Keywords
MFM fellow - fellowship - medical education - complex obstetrics - resident education
Many factors contribute to a medical student's preferences in selection of obstetrics
and gynecology (OBGYN) residency program. One common concern is that the presence
of fellows will negatively impact education, specifically related to surgical experiences
and procedural skills. Students may be concerned that fellows may “steal” the less
common or more complicated procedures, leading to a decrease in their own surgical
volume and inhibiting their learning. The literature is limited and mixed on this
topic. While some data support these concerns,[1]
[2] one study suggests that the presence of urogynecology fellows does not impact resident
confidence with urogynecology procedures.[3] Similarly, for gynecologic oncology procedures, presence of fellows did not impact
self-reported proficiency in radical hysterectomy and lymphadenectomy.[4] No data exist regarding the impact of maternal-fetal medicine (MFM) fellows on resident
confidence with obstetrical procedures. However, unlike a radical hysterectomy or
a lymphadenectomy, which are only done by a subspecialist, most complex obstetric
procedures are performed by general obstetricians.
Core procedures, as outlined by the 11th edition of the Council of Resident Education
in Obstetrics and Gynecology (CREOG) objectives, are those procedures which an individual
who is graduating from OBGYN training should understand and be able to perform independently,
regardless of postresidency plan.[5] These procedures include, but are not limited to, forceps-assisted vaginal delivery
(FAVD), vacuum-assisted vaginal delivery (VAVD), vaginal cerclage, repair of third-degree
lacerations, repair of fourth-degree lacerations, breech extraction of a second twin,
breech vaginal delivery, and cesarean hysterectomy. The Accreditation Council for
Graduate Medical Education (ACGME) also lists these procedures as level 4 in the obstetric
technical skills in the OBGYN milestones from.[6]
Thus, in contrast to many urogynecology and gynecologic onocology procedures, resident
experience and skills in complex obstetrics is critical for future practice. As noted,
limited data exist regarding impact of fellows on resident opportunities with these
procedures. Thus, we sought assess the impact of MFM fellows on resident opportunities
and resultant perceived confidence among residents with complex obstetric procedures.
Methods
We performed a cross-sectional study of OBGYN residents in the United States and Puerto
Rico during the 2017 to 2018 academic year. This study was deemed exempt by the institutional
review board (IRB: Pro00090727). An anonymous electronic survey was developed based
on a prior analogous survey used by Propst et al and Schimpf et al to describe resident
experience in urogynecology but was adapted for obstetrics.[3]
[7] The survey was then edited for clarity and content by a team of subject matter experts
in MFM, as well as a team of subject matter experts, in medical education. After edits,
a pilot survey was sent to local MFM fellows and local residents, to obtain feedback
on question clarity and necessity. The final survey contained of 27 questions, including
demographic data, future career trajectory, and experiences with complex obstetrics.
An anonymous survey link was sent in March 2018, via the CREOG coordinator listserv,
with a request for distribution to their OBGYN residents. A reminder e-mail was resent
through the CREOG coordinator listserv 2 weeks later. All current residents in the
United States and Puerto Rico were eligible to participate. Participants who completed
the survey could elect to submit their e-mail through a separate survey link (that
was not connected to the primary survey) to enter a drawing for an Amazon Gift card.
March was specifically selected due to the late time in the year, to ensure adequate
time for participation in obstetric procedures.
The presence of MFM fellows was delineated by resident report within the survey. The
CREOG 11th edition objectives and the ACGME milestones were used to define the complex
obstetric procedures. Based on these two documents, complex obstetric procedures were
defined as FAVD, VAVD, vaginal cerclage, breech second twin, breech vaginal delivery,
third and 4th degree perineal repairs and cesarean hysterectomy. Also, we were interested
in comfort level with cesarean delivery for a patient with body mass index (BMI) >50 kg/m2. Respondents were asked in a yes/no manner if they had been the primary surgeon on
the above procedures and if they were comfortable performing these procedures independently.
Respondents in their fourth year of training were also asked if they would feel comfortable
performing these procedures postresidency. Information about program type, program
size, number and type of fellowships present, residency year, and gender was also
ascertained.
Comfort performing complex obstetric procedures after graduation from residency was
the primary outcome. Experiences as primary surgeon and comfort performing independently
were also assessed. Given the complexity of these procedures (milestone level 4),
it would be uncommon for an intern (postgraduate year [PGY] 1) or second year (PGY2)
resident to feel comfortable to perform these independently. Thus, when analyzing
comfort while performing independently, only third (PGY3) and fourth year (PGY4) respondents
were included. As noted above, only PGY4 residents were asked about comfort performing
postresidency; thus only PGY4s were included in this analysis. Residents who self-identified
as having MFM fellows present at their training program (pMFM) were compared with
those who did not have MFM fellows present (nMFM).
