Comparison of the self-reported training level between Mexican and Western Europe residents in urology: Results of an international survey

Abstract

Objective: To find out how Mexican residents in urology perceive their own level of training in comparison with how residents in Europe perceive theirs.

Methods: A questionnaire of self-assessment was distributed to 104 European and 24 Mexican urologists-in-training. We assessed the perception of residents about their level of training and factors associated with self-perceived performance.

Results: Mean age of 128 residents was 32.69 ± 3.33 years. Mexican residents spent significantly more time in urological departments than European residents. The weekly amount of hours spent at work was higher in Europe; while the number of residents per hospital was higher in Mexico. Mexican residents reported more reliable support from a supervising senior. European residents perceived they had a superior level regarding transplantation in female urology and urinary lithiasis, whereas Mexican residents felt more confident regarding urological infections and paediatric urology. Factors associated with better self-perceived performance were the number of months in urology, the number of non-urologic rotations and a supervising senior.

Conclusion: Mexican residents in urology perceive that their own level of training is similar to that of European residents. The number of months of training in urology, the number of non-urologic rotations and a supporting senior are associated with a better self-perceived performance.

Introduction

Medical specialization in Mexico has its background in the Colonial Period during sixteenth century. However, it received more support during the Independenc period (nineteenth century) and the current system of residencies was not created until the twentieth century. The specialty of Urology was founded in 1926 by Dr Aquilino Villanueva at ‘Hospital General de Mexico’. Postgraduate courses, however, were not officially instituted until 1942, when the concept of residency was created (Quijano-Pitman 1999). Nowadays, several public institutions, depending on the Ministry of Health, the National Institute of Social Security and others, provide residencies in urology. In Mexico, approximately 2% of candidates who wish to specialize will choose urology. According to the Universidad Nacional Autónoma de México (UNAM) Faculty of Medicine, 114 candidates (1.5% of 7680 eligible) chose such a specialty during the period 2005–2006 (UNAM 2006).

Some studies in Europe and the United States have explored the reasons why a medical student enters urology and have evaluated the opinion of urology residents regarding their training level, future perspectives and quality of life (Kerfoot et al. 2005; Larré et al. 2007). European studies conducted by the European Society of Residents in Urology (ESRU) have highlighted that there are many differences in the training system, when comparing one European country to another (Walsh et al. 2001; Parkar et al. 2005), and that some of these differences may be associated with better or worse performance levels (Larré et al. 2007). Other studies from the European Board of Urology (EBU) have shown that training in Europe may vary, especially due to differences in the practice in some procedures like transplantation or paediatric surgery (Kiely 2000). As far as we know, such studies have never been published for America and a transatlantic comparison would be of interest to identify differences in the training systems which may influence training level.

Table

Practice points

European studies have highlighted the differences in urological training between countries. These may be due to different educational methods, which could be associated with differences in performance. To our knowledge, there are no such studies in America and a transatlantic comparison would be useful to know the opinion of urologists-in-training about the quality of medical and surgical education.

Our main objective was to assess how residents in urology from Mexico perceive their own level of training and to compare the results with those of residents from Western Europe. Our secondary objective was to identify factors associated with better self-perceived performance.

Materials and methods

Between October and December 2006, a questionnaire of self-assessment developed by the ESRU was distributed to residents in urology from five different hospitals in Mexico City with academic programmes accredited by the Universidad Nacional Autónoma de Mexico Faculty of Medicine and the Mexican Board of Urology. The questionnaire in its official version is available at http://www.esru.net/files/Questionnaire%20ESRU%20eng.pdf. It contains 5 pages and 166 questions that explore mainly 3 axes: the quality of life, the quality of training (medical and technical) and the interest and ability in research. The level of English language (understanding, writing and speaking) is also evaluated and a mean mark is calculated according to the self-reported level of knowledge. Medical knowledge was assessed on a three-level scale. Residents were asked the following question: ‘At the moment, are you skilled enough to make medical decisions in the following fields?’. These fields included: oncology, andrology, transplantation, renal failure, urinary tract infections, paediatric urology, female urology and urinary lithiasis. They could answer ‘Not really’ which was scored as 0 (zero), ‘Yes, in some cases’ which was scored as 10, and ‘Yes, absolutely’ which was scored as 20. Concerning technical level, they were asked about their ability to perform different surgical procedures and the evaluation was made through a similar three-level scale with the same scoring system. Residents were asked the following question: ‘At the moment, are you able to perform as first surgeon (helped by a young resident) the following procedures?’ Surgical procedures were grouped in four different types (minor open surgery, major open surgery, endourology and laparoscopy) and the scores from each procedure were used to calculate a mean score in each category (ranging from 0 to 20). The details of each group are reported in Table 1.

