Ann Surg Oncol (2015) 22:3776–3784 DOI 10.1245/s10434-015-4688-8
ORIGINAL ARTICLE – HEALTHCARE POLICY AND OUTCOMES
Attitudes and Perceptions of Surgical Oncology Fellows on ACGME Accreditation and the Complex General Surgical Oncology Certification David Y. Lee, MD1, Devin C. Flaherty, DO, PhD1, Briana J. Lau, MD1, Gary B. Deutsch, MD, MBA1, Daniel D. Kirchoff, MD1, Kelly T. Huynh, MD1, Ji-Hey Lee, PhD2, Mark B. Faries, MD1, and Anton J. Bilchik, MD, PhD1 1
Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John’s Health Center, Santa Monica, CA; 2Department of Biostatistics, The John Wayne Cancer Institute at Providence St. John’s Health Center, Santa Monica, CA
ABSTRACT Background. With the first qualifying examination administered September 15, 2014, complex general surgical oncology (CGSO) is now a board-certified specialty. We aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation. Methods. A 29-question anonymous survey was distributed to fellows in surgical oncology fellowship programs and applicants interviewing at our fellowship program. Results. There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66 %. Ninety-percent of the respondents were aware that completing an ACGME-accredited fellowship leads to board eligibility in CGSO. However, the majority (80 %) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the ACGME accreditation. The fellows in training were concerned about the cost of the exam (90 %) and expressed anxiety in preparing for another board exam (83 %). However, the majority of the respondents believed that CGSO board certification will be helpful (79 %) in
Presented in part at the meeting of the Society of Surgical Oncology Annual Cancer Symposium, Dallas, TX, 2015. Ó Society of Surgical Oncology 2015 First Received: 16 February 2015; Published Online: 30 June 2015 A. J. Bilchik, MD, PhD e-mail: [email protected]
obtaining their future career goals. Interestingly, candidate fellows appeared more focused on a career in general complex surgical oncology (p = 0.004), highlighting the impact that fellowship training may have on organ-specific subspecialization. Conclusions. The majority of the surveyed surgical oncology fellows and candidates believe that obtaining board certification in CGSO is important and will help them pursue their career goals. However, the decision to specialize in surgical oncology does not appear to be motivated by ACGME accreditation or the new board certification.
The American Society of Clinical Oncology predicts that by 2020, there will be an 81 % increase in people living with cancer, yet there will be a only 14 % increase in the number of practicing oncologists.1 Although the incidence of cancer is on the rise, improving the quality of care and training physicians capable of delivering high-quality cancer care continues to remain a challenge.2–5 Although the field of surgical oncology has grown, much of the surgical cancer care in the United States continues to be delivered by general surgeons.6 As a result of the increasing number of cancer patients, this is unlikely to change. However, it is important to train surgical oncologists who can collaborate with general surgeons and serve as catalysts in the advancement of cancer treatment.7–9 In July 1980, Walter Lawrence Jr. remarked in his Society of Surgical Oncology (SSO) presidential address that ‘‘the relative lack of detailed guidelines and funding sources for postresidency surgical oncology training programs’’ serves as a deterrent to education and establishment
Attitudes of Fellows on ACGME Accreditation
of surgical oncology departments at universities.9 This realization led to the formal approval of surgical oncology training programs by the SSO. The number of SSO-approved training programs steadily increased, from 8 in 1986 to 19 in 2009. Training requirements were established by the Ad Hoc Committee on Surgical Oncology, and trainees of SSO-approved surgical oncology programs were required to obtain expertise in the performance of complex procedures as defined by the Surgical Residency Patient Care Curriculum Outline (SCORE) project.10 Although initial efforts to officially recognize surgical oncology as a board-certified subspecialty were denied in 1989, the continued maturation of the field culminated in the recently implemented subspecialty certificate in complex general surgical oncology (CGSO) in 2011.10 The CGSO became the first board-approved surgical subspecialty since 1986 with administration of a written CGSO qualifying examination on September 15, 2014.11 With this new certification in place, we aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation as well as the new CGSO certification. METHODS This survey-based study was exempted from review by our institution’s review board. We developed an online survey consisting of 29 multiple-choice questions designed to assess the perceptions of current surgical oncology fellows on the ACGME accreditation of surgical oncology programs and the creation of CGSO board certification. The survey was also designed to assess the career goals, board preparation process and attitudes regarding grandfathering of CGSO for surgical oncologists currently in practice. Additionally, voluntary participation was offered to candidates interviewing for a surgical oncology fellowship position at our institution during the 2014 interview season. An e-mail containing the link to the anonymous Webbased survey on SurveyMonkey (Palo Alto, CA) was sent to program coordinators of the 22 surgical oncology fellowship programs listed on the SSO website. Candidates were offered the same questions on paper. Responses were collected from July through November of 2014. All data collection and statistical analyses were performed using SPSS 17.0 for Windows (IBM, Armonk, NY) and SAS 9.3 (SAS Institute, Cary, NC). Continuous variables were compared by the Student t tests and categorical variables