Operative vaginal delivery was defined as either FAVD or VAVD. A large residency program
size was defined as eight or more residents a year. Long-MFM exposure was defined
as 6 or more months of specific-MFM time in residency, which was at or above the 75%
for the study population. Survey completion rate was defined as total complete responses/total
number of surveys started. Noncompleted surveys were excluded.
Data were analyzed using simple statistics as appropriate with Fisher's exact, Chi–square
tests for categorical variables, and Kruskal–Wallis or t-test for continuous variables. STATA (version 14.0, College Station, TX) was used.
Significance was defined as p-value of <0.05 for the primary analysis. Regression performed to assess adjusted
odds of outcomes and control for confounders.
Results
Four hundred and seventeen residents completed the survey; with a completion rate
of 96.5% (417/432). There was approximately equal distribution among all four residency
years (data not shown). Sixty-six percent (n = 275) of respondents were from nMFM and 33% (n = 142) from pMFM. PMFM respondents were more likely to have > 7 residents/year, be
from an academic residency, and less likely to be planning to practice obstetrics
postresidency ([Table 1], all p < 0.01). Plan to pursue MFM fellowship did not differ ([Table 1]).
Table 1
Demographic data
|
Demographic
|
MFM fellows present
n = 142 (%)
|
No MFM fellows
n = 275 (%)
|
p-Value
|
|
Age 26–30 (y)
|
97 (68)
|
198 (72)
|
0.61
|
|
Female gender
|
125 (88)
|
242 (88)
|
0.99
|
|
Upper level resident (PGY3 and 4)
|
60 (42)
|
142 (55)
|
0.07
|
|
Big program (>7 residents/year)
|
95 (67)
|
72 (26)
|
<0.01
|
|
Academic residency
|
124 (87)
|
184 (67)
|
<0.01
|
|
Dedicated MFM rotation
|
129 (91)
|
259 (9)
|
0.09
|
|
Median months of MFM (IQR)
|
3 (2–6)
|
4 (3–6)
|
<0.01
|
|
Plan to practice OB
|
75 (53)
|
183 (67)
|
<0.01
|
|
Plan MFM fellowship
|
18 (13)
|
24 (9)
|
0.20
|
Abbreviations: IQR, interquartile range; MFM, maternal-fetal medicine; OB, obstetrics;
PGY, postgraduation year.
Note: all data are n (%), unless otherwise noted.
When considering all residents, PGY1–4, nMFM residents were more likely to have been
primary surgeon on a VAVD (77 vs. 63%, p < 0.01). No difference in primary surgeon experience was seen for FAVD, (48 vs. 57%,
p = 0.09), breech deliveries, third- or fourth-degree laceration repairs, cerclage,
or cesarean hysterectomy ([Table 2]). Among residents in PGY3 and 4, pMFM residents were more likely to feel comfortable
with breech extraction of a second twin (48 vs. 33%, p = 0.04). Comfort levels with other procedures did not differ ([Table 3]).
Table 2
Resident as primary surgeon by presence of MFM fellows (includes PGY1–4)
|
Procedure
|
MFM fellows present
n = 142 (%)
|
No MFM fellows
n = 275 (%)
|
p-Value
|
|
VAVD
|
85 (63)
|
201 (77)
|
<0.01
|
|
FAVD
|
76 (57)
|
125 (48)
|
0.09
|
|
Any OVD
|
95 (67)
|
204 (74)
|
0.12
|
|
Cerclage
|
79 (59)
|
166 (63)
|
0.39
|
|
Breech extraction
|
50 (37)
|
86 (33)
|
0.37
|
|
Breech vaginal delivery
|
22 (16)
|
59 (23)
|
0.14
|
|
4th-degree perineal repair
|
47 (36)
|
97 (37)
|
0.78
|
|
3rd-degree perineal repair
|
34 (25)
|
65 (25)
|
0.90
|
|
Cesarean delivery on BMI > 50 kg/m2
|
116 (8)
|
234 (89)
|
0.42
|
|
Cesarean hysterectomy
|
25 (19)
|
60 (23)
|
0.33
|
Abbreviations: BMI, body mass index; FAVD, forceps-assisted vaginal delivery; MFM,
maternal-fetal medicine; OVD, operative vaginal delivery; PGY, postgraduation year;
VAVD, vacuum-assisted vaginal delivery.
