SPECIAL ARTICLE
EDUCATION JOHN
J. MURPHY,
Philadelphia,
OF UROLOGISTS* M.D.
Pennsylvania
A urologist is a surgeon concerned with the diagnosis and treatment of abnormalities and diseases of the urogenital tract in the male and the urinary tract in the female. Special areas of interest demand expertise in urinary tract infections, pediatric-urologic problems, male infertility and sexual problems, hemodialysis and renal transplantation, renal hypertension, endocrinologic aspects of diseases of the adrenal, testes and prostate, and immunologic aspects of renal diseases and cancer. To train a surgeon properly in this varied and complex field is a difficult undertaking, and yet it is apparent that this has been attempted in some programs which are ill equipped to do so. From the start of the physician’s medical school training there is no semblance of a standard approach to the teaching of urology. In the course of interviewing applicants for internship and residency over more than twenty years, I have been distressed with the lack of exposure of students to even the basic aspects of urology. Regardless of his choice of practice any physician must have some knowledge of the fundamentals of urology. I urge that the section on urology of this association formulate guidelines for this purpose and present them to all schools of medicine in this country. Two years of training after graduation from medical school are now required prior to specialty training. It has been common practice to encourage physicians-in-training who are interested in urology to spend this time in surgically oriented programs. I do not believe that this is essential. Little responsibility is given to the recent graduate in most centers, and much more useful knowledge might be acquired in a broad exposure to *Presented at the Annual Meeting of the American Medical Association, Section Council on Urology, Atlantic City, New Jersey, June 16, 1975.
UROLOGY
/ JANUARY 1976
/ VOLUME VII, NUMBER 1
common medical problems and their management. Concerning the graduate training programs in urology, much consideration has been given to the optimal number which should be functioning. A recent meeting of the American Urological Association Council on Education indicated that at the present time we are training an adequate number of urologists, but with an increase in the number of training programs from 179 in 1968 to 188 in 1975, and in the number offering first-year positions from 222 in 1968 to 320 we will be overproducing at an increasing rate. The danger of this is considered to be that an excess of surgeons leads to unnecessary surgery and higher fees. This is an extremely complex problem with factors such as maldistribution of urologists and the impact of foreign medical graduates. In 1974 there were 794 candidates for the American Board of Urology, 26 per cent of whom were foreign medical graduates. In 1975 there were 844 candidates for the Board, and 32 per cent were foreign medical graduates. Management of this problem is as difficult as that of maldistribution. It is apparent that it is proper to consider reducing the number of training programs. This can be done by careful assessment of the quality of the programs. To accomplish the objectives an adequate residency should have sufficient senior staffto provide instruction in diagnosis and surgical technique, supervision of all these activities, and especially the teaching ofjudgment in the selection of diagnostic procedures and indications for surgery. The ever-increasing array of sophisticated diagnostic tools is awesome and confusing to the young trainees. They need guidance in their use for many are superfluous, and all are costly. Indications for endoscopy and surgery must be taught carefully. A request for urologic consulta-
73
TABLE I. Estimate of pediatric-urologic hospital loacls Pediatric-urologic discharges . . . . . . .60 per 100,000 total population United States population under age seventeen in 1970 . . . . . . . . . . . . . . . . . . . . .32.4% Pediatric-urologic discharges per year . . . . . . . . . . . . . . . . . . . . . . . . . . ...127.000 Potential hospital work-load per practicing urologist . . . . . . . . . . . . .25 per year Pediatric urologists needed at 400 admissions per year . . . . . . . . . . , . . . . . . . .317
tion is not an indication for cystoscopy! Yet, in my experience, many practicing urologists regard it to be such. Not every male with voiding symptoms requires prostatectomy. Some ureteral calculi, in fact many, will pass spontaneously. Most renal cysts need not be excised. In these situations and others I have seen glaring examples of unwarranted surgical intervention. Dr. I. S. Ravdin told me many times that it was most important to learn when not to operate. The resident in a good program will learn that well. An acceptable training program should provide exposure of the trainee to other disciplines such as nephrology, endocrinology, cardiology, chemotherapy, and others. This can be done by attendance at conferences or by didactic sessions. Formal reviews of the literature and pathology are essential. The place of research in the training program is a matter of opinion. I have found it to be a great stimulant for our residents, and I recommend that