Table 1.  Surgical procedures included in each group

Minor open surgery	Major open surgery	Endourology	Laparoscopy
– Simple nephrectomy	– Radical nephrectomy	– Transurethral resection of prostate	– Radical nephrectomy
– Prostatic Adenomectomy	– Partial nephrectomy	– Transurethral resection of bladder tumour	– Radical prostatectomy
– TVT, TOT^a	– Nephroureterectomy	– Rigid ureteroscopy	– Sacrocolpopexy
– Sacrocolpopexy	– Radical prostatectomy	– Flexible ureteroscopy	– Varicocelectomy
– Colpoperineorrhaphy	– Cystoprostatectomy/Bricker	– Percutaneous nephrostomy
– Vasectomy	– Cystoprostatectomy/orthotopic neobladder	– Extracorporeal lithotripsy
– Nesbit procedure	– Adrenalectomy
– Circumcision	– Kidney transplant
– Pyeloplasty	– Donor nephrectomy (cadaver/living donor)

Note: ^aTVT = Tension-free Vaginal Tape; TOT = Trans-Obturator Tape.

The answers of residents in urology from Mexico were compared to those of their colleagues trained in accredited centres from France, the United Kingdom, Germany and Spain. European data were collected between June 2005 and February 2007 using the same questionnaire which was sent to residents from the ESRU database and also given to and filled by residents present at the European Urology Residents Educational Programme (EUREP) during the 2005 and 2006 sessions in Prague.

The comparison comprised the self-reported medical and technical performance level. In addition, data including: the total number of months as a resident, number of months in urology, number of non-urology rotations, number of residents in each department, number of hours of weekly work, the use of a logbook, the presence of an active supporting senior and the level of English language knowledge were evaluated to determine the supposed association with better medical and surgical self-perceived performance.

Data were compared using Student t-test or chi-square test. Factors associated with better performance were assessed using logistic regression. Results were expressed as percentage or mean ± SD (range). They were considered statistically significant with a p-value <0.05. The statistical analysis was carried out with the software StatView version 5.0 for Windows (SAS Institute, Cary, NC, USA).

Results

The questionnaires of 128 residents were analyzed, 104 coming from Western Europe (France 46, the United Kingdom 17, Germany 28 and Spain 13), and 24 from Mexico. Eleven were women (8.8%) and the mean age was 32.70 ± 3.33 years (range 25–44).

The detailed results are shown in Table 2. There was no difference in the mean number of months as a resident between Europe and Mexico (p = 0.85), however, Mexican residents spent a greater number of months in urology (p = 0.01). The mean number of weekly work hours was 10 hours more in Europe (p = 0.002), whereas there were 2.5 times more residents per hospital in Mexico (p < 0.001). Mexican residents reported more reliable support from an active senior surgeon (p = 0.001).

Table 2.  Comparison of main characteristics between residents in urology

	Europe (n = 104)	Mexico (n = 24)	p-value
Age	32.85 ± 3.52 (25–44)	32.00 ± 2.25 (29-37)	0.27^a
No. of months as resident	62.85 ± 28.41 (12–176)	63.95 ± 16.04 (45–109)	0.85^a
Months in urology	33.80 ± 13.29 (6–72)	41.20 ± 6.32 (33–48)	0.01^a
No. of different urology departments	3.32 ± 1.64 (1–7)	3.79 ± 1.50 (2–7)	0.20^a
No. of different non-urology rotations	3.22 ±.43 (1–6)	2.62 ± 2.01 (1–8)	0.09^a
Hours of work per week	67.69 ± 12.64 (35–100)	57.87 ± 16.43 (40–108)	0.002^a
No. of residents per department	6.13 ± 4.75 (1–26)	15.04 ± 5.40 (6–24)	<0.001^a
Active senior support	15.38%	45.83%	0.001^b
Logbook use	35.16%	20.83%	0.18^b

Notes: Results given as mean ± SD (range).

