Program Directors' Perspectives on Residency Applications in the Post‒United States Medical Licensing Examination Step 1 Era: A Case for Standardized Letters of Recommendation?

INTRODUCTION: The United States Medical Licensing Examination (USMLE) Step 1 test evolved into a key metric utilized by program directors (PDs) in assessing candidates for residency. The transition to a USMLE Step 1 binary pass/fail scoring system has resulted in a loss of an important objective assessment. With national movements toward pass/fail systems for clerkship grading and trends toward abandonment of class ranking, assessing residency applications has become increasingly challenging. METHODS: The Society of Academic Urologists convened a task force to, in part, assess the perspectives of urology PDs regarding the importance of various aspects of a residency application for predicting clinical performance. An anonymous survey was disseminated to all urology PDs in the US. Perspectives on 11 potential application predictors of clinical performance and demographics were recorded. Descriptive statistics characterized PD responses. Friedman test and pairwise Wilcoxon tests were used to evaluate the relative ranks assigned to application elements by PDs. RESULTS: There was a 60.5% response rate (89/147). Letters of recommendation (LORs) were ranked as the most important predictor, with a mean rank of 2.39, median of 2 (IQR 1-3). Clerkship grades and USMLE Step 1 were comparable and ranked second. Medical school reputation ranked the lowest. There was significant subjective heterogeneity among categories; however, this was less so for LORs, which predominated as the most important factor among application elements (P < .001). CONCLUSIONS: To our knowledge, this is the largest sample size assessing PD perspectives on application factors that predict clinical performance. The second (clerkship grades) and third (USLME Step 1) most important factors moving toward binary pass/fail systems create an opportunity for actionable change to improve assessment objectivity. Our data demonstrate LORs to be the most important factor of residency applications, making a compelling argument for moving toward a standardized LOR to maximize this tool, mitigate bias, and improve interreviewer reliability.

Excision of recurrent penile schwannoma with neurovascular bundle sparing: A novel surgical approach.

Penile schwannomas are rare, often painless lesions usually growing on the dorsum of the penis. A young and otherwise healthy male with recurrent painful penile schwannomas and decreased libido was successfully treated with surgical excision. Through fine dissection of the nerve fascicles leading to the primary schwannoma, the lesion was successfully removed without compromising erectile or ejaculatory function. This novel approach allowed for significant symptomatic relief and improved quality of life.

Financial Toxicity for Female Patients with Urinary Incontinence.

PURPOSE OF REVIEW: Urinary incontinence (UI) is a common global condition that has been noted to disproportionately affect women. In this review, the authors present discussion of factors contributing to cost of care and various modalities of cost-effective care for UI for female patients. RECENT FINDINGS: We found insurance and out-of-pocket (OOP) costs strongly impact of costs for patients. Further, in evaluation of UI, diagnosis can be a costly multi-step process for effective treatment. Treatment can be multimodal, including non-surgical (e.g., pessary, vaginal insert, pelvic floor muscle training, or PFMT), of which PFMT is a cost-effective, effective, and accessible treatment. Pharmacologic management is generally second-line for overactive bladder, but anti-muscarinic drugs and beta-3 agonists are cost-effective depending on willingness-to-pay and the health system in which they are acquired, respectively. Surgical management is considered the most cost-effective treatment as willingness-to-pay increased, with minimally invasive slings being the mainstay. Other relatively novel treatments are also discussed (e.g., EMSELLA) but require further research. Additionally, we discuss systematic barriers in decisions to seek care for urinary incontinence. Urologists are key agents in treating UI for their female patients, and seeking cost-effective options for treatment remains pivotal for quality care.

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling. METHODS: We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery. RESULTS: Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement. CONCLUSIONS: UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries.

OBJECTIVE: In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP. STUDY DESIGN: Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. RESULTS: Over the study time period, the number of women with a diagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245-23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009). CONCLUSION: Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use. These data suggest that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.

Prevalence and correlates of urinary incontinence among older community-dwelling women.