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with the v2 test. In addition, a logistic regression model was constructed to study the association of respondent demographics with responses. RESULTS Study Demographics There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66 % (73 of 110).12 The majority of our respondents were men, were U.S. medical school graduates, and had completed or were completing residency training at university or university-affiliated hospitals. The demographics of the survey respondents are listed in Table 1. Attitudes and Perceptions toward the ACGME Accreditation Ninety-seven percent (107 of 110) of the respondents stated that they were aware of the recent accreditation of SSO programs by the ACGME. Similarly, 90 % (99 of 110) of the respondents were aware that completing an ACGMEaccredited fellowship would lead to board eligibility in CGSO. Although 80 % (78 of 110) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the recent ACGME accreditation, 63 % (70 of 110) of all respondents stated that they were more likely to apply to an ACGME-accredited program than a nonaccredited program. Responses by training levels are shown in Fig. 1a. Candidates expressed a stronger preference for an ACGME-accredited program than current fellows (84 vs. 56 %, p = 0.007). On regression analysis, candidates were more likely to prefer an ACGME-accredited program to a nonaccredited program compared to first-year fellows [odds ratio (OR) 3.4, 95 % confidence interval (CI) 1.1–11.2, p = 0.038] and to the second- and third-year fellows (OR 4.3, 95 % CI 0.3–3.1, p = 0.012) (Table 2). Only 11 % (12 of 108) of the survey respondents stated that the institution of ACGME regulations will have a positive impact on the training of surgical oncologists, while close to half (47 %) of the respondents stated that there will be no impact on the training by the addition of ACGME regulations. Thirty percent (32 of 108) of the respondents stated that the regulations will have a negative impact on the training, while 12 % (13 of 108) of the respondents stated that they were not sure (Fig. 1b).
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TABLE 1 Demographics and career goals of respondents Characteristic
Candidates (n = 31)
Fellows (n = 79)
Male
16 (52 %)
45 (58 %)
Female
15 (48 %)
33 (42 %)
Gender
0.564
Training level
NA
First year
36 (46 %)
Second year
36 (46 %)
Third year
6 (8 %)
Training location
NA
Northeast
36 (32 %)
West Coast
15 (19 %)
Midwest South
7 (9 %) 23 (29 %)
Canada
7 (9 %)
General surgery residency
0.555
Community/military hospital
3 (3 %)
5 (6 %)
University/university affiliate
28 (97 %)
73 (94 %)
1 (3 %)
14 (18 %)
International medical graduate (yes)
p
Career plan after fellowship
0.046 1.000
Academic/university affiliate
31 (100 %)
76 (100 %)
Private practice/additional training
0
0
Multiple answer choices were allowed for board preparation and subspecialty; columns thus may not add up to total
Attitudes and Perceptions toward CGSO Certification Seventy-eight percent (85 of 109) of the respondents stated that their decision to enter surgical oncology was not impacted by the creation of new subspecialty certificate in CGSO. However, 78 % (84 of 108) stated that certification of CGSO makes surgical oncology a more attractive subspecialty for general surgery trainees. Furthermore, 86 % (93 of 108) of respondents stated that obtaining board certification in CGSO is important to them and 81 % (87 of 108) stated that board certification in CGSO would help them achieve their career goals. Significantly more candidates stated that obtaining a certification will be help in obtaining their career goals compared to current fellows (94 vs. 73 %, p = 0.020) (Fig. 1c). Significantly more current fellows expressed concerns for the cost of the exam compared to candidates (90 vs. 68 %, p = 0.006). The first-year fellows (OR 3.7, 95 % CI 1.02–13.3, p = 0.0464) as well as the second- and thirdyear fellows (OR 4.5, 95 % CI 1.3–16.2, p = 0.0204) were more likely to state that they were concerned with the cost of the CGSO examination compared to the candidates. Along with a concern for higher cost, there was also a higher level of anxiety regarding the CGSO examination amongst the current trainees compared to the candidates. A significantly higher proportion of the current fellows expressed anxiety regarding the CGSO examination
compared to the candidates (83 vs. 48 %, p \ 0.0003). First-year fellows were 8 times more likely (OR 8.0, 95 % CI 2.3–28.2, p = 0.0012) and second- and third-year fellows were almost 4 times as likely (OR 3.9, 95 % CI 1.4–10.8, p = 0.0087) to state than candidates that they were anxious about passing the CGSO examination (Table 2). Twenty-four percent (25 of 105) of the respondents stated that they did not enter surgical oncology directly from residency. Of these 25 fellows, 12 % (3 of 25) stated that they chose to enter surgical oncology to in order to obtain a certification in GCSO. Additionally, none of these respondents stated that they would pursue additional training or a career in research after completing the surgical oncology fellowship. CGSE Preparation Surgical Oncology Self-Assessment Program (SOSAP) was the most popular method of preparing for the boards examination (78 %), followed by surgical oncology textbooks (65 %), tumor conferences and oncology journals (56 %), and general surgery textbooks (17 %) (Fig. 2a). Seventeen percent (19 of 109) of the respondents replied that they were unsure of how to prepare for the exam. All 31 candidates stated that they would retake the exam if did not pass the first time, while 87 % (67 of 77) of the current
Attitudes of Fellows on ACGME Accreditation
3779
A Aware of recent ACGME accreditation of SSO programs
Aware that graduating from ACGME program leads to CGSO board eligibility
Decision to enter surgical oncology was positively impacted by ACGME accreditation of SSO programs
More Likely to Apply to an ACGME accredited program over nonaccredited program 0%
10%
20%
30%
40%
50%
60%
70%
80%
More Likely to Apply to an ACGME accredited program over nonaccredited program
Decision to enter surgical oncology was positively impacted by ACGME accreditation of SSO programs
Fellows (N=79)
56%
20%
86%
95%
Candidates (N=31)
84%
19%
100%
100%
Aware that graduating from ACGME program leads to CGSO board eligibility
90%
100%
Aware of recent ACGME accreditation of SSO programs
ACGME= Accreditation council for graduate medication education; CGSO= Complex general surgical oncology; SSO= Society of Surgical Oncology.
