ORIGINAL REPORTS
The Current State of Hepatopancreatobiliary Fellowship Experience in North America Dhiresh Rohan Jeyarajah, MD, Shirali Patel, MD and Houssam Osman, MD Section of HPB Surgery, Methodist Dallas Medical Center, Dallas, Texas
AIM: The face of hepatopancreatobiliary (HPB) training has changed over the past decade. The growth of focused HPB fellowships, which are vetted with a rigorous accreditation process through the Fellowship Council (FC), has established them as an attractive mode of training in HPB surgery. This study looks at the volumes of HPB cases performed during these fellowships in North America. METHODS: After approval by the FC research committee,
data from all HPB fellowships that had 3 years worth of complete fellow case log data were tabulated and reported (n ¼ 12). For 2-year fellowships, the fellow logs were tabulated at the completion of both years. Those programs that had transplant experience (n ¼ 9) were reported. RESULTS: Data for the current fellows’ case numbers show
that graduating fellows have a median of 26 biliary cases, 19 major liver cases (hemilivers), 28 other liver cases, 40 pancreaticoduodenectomies,18 distal pancreatectomies, and 9 other pancreas cases. The programs that provided transplantation experience had 10 cases for each fellow. CONCLUSION: This study validates that FC-accredited
HPB fellowships have a robust exposure to complex HPB surgery. Fellows completing these fellowships should be well versed in the management and surgical treatment of HPB C 2014 Published by Elsevier patients. ( J Surg 72:144-147. J Inc. on behalf of the Association of Program Directors in Surgery) KEY WORDS: hepatopancreatobiliary, HPB fellowship,
pancreas, surgical training, education COMPETENCIES: Patient Care, Medical Practice-Based Learning and Improvement
Knowledge,
This work was presented at the AHPBA meeting in Miami, FL as an oral presentation. Correspondence: Inquiries to Dhiresh Rohan Jeyarajah, MD, 221 W Colorado Blvd, Pavilion 2, Suite 933, Dallas, TX 75208; fax: (214) 272-8985; E-mail: [email protected], [email protected]
144
INTRODUCTION With the advent of resident work-hours restriction in 2002,1 general surgery residency has changed. Currently, more than 80% of graduating general surgery residents pursue fellowship training.2 There has been a gradual move toward organ-based and disease-based training with the increase in technical and medical knowledge and skill that is needed to treat various conditions. With these changes, there has been an increased emphasis on focused training in diseases of the liver, biliary tree, and pancreas. Some hepatopancreatobiliary (HPB) fellowships were started in the 1990s; however, there was no mechanism for accreditation and the standards were not clearly set. With the advent of minimally invasive (MIS) techniques, the Fellowship Council (FC) was codified in the 1990s. This society initially provided a mechanism for creating standards for MIS fellowships. Laparoscopy was a novel and innovative technique that was the initial focus of savant surgeons within the FC who wanted to train the next generation in these MIS skills. The reach of the FC has grown: this organization now includes most of the non– Accreditation Council for Graduate Medical Education surgical fellowships in North America, including MIS, bariatric, MIS-colorectal, HPB, MIS-thoracic, and laproendoscopic fellowships. Most fellowship types have a sponsoring society and Americas Hepato-Pancreato-Biliary Association (AHPBA) is the sponsoring society for HPB fellowships. The sponsoring society develops the specific accreditation guidelines that are to be used by the accreditation committee of the FC in their review of each fellowship program. As such, the AHPBA guidelines were developed to accredit HPB fellowships. These guidelines use case volume as a metric to measure fellow experience during the HPB fellowship. The case requirements include a total of at least 100 advanced HPB cases, which must include at least 25 pancreas cases, 15 biliary cases, and 25 liver cases, of which at least 15 must be hemilivers.3 The fellow who has completed an HPB fellowship is then allowed to apply for a certificate of completion of training that is provided by the AHPBA through its Education and Training committee. The aim of this study was to evaluate the status of HPB fellowships in North America, specifically
Journal of Surgical Education & 2014 Published by Elsevier Inc. on behalf of the 1931-7204/$30.00 Association of Program Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2014.07.006
with regard to case volume requirements. The hypothesis was that HPB fellowships were providing excellent case volumes to their trainees.
