Defining Expertise in Gynecologic Surgery ...

ORIGINAL ARTICLE

Defining Expertise in Gynecologic Surgery: Perspectives of Expert Gynecologic Surgeons Patricia L. Hardré, PhD,* Mikio Nihira, MD, MPH,† Edgar LeClaire, MD,‡ and Michael Moen, MD§ Objective: The aim of this study was to describe how professional expertise is defined and understood among gynecologic surgeons and what experiential factors contribute to that understanding. Methods: Semistructured interviews with 16 experts in Female Pelvic Medicine and Reconstructive Surgery were conducted to identify how expertise in their field is defined, recognized, and assessed. Independent thematic analysis of the interview transcripts was performed by each member of the research team and then distilled and synthesized into convergent themes. Results: Experts described surgical expertise as difficult to define but with several dominant themes including knowledge, technical skills, clinical experience, adaptability, continuous learning, communication, and professional recognition. Expertise requires judgment in applying technical skills to meet each patient's specific needs. Experts described unique ways of seeing and thinking during surgery, characterized by spatial awareness of relevant anatomy, temporal awareness of future changes, and rapidly adaptive application of their skills enabling them to do difficult tasks with fluidity, making the tasks seem easy to observers. These expert surgeons acknowledged that achieving expertise requires hard work and maintaining expertise requires continuous learning, highlighted by challenge seeking to do the most difficult tasks in their field. They also noted the importance of effective communication of their knowledge to others, which contributes to their perception as experts by colleagues in the field. Conclusions: Surgical expertise is a complex phenomenon with several meaningful themes. Understanding the authentic nature of surgical expertise can be used to support the development of competencies and the effective mentoring of promising surgical trainees to achieve surgical expertise. Key Words: surgical expertise, surgical skills, surgical competence (Female Pelvic Med Reconstr Surg 2016;22: 399–403)

E

xpertise in highly technical professions is complex. Depending on the precise nature of the work, expertise can be defined in a number of ways based on the level of education, past experiences, or performance.1 In the realm of surgery, expertise may be defined objectively using measures such as number of surgeries performed or numbers of complications or subjectively using terms such as “good hands” or “talented” and can be judged by individuals or by a professional community. It may also be defined based on a variety of contexts and tools or tasks, so that a surgeon may be an expert in 1 surgical task but not others (eg, abdominal vs vaginal hysterectomy) or with traditional tools but not with new ones (scalpel vs laparoscopy or robotics). New techniques and technologies add layers of technical skills on top of the original surgical task work and shift the nature and definitions of expertise. This results in difficulty defining and assessing expertise leading many to claim that “they know it when they see it” but often cannot define it apart from performance evidence.2 The challenge of this kind of complexity is that it presents no clear and generalizable From the Colleges of *Education and †Medicine, University of Oklahoma, Norman, OK; ‡University of Kansas College of Medicine, Kansas City, KS; and §Chicago Medical School, Rosalind Franklin University, North Chicago, IL. Reprints: Michael Moen, MD, 1875 Dempster St, Suite 665, Park Ridge, IL 60068. E-mail: [email protected]. Disclosure: The authors have declared they have no conflicts of interest. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000336

criteria for “successful” or “expert” performance, which complicates efforts to codify it for educational and evaluation needs. Every skill and profession has a knowledge base composed of both basic and advanced knowledge and a skill set composed of both general (cross-disciplinary) and field or taskspecific (domain) skills. General skills in surgery include things such as observation, critical reasoning, analysis, problem solving, and adaptive thinking.1 Domain-specific skills in surgery include manual precision, accurate tool-handling, specific surgical techniques, and specific anatomical knowledge.3 Within a given field or domain of practice, competency is defined by a certain body of knowledge and skills, but expertise moves beyond core competencies to a level that involves doing the job faster, better, more effectively, and more adaptively and with fewer errors.4 These are the characteristics that distinguish experts from novices in professional practice. Knowing that some physicians become good, solid practitioners, but with minimal recognition, whereas others develop higher levels of expertise in their field, medical education can benefit from a better understanding of expertise development. Not only does the clear definition of expertise drive educational design, it also supports development through learner knowledge of, and self-regulation toward, clear performance targets.5 Because of the specialized nature of professional expertise, the best initial source to understand it is the experts themselves. The objective of this study was to identify specifically how expert gynecologic surgeons articulate the definitions and standards of excellence in their professional field. This understanding can be used to improve current physician training and competence assessment, contributing to the development of expertise.6