B Not sure if ACGME will have impact on the training
ACGME regulations will have no impact on the training
ACGME regulations will have a negative impact on the training
ACGME regulations will have a positive impact on the training
0%
10%
20%
30%
40%
50%
ACGME regulations will have a positive impact on the training
ACGME regulations will have a negative impact on the training
ACGME regulations will have no impact on the training
Not sure if ACGME will have impact on the training
Fellows (N=79)
10%
30%
46%
13%
Candidates (N=31)
13%
26%
48%
13%
60%
ACGME= Accreditation council for graduate medical education.
FIG. 1 a Attitudes and perception toward ACGME accreditation. b Attitudes and perception toward ACGME regulations on training. c Attitudes and perceptions toward CGSO certification
fellows stated that they would retake the exam if they did not pass on the first try (p = 0.0352). Career Goals/Attitudes Toward Grandfathering Sixty-four percent (69 of 107) of the respondents stated that they would like to have a career in academic surgery,
while 36 % (38 of 107) stated that they would like to practice in a university-affiliated hospital, described as a mix of university and private hospital model. No respondent expressed a preference for a career limited to private practice. In terms of subspecialization, a higher proportion of the candidates stated that they would like to practice general complex surgical oncology compared to the current
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C Obtaining CGSO board certification will be helpful in obtaining career goals
Obtaining CGSO board certification is important
Creation of CGSO board makes surgical oncology attractive to general surgery trainees
Decision to enter surgical oncology was positively impacted by the creation of CGSO board certification 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Decision to enter surgical oncology was positively impacted by the creation of CGSO board certification
Creation of CGSO board makes surgical oncology attractive to general surgery trainees
Obtaining CGSO board certification is important
Obtaining CGSO board certification will be helpful in obtaining career goals
Fellows (N=79)
23%
75%
53%
73%
Candidates (N=31)
16%
81%
68%
94%
CGSO= Complex general surgical oncology.
FIG. 1 continued
fellows (87 vs. 58 %, p = 0.004). A significantly higher portion of current fellows than candidates expressed interest in subspecialties including melanoma/sarcoma, colorectal, and breast surgery (Fig. 2b). The respondents were split on the issue of grandfathering. Fifty-four percent (59 of 109) of the respondents believed that currently practicing surgical oncologists who completed an SSO-approved fellowship before CGSO accreditation should be grandfathered into CGSO, while 36 % (39 of 109) of the respondents responded that grandfathering should not be allowed. The rest were unsure or declined to answer. DISCUSSION Nearly half of the current fellows believed that the ACGME regulations will not affect the training of surgical oncologists. This finding is not surprising, given that SSO programs have a well-established track record of training surgical oncologists and already have incorporated many of the training components and curriculums of the ACGME.10,13,14 Furthermore, many oncologic cases are electively scheduled, allowing journal clubs and tumor boards to occur during regular work hours, thus conforming trainees’ schedules to the duty hours mandated by the ACGME. Interestingly, candidates expressed a stronger preference for ACGME-accredited programs over nonaccredited programs compared to current fellows’ in-training. This may be a result of the awareness that only fellows graduating from ACGME-accredited programs will be
eligible to sit for the CGSO boards. Currently all of the SSO programs have received ‘‘paper accreditation,’’ and many of the programs are receiving site visits. It will be important for programs to obtain or maintain ACGME accreditation in order to attract the best candidates. In general, the attitude toward CGSO certification was favorable. Although most respondents did not enter the surgical oncology subspecialty in order to specifically obtain the CGSO board certification, there was a perception that the certification would be helpful in obtaining career goals. Also there was a general consensus that the certification will make the specialty more attractive to general surgical trainees. Nearly everyone surveyed stated that they would retake the exam if a passing level was not achieved, highlighting the trainees’ perceived importance of obtaining the certification. As surgical oncology continues to develop as a board-certified subspecialty, the ability to obtain board certification may become a primary motivating factor for entering the subspecialty for future applicants. In terms of career goals, all of the current trainees expressed an interest in an academic or academic-oriented career at a university or university-affiliated hospital setting. This follows the practice pattern of current surgical oncologists who are more likely to be in academic practice and spend more time on research compared to surgeons in other surgical subspecialties.15,16 It appears that surgical oncology trainees are a self-selected group of trainees interested in an academically oriented career. Therefore, it will be important for programs to continue to prepare its trainees to be leaders in the fields of education and research.
