How Are We Training The Postgraduate Urologist In Minimally Invasive Surgery?

Main Category: Urology / Nephrology
Also Included In: Medical Students / Training
Article Date: 26 May 2007 - 0:00 PDT

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UroToday.com - Dr. Ralph Clayman, UC Irvine presented a State-of -the-Art lecture "How are We Training the Postgraduate Urologist in Minimally Invasive Surgery?" at the Sunday Plenary session of the AUA in Anaheim, May 20, 2007.

Dr. Clayman presented the issues regarding training post-graduate urologists MIS when many faculty are learning the procedures. Surgical training included educating the mind and training the hand. Surgery is 75% cognitive and only 25% dexterity. Only 49% of urologists in the Midwest do laparoscopy and <5% of their practice is dedicated to it. Only 15% felt that their residencies adequately trained them in laparoscopy.

Regarding cognitive needs, the AUA office of Educations has numerous programs that meet that need. Regarding skills acquisition, there are 3 stages; "cognitive" thought, "integrative" to develop appropriate motor behavior and "autonomous" to make the action second nature. A 2 day course offered at the University of Iowa, follow-up survey found that only 2.5% of attendees actually then performed laparoscopy in their practice.

Miniresidency is a 2-3 day course concept integrating observation of 6 cases and performing 6 cases. This was very exhausting and intensive and a week long course was then developed. 1-2 trainees attend and have an intensive program. The take rate of integrating lap into their practice following the weeklong miniresidency was 70%. The complication rate of these miniresidency surgeons was less than the published average. Competency to bring the skill into the clinical arena and to perform it well is historically related to surgical volume. Clinical volume is often sporadic and perhaps inadequate to achieve the outcomes of high volume surgeons. This is overcome with simulation, he said. Simulation requires a mentor to monitor and correct bad surgical habits. This can be expensive and time consuming. A robotic high fidelity simulator can measure abilities, skills, tasks and procedures and combine these into an operation. Dr. Clayman felt that this is the answer, but it will require validation to discern between levels of expertise. He showed an example where simulation scores the skills of the surgically simulated skill. One study was able to separate medical students, residents, and low volume laparoscopists from high volume surgeons. Simulator trained surgeons were able to complete surgery 20% faster and with a 500% reduction in errors. The morbidity of urologic laparoscopy is 13%, which is 2-3 times greater than in Ob/Gyn and general surgery. Mortality is 0.08%, which is also higher. He concluded that the post-graduate urologist needs a programmatic approach to achieve and maintain these skills.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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