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    New subspecialty will benefit women with pelvic floor disorders

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    As many of our readers may know, the American Board of Medical Specialties (ABMS) recently recognized female pelvic medicine and reconstructive surgery (FPM-RS) as a subspecialty in obstetrics and gynecology. For more than 10 years a unique partnership has existed between the specialties of ob/gyn and urology. The American Board of Obstetrics and Gynecology and the American Board of Urology have certified training programs in female pelvic medicine and reconstructive surgery; however, the ability to examine and certify the fellows who had completed the program required ABMS approval and that step has just been taken.

    There will be a one-time opportunity for established specialists in the field who have not completed an approved fellowship to apply for certification under a "grandfathered" process. The two boards will examine the current scope of their practices and past experiences to determine whether applicants will be eligible for examination for subspecialty certification. After this one-time opportunity, only physicians who have finished an approved fellowship program will be eligible. This brings female pelvic medicine and reconstructive surgery in line with the three other established subspecialties in gynecologic oncology, reproductive endocrinology and infertility, and maternal-fetal medicine.

    How will it affect you?

    What does this mean for the practicing ob/gyn? Early in the subspecialization process there had been concern among generalist ob/gyns that the development of FPM-RS would pose a threat to the scope of their care for women with pelvic prolapse and incontinence. However, many generalists have learned over the past 10 years that having a fellowship-trained, female pelvic physician in their communities has not changed the relationship between patients and their ob/gyns. Many practicing ob/gyns have considerable experience in managing incontinence and prolapse, and this certainly will continue in much the same way that subspecialist and nonsubspecialist care overlap in the care of complex obstetrical patients, patients with early-stage endometrial cancer, and patients with infertility. It does mean that as more senior pelvic floor surgeons who had developed their expertise through years of clinical experience retire, they will be replaced by subspecialty fellowship-trained individuals.

    Customs regarding referral and management of patients with complex pelvic floor disorders differ widely in various communities. In some settings these problems are taken care of exclusively by practicing ob/gyns while in other areas the majority of such care is provided by FPM-RS subspecialty-trained individuals. In addition, whether women with incontinence are cared for by a urologist or an ob/gyn also varies greatly. In a growing number of communities gynecologists may send a patient with a prolapse problem to a urologist. This is somewhat troubling from our specialty standpoint because it indicates a lack of confidence among the ob/gyn community about managing a problem that has long been within our purview.

    It should be noted that there has been remarkable good will and collaboration between the fields of ob/gyn and urology in bringing this new field to subspecialty recognition. The board that oversees the fellowship programs is composed of equal numbers of gynecologists and urologists and, having sat on the board for a number of years, I can assure you that both sides are fully cooperative and focused on improving the quality of care for patients who have pelvic floor disorders.

    It actually has been more difficult for the urology community to accept the concept of subspecialization in FPM-RS because previously there were no ABMS-approved fellowship programs in urology, and specialty areas that have a long history of training, such as pediatric urology and pediatric oncology, also needed to move forward toward subspecialty recognition because they clearly had a longer history than did the subspecialty of female pelvic medicine.

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    John O.L. DeLancey, MD
    DR. DELANCEY is Professor of Gynecology, director of Pelvic Floor Research, University of Michigan Medical School, Ann Arbor, MI.

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