0.9 (0.2–3.1)
1.3 (0.4–4.1)
Second or third year
1.2 (0.5–3.1)
Male
1.3 (0.3–4.9)
2.5 (0.6–10.6)
South
West coast
Referent
No
0.4 (0.1–1.2) Referent
Referent
0.9 (0.2–3.6)
2.4 (0.5–11.0)
Referent
1.1 (0.4–3.3)
Referent
1.9 (0.4–8.2)
1.9 (0.5–7.0)
*
Referent
1.0 (0.4–2.4)
Referent
1.6 (0.5–5.4)
1.5 (0.4–5.3)
Referent
Referent
Referent
Referent
3.1 (0.4–25.4)
0.6 (0.1–3.1)
Referent
1.5 (0.3–6.5)
Referent
*
1.0 (0.1–7.7)
0.2 (0.0–1.5)
Referent
1.3 (0.5–3.6)
Referent
Referent
0.5 (0.2–1.6)
0.3 (0.1–1.4)
Referent
1.3 (0.4–4.2)
Referent
0.9 (0.1–6.3)
0.7 (0.1–3.6)
0.3 (0.1–1.7)
Referent
1.2 (0.5–2.8)
Referent
Referent
1.1 (0.2–5.8)
Not possible
Referent
2.7 (0.5–13.9)
Referent
4.0 (0.6–25.3)
1.6 (0.2–10.4)
*
Referent
0.8 (0.2–2.5)
Referent
4.5 (1.3–16.2)* 3.9 (1.4–10.8) * 0.5 (0.1–2.5)
1.4 (0.3–7.1)
0.4 (0.1–1.7)
Referent
1.1 (0.4–2.8)
Referent
0.2 (0.0–0.95)*
0.2 (0.1–1.2)
Referent
Referent
0.2 (0.07–0.8)
1.1 (0.1–9.9)
Referent
2.7 (0.8–9.3)
Referent
Referent
0.6 (0.2–2.2)
0.7 (0.1–3.7)
Referent
1.1 (0.4–3.0)
Referent
Referent
1.5 (0.5–4.5)
3.9 (0.9–17.6)
Referent
0.7 (0.3–1.7)
Referent
1.6 (0.4–7.7)
2.1 (0.5–8.3)
0.7 (0.2–3.0)
Referent
1.3 (0.6–2.9)
Referent
1.4 (0.5–3.8)
0.5 (0.2–1.6)
Referent
Obtaining CGSO Agree with grand will help with fathering career goals
3.5 (1.2–10.2)* 2.8 (0.3–28.0)
7.3 (0.9–61.1)
1.6 (0.6–4.1)
Referent
0.9 (0.3–2.6)
Referent
0.3 (0.1–1.8)
0.3 (0.1–1.8)
Referent
Obtaining ACGME regulations will CGSO board positively affect is important SOFP
3.7 (1.0–13.3)* 8.0 (2.3–28.2) * 1.1 (0.3–4.6)
Referent
Anxious about passing CGSO board
* p \ 0.05
ACGME Accreditation Council for Graduate Medical Education, CGSO Complex General Surgical Oncology, SOFP Surgical Oncology Fellowship Program, IMG international medical graduate, PGY postgraduate year, Affiliate university affiliate
Data are expressed as odds ratio (95 % confidence interval)
0.2 (0.03–1.9)
Yes
IMG
Referent 0.5 (0.1–2.2)
1.2 (0.2–6.8)
Military/community
1.1 (0.4–2.8)
Referent
1.4 (0.4–5.5)
1.0 (0.3–3.2)
0.5 (0.1–2.0)
Referent
1.9 (0.8–4.2)
Referent
0.2 (0.1–0.7)*
0.3 (0.1–0.9)*
Referent
University/university affiliate Referent
Residency type
University/university affiliate 1.9 (0.6–6.1)
Independent cancer center
Referent
*
Canada/midwest
Type of training program
Referent
Northeast
Region
Referent
Female
Gender
Referent
First year
Concerned More likely to More likely to More likely to apply to surgical with cost apply to an enter surgical of exam oncology due oncology specialty ACGMEto boards accredited program
Candidate
Training level
Characteristic
TABLE 2 Odds of agreeing with the following statements regarding ACGME Accreditation of Surgical Oncology Fellowship Programs and board certification
Attitudes of Fellows on ACGME Accreditation 3781
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A Soft Tissue/Melanoma Colorectal Surgery Endocrine/Head and Neck Breast Complex Upper GI Hepatobiliary General Complex Surgical Oncology 0%
Fellows (N=79) Candidates (N=31)
General Complex Surgical Oncology 58% 87%
10% Hepatobiliary 34% 23%
20%
30%
40%
Complex Upper GI 28%
50%
Breast 20%
16%
60%
70%
Endocrine/Head and Neck 10%
0%
80% Colorectal Surgery 16%
0%
90%
100%
Soft Tissue/Melanoma 33%
0%
6%
Candidates were allowed to choose more than one subspecialty, p
ORIGINAL ARTICLE – HEALTHCARE POLICY AND OUTCOMES
Attitudes and Perceptions of Surgical Oncology Fellows on ACGME Accreditation and the Complex General Surgical Oncology Certification David Y. Lee, MD1, Devin C. Flaherty, DO, PhD1, Briana J. Lau, MD1, Gary B. Deutsch, MD, MBA1, Daniel D. Kirchoff, MD1, Kelly T. Huynh, MD1, Ji-Hey Lee, PhD2, Mark B. Faries, MD1, and Anton J. Bilchik, MD, PhD1 1
Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John’s Health Center, Santa Monica, CA; 2Department of Biostatistics, The John Wayne Cancer Institute at Providence St. John’s Health Center, Santa Monica, CA
ABSTRACT Background. With the first qualifying examination administered September 15, 2014, complex general surgical oncology (CGSO) is now a board-certified specialty. We aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation. Methods. A 29-question anonymous survey was distributed to fellows in surgical oncology fellowship programs and applicants interviewing at our fellowship program. Results. There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66 %. Ninety-percent of the respondents were aware that completing an ACGME-accredited fellowship leads to board eligibility in CGSO. However, the majority (80 %) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the ACGME accreditation. The fellows in training were concerned about the cost of the exam (90 %) and expressed anxiety in preparing for another board exam (83 %). However, the majority of the respondents believed that CGSO board certification will be helpful (79 %) in
Presented in part at the meeting of the Society of Surgical Oncology Annual Cancer Symposium, Dallas, TX, 2015. Ó Society of Surgical Oncology 2015 First Received: 16 February 2015; Published Online: 30 June 2015 A. J. Bilchik, MD, PhD e-mail: [email protected]