Table 3
Comfortable performing independently (among PGY3 + 4)
|
Procedure
|
MFM fellows present
n = 60 (%)
|
No MFM fellows
n = 142 (%)
|
p-Value
|
|
VAVD
|
49 (82)
|
120 (85)
|
0.62
|
|
FAVD
|
25 (42)
|
43 (30)
|
0.12
|
|
Any OVD
|
55 (95)
|
120 (85)
|
0.17
|
|
Cerclage
|
38 (63)
|
91 (64)
|
0.92
|
|
Breech extraction
|
29 (48)
|
47 (33)
|
0.04
|
|
Breech vaginal delivery
|
8 (13)
|
19 (13)
|
0.99
|
|
4th-degree perineal repair
|
28 (47)
|
53 (37)
|
0.22
|
|
3th-degree perineal repair
|
54 (90)
|
115 (81)
|
0.11
|
|
Cesarean delivery on BMI > 50 kg/m2
|
57 (9)
|
126 (89)
|
0.16
|
|
Cesarean hysterectomy
|
13 (22)
|
35 (25)
|
0.65
|
Abbreviations: BMI, body mass index; FAVD, forceps-assisted vaginal delivery; MFM,
maternal-fetal medicine; OVD, operative vaginal delivery; PGY, postgraduation year;
VAVD, vacuum-assisted vaginal delivery.
With regard to comfort performing procedures postresidency, those from nMFM were more
likely to feel comfortable with VAVD compared with pMFM (100 vs. 87%, p = 0.01). There was no difference in comfort performing FAVD postresidency based on
presence of MFM fellows. All graduating PGY4s felt comfortable performing at least
one form of operative vaginal delivery (either VAVD or FAVD; [Table 4]). No differences in postresidency comfort was seen for any other procedures ([Table 4]). After controlling for program size, plan to practice obstetrics postresidency,
and academic programs, no differences existed in likelihood of comfort performing
procedures postresidency for any procedures based on the presence of MFM fellows ([Table 5]). Because all nMFM respondents were comfortable with VAVD postresidency, regression
models could not be run. Of note, among pMFM residents, 94% stated fellows positively
impacted their learning.
Table 4
Procedures that residents would feel comfortable performing in practice (after graduation,
includes only PGY4)
|
Procedure
|
MFM fellows present
n = 31(%)
|
No MFM fellows
n = 64 (%)
|
p-Value
|
|
VAVD
|
27 (87)
|
64 (100)
|
0.01
|
|
FAVD
|
21 (68)
|
35 (56)
|
0.28
|
|
Any OVD
|
31 (100)
|
64 (100)
|
>0.99
|
|
Cerclage
|
24 (80)
|
51 (81)
|
>0.99
|
|
Breech extraction
|
24 (80)
|
44 (69)
|
0.47
|
|
Breech vaginal delivery
|
7 (23)
|
17 (27)
|
0.80
|
|
4th-degree perineal repair
|
27 (87)
|
50 (81)
|
0.57
|
|
3rd-degree perineal repair
|
31 (100)
|
61 (95)
|
0.55
|
|
Cesarean delivery on BMI > 50 kg/m2
|
31 (100)
|
63 (98)
|
>0.99
|
|
Cesarean hysterectomy
|
20 (67)
|
42 (67)
|
>0.99
|
Abbreviations: BMI, body mass index; FAVD, forceps-assisted vaginal delivery; MFM,
maternal-fetal medicine; OVD, operative vaginal delivery; PGY, postgraduation year;
VAVD, vacuum-assisted vaginal delivery.
Table 5
Odds and adjusted odds ratios for procedures that residents would feel comfortable
performing in practice after graduation (includes only PGY4, no fellows as referent
group)[a]
|
Procedure
|
Odds ratio (95% CI)
|
aOR (95% CI)
|
|
FAVD
|
1.68 (0.68–4.14)
|
2.69 (0.33–21.9)
|
|
Cerclage
|
0.96 (0.32–2.86)
|
1.39 (0.23–8.49)
|
|
Breech extraction
|
1.56 (0.58–4.21)
|
2.17 (0.31–15.1)
|
|
Breech vaginal delivery
|
0.89 (0.33–2.35)
|
1.04 (0.24–4.51)
|
|
4th-degree perineal repair
|
1.56 (0.46–5.29)
|
2.41 (0.37–15.8)
|
|
Cesarean hysterectomy
|
1.02 (0.41–2.56)
|
1.30 (0281–5.97)
|
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; FAVD, forceps-assisted
vaginal delivery; PGY, postgraduation year.
a Controlled for program size > 7 residents/year, plan to practice obstetric postresidency,
total months of maternal-fetal medicine and academic programs.
