredited, urology-based FPMRS fellowship. In total, 29.5% of residency programs, representing 25% of US urology residents, had neither a FPMRS fellowship nor any FPMRS certified faculty. The national FPMRS faculty-to-resident ratio was 1:10.8, and 7.4% of faculty at all residency programs were FPMRS certified. In comparison, faculty-to-resident ratios for other subspecialties were: 1:4.7 for pediatrics, 1:3.6 for oncology, 1:5.9 for minimally invasive surgery/endourology, 1:14.2 for trauma/reconstruction, and 1:11.8 for andrology or male sexual/reproductive health. The FPMRS faculty-to-resident ratio was 1:5.1 in programs with a urology-based FPMRS fellowship compared with 1:13.4 in programs without a FPMRS fellowship. CONCLUSIONS: 30% of US urology residency programs lack FPMRS trained faculty. Even when FPMRS faculty are on staff, the field is often underrepresented relative to other urologic subspecialties. Further studies are required to ascertain if inadequate exposure to FPMRS cases and mentors during training contribute to the shortage of urology residents who choose to specialize in FPMRS. This link has important implications for the current shortage of FPMRS providers.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.