obtaining their future career goals. Interestingly, candidate fellows appeared more focused on a career in general complex surgical oncology (p = 0.004), highlighting the impact that fellowship training may have on organ-specific subspecialization. Conclusions. The majority of the surveyed surgical oncology fellows and candidates believe that obtaining board certification in CGSO is important and will help them pursue their career goals. However, the decision to specialize in surgical oncology does not appear to be motivated by ACGME accreditation or the new board certification.
The American Society of Clinical Oncology predicts that by 2020, there will be an 81 % increase in people living with cancer, yet there will be a only 14 % increase in the number of practicing oncologists.1 Although the incidence of cancer is on the rise, improving the quality of care and training physicians capable of delivering high-quality cancer care continues to remain a challenge.2–5 Although the field of surgical oncology has grown, much of the surgical cancer care in the United States continues to be delivered by general surgeons.6 As a result of the increasing number of cancer patients, this is unlikely to change. However, it is important to train surgical oncologists who can collaborate with general surgeons and serve as catalysts in the advancement of cancer treatment.7–9 In July 1980, Walter Lawrence Jr. remarked in his Society of Surgical Oncology (SSO) presidential address that ‘‘the relative lack of detailed guidelines and funding sources for postresidency surgical oncology training programs’’ serves as a deterrent to education and establishment
Attitudes of Fellows on ACGME Accreditation
of surgical oncology departments at universities.9 This realization led to the formal approval of surgical oncology training programs by the SSO. The number of SSO-approved training programs steadily increased, from 8 in 1986 to 19 in 2009. Training requirements were established by the Ad Hoc Committee on Surgical Oncology, and trainees of SSO-approved surgical oncology programs were required to obtain expertise in the performance of complex procedures as defined by the Surgical Residency Patient Care Curriculum Outline (SCORE) project.10 Although initial efforts to officially recognize surgical oncology as a board-certified subspecialty were denied in 1989, the continued maturation of the field culminated in the recently implemented subspecialty certificate in complex general surgical oncology (CGSO) in 2011.10 The CGSO became the first board-approved surgical subspecialty since 1986 with administration of a written CGSO qualifying examination on September 15, 2014.11 With this new certification in place, we aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation as well as the new CGSO certification. METHODS This survey-based study was exempted from review by our institution’s review board. We developed an online survey consisting of 29 multiple-choice questions designed to assess the perceptions of current surgical oncology fellows on the ACGME accreditation of surgical oncology programs and the creation of CGSO board certification. The survey was also designed to assess the career goals, board preparation process and attitudes regarding grandfathering of CGSO for surgical oncologists currently in practice. Additionally, voluntary participation was offered to candidates interviewing for a surgical oncology fellowship position at our institution during the 2014 interview season. An e-mail containing the link to the anonymous Webbased survey on SurveyMonkey (Palo Alto, CA) was sent to program coordinators of the 22 surgical oncology fellowship programs listed on the SSO website. Candidates were offered the same questions on paper. Responses were collected from July through November of 2014. All data collection and statistical analyses were performed using SPSS 17.0 for Windows (IBM, Armonk, NY) and SAS 9.3 (SAS Institute, Cary, NC). Continuous variables were compared by the Student t tests and categorical variables
3777
with the v2 test. In addition, a logistic regression model was constructed to study the association of respondent demographics with responses. RESULTS Study Demographics There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66 % (73 of 110).12 The majority of our respondents were men, were U.S. medical school graduates, and had completed or were completing residency training at university or university-affiliated hospitals. The demographics of the survey respondents are listed in Table 1. Attitudes and Perceptions toward the ACGME Accreditation Ninety-seven percent (107 of 110) of the respondents stated that they were aware of the recent accreditation of SSO programs by the ACGME. Similarly, 90 % (99 of 110) of the respondents were aware that completing an ACGMEaccredited fellowship would lead to board eligibility in CGSO. Although 80 % (78 of 110) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the recent ACGME accreditation, 63 % (70 of 110) of all respondents stated that they were more likely to apply to an ACGME-accredited program than a nonaccredited program. Responses by training levels are shown in Fig. 1a. Candidates expressed a stronger preference for an ACGME-accredited program than current fellows (84 vs. 56 %, p = 0.007). On regression analysis, candidates were more likely to prefer an ACGME-accredited program to a nonaccredited program compared to first-year fellows [odds ratio (OR) 3.4, 95 % confidence interval (CI) 1.1–11.2, p = 0.038] and to the second- and third-year fellows (OR 4.3, 95 % CI 0.3–3.1, p = 0.012) (Table 2). Only 11 % (12 of 108) of the survey respondents stated that the institution of ACGME regulations will have a positive impact on the training of surgical oncologists, while close to half (47 %) of the respondents stated that there will be no impact on the training by the addition of ACGME regulations. Thirty percent (32 of 108) of the respondents stated that the regulations will have a negative impact on the training, while 12 % (13 of 108) of the respondents stated that they were not sure (Fig. 1b).