MATERIALS AND METHODS This study was approved by the institutional review board of the University of Oklahoma and used a fully integrated conceptualization of expertise based on the merging of cognitive and affective elements.7 Frameworks for this study are the theories and research-based principles of expertise and its development3,8–11 and situated and social cognition.12–14 In this descriptive design, the researchers used a reflective narrative technique communicated through semistructured interviews.15–17 This method of gathering qualitative data prompts metacognitive awareness and revelation of important life experiences illuminated by participants' reasoning.18,19 The research initiated and supported the experts' sharing of unique insights and personal narratives with attributions of internal (personal) and external (environmental) factors relating to their professional knowledge, skill development, and expertise. Given the interactions of cognition (thinking), emotions (feeling), and social (interpersonal) experiences in the authentic dynamic of career and professional activities, the interviewers strove to capture all of these elements of the expert surgeons' experiences. Sixteen experts in Female Pelvic Medicine and Reconstructive Surgery were identified based on education and experience, scholarly and professional status, and reputation as experts in the professional community. They were invited to participate by a peer and then scheduled and consented per human subjects'

Female Pelvic Medicine & Reconstructive Surgery • Volume 22, Number 6, November/December 2016

www.fpmrs.net

399

Copyright © 2016 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Hardré et al


requirements. All are practicing high-volume (>80 procedures performed annually) surgeons who also supervise residents, publish scholarly papers, and present at medical conferences. The sample included 9 (56%) men and 7 (44%) women, aged 35 to 72 years (mean, 50 years), with 5 to 35 years in practice posttraining (mean, 19 years). The 16 expert surgeons participated in individual, 30- to 50-minute, semistructured interviews, conducted by an experienced interviewer (generating 10.6 hours of interview data). Guiding points of interest for the interviews are captured in the questions listed hereinafter. They focus on the global topic of defining expertise. The semistructured format used more detailed questions to illuminate and follow up participants' responses as interviews progressed. Beginning with these standard questions, the researcher adapted follow-up questions consistent with the direction of each participant's personal narrative. Interviews were recorded using digital audio recording and observation notes, which were professionally transcribed for coding and analysis.

Interview Questions 1. What does it mean to be an expert in this field? 2. How do you know expertise when you see it? What do you look for? 3. Are there specific guidelines of expertise that all surgeons in the field agree on?

responses: “a combination of knowledge, skill and experience” and “I guess it's a combination of experience, knowledge, technical skill and judgment.” Several responses underscored that the application of knowledge was key: “You have to have a certain level of basic knowledge, and it's how you apply that knowledge that separates out people that are good, great and expert” and “Expertise should be defined as knowledge of a variety of conditions and then experience with a variety of techniques to approach different problems.” These experts noted that expertise can be seen as high-quality work in a broad range of surgical tasks or within a very narrow range of specialized skills, and they tended toward the former, the greater range, to define field expertise. Part of the complexity of expertise is that it requires clinical experience: “somebody who has accumulated enough experience that they've seen pretty much all of the different variations or things that can happen or issues that can go wrong.” The experts contended that nearly anyone who was willing could be taught the basic skills but that there is a degree of innate ability and aptitude that support advancement to the highest level of expertise. These characteristics include inherently fine psychomotor skills, hand-eye coordination, and acute spatial awareness. Some observed that these abilities are even more critical in endoscopic and vaginal surgery compared with open surgery.

Expertise Is Both Adaptive and Controlled

The following sections present the thematic response categories produced by the data. Each is illustrated by exemplar quotes from the expert surgeons.

