Hysteroscopy in daily practice Dongen, H. van

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Hysteroscopy in daily practice

Dongen, H. van

Citation

Dongen, H. van. (2009, February 26). Hysteroscopy in daily practice.

Retrieved from https://hdl.handle.net/1887/13533

Version: Corrected Publisher’s Version

License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden

Downloaded from: https://hdl.handle.net/1887/13533

Note: To cite this publication please use the final published version (if

applicable).

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Chapter 3

Hysteroscopic surgery:

perspectives on skills training

Heleen van Dongen Wendela Kolkman Frank Willem Jansen

Adapted from J Minim Invasive Gynecol 2006;13:121-125

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Chapter 3 22

Introduction

Over the past decades hysteroscopy has become an increasingly important component of gynaecological practice. It remains, however, questionable whether or not the implementation of hysteroscopic procedures into general practice is sufficient. Like all endoscopic procedures, practicing hysteroscopy requires training and experience. Moreover, the safety and outcome of surgical procedures are clearly linked to adequate training [Whitted 2003].

The purpose of this study was to assess the exposure and interest of residents in hysteroscopy, to assess the state of hysteroscopy in daily gynaecological practice and to identify factors influencing hysteroscopic skills training.

Methods

To assess the exposure and interest of residents in hysteroscopy, a survey was sent to all 68 postgraduate year five and six residents Obstetrics and Gynaecology registered at the Dutch Society of Obstetrics and Gynaecology in 2003. To assess the state of hysteroscopy in daily practice, a similar survey was sent to all 151 gynaecologists, working in teaching and non-teaching hospitals, who finished residency within the last five years (1998-2002) and were registered at the Dutch Society of Obstetrics and Gynaecology.

The survey addressed personal and practice demographics, interest and performance of hysteroscopic surgery, current skills, hysteroscopic education during residency, and factors influencing implementation of hysteroscopy in general practice.

Names and addresses were collected from the Dutch Society of Obstetrics and Gynaecology. Each envelope contained a letter of introduction, the survey and a stamped return envelope. The survey was assigned a number to track responses. All collected data were registered anonymously. To maximise the response rate a second mailing was sent after six weeks.

Guidelines issued by the Dutch Society of Obstetrics and Gynaecology, which are similar to the Royal College of Obstetricians and Gynaecologists guidelines of 2001, were used to classify hysteroscopic surgery procedures according to their level of difficulty (level 1-3) [Royal College of Obstetricians and Gynaecologists (RCOG) 2001].

Dutch residents are trained as general gynaecologists [Schutte 2004]. Therefore, specific curriculum guidelines are established containing requirements essential for graduation, such as a number of surgical procedures that needs to be performed by residents as the primary surgeon. Mandatory hysteroscopic procedures are: diagnostic hysteroscopy and biopsy, removal of intrauterine devices (IUD), polypectomy and myomectomy (type 0) (according to the Dutch guidelines classified as level 1 and partly level 2). As the other procedures (partly level 2 and level 3) are not required for graduation, they are considered advanced hysteroscopic procedures (see chapter 2 for the classification of submucous myomas).

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Perspectives on skills 23

In the survey a Likert score was used to have the respondent express agreement or dis- agreement on a five-point scale: 1 (uncomfortable) - 5 (very comfortable), 1 (not interested) - 5 (very interested) or 1 (unimportant) - 5 (very important).

Not all respondents answered all items of the survey; therefore subcalculations with different denominators were made. For some questions multiple answers were allowed.

Since residency training and daily practice are different items, the surveyed residents and gynaecologists were analysed separately.

The results were collected in the statistical SPSS-program (SPSS, version 12, SPSS Inc., Chicago, IL) and analysed using the Student t-test, the Pearson’s Chi-square test and the Mann-Whitney U-test. Significance was reached at a p-value of <0.05.

Results

The response rates of all surveyed residents and gynaecologists in practice were respec- tively 88% and 83%. The mean age of the residents was 35 years (range 30-42). The mean age of the gynaecologists was 39 years (range 32-47). No significant differences were found between respondents and non-respondents in gender and type of clinic (teaching versus non-teaching hospital).