METHODS Institutional review board approval was obtained through the Methodist Health System Institutional Review Board committee. Permission to query the fellow case logs was obtained from the FC research committee. All HPB fellowships registered with the FC were queried. Only those fellowships with 3 years’ worth of data after accreditation were used in the data analysis. Case logs in 2-year fellowships were queried at the completion of both years of fellowship training. There were three 2-year fellowships where the data were incomplete, and so data were available for 2 graduating fellows in each of these programs. Results were tabulated and reported. There are 20 total accredited HPB fellowships in North America (USA and Canada) currently. Of these, 10 fellowships are 2 years in duration and 10 are 1 year in duration. In addition, there is a mechanism by which American Society of Transplant Surgeons (ASTS) transplant fellowships can receive joint accreditation through the FC. There are 2 joint ASTS-FC HPB fellowships. Similarly, there are 3 joint Society for Surgical Oncology (SSO)-FC HPB fellowships. These joint fellowships have to meet the accreditation requirements of their sponsoring society as well as the FC. The FC fellow is required to log their cases through the FC website, and these results are monitored and tracked by the FC accreditation committee.
RESULTS A total of 12 programs were found to have complete data sets for 3 years of fellow case logs. The data is shown in the Figure. Each fellow log is represented by the bar line shown. Table 1 is a summary of case volumes broken up by category. Additionally, the FC case volume requirements are listed for reference.
FIGURE. Case volumes by HPB fellowship programs. liv-maj, hemiliver; liv-min, less than 2 segments; Tx, transplant; panc-PD, pancreaticoduodenectomy; DP, distal pancreatectomy; other, other complex HPB cases.
TABLE 1. Case Volume by Procedure in HPB Fellowships (Median With Standard Deviation) Case Type
Median
Standard Deviation
Fellowship Council Requirement
26 19
10.78 17.66
15 15
28
17.35
Total liver, 25
40 18
14.35 10.13
Total panc, 25 Total panc, 25
10 9
18.90 11.68
Not required Total cases 4100
Biliary Liver— major Liver— minor Panc-PD Distal panc Transplant Other
Panc-PD, pancreaticoduodenectomy.
The results show that the median number of biliary cases is 26 (standard deviation [SD] ¼ 10.78) and the median number of major liver resections (data for hemiliver only included here) is 19 (SD ¼ 17.66). The FC minimal of hemilivers is set at 15 cases. This criterion was introduced separately to total liver numbers. The AHPBA education and training committee members felt that there was a need to ensure fellowship training in hemiliver resection from a technical standpoint. It is noteworthy that these numbers have been declining slightly with the rise of parenchymal-sparing techniques. Some would argue that a posterior-section resection is tougher than a formal hemi–right liver resection. This is an ongoing topic of debate. The median number of minor liver resections was 28 (SD ¼ 17.35). These included resections of equal or less than 2 segments. Unroofing of liver cysts and lesser procedures were generally included in the “other” category. Pancreaticoduodenectomy volume was 40 (SD ¼ 14.35), while distal pancreatectomy volume was 18 (SD ¼ 10.13). The FC requirement for pancreas is 25 cases. It is interesting that there was a preponderance of Pancreaticoduodenectomy cases over distal pancreatectomy cases. This would certainly fit with the presentation of malignant pancreatic disease; however, intraductal papillary mucinous neoplasm and neuroendocrine presentation should be somewhat similar in disease location. The volume data might suggest that most pancreatic resections are being performed for malignant disease. Data comparing the 2-year programs with the 1-year programs are presented in Table 2. These data show that the main difference in experience is in the liver and transplant domains. The volume experience in pancreatic resections is surprisingly similar between the 1- and 2-year fellowships. Of the six 2-year fellowships, 3 have dedicated research experience for 1 year, effectively making the clinical fellowship 1 year long. However, according to their websites, there is some clinical responsibility even during the research time. Of the six 2-year fellowships, 2 had a focus on liver transplantation, and this helped explain their high liver transplant and liver resection volumes. Of the 2-year programs, 1 had a focus on other oncologic diseases, making the effective HPB experience more comparable to a 1-year fellowship.
