Urogynaecology training in the UK: past, present and future

Int Urogynecol J (2009) 20:377–380 DOI 10.1007/s00192-008-0796-3 SPECIAL CONTRIBUTION Urogynaecology training in the UK: past, present and future Swati Jha & Robert Freeman & Philip Toozs-Hobson & David Richmond Received: 1 December 2008 / Accepted: 7 December 2008 / Published online: 9 January 2009 # The International Urogynecological Association 2009 Abstract Introduction With the implementation of Modernising Medical Careers, there has been considerable discussion and debate regarding the role of the urogynaecologist in secondary and tertiary care and how trainees with subspecialty training and those with a special interest fit into the current and future provision of urogynaecology services within the framework of obstetrics and gynaecology as a whole. Discussion Because of these changes, training in urogynaecology has and will continue to see major changes. This will also have an impact on workforce planning and service provision within the NHS. An attempt to highlight these issues has been made in this article. Keywords Urogynaecologist . Advanced training skill module (ATSM) . Subspecialty training S. Jha (*) : P. Toozs-Hobson Department of Urogynaecology, Birmingham Women’s NHS Foundation Trust, Metchley Park Road, Birmingham B15 2TG, UK e-mail: [email protected] R. Freeman Department of Urogynaecology, Derriford Hospital, Derriford Rd, Plymouth PL6, UK D. Richmond Department of Urogynaecology, Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK Introduction In recent years, a combination of technologic, academic, legislative and even societal forces have necessitated change in obstetrics and gynaecology leading to the development of different subspecialities. Urogynaecology as a subspecialty has always existed since the origin of obstetrics and gynaecology, but modern urogynaecology as we know it today can be traced to the 1960s [1]. In fact it has its origins in attempts to repair the errors of bad obstetric management. In 1990, Ingelmen Sundberg of Sweden recognised the need for urogynaecology to be accepted as a specialty in its own right, and for adequate teaching and training to be organised at medical centers [2]. As a subspecialty, urogynaecology offers a fascinating mix of medical and surgical problems affecting the pelvic floor. It deals with the management of urinary and anal incontinence, pelvic organ prolapse, abnormalities of the bladder and bowel as well as the impact of pelvic floor dysfunction on sexual function. As it evolves, it is rapidly expanding and recognises the skills required to meet our patients’ needs over their lifetimes particularly with changing patient expectations and an aging female population. Though there has been no survey assessing the satisfaction rates amongst urogynaecology trainees in the UK, a survey of satisfaction rates amongst US trainees demonstrated that only half of all trainees in Obstetrics and Gynaecology residency programs were happy with their urogynaecology training [3]. Role of BSUG British Society of Urogynaecology (BSUG) was founded in April 2001 following a request from the RCOG for a 378 Int Urogynecol J (2009) 20:377–380 urogynaecology society which might assist the College in matters pertaining to the subspecialty. The Society now has over 200 members both Full (consultant) and Associate (non-consultant). The Society’s main function is to set and raise standards by providing guidelines, training, research and clinical meetings (in conjunction with the RCOG) and is very much in-keeping with the philosophy of the subspecialty itself. Future aims of the Society include implementing the RCOG’s clinical standards by recognising units which provide this service. Other functions include & & & & & Improving knowledge, practice, teaching and research for all obstetricians and gynaecologists by encouraging them to use the BSUG Surgical Audit Database. This is available to all BSUG members as well as joint membership of the International Urogynecology Association (IUGA) which allows members to receive the International Urogynecology Journal thus keeping up to date with research evidence and best practice. Promoting and supporting the concentration of specialised expertise, specialist facilities and clinical material that will be of considerable benefit to patients. Establishing a closer understanding and working relationship with other disciplines e.g. Urology, Coloproctology, Continence Advisory Services etc. In the future to encourage the implementation of national standards and evidence-based practice by officially recognising such units. Accepting major responsibility with the RCOG for higher training and research. The past and present Special skills module/Advanced training skills modules In the past Urogynaecology training in the UK was part of general gynaecological training and prolapse and incontinence surgery were performed by all obstetricians and gynaecologists. In June 2002, the RCOG set up Urodynamics as a special skills module (SSM). This was as part of the RCOG’s attempt to standardise training and skills in specific techniques in obstetrics and gynaecology such as ultrasound, colposcopy, hysteroscopy etc. BSUG hoped that eventually this would develop into a Urogynaecology training module and this has now arisen with the advanced training skills module (ATSM). The Urodynamics SSM was undertaken by trainees in the final 2 years of their obstetrics and gynaecology training i.e. in SpR year 4 and 5. It was presumed that Urodynamics would be undertaken by those wishing to further their careers in urogynaecology however the onus to obtain the surgical skills which are an integral part of that role was on the trainee with no formal requirement. In 2007, recruitment