opportunities for laboratory investigation be provided for all those trainees who have the interest and ability to do this. Clinical research, the evaluation of methods of therapy and so forth, has a place and can teach the young surgeon judgment regarding the literature. However, I strongly oppose anyone being forced into a laboratory to grind out useless data just to publish and not perish. Interdisciplinary conferences, urology-radiology, urology-endocrinology, and others pertinent to the field are very effective in proper and essential cross-pollination. A stone evaluation center comprised of urologists, biochemists, internist, and orthopedic surgeon is interesting, educational, and clinically effective. Presentation of clinical problems with multiple organ diseases to medical and general surgical groups is broadening and keeps the other specialties aware of urologic interests and competence. Male reproductive biology is a promising young science within the specialty and deserving of support and
74
encouragement. Involvement in a transplant program yields valuable experience in management of uremia, hemodialysis, and surgical techniques. The urodynamic laboratory has matured into a valuable clinical asset and should be part of acceptable training programs. Pediatric urology has emerged as a significant entity within the specialty. Considerable thought is wisely being given to determination of its present status and future needs. In Dr. Sam Ambrose’s report to the coordinating council of urology of the American Urological Association it appears that by allowing a pediatric urologist 400 admissions per year, 317 urologists could handle the entire pediatric work in this country (Table I). Of course they would have to be strategically placed. A survey of the urologic training programs in existence has been started, and data from fourteen hospitals showed an average of 495 pediatric admissions annually (Table II). The demand for pediatric urologists is clear and may be projected with confidence. These data when complete will help greatly to ensure the training of the proper number of pediatric urologists for the necessary pediatric centers. Exposure of all trainees to pediatric urology will continue to be important. The well-grounded urologist must be able to recognize urologic problems in infants and children, institute proper primary care, and know when and where to refer them for pediatric-urologic care. What constitutes adequate experience with children is not clear at this time. A recent survey revealed that most programs responding to the survey had at least one rotation during which the trainee’s only responsibility was pediatric urology. The duration of this exposure varied from four months to one year. The survey continues and when completed should clarify the matter of available material and experience, but the adequacy of
TABLE II.
Survey
of urologic
Total urologic beds Average Pediatric-urologic beds Average Per cent of total Total annual admissions Average Pediatric annual admissions Average Per cent of total
training
programs*
29 to 129 74.5 3 to 26 11 14.7 1,381 to 5,426 2,499 287 to 882 495 19.8
*Information requested from 24 hospitals and adequate data supplied by 14.
UROLOGY / JANUARY 1976 / VOLUME VII, NUMBER 1
effectiveness. In 1971 the American College of Surgeons, with the help of the National Board of Medical Examiners, designed an assessment program enabling an individual to determine the status of his knowledge in nine areas of surgery. This surgical education and self-assessment program called SESAP I was utilized by 15,000 surgeons. Computerized assessment of each participant’s performances was provided in absolute confidence, and references provided so that the surgeon could remedy any deficiences in his knowledge. This year SESAP II provides a syllabus containing a critique of each item in the examination. This critique identifies the surgical principles underlying the item, suggests why the “detractors” are not correct, and indicates why the knowledge is important in practice. Participation in SESAP II and a modification of this approach might prove useful in our efforts toward continuing education. A number of items pertaining to the material presented at the seminar would be prepared prior to the session, together with a critique and references for each item. Each physician attending the session would indicate whether or not he chose to participate in the self-assessment at the end of the session. The examination forms would be prepared in duplicate with a copy to be retained by the educational committee. This copy would be unmarked so that the examinee would not be identified. Each individual performance would be assessed by computer and the results mailed to each participant together with the critiques and references. This would accomplish three objectives. It would inform the participating physician of his knowledge of the subjects covered by the seminar and educate him in his deficient areas by the critiques and references; would provide proof of his participation in this continuing education session; and would permit the faculty to judge the effectiveness of their efforts. I am certain that this approach will be very worthwhile in the continuing education of urologists.
