Exposure to the reproductive endocrinology subspecialty among obstetrics and gynecology residency programs

Abstract

Purpose

Prior studies found that Ob-gyn trainees believe they have inadequate experience in the REI subspecialty. We evaluated the amount of time devoted to REI within the 4-year rotation schedule of ACGME-accredited Ob-gyn residency programs.

Methods

A list of current Ob-gyn residency programs, both with and without REI fellowships, was created using ACOG and ACGME databases. The programs’ websites were reviewed, or the program coordinator was queried to determine the length and year of REI rotation, and the career or fellowships pursued by alumni. Wilcoxon rank sum test was utilized to assess differences in total REI rotation time between REI-affiliated and non-affiliated programs. Spearman’s correlation was utilized to assess the association between total REI exposure and the percentage of alumni pursuing REI fellowships.

Results

Cumulative length of REI rotations throughout residency ranged from 0 to 20 weeks. Mean cumulative rotation length was greater in non-REI than in REI-affiliated programs (7.4 weeks vs. 6.1 weeks, p = 0.007). However, REI-affiliated programs had greater exposure to REI rotations during the first 2 years of residency (3.9 weeks vs 3.1 weeks, p = 0.042). Among all programs, 24% had the REI rotation in PGY-1, 61% in PGY-2, 50% in PGY-3, and 16% in PGY-4. The proportion of alumni matching in REI fellowship was significantly greater in REI-affiliated programs than non-REI affiliated programs (9.5% vs. 3.1%, p < 0.001).

Conclusion

Compared to non-REI affiliated programs, Ob-gyn residencies affiliated with REI fellowships spend less time throughout residency training in REI rotations while sending a greater proportion of residents to REI fellowships.

Introduction

The increased prevalence of infertility, as well as the limited number of physicians trained in Reproductive Endocrinology and Infertility (REI), highlight the need for more physicians trained in Reproductive Endocrinology and Infertility (REI) [1]. Increased education, support, and counseling are necessary to facilitate optimal care for couples struggling to conceive. Obstetrics and gynecology (Ob-gyn) residency aims to train residents and equip them with comprehensive knowledge to prepare for general practice or future subspecialty training. The Accredited Counsel for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education (GME) and Ob-gyn do not require clinical exposure to Reproductive Endocrinology and Infertility (REI) [2].

Prior studies have found that Ob-gyn residents often have deficits in knowledge and exposure to the field of REI [3]. For example, Ob-gyn residents underperform on REI questions on the in-training examinations compared to other sections of the exam, correctly answering only 42–67% of REI-related questions [4]. The lower exam scores identify a gap in current residents’ REI knowledge base [4]. Another study aimed to assess residents’ perception of their REI rotation during residency [5]. This included satisfaction with the quality and duration of the rotation and self-reported knowledge of REI. Of 4670 resident responses, it found that the duration of rotation on REI varied by residency and postgraduate year. Eighty-four percent of respondents were allowed to take a vacation during the REI rotation. In addition, 40% of the respondents reported their knowledge was poor [5]. Lastly, Guntupalli et al. evaluated the perceptions of fellowship program directors of incoming clinical fellows from four Ob-gyn subspecialties and found that residents applying to REI may be deficient in surgical skills that are required to be completed independently as a fellow [6].

These findings suggest that residents may not receive enough exposure to REI during their residency training. The current study was done to evaluate the amount of time devoted to REI within the 4-year rotation schedule of ACGME-accredited Ob-gyn residency programs and explore whether residents in programs that are not affiliated with an REI fellowship and residents in programs affiliated with an REI fellowship differ in their cumulative exposure to REI during residency.

