Female pelvic medicine and reconstructive surgery fellowships

The American Board of Urology and The American Board of Obstetrics and Gynecology recently announced that they have agreed to “sponsor and accredit jointly a new subspecialty in Female Pelvic Medicine and Reconstructive Surgery (FPMRS).” This is a commendable effort and one that, in principle, will do much to enhance the training of a new breed of surgical sub-specialists who will become the teachers of the next generation of urologists and gynecologists. The end result should bea great boon to women who suffer from lower urinary tract symptoms (LUTS) and disorders of the pelvic floor. If these programs are to be meaningful, though, it is important that the training is truly multi-disciplinary and that each program has sufficient input by both gynecologists and urologists to ensure that the trainee is exposed to all the relevant nuances of each specialty. That means the urologist should be trained to diagnose and treat disorders of the uterus (including hysterectomy and reconstructive prolapse surgery) and that the gynecologist should learn about disorders of the bladder (including cystoscopy and augmentation enterocystoplasty). Both urologists and gynecologists should learn about fecal incontinence and hemorrhoids. After a generation or two, the distinction between gynecologist and urologist will fade and the sub-specialist will be called a pelvic surgeon or some facsimile thereof. There are a number of obstacles to this endeavor that need to be reckoned with. First, there is the problem of the curriculum itself. At most institutions there is little variety in the type of procedures that are done. When it comes to urinary incontinence, for example, at most university centers the experts have a passionate adherence to one of two surgical procedures to the exclusion of all the (hundred or more) others. Some sites have a large neurogenic population; others see none at all. Some see cancer patients; others do not. Further, LUTS are just as common in men as women and many programs diagnose and treat both men and women. There is a lot to be learned from each sex that applies to the other. Second, there are the obvious political ramifications. Incontinence surgery and prolapse surgery are currently performed mostly by general urologists and gynecologists. As mentioned above, there are other fellowship programs that train urologists in the surgical and non-surgical treatment of LUTS and pelvic floor disorders in men and women. And there is a whole cadre of surgeons who have completed fellowship training prior to the establishment of the joint sponsorship. Currently, there are no plans to “grandfather” them in. None of these groups will take kindly to the intrusion on their turf, especially if FPMRS training entitles its graduates to an advantage in attaining surgical privileges and reimbursement from third party payers. Third, in the United States, HCFA regulations prohibit part B Medicare comNeurourology and Urodynamics 19:635–636 (2000)