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TABLE 1 Demographics and career goals of respondents Characteristic
Candidates (n = 31)
Fellows (n = 79)
Male
16 (52 %)
45 (58 %)
Female
15 (48 %)
33 (42 %)
Gender
0.564
Training level
NA
First year
36 (46 %)
Second year
36 (46 %)
Third year
6 (8 %)
Training location
NA
Northeast
36 (32 %)
West Coast
15 (19 %)
Midwest South
7 (9 %) 23 (29 %)
Canada
7 (9 %)
General surgery residency
0.555
Community/military hospital
3 (3 %)
5 (6 %)
University/university affiliate
28 (97 %)
73 (94 %)
1 (3 %)
14 (18 %)
International medical graduate (yes)
p
Career plan after fellowship
0.046 1.000
Academic/university affiliate
31 (100 %)
76 (100 %)
Private practice/additional training
0
0
Multiple answer choices were allowed for board preparation and subspecialty; columns thus may not add up to total
Attitudes and Perceptions toward CGSO Certification Seventy-eight percent (85 of 109) of the respondents stated that their decision to enter surgical oncology was not impacted by the creation of new subspecialty certificate in CGSO. However, 78 % (84 of 108) stated that certification of CGSO makes surgical oncology a more attractive subspecialty for general surgery trainees. Furthermore, 86 % (93 of 108) of respondents stated that obtaining board certification in CGSO is important to them and 81 % (87 of 108) stated that board certification in CGSO would help them achieve their career goals. Significantly more candidates stated that obtaining a certification will be help in obtaining their career goals compared to current fellows (94 vs. 73 %, p = 0.020) (Fig. 1c). Significantly more current fellows expressed concerns for the cost of the exam compared to candidates (90 vs. 68 %, p = 0.006). The first-year fellows (OR 3.7, 95 % CI 1.02–13.3, p = 0.0464) as well as the second- and thirdyear fellows (OR 4.5, 95 % CI 1.3–16.2, p = 0.0204) were more likely to state that they were concerned with the cost of the CGSO examination compared to the candidates. Along with a concern for higher cost, there was also a higher level of anxiety regarding the CGSO examination amongst the current trainees compared to the candidates. A significantly higher proportion of the current fellows expressed anxiety regarding the CGSO examination
compared to the candidates (83 vs. 48 %, p \ 0.0003). First-year fellows were 8 times more likely (OR 8.0, 95 % CI 2.3–28.2, p = 0.0012) and second- and third-year fellows were almost 4 times as likely (OR 3.9, 95 % CI 1.4–10.8, p = 0.0087) to state than candidates that they were anxious about passing the CGSO examination (Table 2). Twenty-four percent (25 of 105) of the respondents stated that they did not enter surgical oncology directly from residency. Of these 25 fellows, 12 % (3 of 25) stated that they chose to enter surgical oncology to in order to obtain a certification in GCSO. Additionally, none of these respondents stated that they would pursue additional training or a career in research after completing the surgical oncology fellowship. CGSE Preparation Surgical Oncology Self-Assessment Program (SOSAP) was the most popular method of preparing for the boards examination (78 %), followed by surgical oncology textbooks (65 %), tumor conferences and oncology journals (56 %), and general surgery textbooks (17 %) (Fig. 2a). Seventeen percent (19 of 109) of the respondents replied that they were unsure of how to prepare for the exam. All 31 candidates stated that they would retake the exam if did not pass the first time, while 87 % (67 of 77) of the current
Attitudes of Fellows on ACGME Accreditation
3779
A Aware of recent ACGME accreditation of SSO programs
Aware that graduating from ACGME program leads to CGSO board eligibility
Decision to enter surgical oncology was positively impacted by ACGME accreditation of SSO programs
More Likely to Apply to an ACGME accredited program over nonaccredited program 0%
10%
20%
30%
40%
50%
60%
70%
80%
More Likely to Apply to an ACGME accredited program over nonaccredited program
Decision to enter surgical oncology was positively impacted by ACGME accreditation of SSO programs
Fellows (N=79)
56%
20%
86%
95%
Candidates (N=31)
84%
19%
100%
100%
Aware that graduating from ACGME program leads to CGSO board eligibility
90%
100%
Aware of recent ACGME accreditation of SSO programs
ACGME= Accreditation council for graduate medication education; CGSO= Complex general surgical oncology; SSO= Society of Surgical Oncology.