Methods and materials

Our study was deemed exempt by the Northwestern University IRB institutional review board as research not involving human subjects (IRB ID: STU00216090). A list of current Ob-gyn residency programs was created using ACOG’s list of current residencies, and a list of programs with affiliated REI fellowships was assembled using ACGME’s database. The programs’ public websites were reviewed to determine the length and year of REI rotation, and career or fellowships pursued by alumni. Data regarding successful REI matches were collected from the previous 5 years (2017–2021). If the information was not found on the program’s website, program coordinators were contacted by email or by telephone call. If there was no response within 2 days, another attempt to contact was made. If there was still no response, the information was considered missing in the data analysis. Early exposure to REI was defined as REI rotations that occurred during the first 2 years of residency.

Welch Two Sample t-test was utilized to assess differences in total and early REI rotation time between REI-affiliated and non-affiliated programs, while Chi-square tests assessed differences in the proportion of alumni who pursued REI fellowship, as well as the timing of REI rotations throughout residency. Spearman’s correlation was utilized to assess the association between total REI exposure and the percentage of alumni matched in REI fellowships. Statistical analyses were performed using R, Version 4.0.5 (R Foundation for Statistical Computing, Vienna, Austria). A two-tailed p < 0.05 was deemed to be statistically significant for the above analyses.

Results

Data was accrued from 46 of 49 (94%) REI-affiliated programs and 162 of 178 (91%) non-REI affiliated programs. Among all programs, the cumulative length of REI rotations throughout residency ranged from 0 to 20 weeks (Fig. 1). Mean cumulative rotation length was greater in non-REI than in REI-affiliated programs (7.4 weeks vs. 6.1 weeks, p = 0.007) (Table 1). However, REI-affiliated programs had greater earlier exposure to REI rotations during the first 2 years of residency (3.9 weeks vs. 3.1 weeks, p = 0.042). Among REI-affiliated programs, 30% had an REI rotation in PGY-1, 61% in PGY-2, 37% in PGY-3, and 13% in PGY-4. Among non-REI affiliated programs, 21% had an REI rotation in PGY-1, 61% in PGY-2, 54% in PGY-3, and 17% in PGY-4. The proportion of alumni matched into REI fellowship was significantly greater in REI-affiliated programs than non-REI affiliated programs (9.5% vs. 3.1%, p < 0.001) (Table 1). We did not find a significant correlation between length of REI exposure and the proportion of alumni that matched in REI fellowship (r =  − 0.14, p = 0.164) (Fig. 2).

Fig. 1.

Time devoted to REI rotation during residency by ACGME accredited Ob-gyn program

Table 1.

Total weeks of REI rotations over all 4 years of residency, total weeks of early exposure as defined by rotation time during the PGY1 and PGY2 years, and proportion of alumni from REI affiliated and REI non-affiliated programs that matched into REI fellowship. p-values from Wilcoxon rank sum test for continuous variables

Characteristic	Overall, N = 227	Non-REI affiliated, N = 178	REI Affiliated, N = 49	p-value
Total rotation time in REI
(Mean (SD))   [Min, Max]	7.11 (3.15) [0, 20]	7.44 (3.24) [0, 20]	6.12 (2.63) [4, 16]	0.007
Total early exposure to REI
(Mean (SD))   [Min, Max]	3.27 (2.83) [0, 16]	3.09 (2.93) [0, 16]	3.91 (2.31) [0, 8]	0.042
% of alumni matched REI fellowship
(Mean (SD))	4.97% (6.44%)	3.09% (4.44%)	9.45% (8.12%)	<0.001

Fig. 2.

Association between total REI exposure over 4 years of residency and percentage of alumni successfully matching into REI fellowships. p-value from Spearman’s correlation

Discussion

This study examined the time devoted to REI rotations during ACGME-accredited Ob-gyn residencies. We found that compared to non-REI affiliated programs, Ob-gyn residencies affiliated with REI fellowships have less time dedicated to REI rotations but have a greater proportion of residents match into REI fellowships. We did find that as a whole, REI-affiliated programs had more time devoted to REI rotations at the beginning of their training. It is possible that this early exposure serves to increase engagement in the field and facilitate early mentorship. These closer working relationships with REI faculty enables residents to become involved in research projects which further propels career trajectories. Additionally, REI-affiliated programs have a greater advantage in networking with REI physicians. While they may have limited exposure, they have more opportunities to make connections with physicians than residents in programs without an associated REI fellowship. Equipped with these connections and mentorships, residents from REI-affiliated intuitions may be better suited for a successful match.

