LETTER TO THE EDITOR Issues With “Issues in General Surgery Residency Training—2012” To the Editor: e read with great interest the opinion article, titled “Issues in General Surgery Residency Training—2012,” by Drs Lewis and Klingensmith.1 Although we agree that the landscape of general surgical training has changed significantly in the past 2 decades for many of the reasons outlined in their article, we take issue with several of the opinions put forth in the context of advanced laparoscopic surgical training. The authors comment that surgical residents have lost significant operative experience in open abdominal procedures and that this experience has not been replaced with a comparable experience in complex laparoscopic abdominal surgery due, in part, to the development of laparoscopic surgery fellowships. To our knowledge, there are no clear data to support this statement. Previous reports have supported the contrary, having indicated that although open abdominal cases have decreased, overall resident case volume has remained relatively stable and the effects of establishing a fellowship program on resident case volume are minimal.2,3 Case volume is only one metric, and the potential educational benefits of fellows and residents operating together are more challenging to objectively evaluate but equally important. Establishing clear expectations before cases and an excellent working relationship between residency and fellowship directors can result in a mutually beneficial experience for both residents and fellows. Many pioneers in advancing minimally invasive surgical (MIS) techniques came from the private sector, as noted by Lewis and Klingensmith. This, however, in no way diminishes their contributions to advancing the field of advanced laparoscopic surgery. Many of these pioneers were the first to recognize a gap in surgical training and developed MIS fellowships. Over time, these leaders in the field saw the benefits of a more formal matching process, including oversight, and the Fellowship Council was born.4 To say that “ . . . this entire system operates out-
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Disclosure: Dr Kothari serves as a preceptor for Torax Medical Inc (Shoreview, MN). Dr Ponce serves as a consultant for Allergan Inc (Irvine, CA), Vibrynt Inc (Redwood City, CA), and ReShape Medical (San Clemente, CA). C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26104-e0113 DOI: 10.1097/SLA.0000000000000501
side any regulatory framework . . . ” is erroneous. Today, the Fellowship Council has representatives from the major gastrointestinal surgical societies, including the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons, the Society for Surgery of the Alimentary Tract, the Americas Hepato-Pancreato-Biliary Association, and the American Society of Colon and Rectal Surgeons, and overseas accreditation of more than 145 fellowships with emphasis on bariatric/metabolic, endoscopic, hepatobiliary, colorectal, and thoracic surgery. Drs Lewis and Klingensmith referenced a landmark survey by Yeo et al5 but failed to mention that 27.5% of resident respondents agreed with the statement: “I worry that I will not feel confident enough to perform procedures by myself before I finish training.” This is similar to a survey of MIS fellows in which 19% stated that they pursued an MIS fellowship to compensate for a lack of exposure and/or case volume during residency.6 In another survey, MIS fellows were asked to estimate the number of procedures that were necessary to perform to obtain competence. For the majority of advanced laparoscopic procedures, the respondents’ estimated number far exceeded the mean number of ACGME-documented cases.7 The benefits of MIS fellowships have been supported by survey data in which most fellows reported high overall satisfaction, with 85% reporting that their fellowship met their expectations,7 75% felt that their fellowship training was extremely beneficial, and 86% would recommend their former fellowship to future applicants without reservation.6 In addition, in an era of transparency and evidence-based outcomes, there are several reports demonstrating the benefits of fellowship training in eliminating the learning curve for complex laparoscopic procedures.8,9 With regard to funding, the authors are correct in that years past many advanced laparoscopic surgery fellowships were funded directly by industry. However, to state that “the availability of such funding continues to the present and operates outside any regulatory framework related to surgical education” is erroneous. Both industry and fellowship directors saw the potential conflict with direct funding and sought a mutually beneficial solution. The Foundation for Surgical Fellowships, founded in 2009, is an independent board that oversees the funding of the bulk of these fellowships. Grants are awarded on an annual basis, based on blinded applications and a rigorous review process by the board. The Fellowship Council, industry, and private individuals donate to the Foundation for Surgical Fellowships but have no direct say as to where the monies can be allocated.