Of the responding gynaecologists twelve (9.6%) were specialised in maternal foetal medicine and worked in a university hospital. These gynaecologists do not perform any hysteroscopic surgery and were therefore excluded from further analysis. From here on we continued to analyse the returned surveys of the remaining 113 responding gynaecologists.

Residents

Nearly all residents (98%) were interested in performing hysteroscopic surgery. Eighty percent felt that residency prepared them well for the educational goals as stated in the curriculum guidelines for residency training. Significantly (p=0.02) fewer residents (53%) expected to be prepared adequately for advanced procedures, in addition to the educational goals.

Table 1 shows the percentage of residents interested in each specific procedure. All residents showed to have interest in performing the mandatory and additionally one or more advanced hysteroscopic procedures. The majority of the residents, varying from 78% to 100% depending on type of the procedure, were performing one of the mandatory procedures. Fewer residents (0%-51%) were performing advanced procedures. As shown in table 2, residents felt competent (Likert score>3) performing mandatory and advanced hysteroscopic procedures.

Gynaecologists

Of the responding gynaecologists 94% were interested in performing hysteroscopic surgery. Nearly all gynaecologists, varying from 82% to 98% depending on type of the

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Chapter 3 24

procedure, performed one of the mandatory hysteroscopic procedures as taught during residency (table 1). Fewer gynaecologists (4%-52%) were performing advanced hysteroscopic procedures in their practices. Eighty-eight percent of the gynaecologists were interested in performing one or more advanced procedures in the near future. Regarding their self-perceived competencies, gynaecologists felt competent performing mandatory and advanced hysteroscopic procedures, (Likert score>3; table 2). When comparing the self-perceived competencies between residents and gynaecologists, the latter felt significantly more competent in performing all mandatory procedures (p<0.05), except for hysteroscopic IUD removal.

Implementation

At graduation 69% of the gynaecologists felt to be adequately trained in performing mandatory hysteroscopic procedures. Significantly (p<0.001) fewer gynaecologists (35%) felt that their training was adequate to perform the advanced procedures they desired to perform.

Table 1 Interest in hysteroscopy per level of difficulty.

Hysteroscopic procedure

Interest in hysteroscopy would like to perform

(%)

perform now (%)

not interested (%) resident gynae-

cologist resident gynae-

cologist resident gynae- cologist Level 1

Diagnostic hysteroscopy* – 1 100 98 – 1

IUD removal* 12 2 88 96 – 2

Level 2

Polypectomy* 5 5 93 93 2 2

Myomectomy type 0* 20 13 78 82 2 5

Simple synechiolysis 53 37 45 47 2 16

Endometrial ablation 43 28 47 51 10 21

Septum resection 61 55 20 12 19 34

Level 3

Myomectomy type I 46 33 51 52 3 15

Myomectomy type II 65 48 12 22 23 30

Major synechiolysis 45 40 4 5 51 55

Hysteroscopic sterilisation 25 26 – 1 75 73

* Mandatory procedures for graduation, levels according to the Royal College of Obstetricians and Gynaecologists.

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Gynaecologists felt that a lack of attention during residency (48%) was the most important factor influencing implementation of advanced hysteroscopic procedures in daily practice. Not being the primary surgeon during residency was considered the most important limiting factor for acquiring advanced skills (Likert score=4; table 3). Lack of appropriate patients was also found important (Likert score=3).

The majority of gynaecologists felt that the preferred level of competence of advanced hysteroscopic surgery could be reached best by inviting an advanced endoscopic gyn- aecologist to teach them in their own clinic (49%). Others felt this could be achieved by teaching themselves in the operating theatre (34.3%) or learning skills during courses and congresses (31.4%).

Table 2 | Median self-perceived competence per level of difficulty.