B Not sure if ACGME will have impact on the training
ACGME regulations will have no impact on the training
ACGME regulations will have a negative impact on the training
ACGME regulations will have a positive impact on the training
0%
10%
20%
30%
40%
50%
ACGME regulations will have a positive impact on the training
ACGME regulations will have a negative impact on the training
ACGME regulations will have no impact on the training
Not sure if ACGME will have impact on the training
Fellows (N=79)
10%
30%
46%
13%
Candidates (N=31)
13%
26%
48%
13%
60%
ACGME= Accreditation council for graduate medical education.
FIG. 1 a Attitudes and perception toward ACGME accreditation. b Attitudes and perception toward ACGME regulations on training. c Attitudes and perceptions toward CGSO certification
fellows stated that they would retake the exam if they did not pass on the first try (p = 0.0352). Career Goals/Attitudes Toward Grandfathering Sixty-four percent (69 of 107) of the respondents stated that they would like to have a career in academic surgery,
while 36 % (38 of 107) stated that they would like to practice in a university-affiliated hospital, described as a mix of university and private hospital model. No respondent expressed a preference for a career limited to private practice. In terms of subspecialization, a higher proportion of the candidates stated that they would like to practice general complex surgical oncology compared to the current
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D. Y. Lee et al.
C Obtaining CGSO board certification will be helpful in obtaining career goals
Obtaining CGSO board certification is important
Creation of CGSO board makes surgical oncology attractive to general surgery trainees
Decision to enter surgical oncology was positively impacted by the creation of CGSO board certification 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Decision to enter surgical oncology was positively impacted by the creation of CGSO board certification
Creation of CGSO board makes surgical oncology attractive to general surgery trainees
Obtaining CGSO board certification is important
Obtaining CGSO board certification will be helpful in obtaining career goals
Fellows (N=79)
23%
75%
53%
73%
Candidates (N=31)
16%
81%
68%
94%
CGSO= Complex general surgical oncology.
FIG. 1 continued
fellows (87 vs. 58 %, p = 0.004). A significantly higher portion of current fellows than candidates expressed interest in subspecialties including melanoma/sarcoma, colorectal, and breast surgery (Fig. 2b). The respondents were split on the issue of grandfathering. Fifty-four percent (59 of 109) of the respondents believed that currently practicing surgical oncologists who completed an SSO-approved fellowship before CGSO accreditation should be grandfathered into CGSO, while 36 % (39 of 109) of the respondents responded that grandfathering should not be allowed. The rest were unsure or declined to answer. DISCUSSION Nearly half of the current fellows believed that the ACGME regulations will not affect the training of surgical oncologists. This finding is not surprising, given that SSO programs have a well-established track record of training surgical oncologists and already have incorporated many of the training components and curriculums of the ACGME.10,13,14 Furthermore, many oncologic cases are electively scheduled, allowing journal clubs and tumor boards to occur during regular work hours, thus conforming trainees’ schedules to the duty hours mandated by the ACGME. Interestingly, candidates expressed a stronger preference for ACGME-accredited programs over nonaccredited programs compared to current fellows’ in-training. This may be a result of the awareness that only fellows graduating from ACGME-accredited programs will be
eligible to sit for the CGSO boards. Currently all of the SSO programs have received ‘‘paper accreditation,’’ and many of the programs are receiving site visits. It will be important for programs to obtain or maintain ACGME accreditation in order to attract the best candidates. In general, the attitude toward CGSO certification was favorable. Although most respondents did not enter the surgical oncology subspecialty in order to specifically obtain the CGSO board certification, there was a perception that the certification would be helpful in obtaining career goals. Also there was a general consensus that the certification will make the specialty more attractive to general surgical trainees. Nearly everyone surveyed stated that they would retake the exam if a passing level was not achieved, highlighting the trainees’ perceived importance of obtaining the certification. As surgical oncology continues to develop as a board-certified subspecialty, the ability to obtain board certification may become a primary motivating factor for entering the subspecialty for future applicants. In terms of career goals, all of the current trainees expressed an interest in an academic or academic-oriented career at a university or university-affiliated hospital setting. This follows the practice pattern of current surgical oncologists who are more likely to be in academic practice and spend more time on research compared to surgeons in other surgical subspecialties.15,16 It appears that surgical oncology trainees are a self-selected group of trainees interested in an academically oriented career. Therefore, it will be important for programs to continue to prepare its trainees to be leaders in the fields of education and research.
