Since the FLS test became available in 2004, the number of physicians seeking FLS certification rose annually. A study of the first 5 years of FLS certification testing (2004-2009) shows an overall pass rate of 88% on the examination – close to the target pass rate of 90% established during the test-setting process. Almost 20% of the test participants over this time period were attending surgeons; the rest were senior residents or fellows (the largest participant group) and junior residents. A small number – 4% – were gynecologists (Surg. Endosc. 2011;25:1192-8).
In 2008, the ACS went one step further by requiring all general surgery residents, starting in 2009, to complete and pass the FLS course before achieving board certification. This mandate set minimum standards for basic cognitive and technical skills, and encouraged a uniform framework for laparoscopy training in general surgery residency programs.
Urology has similarly deliberated and addressed the idea that standard training and credentialing initiatives are critical to have and to update as surgical technology and techniques evolve. The American Urologic Association has developed and is validating a Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum similar to FLS for laparoscopic cognitive and technical skills. The association also has created a Simulation Advisory Board that will vet current and future skills courses and provide guidance for matching learning objectives with effective simulation-based technologies. In addition, the AUA is expanding a preexisting urology-specific robotic skills curriculum and, along with AAGL, SAGES, and the Minimally Invasive Robotic Association, is developing a Fundamentals of Robotic Skills curriculum.
Essential Gynecologic Knowledge
As minimally invasive surgery becomes mainstream, it is important for gynecologic surgeons to be familiar with the fundamentals of laparoscopic gynecologic surgery and hysteroscopy, whether or not they are utilizing or planning to utilize robotic technology.
Development of the cognitive portion of EMIG is the first step of an AAGL-led effort that will ensure that gynecology meets the need for a standardized, demonstrable set of skills. As it takes shape and gains acceptance, the EMIG assessment should provide a standardized tool for physicians, patients, hospitals and payers to identify gynecologic surgeons who have demonstrated the knowledge and skills necessary to understand the intricacies of minimally invasive gynecology.
Unlike the FLS, the EMIG test is specifically focused on gynecology and includes hysteroscopy. Hundreds of physicians were involved in completing a survey, writing psychometrically correct items, and reviewing questions. A test development psychometrician directed the AAGL through test development and technical review and performed a psychometric edit.
As of May 2012, beta testers were scheduled to answer approximately 380 questions, over two sessions totaling 6-8 hours, in a proctored environment. From the results, two forms of the test, with approximately 125 questions each, will be created. A passing score will be determined, and the test will be made available in online test delivery software so it can be taken anywhere in the world – after its first run at the AAGL meeting this fall.
Concurrently, the AAGL has been developing an approach to testing psychomotor skills, which is needed, along with cognitive assessment, to ascertain the qualifications of a surgeon. The AAGL identified essential skills by asking more than 1,000 physicians to rank the importance and frequency of the skills. This information will be used to evaluate skills trainers and testing instruments.
Eventually, it is hoped, a standardized core curriculum – based on the EMIG knowledge base – will be developed and incorporated into residency programs, just as it has been for general surgery. Such a curriculum could also be implemented in the Fellowship in Minimally Invasive Gynecologic Surgery, cosponsored by the AAGL and the Society of Reproductive Surgeons (an affiliate society of the American Society for Reproductive Medicine), in which case it could be longer in duration.
A standardized core curriculum could be implemented as well in the growing number of postgraduate courses that are available to practicing gynecologic surgeons; in this case, the curriculum would be shorter in duration.
A proposal for a formal gynecologic endoscopy curriculum, published a few years ago in The Journal of Minimally Invasive Gynecology (J. Minim. Invasive Gynecol. 2009;16:416-21), envisions a quarterly system with an online examination given after quarters 1 and 2, a hands-on examination given after quarter 3, and a demonstration of leadership and teaching skills in the operating room after quarter 4.
As envisioned in the proposed curriculum, the first quarter would focus on knowledge of pelvic and abdominal anatomy that is specific to laparoscopy and gynecology, including the major branches of anterior and posterior division of the internal iliac artery and the major nerve supplies to the pelvis. Knowledge of the physiology and principles of creating and maintaining pneumoperitoneum and the principles and application of electrosurgery, ultrasonic energy, and various laser energy sources, for instance, also would be acquired.