Annals of Surgery r Volume 261, Number 4, April 2015
The authors concluded that “ . . . .perhaps additional training is needed.” In the face of the current duty-hour restrictions imposed on residents, we could not agree more. Clearly, there is a gap in the knowledge base, technical skills, competency, and confidence of many graduating surgical residents in the United States today. Currently, fellowships, under the oversight of the Fellowship Council, are addressing this gap. It is hoped that ongoing dialogue between the Fellowship Council and the American Board of Surgery will result in a mutually beneficial training model for the future of surgical education. Shanu N. Kothari, MD, FACS Minimally Invasive Bariatric and Advanced Laparoscopy Fellowship Department of General and Vascular Surgery Gundersen Health System La Crosse, WI [email protected] Jaime Ponce, MD, FACS, FASMBS Department of Bariatric Surgery Hamilton Medical Center Dalton, GA Memorial Hospital Chattanooga, TN
REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery residency training—2012. Ann Surg. 2012;256:553–559. 2. Carson JS, Smith L, Are M, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development? Am J Surg. 2011;202:720–726. 3. Kothari SN, Cogbill TH, O’Heron CT, et al. Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience. J Surg Educ. 2008;65:393–396. 4. Swanstrom LL, Park A, Arregui M, et al. Bringing order to the chaos: developing a matching process for minimally invasive and gastrointestinal postgraduate fellowships. Ann Surg. 2006;243:431– 435. 5. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents. JAMA. 2009;302:1301– 1308. 6. Grover BT, Kothari SN, Kallies KJ, et al. Benefits of laparoscopic fellowship training: a survey of former fellows. Surg Innov. 2009;16:283–288. 7. Park A, Kavic SM, Lee TH, et al. Minimally invasive surgery: the evolution of fellowship. Surgery. 2007;142:505–511. 8. Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc. 2010;24:138–144. 9. Kothari SN, Boyd WC, Larson CA, et al. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg. 2005;15:323–329.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Disclosure: Dr Kothari serves as a preceptor for Torax Medical Inc (Shoreview, MN). Dr Ponce serves as a consultant for Allergan Inc (Irvine, CA), Vibrynt Inc (Redwood City, CA), and ReShape Medical (San Clemente, CA). C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26104-e0113 DOI: 10.1097/SLA.0000000000000501
side any regulatory framework . . . ” is erroneous. Today, the Fellowship Council has representatives from the major gastrointestinal surgical societies, including the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons, the Society for Surgery of the Alimentary Tract, the Americas Hepato-Pancreato-Biliary Association, and the American Society of Colon and Rectal Surgeons, and overseas accreditation of more than 145 fellowships with emphasis on bariatric/metabolic, endoscopic, hepatobiliary, colorectal, and thoracic surgery. Drs Lewis and Klingensmith referenced a landmark survey by Yeo et al5 but failed to mention that 27.5% of resident respondents agreed with the statement: “I worry that I will not feel confident enough to perform procedures by myself before I finish training.” This is similar to a survey of MIS fellows in which 19% stated that they pursued an MIS fellowship to compensate for a lack of exposure and/or case volume during residency.6 In another survey, MIS fellows were asked to estimate the number of procedures that were necessary to perform to obtain competence. For the majority of advanced laparoscopic procedures, the respondents’ estimated number far exceeded the mean number of ACGME-documented cases.7 The benefits of MIS fellowships have been supported by survey data in which most fellows reported high overall satisfaction, with 85% reporting that their fellowship met their expectations,7 75% felt that their fellowship training was extremely beneficial, and 86% would recommend their former fellowship to future applicants without reservation.6 In addition, in an era of transparency and evidence-based outcomes, there are several reports demonstrating the benefits of fellowship training in eliminating the learning curve for complex laparoscopic procedures.8,9 With regard to funding, the authors are correct in that years past many advanced laparoscopic surgery fellowships were funded directly by industry. However, to state that “the availability of such funding continues to the present and operates outside any regulatory framework related to surgical education” is erroneous. Both industry and fellowship directors saw the potential conflict with direct funding and sought a mutually beneficial solution. The Foundation for Surgical Fellowships, founded in 2009, is an independent board that oversees the funding of the bulk of these fellowships. Grants are awarded on an annual basis, based on blinded applications and a rigorous review process by the board. The Fellowship Council, industry, and private individuals donate to the Foundation for Surgical Fellowships but have no direct say as to where the monies can be allocated.
Annals of Surgery r Volume 261, Number 4, April 2015
The authors concluded that “ . . . .perhaps additional training is needed.” In the face of the current duty-hour restrictions imposed on residents, we could not agree more. Clearly, there is a gap in the knowledge base, technical skills, competency, and confidence of many graduating surgical residents in the United States today. Currently, fellowships, under the oversight of the Fellowship Council, are addressing this gap. It is hoped that ongoing dialogue between the Fellowship Council and the American Board of Surgery will result in a mutually beneficial training model for the future of surgical education. Shanu N. Kothari, MD, FACS Minimally Invasive Bariatric and Advanced Laparoscopy Fellowship Department of General and Vascular Surgery Gundersen Health System La Crosse, WI [email protected] Jaime Ponce, MD, FACS, FASMBS Department of Bariatric Surgery Hamilton Medical Center Dalton, GA Memorial Hospital Chattanooga, TN
REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery residency training—2012. Ann Surg. 2012;256:553–559. 2. Carson JS, Smith L, Are M, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development? Am J Surg. 2011;202:720–726. 3. Kothari SN, Cogbill TH, O’Heron CT, et al. Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience. J Surg Educ. 2008;65:393–396. 4. Swanstrom LL, Park A, Arregui M, et al. Bringing order to the chaos: developing a matching process for minimally invasive and gastrointestinal postgraduate fellowships. Ann Surg. 2006;243:431– 435. 5. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents. JAMA. 2009;302:1301– 1308. 6. Grover BT, Kothari SN, Kallies KJ, et al. Benefits of laparoscopic fellowship training: a survey of former fellows. Surg Innov. 2009;16:283–288. 7. Park A, Kavic SM, Lee TH, et al. Minimally invasive surgery: the evolution of fellowship. Surgery. 2007;142:505–511. 8. Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc. 2010;24:138–144. 9. Kothari SN, Boyd WC, Larson CA, et al. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg. 2005;15:323–329.
www.annalsofsurgery.com | e113
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