Our study adds to an existing body of literature that explores the influence of early exposure on fellowship pursuit. In the field of general surgery, one study focused on characteristics that drive residents to pursue fellowship. It was concluded that exposure to subspecialties, without specifying the time of exposure, and subspecialty faculty availability are key underlying factors for increasing fellowship pursuit [7]. Additional research supports the notion that early clinical exposure specifically can lead to increased interest in specific fields. For example, a study conducted by Nelson et al. aimed to assess factors that contribute to residents pursuing subspecialty fellowships, specifically pediatric pulmonology. The authors concluded that early exposure to the pediatric pulmonology subspecialty would be needed to increase recruitment to the field [8]. Similar findings have been found among surgical subspecialties. Another study focusing on the choice to pursue a cosmetic surgery fellowship among plastic surgery residents found it was largely influenced by early exposure to aesthetic training during the early years of residency. The study emphasized that early exposure would increase both familiarity and interest to the field [9].

The limited exposure to the field of REI may reflect underlying restrictions that residency programs are required to adhere. Over the past decade, there have been significant changes to residency programs including duty hours restrictions, increased supervision, and education and training [10, 11]. Much research has been conducted on the impact of these new restrictions on the quality of Ob-gyn residents [12]. Limitations placed on the work duty hours by the ACGME impacted the allotted time for resident education [13]. This suggests that alternate lectures and opportunities for direct patient interactions would need to be implemented to enhance clinical learning. One study assessed web-based teaching to increase resident education in pediatric and adolescent gynecology. This web-based program does not violate new ACGME requirements because it could be completed at home. The study found that this method of education was an effective way to improve baseline knowledge among Ob-gyn residents [14]. There is not much research regarding the impact of web-based programs on the knowledge of REI fellows. However, a study conducted by Alvero and colleagues found that computer programs that utilized case-based approaches may be an effective method of improving the curriculum among residents as it promotes life-long learning and allows for self-pacing [15]. Future research should explore different methods of training that meet ACGME requirements and also broaden resident exposure to subspecialties. It is crucial to continue these efforts to expand teaching and spark interest to the field of REI. A lack of exposure to this important subspeciality can ultimately limit interest and recruitment of trainees who desire to go into fellowship [16].

Although we believe our study addresses a gap in the current research that pertains to resident exposure to REI, the study was not without limitations. Our study’s primary weakness was our limited sample set. While all ACGME accrediting Ob-gyn programs were contacted, some program coordinators did not respond or did not have all the information that was asked. Data collected from the program websites may not be routinely updated which may have skewed our results. Our study was also limited by data that was not publicly available. We could not gather information of non-traditional applicants, those who took a year off during residency and applied during a later cycle or those who may not have matched the first time but may have been successful during an alternate cycle. In addition, our study did not consider the elective time that is offered to residents. During these elective times, residents can choose a subspecialty of interest and increase their exposure to a specific field of Ob-gyn. Despite these limitations, our findings highlight the discrepancy in REI exposure and suggest that earlier exposure may impact residents’ career choices. Future research should be done to see if early exposure to other Ob GYN subspecialties is also associated with more residents pursuing fellowships in those specialties.

Conclusion

REI-affiliated programs devote more time to REI rotations at the beginning of training, suggesting that this may offer residents more opportunities to interact and foster relationships and research interests within the field of REI. The findings of this study may provide insight and impetus for alternative structuring of block schedules to enhance residents’ ability to successfully match in Ob-gyn subspecialty fellowship programs.

Data availability

Data is available by contacting corresponding author.

Declarations

Ethics approval

Our study was deemed exempt by the Northwestern University institutional review board as research not involving human subjects (IRB ID: STU00216090).

Conflict of interest

The authors declare no competing interests.