Determining the Programmatic Factors that Enable Pediatric Urology Fellows to Meet Graduation Targets on the Surgical Ability Milestones - A Mixed Methods Study
Christopher Jaeger, MD1, Louis-Philippe Thibault, MD2, Kate Kraft, MD3, Joshua Nagler, MD1, Donna Luff, PhD1, Eric Holmboe, MD4, Kenji Yamazaki, PhD4, Roy Phitayakorn, MD5.
1Boston Children's Hospital, Boston, MA, USA, 2CHU Sainte-Justine, Montreal, QC, Canada, 3University of Michigan, Ann Arbor, MI, USA, 4Accreditation Council for Graduate Medical Education, Chicago, IL, USA, 5Massachusetts General Hospital, Boston, MA, USA.
Background: The Accreditation Council for Graduate Medical Education (ACGME) directed a working group of Pediatric Urologists to develop the Pediatric Urology Milestones for fellowship programs as part of a competency-based medical education framework. Four of the 22 sub-competencies detailed on the Milestones rubric published in 2015 are known as the Surgical Ability Milestones (SAM). The SAM define graduation targets for fellows in genital reconstruction, open abdominal/ retroperitoneal surgery, endoscopy, and laparoscopic/ robotic surgery. Training programs are tasked with designing curricula to ensure its fellows achieve graduation targets in the SAM. No study in the surgical education literature has defined the programmatic factors that enable surgical trainees to meet graduation targets. Insight into these programmatic factors could aid stakeholders in achieving the optimal learning conditions for trainees that could ultimately improve outcomes on the SAM. This study sought to determine the essential programmatic factors that enable Pediatric Urology fellows to meet graduation targets on the SAM.
Methods:An explanatory, sequential mixed-methods study was performed. Thirteen program factors that could reasonably impact surgical skill development were abstracted from the ACGME resident/fellow annual survey framework. Primary stakeholders included current fellowship program directors and recently graduated fellows who trained in the Milestone era. Both stakeholder groups rated the relative importance of each program factor on a 5-point Likert scale via an electronic survey. Factor ratings were dichotomized as highly important or not and then compared between stakeholder groups using Chi-squared tests. The top program factors were isolated using descriptive statistics to inform the creation of a qualitative interview guide. Participants from both stakeholder groups participated in semi-structured interviews following a criterion-based, purposeful sampling process based on American Urological Association section membership and program year of establishment. Inductive thematic analysis of interview data was performed to identify the final set of essential programmatic factors.
Results:Survey response rates of 33% (n=40/122) and 44% (n=12/27) were obtained for recently graduated fellows and program directors, respectively. There was no statistically significant difference in ratings between groups. Six program factors (Table) were selected for further study as they were rated as highly important in greater than 80% of responses. Ten recently graduated fellows and 4 program directors were interviewed for 36 to 69 minutes in duration. Five themes were identified that revealed essential programmatic factors: (1) learner-centered faculty instruction, (2) surgical skills practice with faculty coaching, (3) purposeful practice variability, (4) tailored learning experiences, and (5) psychologically safe learning environment (Figure).
Conclusions:The essential programmatic factors that enable Pediatric Urology fellows to meet graduation targets on the SAM are multi-faceted and closely align with foundational learning theories. Training programs should seek to ensure curricula account for each programmatic factor to maximize the surgical abilities of Pediatric Urology fellows. 
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