A prominent theme was the need for surgical expertise to be adaptive because every case is different: “knowing the procedure, knowing what you want to accomplish, and then just modifying it slightly given the individual variances from patient to patient.” Beyond expected variations, surgeons are often confronted with unexpected circumstances during an operation, even midprocedure, and they need to be equipped to respond to them. One expert put it this way: “Every patient is different anatomically…there are so many variables…the expert is the one who…When things go wrong, they can adapt…[to] a variety of anatomic differences and complications…being able to improvise, but improvise in a safe and logical way.” Adaptivity in fixing problems is balanced by other factors, such as resources and risks: “Expertise is also manifested in your ability to correct something when it goes wrong or something is unplanned…in an expedient manner, without hurting a patient.”

Expertise Lacks Precise Definition

Expert Ways of Seeing and Thinking

Most of the expert surgeons began by hedging on the question with answers such as, “It's difficult to define,” “There are a lot of definitions,” and “That's a tough question, because I don't think it's really defined.” Surgeons noted that expertise in the field is continually evolving: “You could be an expert at one thing, but this is technology and life, and we're always striving to do better, so as soon as you stagnate, you won't be an expert tomorrow”; “In the time that I have been here, which is twenty years, the field has completely changed in terms of devices, procedures, so continuing education for that reason alone is crucial”; and “It's an ever-changing kind of surgical specialty.”

They described experts as having distinct conceptual ways of seeing and thinking about their tasks. This surgical vision stood out for most participants as a critical skill, to help surgeons “sort out the most important parts of a task [from less important distractions, and] come to the simplicity of what it is” and, by these processes, “getting better surgical results.” Besides this special, taskspecific way of “seeing” the problem, they included in expertise seeing the solution: “Some of [expertise] is the ability to think spatially and three dimensionally as to how the parts need to come together to look the way normal anatomy should.” They agreed that experts developed more rapidly adaptive reasoning and skill application than other surgeons, to the degree that they felt they worked much harder than others recognized. As 1 participant said: “Expertise means doing all of the most difficult things but making them look easy.” Some articulated expert ways of approaching surgery as thinking and managing beyond the present task: “Experts are thinking way beyond the procedure, about what the issues are for this particular patient. You've moved into another dimension, thinking of the other things that are going to influence your approach.” Thinking ahead leads to greater efficiency in surgery,

The analysis of responses was consistent with systematic practice in qualitative research analysis.20,21 The researchers conducted independent thematic analysis of the interview transcripts. Then, they met, compared notes, and distilled and synthesized their observations into convergent themes. Thematic analysis of rich qualitative data is a reciprocal, recursive process of coding by segmenting the data into dominant emergent categories and then developing them into a coherent and meaningful set of examples illustrating those thematic response categories.22

RESULTS

Expertise Is Complex and Multifaceted All these experts agreed that expertise involves and builds from some combination of knowledge, skills, training, and experience. Foundational knowledge is the first key component that was mentioned: “an impressive knowledge base at least” and “you need to have basic knowledge of anatomy and procedures, absolutely.” The experts went on to emphasize that the rest of expertise built on that foundation of knowledge. The whole of expertise built on and beyond knowledge, as exemplified in these convergent

400

www.fpmrs.net

© 2016 Wolters Kluwer Health, Inc. All rights reserved.



an important factor for patient safety, as well as economy of work: “What you start to see…is thinking in the present time, what is the task at hand, but also preparing like the chess game…a better understanding of the whole comprehensive case.”

Expert Surgical Judgment Judgment is a critical element of surgical expertise and involves weighing options and tradeoffs in complex cases. Expert judgment includes long-term and big picture thinking about patient needs and potential risks, “avoiding problems, seeing them before they happen.” Expert judgment also requires knowing precisely when and how to apply specific skills: “It's a matter of experience, but also having judgment and understanding the big picture…a lot of technical skills, but…It doesn't matter how good you are at doing something if you shouldn't be doing it in the first place. It's judgment. It's the right operation on the right patient at the right time for the right reason.” Experts use judgment when trying new things: “It's the ability to try new things, but with some discerning. You have some discernment from prior experience and judgment.” Professional judgment is nuanced by the integration of adaptive reasoning to the unexpected: “anatomy, knowledge of the procedure, but then there's the certain ability to put it all together, think on your feet, all those things…because often you'll end up in situations where this wasn't in the textbook…I don't know what's going to happen until I get in there.”