OBJECTIVES: As the aging population in the United States grows, the investigation of urinary incontinence (UI) issues becomes increasingly important, especially among women. Using data from the California Health Interview Survey (CHIS), we sought to determine the prevalence and correlates of UI among an ethnically diverse population of older community-dwelling women. METHODS: A total of 5374 female Californians aged 65 years or older participated in a population-based, cross-sectional random-digit-dialing telephone survey. The CHIS 2003 adult survey included 1 question for Californians aged 65 years or older about UI. Additional information collected via the self-reported survey included demographics (age, race/ethnicity, education, and household income), general health data (self-reported health status, height and weight, fall history, and special equipment needs), medical comorbidities, and health behaviors (tobacco use, physical activity, and hormone replacement therapy). RESULTS: The estimated statewide female prevalence rate for UI was 24.4%. Prevalence rates increased with age. Urinary incontinence was significantly associated with poorer overall health (adjusted odds ratio [OR], 3.43; P < 0.001), decreased mobility (OR, 1.81; P = 0.004), current use of hormone replacement therapy (OR, 1.72; P < 0.001), being overweight or obese (OR, 1.60; P < 0.001), a history of falls (OR, 1.53; P = 0.002), and a history of heart disease (OR, 1.38; P = 0.010). After adjusting for all health factors, UI was not found to have any significant association with the level of education, household poverty status, or smoking status. CONCLUSIONS: Urinary incontinence prevalence among this diverse group of older community-dwelling Californian women parallels that of other population-based studies. The CHIS demonstrated that poor health, increased BMI, falls, and decreased mobility are strongly correlated with UI.

Short-term outcomes of vaginal mesh placement among female Medicare beneficiaries.

OBJECTIVE: To compare short-term outcomes between prolapse repairs with and without mesh using a national data set. Mesh use in surgical treatment of pelvic organ prolapse has gained wide popularity. However, mesh complications have increased concomitantly with its use. METHODS: Public Use File data were obtained for a 5% random national sample of female Medicare beneficiaries aged 65 years and older. Women who underwent prolapse surgery were identified using Current Procedural Terminology Coding System, Fourth Edition (CPT-4) codes. Because the code for mesh placement was effected in 2005, we separated patients into 3 cohorts as follows: those who underwent prolapse repairs from 1999 to 2000 (presumably without mesh), those who underwent repairs from 2007 to 2008 (presumably without mesh), and those with mesh (based on CPT-4 code 57267) from 2007 to 2008. One-year outcomes were identified using International Classification of Diseases, Ninth Revision diagnosis and procedure codes and CPT-4 procedure codes. RESULTS: A total of 9180 prolapse repairs without mesh were performed from 1999 to 2000, 7729 without mesh from 2007 to 2008, and 1804 prolapse repairs with mesh from 2007 to 2008. Prolapse reoperation within 1 year of surgery was higher in nonmesh vs mesh cohorts (6%-7% vs 4%, P <.02). Mesh removal rates were higher in mesh vs nonmesh group (4% vs 0%-1%, P <.001). Mesh use was associated with more dyspareunia, mesh-related complications, and urinary retention, even when controlling for concomitant sling. CONCLUSION: Mesh to treat pelvic organ prolapse and stress urinary incontinence was associated with a small decrease in early reoperation for prolapse. This decrease came at the expense of increased rates of pelvic pain, retention, mesh-related complications, and mesh removal.

Development of quality indicators for women with urinary incontinence.

AIMS: To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs). METHODS: We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale. RESULTS: QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale. CONCLUSIONS: We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States.

Quality-of-care indicators for pelvic organ prolapse: development of an infrastructure for quality assessment.

