The Systemic Decline of Vaginal Surgery
With a passion for vaginal surgery and resident education, Dr. Miyazaki has become increasingly concerned with the systemic decline of teaching the art of vaginal surgery.
At his home institution, for example, Dr. Miyazaki noted the average number of vaginal hysterectomies performed annually by graduating residents from 2007 to 2009 was 30 per resident, a 77 percent decrease from the 130 annual hysterectomies Dr. Miyazaki performed during his residency training. In 2013, it is anticipated that the annual number of resident-performed hysterectomies at the same institution will drop to about 20 per resident on average – an 85 percent decline in fewer than 20 years.
These issues are not institution specific, but rather a concern in residency programs across the country. Consequently, dramatic declines in surgical experience are causing problems with objective verification of minimal competency levels as residents graduate from one level to the next, prompting the Accreditation Council for Graduate Medical Education (ACGME) and American Congress of Obstetricians and Gynecologists (ACOG) to develop and implement the Milestone Project. As highlighted in the September 2008 ACGME Bulletin, “the overarching goal of the Milestone Project is to provide outcomes-based accreditation.” The intent of the project is to “reassure the public that physicians entering clinical practice have demonstrated the educational outcomes and proved their proficiency in all dimensions of the domains of clinical competency required to graduate from an accredited program.”
The Miya Model Story
The current standard for vaginal surgery instruction is reliant upon both live surgery and the use of training cadavers. These approaches suffer from several handicaps, including: patient risks, liability risks, availability limitations, high costs and high demand on proctoring surgeons. Over time, these limitations have caused a decrease in resident exposure to live training cases. In fact, Dr. Miyazaki conducted research at his home institution, finding the number of hysterectomies performed by residents has drastically decreased. Current residents are performing about a quarter of the number of hysterectomies Dr. Miyazaki performed during his own residency, just two decades ago. Trends in health care and a growing shortage in funding dollars suggest that this alarming dynamic will only continue to get worse.
These issues are not institution specific and have become an ever growing problem in residency programs across the country. Consequently, dramatic declines in surgical experience are generating a growing interest in the objective verification of minimal competency levels as residents graduate from one level to the next, prompting the Accreditation Council for Graduate Medical Education (ACGME) and American Congress of Obstetricians and Gynecologists (ACOG) to develop and implement the Milestone Project.