Expert Communication Surgical expertise involves interpersonal skills and communication with everyone involved in the success of surgical cases: “personal skills, getting along with patients, colleagues, team members. That's also very important.” Communicating with patients accurately and sensitively is a key part of surgical expertise: “just even talking about long-term efficacy and cure, and the implications and limitations of our knowledge…the patient certainly needs to understand.” Beyond patient care, experts' teaching and mentoring (of students and colleagues) depend on expertise in communication: “the ability to communicate…your experience and communicate it correctly…people look up to you or look to you for answers.” One expert noted that teaching requires refined understanding: “If you're able to teach and give back, that separates out another layer of expertise because you really have to know how to take everything you know, assimilate that, and deliver that back to somebody…. If you're able to do that successfully, that's another level of expertise.”

Experts Learn and Practice Continually and Seek and Embrace Challenge In a rapidly changing field, maintaining expertise requires continuous learning. “There's got to be that inner drive that brings ‘I want to be better’, and then ‘How do I get better?’…. You've done thousands of this, but there's still opportunity to learn…. There's pride in wanting to be good at your craft…no matter what you do. There's pride in ownership in that. I think that's maybe where levels of expertise get influenced to some degree…. I want to be good at what I do. If that's expertise, so be it.” One expert noted that an expert needs not only to learn continually but also to know his/her limitations: “You're going to refine techniques, and…get better at things, but that's your foundation. If you can't operate, you shouldn't operate.” Besides learning new knowledge and skills, experts practice continually to maintain their skills: “I am an expert at the things I do a lot of ” and “Honestly, expertise is experience that you have to keep building on.” Many of these expert surgeons do not consider © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Defining Gynecologic Surgery Expertise

themselves experts: “I will probably never, ever be able to claim I'm a true expert because I think that's ongoing…. I think it will take a lifetime…about the time I'm ready to retire I might be an expert.” Experts described themselves as seeking out and embracing new challenges continuously: “The one who looks for cases that are difficult or unusual and enjoys doing those because it's a challenge, there's a problem to be solved” and “It's like a test every day. I like the test. I like the challenge.”

Contrasts in Defining Expertise Asked how they and the rest of the medical community recognized expertise, they described differences between clinical expertise (indicated by experience), research reputation (indicated by publications), and public reputation (indicated by speaking). They noted that both research productivity and years of clinical experience tend to be considered evidence of expertise: “Some people are going to consider somebody an expert if they have done a lot of research and publications on a certain topic. Some are going to consider them an expert if they've had years of clinical experience, versus some are going to consider them an expert if they have mastered a novel technique.” Although they acknowledged the value of various dimensions of expertise, the dominant value of these expert surgeons was, not surprisingly, invested in excellence in surgical practice: “Ideally both [scholarship and practice], but if I had to gravitate, I would gravitate more toward procedural expertise…. It's very difficult to determine who has experience, but easy to discern who has [published] papers.” Most valued surgical expertise and helping patients as the greater “good.” All of the surgeons agreed that the ultimate criterion of expertise is a track record of successful surgery for the patients, “ultimately having a good and safe outcome for the patient, which is really the final benchmark for all of us.”