INTRODUCTION AND HYPOTHESIS: A paucity of data exists addressing the quality of care provided to women with pelvic organ prolapse (POP). We sought to develop a means of measuring this quality through the development of quality-of-care indicators (QIs). METHODS: QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. The indicators were then presented to a panel of nine experts. Using the RAND Appropriateness Method, we analyzed each indicator's preliminary rankings. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which panelists individually re-rated the indicators. QIs with median scores of at least 7 were considered valid. RESULTS: QIs were developed that addressed screening, diagnosis, work-up, and both nonsurgical and surgical management. Areas of controversy included whether screening should be performed to identify prolapse, whether pessary users should undergo a vaginal examination by a health professional every 6 months versus annually, and whether a colpocleisis should be offered to older women planning to undergo surgery for POP. Fourteen out of 21 potential indicators were rated as valid for pelvic organ prolapse (median score ≥7). CONCLUSION: We developed and rated 14 potential quality indicators for the care of women with POP. Once these QIs are tested for feasibility they can be used on a larger scale to measure and compare the care provided to women with prolapse in different clinical settings.

Communication barriers among Spanish-speaking women with pelvic floor disorders: lost in translation?

OBJECTIVES: The purpose of our study was to evaluate barriers in communication and disease understanding among office staff and interpreters when communicating with Spanish-speaking women with pelvic floor disorders. METHODS: We conducted a qualitative study to evaluate barriers to communication with Spanish-speaking women with pelvic floor disorders among office staff and interpreters. Sixteen office staff and interpreters were interviewed; interview questions focused on experiences with Spanish-speaking patients with pelvic floor disorders in the clinic setting. Interview transcripts were analyzed qualitatively using grounded theory methodology. RESULTS: Analysis of the interview transcripts revealed several barriers in communication as identified by office staff and interpreters. Three major classes were predominant: patient, interpreter, and system-related barriers. Patient-related barriers included a lack of understanding of anatomy and medical terminology and inhibited discussions due to embarrassment. Provider-related barriers included poor interpreter knowledge of pelvic floor vocabulary and the use of office staff without interpreting credentials. System-related barriers included poor access to information. From these preliminary themes, an emergent concept was revealed: it is highly likely that Spanish-speaking women with pelvic floor disorders have poor understanding of their condition owing to multiple obstacles in communication. CONCLUSIONS: There are many levels of barriers to communications with Latin women treated for pelvic floor disorders, arising from the patient, interpreter, and the system itself. These barriers contribute to a low level of understanding of their diagnosis, treatment options, and administered therapies.

Communication between physicians and Spanish-speaking Latin American women with pelvic floor disorders: a cycle of misunderstanding?

OBJECTIVE: This study aimed to assess the effect of the initial visit with a specialist on disease understanding among Spanish-speaking women with pelvic floor disorders. METHODS: Spanish-speaking women with referrals suggestive of urinary incontinence (UI) and/or pelvic organ prolapse (POP) were recruited from public urogynecology clinics. Patients participated in a health literacy assessment and interview before and after their physician encounter. All interviews were analyzed using Grounded Theory qualitative methods. RESULTS: Twenty-seven women with POP (n = 6), UI (n = 11), and POP/UI (n = 10) were enrolled in this study. The mean age was 55.5 years, and most women had marginal levels of health literacy. From our qualitative analysis, 3 concepts emerged. First, was that patients had poor understanding of their diagnosis before and after the encounter regardless of how extensive the physician's explanation or level of Spanish-proficiency. Second, patients were overwhelmed with the amount of information given to them. Lastly, patients ultimately put their trust in the physician, relying on them for treatment recommendations. CONCLUSIONS: Our findings emphasize the difficulty Spanish-speaking women with low health literacy have in understanding information regarding pelvic floor disorders. In this specific population, the physician has a major role in influencing patients' treatment decisions and helping them overcome fears they may have about their condition.

The financial burden of stress urinary incontinence among women in the United States.

Stress urinary incontinence (SUI) is a common medical problem affecting 25% to 50% of women in the United States. This article reviews the literature on the current systems- and population-based costs of management of SUI in women. A PubMed search was conducted to seek studies examining the cost of various management options. Both nonsurgical and surgical management can effectively improve symptoms of SUI at a wide spectrum of costs. Over $12 billion are spent annually, an amount that continues to grow. Patients pay out-of-pocket for 70% of conservative management, amounting to a significant individual financial burden. Systems-based cost of SUI management continues to rise with the aging population. Costs to both individuals and systems may be mitigated if more patients are treated with intent to cure and as surgical management transitions from inpatient to outpatient procedures.