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Milestone Assessment of Minimally Invasive Surgery in Pediatric Urology Fellowship Programs
Paul H. Smith, III, MD, Melinda Carpenter, MS, Katherine W. Herbst, MS, Christina Kim, MD.
Connecticut Childrens Medical Center, Hartford, CT, USA.

BACKGROUND:
In the past decade, minimally invasive surgery (MIS) has become an important aspect of Pediatric Urology fellowship training. In 2014, the ACGME published the Pediatric Urology Milestone project as a metric for fellow proficiency in multiple facets of training, with specific categorization in robotic/laparoscopic procedures (Figure). A Milestone score of 4 is designed as the graduation target. Our study assessed trends in MIS training, and utilization of the Milestones.
METHODS:
With permission from the Society of Pediatric Urology (SPU), we surveyed Pediatric Urology program directors (PD) and fellows who completed their clinical year in 2015. We queried familiarity with the Milestone project, utilization of the Milestones, robotic/laparoscopic case volume and training experience, and perceived competency with robotic/laparoscopic surgery at the start and end of the fellowship clinical year. Responses were accepted between August and November 2015. Surveys were excluded if incomplete or if the responder did not identify as a PD or post-clinical year fellow.
RESULTS:
Surveys were distributed via e-mail to 35 fellows and 30 program directors. Sixteen fellows (46%) and 14 (47%) program directors responded. All fellows reported some robotic experience prior to fellowship and 69% performed greater than 50 robotic/laparoscopic surgeries during residency. Fellow robotic/laparoscopic case volume varied: 3 had 1-10 cases (19%), 4 had 11-20 cases (25%), and 9 had greater than 20 cases (56%). Supplementary or robotics training modalities included simulation (9), animal models (6), surgical videos (7), and courses (2).
Comparison of beginning and end of fellowship robotic/laparoscopic Milestone assessment revealed scores of less than 3 in 10 (62%) fellow self-assessments and 10 (75%) program director assessments at the start of training. End of training Milestone scores greater than four were seen in 12 (75%) fellow self-assessments and 8 (57%) of program director assessments.
All PD Milestone scores increased throughout the clinical year. All PDs utilized the Milestones to provide feedback to the fellow.
CONCLUSIONS:
In our study, Milestone assessment demonstrated improvement in fellow’s MIS skills during their training. However, 43% of PDs did not rate their fellow at the graduation target for MIS skills. We saw wide variation in supplemental training modalities. We must critically consider the best ways to teach MIS in Pediatric Urology fellowship training.


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