DISCUSSION This study examined the key elements of expertise in gynecologic surgery, as it is defined by experts themselves. Experts agreed (converged) on defining expertise as integrating scholarly knowledge and skills across a broad range of applications and implementing it with a high quality of execution. They defined surgical expertise in several ways, including technical knowledge and skills, magnitude and range of experience, and recognition in the professional community. They acknowledged that experts exhibit specialized kinds of visualization and judgment, supported by continuous learning and practice and fueled by passion and caring. They emphasized that expertise is not static; instead, it is necessary to continue working to maintain their expertise. They seek out and embrace challenges, learning to do the most difficult tasks and solve the most difficult problems in their field. These findings are consistent with previous studies reporting expertise as a complex, multidimensional phenomenon, including initial aptitudes, formal education or experience, and continuous development over a career, based on needs, opportunity, additional input and modeling, and ongoing reflective experience.3 Their descriptions of striving to learn and continuously improve are consistent with theoretical frameworks of optimal motivation that supports excellence and innovation.23,24 The participants also described gynecologic surgical expertise as adaptive and controlled, responsive to the unique demands of a variety of cases, while also maintaining the standards of best practice. These findings are consistent with scholarship positing expertise as an adaptive skill in a variety of situations reaching across the domain.9 They articulated elements of complex professional judgment needed to apply their technical skills www.fpmrs.net

401


Hardré et al


to meet each patient's needs. These physicians' descriptions of professional judgment reflect a similar framework as the naturalistic decision making theoretically inherent in all applied professions.24–26 Expertise in complex problem-solving skills (such as surgery) requires situational awareness of the need, possible solutions, and expert reasoning about the best options for a particular case.8,26 Experts described unique ways of seeing and thinking during surgery, characterized by 3-dimensional spatial visualization of the relevant anatomy and problem space; a set of short- and longterm task goals, including awareness of future changes that could require adjusting those goals; and rapidly adaptive reasoning about their skill application that enabled them to do difficult tasks but make them look fluid and even easy to observers. They also described various types of communication that were part of surgical expertise, including communication with colleagues, team members, patients, and their families and communication for teaching and mentoring, sharing their expertise with others to extend the quality of work in their field. These findings are consistent with research indicating that social context, social support, and encouragement play a role in all learning, expertise development, and expert performance.10,14 These findings also relate to the issue of “soft skills” as critical for expertise among physicians, reflected in their emphasis of the role of interpersonal communication in patient care and in professional collaboration and mentoring. Experts themselves described surgical expertise as requiring individuals to be disciplined, focused, and self-sacrificing not only to develop but also to maintain their skills. This level of dedication to surgical practice is informative when considering how we identify and evaluate learners on their path to develop expertise. Interestingly, although the questions to our experts were open ended, much of their discussion regarding expertise focused on different aspects, which characterize professionalism. The current Accreditation Council for Graduate Medical Education Milestones for Female Pelvic Medicine and Reconstructive Surgery27 has a single milestone devoted to professionalism, and there are no currently well-accepted instruments to assess this critical area of performance. Understanding the true nature of expertise will allow further investigation into identifying learners with the potential for attaining expertise, identifying mentors with the capability of teaching expertise, creating tools that can adequately assess progress along the continuum of expertise, and developing training environments in which expertise can be promoted.

Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:683–704. 5. Zimmerman BJ. Development and adaptation of expertise: the role of self-regulatory processes and beliefs. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006: 31–40. 6. Nihira MA. The value of criterion-based surgical education. Female Pelvic Med Reconstr Surg 2012;18:257–258. 7. Dai DY, Sternberg RJ. Beyond cognitivism: toward an integrated understanding of intellectual functioning and development. In Yun Dai D, Sternberg RJ, eds. Motivation, Emotion and Cognition: Integrative Perspectives on Intellectual Functioning and Development. Mahwah, NJ: Lawrence Erlbaum; 2004:3–40. 8. Endsley MR. Expertise and situation awareness. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:633–652. 9. Feltovich PJ, Prietula MJ, Ericsson K. Studies of expertise from psychological perspectives. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:41–68. 10. Hunt E. Expertise, talent and social encouragement. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:31–40. 11. Sosniak LA. Retrospective interviews in the study of expertise and expert performance. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:287–302. 12. Fiske ST, Taylor SE. Social Cognition. New York, NY: McGraw-Hill; 1991. 13. Robbins P, Aydede M. A short primer on situated cognition. In: Robbins P, Aydede M, eds. The Cambridge Handbook of Situated Cognition. New York, NY: Cambridge University Press; 2009:3–10. 14. Smith ER, Conrey FR. The social context of cognition. In: Robbins P, Aydede M, eds. The Cambridge Handbook of Situated Cognition. New York, NY: Cambridge University Press; 2009:454–465. 15. Stake RE. Qualitative Research: Studying How Things Work. New York, NY: Guilford Press; 2010. 16. Van Manen M. Researching Lived Experience. Albany, NY: SUNY Press; 1990.