Journal of Surgical Education Volume 72/Number 1 January/February 2015
145
TABLE 2. Mean Case Volume by Procedure and by Number of Year of Fellowship—1-Year Compared With 2-Year Programs Case Type Biliary Liver— major Liver— minor Panc-PD Distal panc Transplant Other
1-Year 2-Year Fellowship Fellowships Fellowships Council (n ¼ 6) (n ¼ 6) Requirement 25.55 17.61
26.17 37.06
15 15
28.05
37.94
Total liver, 25
40.11 20.95
38.95 15.89
Total panc, 25 Total panc, 25
7.73 13.08
34.39 16.36
Not required Total cases 4100
Panc-PD, pancreaticoduodenectomy.
Data regarding ultrasound experience are not presented here. There is no set ultrasound volume requirement, although this has been an area of much focus. All fellows are exposed to the utilization of ultrasound in the fellowship time, and the cases they perform are logged on the FC website, with greater clarity in the last 2 years. This focus is one that has increased with the development of a specific HPB ultrasound course by the AHPBA. Ultrasound will likely become a metric required for accreditation in the future.
DISCUSSION This study is the first of its kind to clearly describe the case volumes for fellows in liver, pancreas, and biliary surgery in dedicated HPB fellowships. These data would suggest that HPB fellowship training provides an extremely robust case experience for those planning a career in HPB surgery. The training paradigm has changed over the past 15 years with the advent of specialization and surgical fellowships. The paradigm in the 1990s was that all general surgeons were well trained and competent to operate on all areas of surgery; this would include vascular, colorectal, breast surgery, and HPB surgery. The 2000s brought the institution of the 80-hour work week along with a change in surgical culture. Some of this was indeed needed, as the long work hours of the past were less than humane. The change in generational attitudes has also molded trainees’ desire to pursue fellowship training. Trainees desire postresidency training for many reasons. A primary reason listed by trainees was that they wanted to master a specific area of surgery.2 Breast, colorectal, and vascular surgeries have now become their own entities, and HPB surgery has begun this journey. The aim of this study was to examine the case experience that HPB fellows obtained during their fellowship time. The results suggest that their experience is robust. 146
It is of interest that 1- and 2-year fellowships both provided excellent experience in HPB surgery. The main areas of difference were the transplant and liver resection domains. This was likely driven by the fact that some of these 2-year programs were heavily weighted toward a liver transplant experience. To place the data presented in this article in perspective, one must look at the experience of graduating chief residents in HPB surgery. An article by the Pawlik group examined this very question.4 They found that there had been a slight increase in liver volume over the period studied from 2003 to 2012, with a current median liver case volume of 8.0 (5.14) and mean liver volume of 9.4 (SD ¼ 3.4). The median pancreatic case volume for graduating chief residents was 8.0 (4.20) and the mean case volume was 11.3 (SD ¼ 4.3). The mean biliary volume was 3.8 (SD ¼ 2.1). The authors found that 50% of graduating chief residents had performed fewer than 10 HPB cases at the time of graduation. These data would suggest that HPB experience during residency is inadequate to prepare general surgery residents for a HPB surgical practice. The importance of the nonoperative care of the HPB patient is an area that is focused on during fellowship. The choice of which patient requires a major HPB surgery is as important as the technical aspect of the surgery itself. Recognition of complications after major HPB surgery is critical to the outcome of the patient. Many of these nonoperative aspects to surgery have been “squeezed” with the focus on residency work hours. Time in clinic and immersion in the postoperative care of these complex patients has been compromised, with a focus on counting the case experience as the major metric. This area of nonoperative assessment and care of the HPB patient is a key component of HPB fellowship training. To truly understand these data completely, it is important to provide a comparison with other potential pathways of training in HPB surgery: the SSO and the ASTS have potential pathways for training in HPB surgery. The SSO required a total of 150 cancer-related cases, of which 15 have to be gastrointestinal cancer cases.5 The ASTS defines potential pathways for training in HPB surgery: heptaobiliary includes 35 liver cases, of which 15 are biliary cases and 15 are major liver resections and HPB includes heptaobiliary and 15 pancreas cases.6 Many ASTS and SSO training programs provide much greater exposure to HPB surgery, and some can provide an experience that is similar to that shown in this article. The FC-HPB accreditation guidelines call for a more robust case experience than any of the other possible training pathways; the data presented here show that the experience of FC-HPB fellows is robust and clearly adheres to these guidelines. It is important to understand that there is more to surgical training than just technical experience. The SSO pathway, for example, clearly defines nonsurgical rotations that are critical to the understanding of the oncology