pediatric training for the average trainee will have to be determined by other methods. A vital aspect of the education of any physician which is too often neglected is the doctor-patient relationship. The importance of this cannot be overemphasized in today’s milieu of lay and legal accusation and castigation. How to teach it? By far the best method is by example. If the senior staff demonstrates consideration, kindness, tact, and diplomacy in their handling of patients, the urologist-in-training is certain to learn, as we say, by osmosis. In addition the staff and fellow residents must be critical of any words or actions by any trainee which offend, hurt, or frighten the patient. Physicians-in-training must be reminded that patients are often frightened to begin with, unable to comprehend medical terms, often misinterpret what they think they hear, and repress or forget vital information told to them. Careful explanation and reexplanation of all aspects of diagnostic and therapeutic measures, provided in lay terms, in a confident but not overbearing manner is an effective way to gain a patient’s confidence and trust. One must be interested and demonstrate this interest; never be too busy to listen. The patient’s family and friends must be kept informed. Cheerfulness and optimism must be tempered with honesty. Again, the best method of delivering this large order is by example. After the young surgeon has completed his residency, passed the first part of the examination by the American Board of Urology, and two years later the second part, is that the end of his education? It should not be and, in fact, it cannot be. It has become increasingly apparent that some form of reevaluation of all physicians is necessary and, in time, will be mandatory. How best to continue the education of the urologist? Methods in use at the present time include the journals, didactic tape recordings, video tapes, local, national, and international meetings, postgraduate courses, seminars, and so on. Utilization of these is difficult to assess, but there is available a means of measuring their
UROLOGY
/ JANUARY 1976 / VOLUME
VII,
NUMBER
Philadelphia,
1
3400 Spruce Street Pennsylvania 19104
75
EDUCATION JOHN
J. MURPHY,
Philadelphia,
OF UROLOGISTS* M.D.
Pennsylvania
A urologist is a surgeon concerned with the diagnosis and treatment of abnormalities and diseases of the urogenital tract in the male and the urinary tract in the female. Special areas of interest demand expertise in urinary tract infections, pediatric-urologic problems, male infertility and sexual problems, hemodialysis and renal transplantation, renal hypertension, endocrinologic aspects of diseases of the adrenal, testes and prostate, and immunologic aspects of renal diseases and cancer. To train a surgeon properly in this varied and complex field is a difficult undertaking, and yet it is apparent that this has been attempted in some programs which are ill equipped to do so. From the start of the physician’s medical school training there is no semblance of a standard approach to the teaching of urology. In the course of interviewing applicants for internship and residency over more than twenty years, I have been distressed with the lack of exposure of students to even the basic aspects of urology. Regardless of his choice of practice any physician must have some knowledge of the fundamentals of urology. I urge that the section on urology of this association formulate guidelines for this purpose and present them to all schools of medicine in this country. Two years of training after graduation from medical school are now required prior to specialty training. It has been common practice to encourage physicians-in-training who are interested in urology to spend this time in surgically oriented programs. I do not believe that this is essential. Little responsibility is given to the recent graduate in most centers, and much more useful knowledge might be acquired in a broad exposure to *Presented at the Annual Meeting of the American Medical Association, Section Council on Urology, Atlantic City, New Jersey, June 16, 1975.