to Specialty Training (ST) underwent a radical change. This programme of change, Modernising Medical Careers (MMC), aims to improve the quality of care for patients through reform and improvement in postgraduate medical education and training. In accordance with MMC, specialty training in obstetrics and gynaecology now consists of basic, intermediate and advanced training over 7 years. Year 6 and 7, which are equivalent to SpR years 4 and 5, will be utilised for the acquisition of specialist skills through the Advanced Skills Training Modules or Subspecialist Training (SST). These were introduced in August 2007 by the RCOG and accepted by PMETB. There are currently 20 ATSM. The curriculum defines each stage of learning and is explicit in the detailed knowledge, skills and attitudes described for every aspect of practice. The ATSM are designed to develop skills suitable for future career progress within the consultant career pathways detailed in the RCOG document ‘The Future Role of the Consultant’ (http:// www.rcog.org.uk/index.asp?PageID=1759). A trainee is offered career guidance in order to make realistic decisions about advanced training. All general trainees continue to develop their core skills in Obstetrics and Gynaecology throughout their final 2 years to the Certificate of completion of Training and the curriculum reflects the development of these skills. Table 1 shows the number of trainees registered for the SSM and the ATSM. The Urogynaecology ATSM incorporates the features of the Urodynamics SSM but also includes the basic surgical skills required by a gynaecologist practicing urogynaecology as their special interest. It has been developed as a form of ‘office Urogynaecology’ with training in the basic investigations and procedures such as urodynamics, cystoscopy and primary surgery for incontinence and prolapse e.g. vaginal hysterectomy and repair and mid-urethral slings/tapes. The anticipated time for completion of the Urogynaecology ATSM is 12 months. Table 1 Trainees registered in the SSM and ATSM (October 2008) Module Urodynamics (SSM) Urogynaecology (ATSM) Registered Registered Trainees Non-training trainees non-training completed grades grades completed 19 – 24 NA 111 5 29 NA Int Urogynecol J (2009) 20:377–380 Subspecialty training Subspecialty training was developed to improve knowledge, practice, teaching and research in a specialty. The first SST programme in obstetrics and gynaecology in the UK was set up in 1984, and was in Gynaecological Oncology. It was Professor Stuart Stanton in 1981 who persuaded the college to have Urogynaecology (then ‘Gynaecological Urology’) as a subspecialty recognised by the College. It was eventually agreed that this would be a smaller subspecialty compared with oncology, materno-fetal medicine and reproductive medicine. The first Urogynaecology subspecialty training programme was set up at St George’s Hospital, London in November 1992. Subsequently other programmes were set up and there are today 16 (Table 2), though not all programmes have trainees in post at one time. Each programme has a welldefined syllabus produced by the RCOG subspecialty training committee in conjunction with BSUG and the training centres also need to fulfill certain requirements. These include an adequate clinical workload, a programme which embodies teaching, training, research and audit, adequate staffing to support training, collaboration with related disciplines and a programme director responsible for supervision and training. There has been a strong academic input in this training which includes structured research training except for those trainees who have undertaken research prior to entering a programme. As a result they are research exempt and they complete a 2-year programme rather than three. The future of the research component is currently under discussion. The main differences in the learning objectives of the SST when compared to the ATSM include the ability to undertake advanced forms of investigation e.g. video Table 2 Urogynaecology subspecialty training programmes in the UK (16) Centre Birmingham Women’s Hospital Cambridge: Addenbrookes Hospital Glasgow: Glasgow Royal Infirmary Leeds: St James’s University Hospital Leicester Royal Infirmary Liverpool Women’s Hospital London: Kings College Mayday Health care NHS Trust Saint Mary’s Hospital UCL Manchester: St Marys Hospital Oxford: John Radcliffe Hospital Plymouth (Derriford Hospital) + Bristol (Southmead Hospital) (2 posts) Sheffield (Royal Hallamshire Hospital) Swansea 379 urodynamics (VCU), anorectal physiology, complex prolapse and incontinence surgery, both primary and secondary and work as part of a multi-disciplinary team with continence advisors, physiotherapists, urologists, coloproctologists, geriatricians etc. Subspecialty trainees can go to other centres to undertake a module that is not provided in their own department e.g. complex surgical procedures such as artificial sphincters, CLAM cystoplasty and sacral nerve root stimulation. To be able to provide these services as a consultant, take on national responsibilities and to become a Subspecialty Programme Director in the future, all subspecialty trainees will need their clinical and research training to be of the highest standard [4]. The prerequisite for appointment to an SST programme is that the trainee should have completed 5 years of training and demonstrated keenness and enthusiasm for the specialty. With the reduction in working hours and hence training time, there may be an argument for increasing the duration of subspecialty clinical training to 3 years as opposed to two. The future The BSUG has laid down a clear definition of the title “Urogynaecology” (http://www.rcog.org.uk/resources/Public/ pdf/bsugnewsletter_011204.pdf). In