Journal of Surgical Education Volume 72/Number 1 January/February 2015
patient. The ASTS pathway provides an excellent understanding of chronic liver disease and immunosuppression. The FC guidelines have focused on these nonsurgical aspects of HPB surgery and the accreditation process pays careful attention to these parameters. For example, the HPB fellows must participate in an outpatient experience where patients with complex HPB diseases are seen and discussed in a multidisciplinary manner. The program must provide exposure to both benign and malignant diseases. There is discussion about whether nonoperative management of HPB disease should be specifically tracked and included in the FC accreditation requirements. Other specific areas of exposure include the use of ultrasound in HPB surgery and experience with interventional radiology and advance GI techniques in managing the complex HPB patient. The role of ultrasound training has been taken seriously by the AHPBA, and there has been the development of a HPB ultrasound course that fellows are encouraged to take. Metrics for measurement of ultrasound experience are being defined. More accurate recording of ultrasound experience is now being required through the FC case log system. In summary, the AHPBA-sponsored FC-HPB programs provide an excellent operative experience for fellows training in HPB surgery. This study demonstrates that there is excellent adherence to FC accreditation and requirements.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
Report of the ACGME Work Group on Resident Duty Hours. Chicago, IL: ACGME; 2002. 2. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV.
Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216(4):764-771. 3. Fellowship Council Accreditation Guidelines and Def-
initions. Available at: 〈https://fellowshipcouncil.org〉; February 2013 [update]. 4. Sachs T, Ejaz A, Weiss M, et al. Assessing the experience
in complex HPB surgery among graduating chief residents: is the operative experience enough? Surgery. 2014;156(2):385-393. 5. Society of Surgical Oncology. Available at: 〈http://sur
gonc.org/training-education/surgical-oncology/programrequirements〉. 6. American Society of Transplant Surgeons. Available at:
〈http://asts.org/education/fellowship-resources/accredita tion〉.
Journal of Surgical Education Volume 72/Number 1 January/February 2015
147
The Current State of Hepatopancreatobiliary Fellowship Experience in North America Dhiresh Rohan Jeyarajah, MD, Shirali Patel, MD and Houssam Osman, MD Section of HPB Surgery, Methodist Dallas Medical Center, Dallas, Texas
AIM: The face of hepatopancreatobiliary (HPB) training has changed over the past decade. The growth of focused HPB fellowships, which are vetted with a rigorous accreditation process through the Fellowship Council (FC), has established them as an attractive mode of training in HPB surgery. This study looks at the volumes of HPB cases performed during these fellowships in North America. METHODS: After approval by the FC research committee,
data from all HPB fellowships that had 3 years worth of complete fellow case log data were tabulated and reported (n ¼ 12). For 2-year fellowships, the fellow logs were tabulated at the completion of both years. Those programs that had transplant experience (n ¼ 9) were reported. RESULTS: Data for the current fellows’ case numbers show
that graduating fellows have a median of 26 biliary cases, 19 major liver cases (hemilivers), 28 other liver cases, 40 pancreaticoduodenectomies,18 distal pancreatectomies, and 9 other pancreas cases. The programs that provided transplantation experience had 10 cases for each fellow. CONCLUSION: This study validates that FC-accredited
HPB fellowships have a robust exposure to complex HPB surgery. Fellows completing these fellowships should be well versed in the management and surgical treatment of HPB C 2014 Published by Elsevier patients. ( J Surg 72:144-147. J Inc. on behalf of the Association of Program Directors in Surgery) KEY WORDS: hepatopancreatobiliary, HPB fellowship,
pancreas, surgical training, education COMPETENCIES: Patient Care, Medical Practice-Based Learning and Improvement
Knowledge,
This work was presented at the AHPBA meeting in Miami, FL as an oral presentation. Correspondence: Inquiries to Dhiresh Rohan Jeyarajah, MD, 221 W Colorado Blvd, Pavilion 2, Suite 933, Dallas, TX 75208; fax: (214) 272-8985; E-mail: [email protected], [email protected]