UROLOGY
/ JANUARY 1976
/ VOLUME VII, NUMBER 1
common medical problems and their management. Concerning the graduate training programs in urology, much consideration has been given to the optimal number which should be functioning. A recent meeting of the American Urological Association Council on Education indicated that at the present time we are training an adequate number of urologists, but with an increase in the number of training programs from 179 in 1968 to 188 in 1975, and in the number offering first-year positions from 222 in 1968 to 320 we will be overproducing at an increasing rate. The danger of this is considered to be that an excess of surgeons leads to unnecessary surgery and higher fees. This is an extremely complex problem with factors such as maldistribution of urologists and the impact of foreign medical graduates. In 1974 there were 794 candidates for the American Board of Urology, 26 per cent of whom were foreign medical graduates. In 1975 there were 844 candidates for the Board, and 32 per cent were foreign medical graduates. Management of this problem is as difficult as that of maldistribution. It is apparent that it is proper to consider reducing the number of training programs. This can be done by careful assessment of the quality of the programs. To accomplish the objectives an adequate residency should have sufficient senior staffto provide instruction in diagnosis and surgical technique, supervision of all these activities, and especially the teaching ofjudgment in the selection of diagnostic procedures and indications for surgery. The ever-increasing array of sophisticated diagnostic tools is awesome and confusing to the young trainees. They need guidance in their use for many are superfluous, and all are costly. Indications for endoscopy and surgery must be taught carefully. A request for urologic consulta-
73
TABLE I. Estimate of pediatric-urologic hospital loacls Pediatric-urologic discharges . . . . . . .60 per 100,000 total population United States population under age seventeen in 1970 . . . . . . . . . . . . . . . . . . . . .32.4% Pediatric-urologic discharges per year . . . . . . . . . . . . . . . . . . . . . . . . . . ...127.000 Potential hospital work-load per practicing urologist . . . . . . . . . . . . .25 per year Pediatric urologists needed at 400 admissions per year . . . . . . . . . . , . . . . . . . .317
tion is not an indication for cystoscopy! Yet, in my experience, many practicing urologists regard it to be such. Not every male with voiding symptoms requires prostatectomy. Some ureteral calculi, in fact many, will pass spontaneously. Most renal cysts need not be excised. In these situations and others I have seen glaring examples of unwarranted surgical intervention. Dr. I. S. Ravdin told me many times that it was most important to learn when not to operate. The resident in a good program will learn that well. An acceptable training program should provide exposure of the trainee to other disciplines such as nephrology, endocrinology, cardiology, chemotherapy, and others. This can be done by attendance at conferences or by didactic sessions. Formal reviews of the literature and pathology are essential. The place of research in the training program is a matter of opinion. I have found it to be a great stimulant for our residents, and I recommend that opportunities for laboratory investigation be provided for all those trainees who have the interest and ability to do this. Clinical research, the evaluation of methods of therapy and so forth, has a place and can teach the young surgeon judgment regarding the literature. However, I strongly oppose anyone being forced into a laboratory to grind out useless data just to publish and not perish. Interdisciplinary conferences, urology-radiology, urology-endocrinology, and others pertinent to the field are very effective in proper and essential cross-pollination. A stone evaluation center comprised of urologists, biochemists, internist, and orthopedic surgeon is interesting, educational, and clinically effective. Presentation of clinical problems with multiple organ diseases to medical and general surgical groups is broadening and keeps the other specialties aware of urologic interests and competence. Male reproductive biology is a promising young science within the specialty and deserving of support and
74
encouragement. Involvement in a transplant program yields valuable experience in management of uremia, hemodialysis, and surgical techniques. The urodynamic laboratory has matured into a valuable clinical asset and should be part of acceptable training programs. Pediatric urology has emerged as a significant entity within the specialty. Considerable thought is wisely being given to determination of its present status and future needs. In Dr. Sam Ambrose’s report to the coordinating council of urology of the American Urological Association it appears that by allowing a pediatric urologist 400 admissions per year, 317 urologists could handle the entire pediatric work in this country (Table I). Of course they would have to be strategically placed. A survey of the urologic training programs in existence has been started, and data from fourteen hospitals showed an average of 495 pediatric admissions annually (Table II). The demand for pediatric urologists is clear and may be projected with confidence. These data when complete will help greatly to ensure the training of the proper number of pediatric urologists for the necessary pediatric centers. Exposure of all trainees to pediatric urology will continue to be important. The well-grounded urologist must be able to recognize urologic problems in infants and children, institute proper primary care, and know when and where to refer them for pediatric-urologic care. What constitutes adequate experience with children is not clear at this time. A recent survey revealed that most programs responding to the survey had at least one rotation during which the trainee’s only responsibility was pediatric urology. The duration of this exposure varied from four months to one year. The survey continues and when completed should clarify the matter of available material and experience, but the adequacy of
TABLE II.
