Applying to Urogynecology / FPMRS, with Dr. Edward Kim

We welcome back Dr. Edward Kim, an FPMRS fellow at the University of Pennsylvania, who’s talking with us today about how to apply for urogynecology fellowship!

Disclosures: We’re from a large academic institution. What we say may not apply to those from smaller programs or those from community programs! Please feel free to reach out to us though for other specifics or connections on advice.

  1. What is Urogynecology or FPMRS?

    1. Female pelvic medicine and reconstructive surgery

    2. We are a subspecialty of either Ob/Gyn or Urology that focuses on medical management, surgical management and research of women’s pelvic floor conditions. Vast majority of our surgeries are elective and outpatient or at the most overnight stays. Compared to other gyn surgical subspecialties like gyn onc or MIGS, there is very little inpatient care needs or consults. Our patient population is predominantly older patients with exceptions at institutions that do gender affirming surgeries, peripartum pelvic floor care, etc. Our research areas range from basic science to NIH-funded research network.

    3. Historically, the name FPMRS was created to replace or supplement the name urogynecology in order to relay that our scope of practice can go beyond urologic and gynecologic conditions. However, more recently, the name FPMRS is being re-discussed as the word female is not inclusive especially given that more of us are seeing gender diverse patients and perform gender affirming surgeries.

    4. Long story short, urogynecology and FPMRS are synonymous for the time being but it may evolve.

    5. In terms of the duration of training: For Ob/Gyns it’s a 3 year fellowship and for Urologists it’s a 2 year fellowship. For Ob/Gyns, these 3 years include 12 months of research, as it is for all ABOG certified subspecialties.

    6. Your training will cover a variety of pelvic floor conditions as defined by American Urogynecologic Society’s (AUGS) scope of practice:

      1. Urinary Incontinence

      2. Pelvic organ prolapse

      3. Voiding dysfunction

      4. Neurogenic bladder

      5. Urethral diverticula

      6. Vesico-vaginal and recto-vaginal fistulae

      7. Congenital anomalies of the pelvic floor

      8. Fecal incontinence

      9. Recurrent UTI

      10. IC/BPS

      11. Managing pelvic floor surgery complications and mesh complications

      12. And at some programs:

a)    Transgender care and gender affirming surgeries

b)    Peripartum pelvic floor care

c)     Pelvic pain

d)    Etc.

 

  1. Years I - II

    1. NOTE: Urogyn is EARLY application and EARLY match just like Urology. Urogyn timeline is thus a few months earlier than other Ob/Gyn subspecialties. Applications OPEN in NOVEMBER/DECEMBER and CLOSE by January of PGY3 year, interview in SPRING of PGY3 year and match by AUGUST of PGY4 year. So solidifying your interest in urogyn earlier in residency is beneficial.

    2. If you are at a residency with big urogyn presence and have fellowship. Typically you will rotate through or be exposed to urogyn as junior residents. If so,

      1. See what your attendings and fellows do. Talk to them about why they went into it. Do you like major and minor urogyn surgeries? How about the predominantly older patient population?

      2. See what kind of scholarly activities are happening in the division. Ask if you can be more involved with research. This will help you get “plugged in” with the division.

      3. Do well on CREOGs but not a huge deal until your third year. Show an upward trend if you can.

    3. If you are not at a residency with big urogyn presence

      1. Identify a local urogyn faculty or urogyn division.

      2. If your residency and host institution allow, do an away rotation. Try to impress them and get a great letter. Ideally, you should have at least one urogyn write a letter of recommendaiton for you.

      3. At the least, do scholarly work like a book chapter or full on research project.

    4. PGY2s should consider either:

      1. AUGS Resident Scholars Program that gives funding to attend AUGS meeting to network and be exposed to the greater urogyn world

      2. ABLE Scholar Travel Award that is similar to the resident scholars program but focused on residents from diverse backgrounds

      3. You can apply as a PGY3, but by the time you attend AUGS, your fellowship application process will already be in full swing. So try to go in PGY2 year to network if you can.

  2. Third Year

    1. Identify people that can write your letter of recommendation.

    2. Continue your research projects and other scholarly activities

    3. If you haven’t already, apply for either resident scholar programs that I mentioned

    4. Applications open in November/December!

      1. So in the summer/early fall time, look at AUGS’ listing of fellowship programs. Look at each program’s information. Make a list of programs you’d be interested in

      2. Sit down with your mentor/fellows and edit or add to the list

a)    Talk about: research heavy? Academic versus private after graduation? Specific niches like gender affirming care, basic science research, dual degree opportunities?

  1. Applications

    1. Overview: Applications open in November/December and close in January typically. Interview invitations will be sent out around February. Interviews are from March to June. With the match in August.

    2. In early fall of PGY3 year, update your CV and get the application material together.

    3. Write your personal statement and have your mentors review it. Help the readers understand why urogyn and what you want to accomplish in your career.

    4. Most programs will not review the application as soon as the application opens in Nov/Dec. Do submit on the earlier side because you don’t know what the process is like at your top choice programs. But don’t rush at the cost of making mistakes in your application.

    5. All programs will send out interview invites on a single designated day typically in February.

      1. Just like in residency, be prompt about responding to interview invites as to not end up on the waitlist.

  2. Interviews

    1. Back in our day for Nick Fei and I, we spent a lot of money on in-person interviews! Virtual interviews are wallet-friendly and schedule-friendly, but they are also exhausting! Allow yourself some breaks and downtime between interviews if you can and try to optimize the number of interviews you do.

    2. You all know this by this point in your career but:

      1. Do your homework on the program! Some programs have good information about their programs on their websites or on their AUGS program listing. Try not to ask questions that is reasonably evident lest you want to be seen as not interested in the program. Ask people you know about the programs. Networking at AUGS will come in handy.

      2. Know the program faculty and what their interests are

      3. Have a list of questions:

a)    Surgical modality breakdown: robotic, vaginal, laparoscopic, etc.

b)    What kinds of non-bread and butter urogyn things do they do? Gender affirming care, peripartum pelvic floor issues, etc.?

c)     What is their research year structure? One full year? Or 12 months broken up throughout?

d)    What kinds of research do their fellows do? Basic science? Clinical?

      1. For logistical questions like calls, transportations, try to save those for the fellows or perhaps the PD

    1. It’s hard to get a sense on virtual interview days but try to see if the division members seem friendly and collegial with one another.

    2. See if everyone in the division makes it to the interview. Programs that are vested in their fellowship will try very hard to pick a time and day that works for everyone, block out their ORs and clinics, etc.

  1. Rank Lists

    1. Make your rank list and seek feedback from your mentors. Think about geography and what you want in a program. 3 years is a long time and you will have a lot more free time in urogyn fellowship compared to residency or even other ob/gyn subspecialties! So being at a place that you can be with family, friends, or things you like doing are also something to consider.

    2. Be sure to reach out to a few programs that you really loved. You voluntarily telling your top choices that they are your top choices is not against the NRMP rules.

      1. Some programs do not write back at all.

      2. To really support your emails of interest; Ask your mentors to reach out on your behalf.

    3. It’s hard to know which programs want thank you emails or not. Try to lean on the side of doing them. Again, some program and interviewers will not write back. That’s okay!

Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

  • Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

  • Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

  • Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.