144
INTRODUCTION With the advent of resident work-hours restriction in 2002,1 general surgery residency has changed. Currently, more than 80% of graduating general surgery residents pursue fellowship training.2 There has been a gradual move toward organ-based and disease-based training with the increase in technical and medical knowledge and skill that is needed to treat various conditions. With these changes, there has been an increased emphasis on focused training in diseases of the liver, biliary tree, and pancreas. Some hepatopancreatobiliary (HPB) fellowships were started in the 1990s; however, there was no mechanism for accreditation and the standards were not clearly set. With the advent of minimally invasive (MIS) techniques, the Fellowship Council (FC) was codified in the 1990s. This society initially provided a mechanism for creating standards for MIS fellowships. Laparoscopy was a novel and innovative technique that was the initial focus of savant surgeons within the FC who wanted to train the next generation in these MIS skills. The reach of the FC has grown: this organization now includes most of the non– Accreditation Council for Graduate Medical Education surgical fellowships in North America, including MIS, bariatric, MIS-colorectal, HPB, MIS-thoracic, and laproendoscopic fellowships. Most fellowship types have a sponsoring society and Americas Hepato-Pancreato-Biliary Association (AHPBA) is the sponsoring society for HPB fellowships. The sponsoring society develops the specific accreditation guidelines that are to be used by the accreditation committee of the FC in their review of each fellowship program. As such, the AHPBA guidelines were developed to accredit HPB fellowships. These guidelines use case volume as a metric to measure fellow experience during the HPB fellowship. The case requirements include a total of at least 100 advanced HPB cases, which must include at least 25 pancreas cases, 15 biliary cases, and 25 liver cases, of which at least 15 must be hemilivers.3 The fellow who has completed an HPB fellowship is then allowed to apply for a certificate of completion of training that is provided by the AHPBA through its Education and Training committee. The aim of this study was to evaluate the status of HPB fellowships in North America, specifically
Journal of Surgical Education & 2014 Published by Elsevier Inc. on behalf of the 1931-7204/$30.00 Association of Program Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2014.07.006
with regard to case volume requirements. The hypothesis was that HPB fellowships were providing excellent case volumes to their trainees.
METHODS Institutional review board approval was obtained through the Methodist Health System Institutional Review Board committee. Permission to query the fellow case logs was obtained from the FC research committee. All HPB fellowships registered with the FC were queried. Only those fellowships with 3 years’ worth of data after accreditation were used in the data analysis. Case logs in 2-year fellowships were queried at the completion of both years of fellowship training. There were three 2-year fellowships where the data were incomplete, and so data were available for 2 graduating fellows in each of these programs. Results were tabulated and reported. There are 20 total accredited HPB fellowships in North America (USA and Canada) currently. Of these, 10 fellowships are 2 years in duration and 10 are 1 year in duration. In addition, there is a mechanism by which American Society of Transplant Surgeons (ASTS) transplant fellowships can receive joint accreditation through the FC. There are 2 joint ASTS-FC HPB fellowships. Similarly, there are 3 joint Society for Surgical Oncology (SSO)-FC HPB fellowships. These joint fellowships have to meet the accreditation requirements of their sponsoring society as well as the FC. The FC fellow is required to log their cases through the FC website, and these results are monitored and tracked by the FC accreditation committee.
RESULTS A total of 12 programs were found to have complete data sets for 3 years of fellow case logs. The data is shown in the Figure. Each fellow log is represented by the bar line shown. Table 1 is a summary of case volumes broken up by category. Additionally, the FC case volume requirements are listed for reference.
FIGURE. Case volumes by HPB fellowship programs. liv-maj, hemiliver; liv-min, less than 2 segments; Tx, transplant; panc-PD, pancreaticoduodenectomy; DP, distal pancreatectomy; other, other complex HPB cases.
TABLE 1. Case Volume by Procedure in HPB Fellowships (Median With Standard Deviation) Case Type
Median
Standard Deviation
Fellowship Council Requirement
26 19
10.78 17.66
15 15
28
17.35
Total liver, 25
40 18
14.35 10.13
Total panc, 25 Total panc, 25
10 9
18.90 11.68
Not required Total cases 4100
Biliary Liver— major Liver— minor Panc-PD Distal panc Transplant Other
Panc-PD, pancreaticoduodenectomy.