Survey
of urologic
Total urologic beds Average Pediatric-urologic beds Average Per cent of total Total annual admissions Average Pediatric annual admissions Average Per cent of total
training
programs*
29 to 129 74.5 3 to 26 11 14.7 1,381 to 5,426 2,499 287 to 882 495 19.8
*Information requested from 24 hospitals and adequate data supplied by 14.
UROLOGY / JANUARY 1976 / VOLUME VII, NUMBER 1
effectiveness. In 1971 the American College of Surgeons, with the help of the National Board of Medical Examiners, designed an assessment program enabling an individual to determine the status of his knowledge in nine areas of surgery. This surgical education and self-assessment program called SESAP I was utilized by 15,000 surgeons. Computerized assessment of each participant’s performances was provided in absolute confidence, and references provided so that the surgeon could remedy any deficiences in his knowledge. This year SESAP II provides a syllabus containing a critique of each item in the examination. This critique identifies the surgical principles underlying the item, suggests why the “detractors” are not correct, and indicates why the knowledge is important in practice. Participation in SESAP II and a modification of this approach might prove useful in our efforts toward continuing education. A number of items pertaining to the material presented at the seminar would be prepared prior to the session, together with a critique and references for each item. Each physician attending the session would indicate whether or not he chose to participate in the self-assessment at the end of the session. The examination forms would be prepared in duplicate with a copy to be retained by the educational committee. This copy would be unmarked so that the examinee would not be identified. Each individual performance would be assessed by computer and the results mailed to each participant together with the critiques and references. This would accomplish three objectives. It would inform the participating physician of his knowledge of the subjects covered by the seminar and educate him in his deficient areas by the critiques and references; would provide proof of his participation in this continuing education session; and would permit the faculty to judge the effectiveness of their efforts. I am certain that this approach will be very worthwhile in the continuing education of urologists.
pediatric training for the average trainee will have to be determined by other methods. A vital aspect of the education of any physician which is too often neglected is the doctor-patient relationship. The importance of this cannot be overemphasized in today’s milieu of lay and legal accusation and castigation. How to teach it? By far the best method is by example. If the senior staff demonstrates consideration, kindness, tact, and diplomacy in their handling of patients, the urologist-in-training is certain to learn, as we say, by osmosis. In addition the staff and fellow residents must be critical of any words or actions by any trainee which offend, hurt, or frighten the patient. Physicians-in-training must be reminded that patients are often frightened to begin with, unable to comprehend medical terms, often misinterpret what they think they hear, and repress or forget vital information told to them. Careful explanation and reexplanation of all aspects of diagnostic and therapeutic measures, provided in lay terms, in a confident but not overbearing manner is an effective way to gain a patient’s confidence and trust. One must be interested and demonstrate this interest; never be too busy to listen. The patient’s family and friends must be kept informed. Cheerfulness and optimism must be tempered with honesty. Again, the best method of delivering this large order is by example. After the young surgeon has completed his residency, passed the first part of the examination by the American Board of Urology, and two years later the second part, is that the end of his education? It should not be and, in fact, it cannot be. It has become increasingly apparent that some form of reevaluation of all physicians is necessary and, in time, will be mandatory. How best to continue the education of the urologist? Methods in use at the present time include the journals, didactic tape recordings, video tapes, local, national, and international meetings, postgraduate courses, seminars, and so on. Utilization of these is difficult to assess, but there is available a means of measuring their
UROLOGY
/ JANUARY 1976 / VOLUME
VII,
NUMBER
Philadelphia,
1
3400 Spruce Street Pennsylvania 19104
75