the UK, consultants practicing Urogynaecology fall into three groups i.e. those who do surgery for prolapse and incontinence, those who undertake all aspects of Urogynaecology as a specialist interest and those who are subspecialists. The obstetrician and gynaecologist with a special interest in urogynaecology will continue to have a considerable obstetric and general gynaecology workload. Subspecialists on the other hand are those who, after undertaking appropriate training and the acquisition of special expertise, will devote at least half and probably more of their working time in the subspecialty either in a District General Hospital or in a Tertiary Centre. However, even subspecialists are likely to continue to be actively involved in obstetrics and this is entirely appropriate in terms of prevention of pelvic floor dysfunction on the labour ward by the education of Midwives and trainees and also being present to help with the prevention and treatment of anal sphincter injuries. The BSUG is committed to ensuring that subspecialty trainees continue to maintain their obstetric skills by staying on the obstetric on-call rota during their 2–3 year training. As this will be an important part of their future consultant job plan. Subspecialty training was originally planned for ‘super specialists’ as in Oncology. However, in Urogynaecology fewer were required and the majority have taken up posts in District General Hospitals. By 2008, 15 subspecialty trainees have taken up pure urogynaecology consultant posts and nine ‘special interest’ posts. This is likely to change in the 380 future with more subspecialty trainees taking up ‘special interest’ posts. Due to the more complex nature of the work required and the shortened training, there will be a requirement for trainees to have more exposure to this type of work, particularly as the generalists who currently do a lot of the pelvic floor surgery, retire. BSUG doesn’t believe this can be done in 1 year through the ATSM and therefore there is a need for more subspecialty training through the extra 2 to 3 years. This, however, will be dependent upon trainees entering programmes, which is unlikely to happen unless Urogynaecology posts are being created. Although the merits of sub-specialisation within surgery are said to be self evident and in the interests of the patients, neither assertion has been proven. Taylor states succinctly that “the predominant argument in favour of super-specialisation relates to the perception that high volume in surgery equates with better outcome” [5]. This is also alluded to by NICE in the ‘surgical competence’ section of their Urinary Incontinence Guidance (http://www. nice.org.uk/nicemedia/pdf/word/CG40quickrefguide1006. pdf). Subspecialists in Urogynaecology have a lead role to play in setting up multidisciplinary teams and an integrated service, provide evidence based practice as per national standards, collaborate with colorectal surgeons, urologists, continence advisors, physiotherapist, geriatricians and paediatricians as well as implementing new procedures with appropriate audit and undertake research which is likely to benefit patients. By separating those who have a ‘special interest’ from the subspecialists, the workload in the years to come will be shared so that the primary prolapse and incontinence work will be undertaken in all units while recurrent prolapse and complicated continence work would be the domain of subspecialist/tertiary referral urogynaecology units. The number required will be based on expected needs. The Workforce Planning Committee of the RCOG (2008) has drafted a report for estimating the number of Subspecialists that will be required for the future. It is estimated that 50 Subspecialty trained and about 225 Special interest consultants will be required over the next 10 years. The balance may however shift in the years to come. Conclusion With the changing patient population, advances in technology, the changing composition and working hours of Int Urogynecol J (2009) 20:377–380 staff, patient expectations and evidence regarding efficacy and safety (especially of new procedures), there is an urgent need to review how, where and by whom care is delivered in the subspecialty of Urogynaecology and to consider the future workforce requirements in issues of training. With an aging population and increasing workload, having a subspecialist might be an advantage for many departments especially at a time when there is competition from independent sector agencies for this work. While some colleagues might regard this as a ‘threat’ to their practice, others will feel that the benefits gained from raising their department’s profile will be a sign of quality which will attract more secondary and tertiary work while also fulfilling NICE recommendations. Acknowledgements We thank Bettina Muller and Penny Payne, Department of postgraduate training, Royal College of Obstetricians and Gynaecologists, for providing the data for the SSM and ATSMs. Disclosure of Interests All authors are members of the BSUG and are either a subspecialty trainee or trainer for a subspecialty programme. Contribution to Authorship All authors participated in developing the concept of the paper. SJ, RF and PTH participated in the drafting the paper. DR provided the figures from the Workforce Planning Committee of the RCOG. All authors have commented on the submitted version of the paper. Details of ethics approval N/A Funding N/A References 1. Sand PK (2001) Urogynecology: the death of dogma. Int Urogynecol J Pelvic Floor Dysfunct 12(1):1–2 2. Ingelman-Sundberg A (1990) Development of urogynecology in Europe. Int Urogynecol J Pelvic Floor Dysfunct 1(4):223–227 3. 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