The results show that the median number of biliary cases is 26 (standard deviation [SD] ¼ 10.78) and the median number of major liver resections (data for hemiliver only included here) is 19 (SD ¼ 17.66). The FC minimal of hemilivers is set at 15 cases. This criterion was introduced separately to total liver numbers. The AHPBA education and training committee members felt that there was a need to ensure fellowship training in hemiliver resection from a technical standpoint. It is noteworthy that these numbers have been declining slightly with the rise of parenchymal-sparing techniques. Some would argue that a posterior-section resection is tougher than a formal hemi–right liver resection. This is an ongoing topic of debate. The median number of minor liver resections was 28 (SD ¼ 17.35). These included resections of equal or less than 2 segments. Unroofing of liver cysts and lesser procedures were generally included in the “other” category. Pancreaticoduodenectomy volume was 40 (SD ¼ 14.35), while distal pancreatectomy volume was 18 (SD ¼ 10.13). The FC requirement for pancreas is 25 cases. It is interesting that there was a preponderance of Pancreaticoduodenectomy cases over distal pancreatectomy cases. This would certainly fit with the presentation of malignant pancreatic disease; however, intraductal papillary mucinous neoplasm and neuroendocrine presentation should be somewhat similar in disease location. The volume data might suggest that most pancreatic resections are being performed for malignant disease. Data comparing the 2-year programs with the 1-year programs are presented in Table 2. These data show that the main difference in experience is in the liver and transplant domains. The volume experience in pancreatic resections is surprisingly similar between the 1- and 2-year fellowships. Of the six 2-year fellowships, 3 have dedicated research experience for 1 year, effectively making the clinical fellowship 1 year long. However, according to their websites, there is some clinical responsibility even during the research time. Of the six 2-year fellowships, 2 had a focus on liver transplantation, and this helped explain their high liver transplant and liver resection volumes. Of the 2-year programs, 1 had a focus on other oncologic diseases, making the effective HPB experience more comparable to a 1-year fellowship.
Journal of Surgical Education Volume 72/Number 1 January/February 2015
145
TABLE 2. Mean Case Volume by Procedure and by Number of Year of Fellowship—1-Year Compared With 2-Year Programs Case Type Biliary Liver— major Liver— minor Panc-PD Distal panc Transplant Other
1-Year 2-Year Fellowship Fellowships Fellowships Council (n ¼ 6) (n ¼ 6) Requirement 25.55 17.61
26.17 37.06
15 15
28.05
37.94
Total liver, 25
40.11 20.95
38.95 15.89
Total panc, 25 Total panc, 25
7.73 13.08
34.39 16.36
Not required Total cases 4100
Panc-PD, pancreaticoduodenectomy.
Data regarding ultrasound experience are not presented here. There is no set ultrasound volume requirement, although this has been an area of much focus. All fellows are exposed to the utilization of ultrasound in the fellowship time, and the cases they perform are logged on the FC website, with greater clarity in the last 2 years. This focus is one that has increased with the development of a specific HPB ultrasound course by the AHPBA. Ultrasound will likely become a metric required for accreditation in the future.