^aStudent t-test.

^bChi-square test.

There was a statistically significant difference in the self-reported knowledge of English language, with a mean mark of 15.13 ± 5.19 (range 6.6–20) for Mexican and 11.32 ± 6.97 (range 0–20) for European residents (p = 0.01). We found a negative correlation between the self-reported level of English and medical knowledge (r = – 0.24, p = 0.006).

Table 3 shows the evaluation according to the self-reported level of training in the medical and technical fields. Regarding medical knowledge, European residents perceived they had better level in transplantation, female urology and urinary lithiasis (p = 0.005, p = 0.01 and p < 0.001, respectively). On the other hand, Mexican residents considered themselves better trained in urinary tract infections (p = 0.008) and paediatric urology (p = 0.01). Technically, the only significant difference was in minor open surgery, with higher self-reported score for Mexican residents (p = 0.02).

Table 3.  Self-reported level of training of 128 residents in urology

	Europe	Mexico	p-value^a
Medical self-perceived performance*
Oncology	16.17 ± 5.08 (0–20)	15.41 ± 5.09 (10–20)	0.51
Andrology	9.80 ± 6.74 (0–20)	10.41 ± 4.64 (0–20)	0.67
Transplants	10.49 ± 6.94 (0–20)	6.25 ± 4.94 (0–10)	0.005
Infections	13.23 ± 7.46 (0–20)	17.50 ± 4.42 (10–120)	0.008
Paediatrics	10.79 ± 7.70 (0–20)	15.00 ± 5.10 (10–20)	0.01
Female urology	13.11 ± 7.73 (0–20)	8.00 ± 10.05 (0–20)	0.01
Urinary lithiasis	10.00 ± 8.08 (0–20)	2.08 ± 4.14 (0–10)	<0.001
Technical self-perceived performance*
Minor open surgery	11.32 ± 4.99 (0–20)	13.85 ± 3.57 (5.0–18.8)	0.02
Major open surgery	7.28 ± 6.14 (0–20)	8.35 ± 4.64 (0–16.3)	0.42
Endourology	13.06 ± 5.71 (0–20)	13.75 ± 3.75 (5–20)	0.57
Laparoscopy	4.58 ± 5.99 (0–20)	2.60 ± 3.79 (0–12.5)	0.12

Notes: Results given as Mean ± SD (range).

^aStudent t-test.

The number of months in urology was strongly associated with the self-perceived capacity to perform open simple (p = 0.005) and open complex surgery (p = 0.03). In the same line, the number of non-urologic rotations was related to the self-reported ability to perform open simple (p = 0.004), open complex (p = 0.002), endourologic (p = 0.003) and laparoscopic (p = 0.03) procedures. The presence of a supporting senior surgeon and the capacity to perform laparoscopy were also associated (p = 0.04). On the other hand, the number of residents per hospital was inversely related to the self-reported ability to perform endourologic procedures (p = 0.003) and to the hours of weekly work (p = 0.04).

Discussion

Some studies have addressed the self-reported level of training of European residents in urology, specifically from France (Larré et al. 2007). To our knowledge, this is the first one exploring the perception of residents from a country in Latin America. According to our results, the self-perceived level of medical knowledge and technical skills of Mexican urologists-in-training is similar to that of their European colleagues. An interesting finding is the association between the self-expressed level of English language and medical knowledge. Residents reporting lower mark in English were found to have worse self-reported medical knowledge. In our days, speaking and understanding English appears to be essential, since the great majority of current medical literature and the most important advances in science and medicine are published in that language (McCarthy 2007).

Surprisingly, there was no difference in the self-reported level of training in laparoscopic procedures. It is well known that European countries (i.e. France and Germany) have developed urologic laparoscopy since the early 1990s (Guillonneau et al. 1996; Abbou et al. 1999; Rassweiler et al. 1998). Moreover, investigators from France have described a useful five-step model for laparoscopic training (Katz et al. 2003). According to these authors a training programme, including five simple tasks, improves the trainee performance in a short time. Although some centres in Mexico have started to perform laparoscopic surgery (Marquina Sánchez et al. 2003, Marquina Sánchez & Esquivel 2004), its development is still limited and not all residents have access to training in this field. However, some efforts, showing encouraging outcome, have been made to promote laparoscopy practice among Mexican residents (Rodríguez-Covarrubias et al. 2006).