Hysteroscopic procedure

Self- perceived competence Likert score (n)

residents gynaecologists

Level 1

Diagnostic hysteroscopy* 4 (60) 5 (107) †

IUD removal* 4 (53) 5 (106)

Level 2

Polypectomy* 4 (56) 5 (102) †

Myomectomy type 0* 4 (47) 5 (90) †

Simple synechiolysis 4 (27) 4 (51)

Endometrial ablation 3.5 (28) 4 (54)

Septum resection 4 (12) 4 (13)

Level 3

Myomectomy type I 4 (29) 4 (57)

Myomectomy type II 3 (7) 4 (24) †

Major synechiolysis 4 (2) 4 (5)

Hysteroscopic sterilisation – 4 (1)

* Mandatory procedures for graduation, levels according to the Royal College of Obstetricians and Gynaecologists.

† p-value <0.05)

Likert scale; 1=not competent, 5=very competent. Scores above 3 indicate feeling competent, scores less than or equal to 3 indicate not feeling competent.

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Chapter 3 26

Discussion

Both residents and gynaecologists were very interested in hysteroscopic surgery. As the majority of respondents performed the mandatory procedures taught during residency and felt competent with them, we may conclude that incorporation of these basic hysteroscopic procedures into daily practice has been successful. Residents and gynaecologists were also interested in advanced hysteroscopic surgery. However, only a minority of respondents were actually performing these procedures. Those who did, considered themselves competent.

In contrast to the mandatory procedures, in which gynaecologists considered themselves significantly more competent than residents, the self-perceived competencies for nearly all advanced procedures did not differ among both groups. Regarding this, lack of experience among graduating residents may be a limiting factor for evolving skills further in daily practice. These issues are not specific to The Netherlands. Rattner et al. [Rattner 2001] already postulated that in the United States residents not perform- ing enough procedures to feel comfortable, slows implementation. Another American survey among urology residents concluded that those who had received formal laparo- scopic training during residency, were more likely to incorporate these techniques into daily practice [Shay 2002].

The participants in our study suggested that the principle reason for a lack of advanced skills among graduating residents is the limited opportunity to be the primary surgeon.

However, advanced procedures are not incorporated in the curriculum guidelines, and it is therefore not inconceivable that gynaecologists in teaching hospitals are still deal- ing with their own learning curve issues and that this fact robs residents of experience.

Therefore, it is debatable whether advanced hysteroscopic procedures should be inte- grated in the residency program.

Table 3 | Limiting factors causing lack of hysteroscopic skills during residency.

Limiting factor Likert score

median

Lack of opportunity to be primary surgeon 4

Lack of appropriate patients 3

Procedures are not performed 3

Lack of opportunity to be assisting surgeon 2

Lack of interest surgical educator 2

Surgery time too long 2

Lack of correct equipment 2

Lack of trained staff of operating theatre 2

Lack of interest resident 1

Likert scale; 1=unimportant, 5=very important

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If expertise in teaching hospitals becomes sufficient, an increase of caseload and exposure might be expected [Einarsson 2002; Fowler 2000; Heniford 2001]. Thus, in order to attain implementation of advanced hysteroscopic surgery in residency, the resource must first be improved. According to the responding gynaecologists this could best be achieved by inviting an advanced endoscopic surgeon to teach them in the clinic where they practice. A second suggestion was to learn skills during courses and subsequently teach themselves by independently performing new procedures. There is, however, con- siderable controversy regarding the usefulness of these courses, as evidence suggests that surgeons participating in endoscopy courses are often not able to integrate the learned procedures into their practices [Rogers 2001]. We rather consider inviting an endoscopist, as a mentor during hysteroscopic procedures, a better option for teaching these features [Kolkman 2007].

Since the diffusion of hysteroscopic surgery is still evolving, an aspect of our study that could be criticised is that the skills assessment of gynaecologists currently in practice may not accurately reflect the competencies of residents in the future. Therefore, to approximate the future skills of our residents, only recently graduated gynaecologists were surveyed. Another limitation is that we measured only self-perceived competencies, which may not always reflect the actual competency of a particular respondent.