Barriers to Referral to Fellowship-trained Minimally Invasive Gynecologic Surgery Subspecialists

Abstract

Study Objective: To determine patterns and barriers for referral to fellowship-trained minimally invasive gynecologic surgeons. Design: Questionnaire. Setting: United States and its territories and Canada. Participants: Actively practicing general obstetrician/gynecologists (OB/GYNs). Interventions: Internet-based survey. Measurements and Main Results: Of 157 respondents, 144 (91.7%) general OB/GYNs were included. Subspecialty fellowship training resulted in the exclusion of 13 ( 8.3%) respondents. A total of 86 respondents (59.7%) considered referral to fellowship-trained minimally invasive gynecologic surgery (MIGS) subspecialists. The top 3 cited reasons for nonreferral were adequate residency training (n = 84, 58.3%), preference for continuity of care (n = 48, 33.3%), and preference for referral to other subspecialists (n = 46, 31.9%). The top 3 cited reasons for referral to MIGS subspecialists were complex pathology (n = 92, 63.9%), complex medical and/or surgical history (n = 76, 52.8%), and out of scope of practice (n = 53, 36.8%). If providers required intraoperative assistance, respondents consulted an OB/GYN colleague with comparable training (n = 50, 34.7%), gynecologic oncologist (n = 48, 33.3%), or non-OB/GYN surgical subspecialist (n = 33, 22.9%). Factors that were not associated with the decision to refer to MIGS subspecialists included years in practice (p = .13), additional training experiences beyond residency (p = .45), and number of hysterectomies performed by laparotomy (p = .69). Selfreported high-volume surgeons (p <.01) were less likely to refer. In contrast, providers who self-reported as low-volume surgeons (p = .02) and were aware of MIGS subspecialists in the community (p <.01) were more likely to consider referral. Respondents reported using a laparoscopic approach to hysterectomy most frequently (n = 79, 54.9%). In contrast, 36.8% preferred the laparoscopic route for themselves or their partner, whereas 48.6% preferred the vaginal approach. Conclusion: Most of the general OB/GYNs would consider referral to fellowship-trained MIGS subspecialists. Providers who reported adequate residency training and those who preferred continuity of care or referral to other surgical subspecialists were less likely to refer to MIGS subspecialists.

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations

“…However, as noted in a study by Geynisman-Tan et al, 34 an increase in general gynecology referrals likely only partially accounts for this because self-referrals and primary care provider referrals increased at a higher rate over the past several years. While there may be barriers to subspecialty referrals, including long wait times for appointments, travel distance, and preference for continuity of care, 35 it is critical for general gynecologists to improve their referral rates because this seems to be a significant area for improvement to decrease the burden of prolapse recurrence.…”

The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult

“…With the advent of additional surgical training and expertise that MIGS brings to the community at large, the critical need of patients with complex non-oncologic gynecologic disorders that have been traditionally served only by gynecologic oncologists are now being met and relieved [2 ▪ ]. For patients, providers, and the hospital system, MIGS has become an avenue to increase quality metrics across all three domains especially for highly complex cases [3].…”

“…The current volume of cases nationally has transitioned to laparoscopic hysterectomies, with a downtrend of abdominal and vaginal hysterectomies. There continues to be a growing body of evidence assessing the dichotomy of high-volume and low-volume surgeons [2 ▪ ,39]. Although surgical experience and differentiation between high-volume and low-volume surgeons are subjective, gynecologic surgeons with breadth and depth of complexity and disorder have been associated with decreased complications and overall operative costs [38].…”

“…Minimally invasive gynecologic surgery (MIGS) has been a quickly growing subspecialty within the field of obstetrics and gynecology (OBGYN) since its inauguration in 1971 [1]. Amongst contemporary providers, the utilization of MIGS subspecialists, and thus, practice referrals continue to be topics of discussion [2 ▪ ]. As new technology and advances in surgical techniques are introduced to the field of gynecologic surgery, questions arise as to how minimally invasive gynecologic surgeons may be best utilized in different clinical scenarios by their obstetrician–gynecologist colleagues [3]…”

Technical, ergonomic and cognitive learning methodology in transumbilical single‐port laparoscopic hysterectomy

“…7 Studies show that only 20%-28% of graduating residents feel prepared to perform a vaginal hysterectomy independently, while 46%-58% can perform an abdominal hysterectomy, and only 22% can perform a laparoscopic hysterectomy, 8,9 highlighting the need for training in LH and TSPLH. There are programs designed to improve surgical skills, 10 including simulation models, 11 proficiency-based training, or video-based coaching, that offer novice gynecologic surgeons an opportunity to practice laparoscopic hysterectomy before actual surgery. However, detailed surgical elements, obstacles, and countermeasures can only be learned through actual surgical experience.…”