The results of this international survey suggest that residents from Mexico feel more self-confident in performing minor open surgery, which could be related to the greater number of months spent in urology for Mexican residents by the time of the survey and the current widespread use of open urological surgery in Mexico.

Factors associated with an acceptable self-perceived technical performance were: the number of months passed in urology and the number of non-urological rotations during residency. The presence of a supporting senior was important regarding the resident's ability to perform laparoscopic procedures. Using the same methodology, Larré and colleagues found that a supporting senior surgeon and the use of a logbook were associated with better technical performance. They also found that residents carrying out their residency in different urology departments performed better than those trained in a single department (Larré et al. 2007).

Although our findings are encouraging concerning the quality of urological education in Mexico, investigators from that country (Mercado Barajas et al. 2001) have demonstrated that Mexican physicians-in-training from different specialties have difficulties when it comes to critically reading clinical research reports. This study evaluated residents of medical and surgical disciplines. The latter group included, in addition to residents in urology, residents in general, paediatric and plastic surgery. In this group, residents in urology got the best score regarding critical reading of clinical research papers. Although the results from that study do not reflect the situation of all Mexican residents, we still believe that urological education in Mexico could be improved and that all teaching institutions must be certified and residency programmes standardized.

The main issue in the interpretation of these findings is its subjectivity, since it is unknown if the self-reporting of the level of training reflects the reality. Nonetheless, assessment of surgical training level is also performed subjectively by the tutors, and there is no objective tool to accurately assess the surgical level of a trainee. Therefore, the validation of the questionnaire would be difficult and of limited interest concerning the surgical performance. On the other hand, the knowledge part could be more easily validated, for example, by comparing the results of the questionnaire to the results obtained through validated tests such as the examination administered by the EBU which are now used as final exam in some countries in Europe.

Conclusion

The self-reported level of training, including medical knowledge and surgical performance of urology residents from Mexico seems to be similar to that of Western European residents. The knowledge of English language is associated with better knowledge performance. The number of months of urology training, the number of non-urologic rotations and the presence of a supporting senior surgeon are factors associated with better self-perceived surgical performance.

Acknowledgements

We thank Pr Rien J.M. Nijman, Pr Van Poppel, the EBU, the European School of Urology from the European Association of Urology and to national communication officers from ESRU for their help and support in achieving this project, and to Fundación Mexicana Para la Salud for providing an educational grant to Dr Rodríguez-Covarrubias. We would like to thank all residents from Europe and Mexico for their cooperation.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Francisco Rodríguez-Covarrubias

F. RODRIGUEZ-COVARRUBIAS is an attending urologist in a University Hospital in Mexico City, Mexico.

Stina Erikson

S. ERIKSON is the past Chairman of the European Society of Residents in Urology.

Andreas Petrolekas

A. PETROLEKAS is Chairman of the European Society of Residents in Urology. Hometown: Athens, Greece.

Oscar Negrete-Pulido

O. NEGRETE-PULIDO was Chief-resident in Urology in a University Hospital in Mexico City, Mexico. Hometown: León, Guanajuato, Mexico.

SelÇuk Keskin

S. KESKIN was Chairman of the European Society of Residents in Urology and is member of the resident office. Hometown: Ankara, Turkey.

Morgan Rouprêt

M. ROUPRÊT was Chairman of the Association Française des Urologues en Formation. Hometown: Paris, France.

Luis Martínez-Piñeiro

L. MARTÍNEZ-PIÑEIRO was Chairman of Resident's Office of the European Association of Urology. Hometown: Madrid, Spain.

Claude-Clément Abbou

C.-C. ABBOU is the Chairman of the European Urology Scholarship Programme of the EAU. Hometown: Créteil, France.

Guillermo Feria-Bernal

G. FERIA-BERNAL is the head of the Department of Urology in a University Hospital in Mexico City, Mexico. Hometown: Mexico City, Mexico.

Stéphane Larré

S. LARRÉ was Chairman of the European Society of Residents in Urology and is member of the resident office of the EAU. Hometown: Sheffield, UK.