0.9 (0.2–3.1)
1.3 (0.4–4.1)
Second or third year
1.2 (0.5–3.1)
Male
1.3 (0.3–4.9)
2.5 (0.6–10.6)
South
West coast
Referent
No
0.4 (0.1–1.2) Referent
Referent
0.9 (0.2–3.6)
2.4 (0.5–11.0)
Referent
1.1 (0.4–3.3)
Referent
1.9 (0.4–8.2)
1.9 (0.5–7.0)
*
Referent
1.0 (0.4–2.4)
Referent
1.6 (0.5–5.4)
1.5 (0.4–5.3)
Referent
Referent
Referent
Referent
3.1 (0.4–25.4)
0.6 (0.1–3.1)
Referent
1.5 (0.3–6.5)
Referent
*
1.0 (0.1–7.7)
0.2 (0.0–1.5)
Referent
1.3 (0.5–3.6)
Referent
Referent
0.5 (0.2–1.6)
0.3 (0.1–1.4)
Referent
1.3 (0.4–4.2)
Referent
0.9 (0.1–6.3)
0.7 (0.1–3.6)
0.3 (0.1–1.7)
Referent
1.2 (0.5–2.8)
Referent
Referent
1.1 (0.2–5.8)
Not possible
Referent
2.7 (0.5–13.9)
Referent
4.0 (0.6–25.3)
1.6 (0.2–10.4)
*
Referent
0.8 (0.2–2.5)
Referent
4.5 (1.3–16.2)* 3.9 (1.4–10.8) * 0.5 (0.1–2.5)
1.4 (0.3–7.1)
0.4 (0.1–1.7)
Referent
1.1 (0.4–2.8)
Referent
0.2 (0.0–0.95)*
0.2 (0.1–1.2)
Referent
Referent
0.2 (0.07–0.8)
1.1 (0.1–9.9)
Referent
2.7 (0.8–9.3)
Referent
Referent
0.6 (0.2–2.2)
0.7 (0.1–3.7)
Referent
1.1 (0.4–3.0)
Referent
Referent
1.5 (0.5–4.5)
3.9 (0.9–17.6)
Referent
0.7 (0.3–1.7)
Referent
1.6 (0.4–7.7)
2.1 (0.5–8.3)
0.7 (0.2–3.0)
Referent
1.3 (0.6–2.9)
Referent
1.4 (0.5–3.8)
0.5 (0.2–1.6)
Referent
Obtaining CGSO Agree with grand will help with fathering career goals
3.5 (1.2–10.2)* 2.8 (0.3–28.0)
7.3 (0.9–61.1)
1.6 (0.6–4.1)
Referent
0.9 (0.3–2.6)
Referent
0.3 (0.1–1.8)
0.3 (0.1–1.8)
Referent
Obtaining ACGME regulations will CGSO board positively affect is important SOFP
3.7 (1.0–13.3)* 8.0 (2.3–28.2) * 1.1 (0.3–4.6)
Referent
Anxious about passing CGSO board
* p \ 0.05
ACGME Accreditation Council for Graduate Medical Education, CGSO Complex General Surgical Oncology, SOFP Surgical Oncology Fellowship Program, IMG international medical graduate, PGY postgraduate year, Affiliate university affiliate
Data are expressed as odds ratio (95 % confidence interval)
0.2 (0.03–1.9)
Yes
IMG
Referent 0.5 (0.1–2.2)
1.2 (0.2–6.8)
Military/community
1.1 (0.4–2.8)
Referent
1.4 (0.4–5.5)
1.0 (0.3–3.2)
0.5 (0.1–2.0)
Referent
1.9 (0.8–4.2)
Referent
0.2 (0.1–0.7)*
0.3 (0.1–0.9)*
Referent
University/university affiliate Referent
Residency type
University/university affiliate 1.9 (0.6–6.1)
Independent cancer center
Referent
*
Canada/midwest
Type of training program
Referent
Northeast
Region
Referent
Female
Gender
Referent
First year
Concerned More likely to More likely to More likely to apply to surgical with cost apply to an enter surgical of exam oncology due oncology specialty ACGMEto boards accredited program
Candidate
Training level
Characteristic
TABLE 2 Odds of agreeing with the following statements regarding ACGME Accreditation of Surgical Oncology Fellowship Programs and board certification
Attitudes of Fellows on ACGME Accreditation 3781
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D. Y. Lee et al.
A Soft Tissue/Melanoma Colorectal Surgery Endocrine/Head and Neck Breast Complex Upper GI Hepatobiliary General Complex Surgical Oncology 0%
Fellows (N=79) Candidates (N=31)
General Complex Surgical Oncology 58% 87%
10% Hepatobiliary 34% 23%
20%
30%
40%
Complex Upper GI 28%
50%
Breast 20%
16%
60%
70%
Endocrine/Head and Neck 10%
0%
80% Colorectal Surgery 16%
0%
90%
100%
Soft Tissue/Melanoma 33%
0%
6%
Candidates were allowed to choose more than one subspecialty, p