REFERENCES 1. Norman G, Eva K, Brooks L, Hamstra S. Expertise in medicine and surgery. In: Anders Ericsson K, Charness N, Feltovich PJ, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:339–354. 2. Cianciolo AT, Matthew C, Sternberg RJ, et al. Tacit knowledge, practical intelligence and expertise. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:613–632. 3. Alexander P. A model of domain learning: reinterpreting expertise as a multidimensional, multistage process. In: Yun Dai D, Sternberg RJ, eds. Motivation, Emotion and Cognition: Integrative Perspectives on Intellectual Functioning and Development. Mahwah, NJ: Lawrence Erlbaum; 2004:273–298. 4. Ericsson KA. The influence of experience and deliberate practice on the development of superior expert performance. In: Anders Ericsson K,

402

www.fpmrs.net

17. Yin RK. Qualitative Research From Start to Finish. New York, NY: Guilford; 2011. 18. Kvale S, Brinkman S. Interviews: Learning the Craft of Qualitative Research Interviewing. 2nd ed. Thousand Oaks, CA: Sage; 2009. 19. Rubin HJ, Rubin IS. Qualitative Interviewing: The Art of Hearing Data. 3rd ed. Sage: Thousand Oaks, CA; 2012. 20. Bazeley P. Qualitative Data Analysis: Practical Strategies. Thousand Oaks, CA: Sage; 2013. 21. Johnson RB, Christiansen L. Educational Research: Quantitative, Qualitative and Mixed Approaches. 5th ed. Thousand Oaks, CA: Sage; 2014. 22. Merriam SB, Caffarella RS, Baumgartner LM. Learning in Adulthood. 3rd ed. San Francisco, CA: Jossey-Bass; 2007. 23. Dweck CS, Mangels JA, Good C. Motivational effects on attention, cognition, and performance. In: Yun Dai D, Sternberg RJ, eds. Motivation, Emotion and Cognition: Integrative Perspectives on




Intellectual Functioning and Development. Mahwah, NJ: Lawrence Erlbaum; 2004:41–56. 24. Ross KG, Shafer JL, Klein G. Professional judgments and “naturalistic decision-making”. In: Anders Ericsson K, Charness N, Hoffman RR, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press; 2006:403–420. 25. Bereiter C, Scardamalia M. Surpassing Ourselves. Peru, IL: Open Court Publishing; 1993.

Defining Gynecologic Surgery Expertise

26. Busemeyer JR, Jessup RK, Dimperio E. The dynamic interactions between situations and decisions. In: Robbins P, Aydede M, eds. The Cambridge Handbook of Situated Cognition. New York, NY: Cambridge University Press; 2009:307–321. 27. American Board of Obstetrics and Gynecology and the American Board of Urology. The Female Pelvic Medicine and Reconstructive Surgery Milestone Project. Available at: http://www.acgme.org. Accessed November 25, 2013.

Pelvic Floor Disorders Registry: Purpose and Development: Erratum In the article on pages 77–82 of the March/April 2016 issue, PFDR Development section, last paragraph, 2nd column at the top page 80 should read as follows: These sites commenced site enrollment activities (training, IRB approval as needed) and are providing feedback to registry staff and committee members about site initiation and registry enrollment processes. In the Conclusions and Future Directions section, the first sentence should read as follows: After more than 3 years… , the PFDR voluntary registries (Quality Improvement and Research) are finally available for use by pioneer sites and soon will be available for broader participation. Reference: Bradley CS, Visco AG, Weber LeBrun EE, Barber MD. Pelvic Floor Disorders Registry: purpose and development. Female Pelvic Med Reconstr Surg 2016;2277–82.


www.fpmrs.net

403