Discussion
In this study, over 400 OBGYN residents experienced as a primary surgeon with VAVD
and comfortable in performing VAVD independently were higher among nMFM residents.
Otherwise, no differences were noted between trainees' comfort levels with complex
obstetric procedures between nMFM and pMFM programs. In other words, the presence
of MFM fellows does not appear to impact residents' anticipated comfort level in performing
complex obstetric procedures after graduation, even after controlling for confounders.
Declining surgical volume in training programs is well documented and obstetrics is
no exception. Nationally, the number of twin vaginal deliveries and operative vaginal
deliveries is decreasing.[8] Thus, concerns from undergraduate medical learners and OBGYN trainees regarding
exposure and experiences with these and other obstetric procedures are warranted.
These concerns are also faced outside of OBGYN. However, it is reassuring that among
urology and general surgery trainees, the presence of fellows has been shown to have
minimal impact on resident surgical experiences.[9]
[10] In emergency medicine, programs with fellowship have actually increased resident
procedural numbers.[11] Within our own field, Propst et al also noted this to be true when urogynecology
fellows were present.[3] Data from this study suggest similarly that obstetric surgical experiences are also
not impacted by presence of MFM fellows.
The impact of fellows on resident education also is important. Fellows are closest
in age and training to medical learners and are often quite clinically active, thus
their frequent interactions with learners are in a unique position to have an important
and immediate impact on our trainees. In a study on the impact neonatology fellows,
87.5% of resident respondents described fellows as a very important part of their
education.[12] Schimpf et al, in a survey of urogynecology education, noted that approximately
50% of resident respondents felt that urogynecology fellows positively impacted their
education.[7] More recently, Propst et al performed a similar study, noting that nearly 80% of
resident respondents felt that urogynecology fellows positively influenced their education.[3] In our study, residents from pMFM programs related an overwhelmingly positive impact
of fellows in their training (>90%).
Strengths of this study include that the subject matter is novel for our field and
is critically important as we move forward with the responsibility of adequately training
both residents and fellows. Additionally, the use of CREOG objectives and ACGME milestones
are effective anchors to help identify the appropriate resident skills levels. Additionally,
though no validated tool in obstetric skills exists, survey itself was derived from
survey used by two separate authors in the urogynecology literature.[3]
[7] Also, the makeup of our respondent group diverse, from a large variety of residency
sizes, a mix of academic and nonacademic, and represented all ACOG regions.
Limitations
However, our study is not without limitations. First, responses are all self-reported
and we have no way to corroborate resident statements of experience as primary surgeon.
Similarly, we asked about resident comfort performing these procedures independently,
as well as comfort performing postresidency; there is no way to assess actual surgical
skills or competency based on these responses. We also cannot comment on the experiences
and skills of residents at both nMFM and pMFM programs who did not respond to the
survey. Similarly, impact of obstetric volume is another factor that we did not assess
in our survey that might impact resident experience. However, residency size is based
somewhat by obstetric volume, thus this variable could serve as a sort of proxy for
obstetric volume, as we controlled for this in the analysis. It is important to recognize
that there is no way to accurately estimate response rate. It is difficult to know
how many coordinators who received the e-mail actually opened it. Similarly, we cannot
know how many sent to their residents. Assuming that every OBGYN resident in the United
States and Puerto Rico received the survey, the overall response rate was 8.1% (417/5,
148). However, though our sample size is relatively small, it does represent the largest
sample to date. It should also be noted that other published studies of the impact
of OBGYN fellows in other subspecialties are all smaller in size.[3]
[7]
Conclusion
In conclusion, this study found that the presence of MFM fellows does not appear to
impact the comfort levels of graduating residents in performing complex obstetric
procedures. Though experiences with VAVD may come earlier when MFM fellows are not
present, by graduation, residents report no differences comfort performing some form
of operative vaginal delivery, or with any other complex obstetric procedure after
graduation, based on the presence of MFM fellows during their residency training.
Also importantly, MFM fellows were overwhelmingly noted to have a positive impact
on resident learning. Maybe it is time to consider the positives of training in programs
with fellows! The narrative that fellows “steal” is somewhat based in fear and anecdote.
Maybe the opposite is true!
