Residency graduates should not be expected to perform hypospadias repair without fellowship training: Results from a survey of SPU membership

Background Trainee autonomy has eroded over time as surgery has become more subspecialized and as attending oversight has increased, causing many trainees to seek additional fellowship training beyond resi-dency. Less clear is whether there are cases that attendings view as fellowship-level or privileged cases in which resident-level trainees should not have high levels of autonomy due to complexity or high-stakes outcomes. Objective We sought to better understand current attitudes and practices with regards to trainee autonomy in hypospadias repair as it represents a high complexity procedure within pediatric urology. Study design We administered a RedCap survey to the SPU mem-bership, asking respondents to describe the level of autonomy afforded to trainees in various types of hypospadias repair (distal, midshaft, proximal, perineal) as measured by the Zwisch scale. The Zwisch scale describes the role of the attending in the attending-trainee relationship in a low-to-high trainee autonomy fashion: show and tell; active help; passive help; supervision only. Results 177 of 761 (23%) unique recipients completed our survey and 174 of 177 (98%) of respondents felt that trainees should not perform hypospadias repair independently in practice without addi-tional fellowship training. Among pediatric urolo-gists who train residents, trainee autonomy as measured by the Zwisch scale decreased as the type of hypospadias repair moved from distal to proximal. Discussion There was near unanimous agreement among re-spondents that urology trainees should not perform hypospadias repair in practice without additional pediatric urology fellowship training, and that current practice affords little trainee autonomy in hypospadias repair at the resident level. These findings introduce a new wrinkle into the issue of trainee autonomy: cases in which trainees perhaps should not have autonomy. Concurrently, the concern with such findings is that this intentional lack of autonomy may extend to other urologic procedures that one would expect trainees to be able to perform independently. Conclusion Urology trainees are not expected to be able to perform hypospadias in practice without additional training. This raises the question that there may be other such procedures in urology, and if so, should we as instructors, be forthcoming about the limita-tions of urology residency training to set appropriate trainee expectations?

Automated summary

This study aimed to understand the attitudes and practices regarding trainee autonomy in hypospadias repair among pediatric urologists. The survey results showed near unanimous agreement that trainees should not perform hypospadias repair without additional fellowship training. Trainee autonomy decreased as the complexity of the procedure increased.