Pediatric Urology Fellows' Performance on the Surgical Ability Milestones: Are Graduates Meeting their Targets?
Christopher Jaeger, MD1, Kate Kraft, MD2, Joshua Nagler, MD1, Donna Luff, PhD1, Eric Holmboe, MD3, Kenji Yamazaki, PhD3, Roy Phitayakorn, MD4.
1Boston Children's Hospital, Boston, MA, USA, 2University of Michigan, Ann Arbor, MI, USA, 3Accreditation Council for Graduate Medical Education, Chicago, IL, USA, 4Massachusetts General Hospital, Boston, MA, USA.
Background:Pediatric Urology fellows may not be universally prepared for independent surgical practice. As part of a competency-based medical education (CBME) framework, the Urology Residency Review Committee and the Accreditation Council for Graduate Medical Education (ACGME) developed the Pediatric Urology Milestones project in 2015. Training programs rate each fellow on the milestones rubric, which includes 4 sub-competencies known as the Surgical Ability Milestones (SAM). The SAM include skill descriptions of graduation targets in genital reconstruction, open abdominal/ retroperitoneal surgery, endoscopy, and laparoscopic/robotic surgery. Outcomes on each fellow are reported to the ACGME biannually. This study sought to determine whether Pediatric Urology fellows are prepared for surgical practice by examining programmatic and self-reported outcomes on these SAM.
Methods:Deidentified SAM ratings on all Pediatric Urology fellows between the 2015-2020 academic years were collected from the ACGME. Additionally, all former Pediatric Urology fellows who graduated from 2016-2021 were electronically surveyed and asked to rate their performance on each of the SAM at graduation from fellowship and currently in practice. All SAM ratings were dichotomized as ability rated above or below the defined graduation target. The proportion of fellows not meeting recommended graduation targets were calculated for each individual SAM. Program ratings and former fellow self-ratings were compared using Chi-squared tests.
Results: Twenty-seven training programs reported SAM outcomes on 109 fellows between 2015 and 2020. Outcomes from the 2019 academic year were excluded from the analysis due to ACGME policy stemming from the COVID-19 pandemic. For any individual SAM, 5-17% of fellows failed to meet graduation targets (Figure). Programs reported that 26% of fellows did not meet graduation targets for all four SAMs.
The former fellow survey response rate was 33% (n=40/122). Of respondents, 20-25% perceived their surgical ability at the end of training to be lower than the graduation target on any individual SAM. Approximately, 43% of former fellows perceived they did not meet graduation targets for all four SAM. Former fellows were significantly more likely to report skill at or above the graduation target currently in practice than at graduation from fellowship for each SAM, except in genital reconstruction.
Comparing program ratings and self-ratings, former fellows were more likely than programs to report a lower level of skill versus graduation targets at the conclusion of fellowship training for all SAMs. However, endoscopy was the only SAM sub-competency in which the difference in ratings was statistically significant (p=0.001).
Conclusions: Approximately, 26% of Pediatric Urology fellows in this study did not meet all specialty-defined targets for surgical training during fellowship. Self-ratings of former fellows indicate this training gap may be even larger. Pediatric Urology training programs should work to improve performance of future Pediatric Urology fellows by incorporating modern approaches to surgical education and embracing CBME principles. Pediatric Urology should also continually reassess graduation targets to ensure the expectations are realistic and equate to practice readiness. 
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