Differences in early career operative experiences among pediatric urologists

Previous research suggests that pediatric urologists feel well trained by their fellowship for cases encountered early in their career. We questioned the complexity and diversity of cases new pediatric urologists were actually performing.

The aim was to identify the frequency with which newly trained pediatric urologists are performing various procedures, investigate which factors are associated with case complexity and diversity, and evaluate for differences between male and female surgeons.

Case logs of urologists from July 30, 2007, to June 30, 2013, initially applying for the certifying examination who self-identified as pediatric urologists were reviewed. Data points included cases/dates, and surgeon demographics. An in-depth analysis was performed on 51 index cases from the 71 included pediatric urologists, for which a level of complexity was assigned.

Compared with the bottom volume quartile, surgeons in the top quartile performed more cases of minimal (115.9 ± 8.7 vs. 51.7 ± 8.7, p < 0.001), moderate (31.1 ± 2.7 vs. 10.1 ± 1.0, p < 0.001) and significant (10.8 ± 1.9 vs. 2.0 ± 0.4, p < 0.001) complexity. More than 90% logged circumcisions, orchiopexies, and inguinal hernia repairs, while less than 1.5% logged open nephroureterectomies or complete male epispadias repair. Surgeons submitted at least one of 17.2 ± 0.5 (range 5-28) unique codes. The figure presents the percentage of current procedural terminology (CPT) codes performed by each urologist. Surgeons with the least case diversity performed a higher percentage of low-complexity cases, and lower percentages of moderate and complex cases (p < 0.001). Males, comprising 60.6% of urologists, performed more cases than females (342.9 ± 30.9 vs. 229.1 ± 18.1, p = 0.007), averaging more cases of minimal (95.0 ± 6.6 vs. 73.3 ± 4.6, p = 0.018) and significant (6.7 ± 1.0 vs. 2.8 ± 0.5, p = 0.005) complexity. There was no difference in cases of moderate complexity (22.0 ± 1.9 vs. 18.1 ± 2.1, p = 0.201).

In general, pediatric urologists should expect to perform many minor cases when they enter practice. Women are entering urology in increasing numbers. In our study, female urologists performed fewer cases. This could have implications for the workforce, which in urology in general is expected to decrease.

Case diversity and degree of complexity vary among newly trained pediatric urologists. The urologist with the greatest case diversity never performed 45% of the 51 analyzed CPT codes, while the one with the least case diversity never performed 90% of the codes. Male surgeons performed more operations, particularly those of minimal and significant complexity. The variability in operative experience reinforces the importance of continuing education and mentorship after completion of fellowship.