DISCUSSION This study is the first of its kind to clearly describe the case volumes for fellows in liver, pancreas, and biliary surgery in dedicated HPB fellowships. These data would suggest that HPB fellowship training provides an extremely robust case experience for those planning a career in HPB surgery. The training paradigm has changed over the past 15 years with the advent of specialization and surgical fellowships. The paradigm in the 1990s was that all general surgeons were well trained and competent to operate on all areas of surgery; this would include vascular, colorectal, breast surgery, and HPB surgery. The 2000s brought the institution of the 80-hour work week along with a change in surgical culture. Some of this was indeed needed, as the long work hours of the past were less than humane. The change in generational attitudes has also molded trainees’ desire to pursue fellowship training. Trainees desire postresidency training for many reasons. A primary reason listed by trainees was that they wanted to master a specific area of surgery.2 Breast, colorectal, and vascular surgeries have now become their own entities, and HPB surgery has begun this journey. The aim of this study was to examine the case experience that HPB fellows obtained during their fellowship time. The results suggest that their experience is robust. 146
It is of interest that 1- and 2-year fellowships both provided excellent experience in HPB surgery. The main areas of difference were the transplant and liver resection domains. This was likely driven by the fact that some of these 2-year programs were heavily weighted toward a liver transplant experience. To place the data presented in this article in perspective, one must look at the experience of graduating chief residents in HPB surgery. An article by the Pawlik group examined this very question.4 They found that there had been a slight increase in liver volume over the period studied from 2003 to 2012, with a current median liver case volume of 8.0 (5.14) and mean liver volume of 9.4 (SD ¼ 3.4). The median pancreatic case volume for graduating chief residents was 8.0 (4.20) and the mean case volume was 11.3 (SD ¼ 4.3). The mean biliary volume was 3.8 (SD ¼ 2.1). The authors found that 50% of graduating chief residents had performed fewer than 10 HPB cases at the time of graduation. These data would suggest that HPB experience during residency is inadequate to prepare general surgery residents for a HPB surgical practice. The importance of the nonoperative care of the HPB patient is an area that is focused on during fellowship. The choice of which patient requires a major HPB surgery is as important as the technical aspect of the surgery itself. Recognition of complications after major HPB surgery is critical to the outcome of the patient. Many of these nonoperative aspects to surgery have been “squeezed” with the focus on residency work hours. Time in clinic and immersion in the postoperative care of these complex patients has been compromised, with a focus on counting the case experience as the major metric. This area of nonoperative assessment and care of the HPB patient is a key component of HPB fellowship training. To truly understand these data completely, it is important to provide a comparison with other potential pathways of training in HPB surgery: the SSO and the ASTS have potential pathways for training in HPB surgery. The SSO required a total of 150 cancer-related cases, of which 15 have to be gastrointestinal cancer cases.5 The ASTS defines potential pathways for training in HPB surgery: heptaobiliary includes 35 liver cases, of which 15 are biliary cases and 15 are major liver resections and HPB includes heptaobiliary and 15 pancreas cases.6 Many ASTS and SSO training programs provide much greater exposure to HPB surgery, and some can provide an experience that is similar to that shown in this article. The FC-HPB accreditation guidelines call for a more robust case experience than any of the other possible training pathways; the data presented here show that the experience of FC-HPB fellows is robust and clearly adheres to these guidelines. It is important to understand that there is more to surgical training than just technical experience. The SSO pathway, for example, clearly defines nonsurgical rotations that are critical to the understanding of the oncology
Journal of Surgical Education Volume 72/Number 1 January/February 2015
patient. The ASTS pathway provides an excellent understanding of chronic liver disease and immunosuppression. The FC guidelines have focused on these nonsurgical aspects of HPB surgery and the accreditation process pays careful attention to these parameters. For example, the HPB fellows must participate in an outpatient experience where patients with complex HPB diseases are seen and discussed in a multidisciplinary manner. The program must provide exposure to both benign and malignant diseases. There is discussion about whether nonoperative management of HPB disease should be specifically tracked and included in the FC accreditation requirements. Other specific areas of exposure include the use of ultrasound in HPB surgery and experience with interventional radiology and advance GI techniques in managing the complex HPB patient. The role of ultrasound training has been taken seriously by the AHPBA, and there has been the development of a HPB ultrasound course that fellows are encouraged to take. Metrics for measurement of ultrasound experience are being defined. More accurate recording of ultrasound experience is now being required through the FC case log system. In summary, the AHPBA-sponsored FC-HPB programs provide an excellent operative experience for fellows training in HPB surgery. This study demonstrates that there is excellent adherence to FC accreditation and requirements.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
Report of the ACGME Work Group on Resident Duty Hours. Chicago, IL: ACGME; 2002. 2. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV.
Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216(4):764-771. 3. Fellowship Council Accreditation Guidelines and Def-
initions. Available at: 〈https://fellowshipcouncil.org〉; February 2013 [update]. 4. Sachs T, Ejaz A, Weiss M, et al. Assessing the experience
in complex HPB surgery among graduating chief residents: is the operative experience enough? Surgery. 2014;156(2):385-393. 5. Society of Surgical Oncology. Available at: 〈http://sur
gonc.org/training-education/surgical-oncology/programrequirements〉. 6. American Society of Transplant Surgeons. Available at:
〈http://asts.org/education/fellowship-resources/accredita tion〉.
Journal of Surgical Education Volume 72/Number 1 January/February 2015
147
