Matching Training to Practice

The Fellowship Council (FC), founded as the Minimally Invasive Fellowship Council in 1997, has indeed brought a measure of order to the process of securing a postgraduate training position in minimally invasive surgery (MIS) with the implementation of a match process.¹ The leaders of this group are to be commended for assuming this responsibility to improve the system for prospective trainees and programs. They also are to be commended for studying the initial experience with a user satisfaction survey. While response rates were fairly low from both program directors and applicants, the responses do support the conclusion that the system works quite well. Furthermore, the replies provided some targets for improvement in the process, some of which the fellowship council has already implemented.

One problem identified by the applicants (in fact, a thorn in all our sides) is the interview process. In our many selection processes, from medical students applying for general surgery training to recruitment of fellows for advanced training in the competitive areas of MIS, surgical oncology, pediatric, and plastic surgery, and others, the personal interview process is excessively time-consuming, costly, and to a certain degree unfair for the candidates. One can rightfully conclude that the time invested in our current system is an educational loss for our trainees and an inefficient use of faculty time as well. In the 2003 match, 44 applicants traveled to between 6 and 10 programs and 26 traveled to between 11 and 15 sites, representing for most applicants 2 to 3 weeks of missed training during the chief resident year and thousands of dollars in expenses.

As surgical educators, we need to do better. One possibility is a two-stage interview process. Program directors and applicants could convene on 1 or 2 weekends in the early fall at a central accessible national location for initial interviews. Based on these contacts coupled to an invitation and candidate response deadline, fewer invitations for on-site interviews could be offered to selected applicants who are known entities. Applicants will be more informed regarding which programs they actually wish to pursue as interviews are offered. Then the on-site interview will give candidates a genuine possibility of matching to a specific program the chance to meet faculty and fellows and review the environment. This 2-step process is but one suggestion, and I trust the collective wisdom of the FC could devise a better proposal that might mutually benefit all parties and set an example for other competitive match programs.

The FC is also to be commended as it initiates a fellowship review and accreditation system. Rigorously applied, this will likely raise the quality of training offered by all programs and improve the prospective trainees' assessment of programs. Certainly, the oversight of the Residency Review Committee for Surgery (RRC) in the 1980s led to important overall improvement in the quality of surgical training in this country and improved the fairness and value of the training for the residents.

But now comes the hard part. The next important step is to define the purpose and place for this training in preparing both the next generation of community-based nontertiary care general surgeons and gastrointestinal surgical specialists. As the majority of these fellowships are self-defined as MIS fellowships (with a few focused on bariatric surgery or advanced gastrointestinal or hepatobiliary and pancreatic surgery), is this additional technical training a new requirement for the community general surgeon or is this training designed to create a cadre of specialists with practices focused on patients with complex gastrointestinal surgical conditions? If these skills are in fact essential, as it is increasingly clear they are in all disciplines of surgery, how can we allow this complete training to be acquired only as an adjunct after current training in general surgery? Is it now the case that some form of advanced training has become necessary for all surgeons after a general surgery residency, even those entering midsized community nontertiary center based surgery practices, if not from the patient care perspective, then from the market perspective? Approximately 80% of our trainees believe this is the case, and for the past 2 years MIS fellowships comprised the largest single group of fellowship programs after general surgery training.²

As many surgical educator groups have noted, including the American Surgical Association Blue Ribbon Panel, the American Board of Surgery, and the educational leaders of many surgical societies, those disciplines that once comprised the comprehensive specialty of general surgery are maturing. Not only are technologies rapidly evolving, but so are disease-based management strategies.³ Surgical procedures are more diverse and require more intense training to acquire mastery, and exposure of the quality of care is ever more transparent. Yes, surgical specialization continues to evolve, an inevitable consequence of scientific advance. The key for us now is to match our training with these advances in surgical science and surgical care.

In January 2005, the American Board of Surgery recognized 3 new disciplines within the field of general surgery as distinct evolving specialties. Each was afforded Advisory Council status: gastrointestinal surgery; surgical critical care–trauma-burn-emergency surgery, and transplantation surgery. These maturing disciplines join the existing boards of the American Board of Surgery, the Pediatric Surgery Board, and the Vascular Surgery Board. The purpose of these councils is to define these surgical disciplines: the scope of practice and procedural competencies and the optimal training pathways. The memberships were formed by surgeons recommended by the surgical societies supporting these specialties. The FC is represented on the advisory council for gastrointestinal surgery.⁴

Each of these evolving specialties offers advanced training after a resident has completed a 5-year general surgery residency. We would anticipate that these advanced training pathways would “push the envelope” in these fields refining advances in patient care that, in time, will be refunneled into the core substance of general surgical training and practice of nontertiary community-based general surgeons. Certainly, that has happened with many laparoscopic procedures to date: cholecystectomy, appendectomy, hernia repair, and soon colectomy. With time, the “advanced” techniques are folded back into the community standard of practice by community surgeons. The trick is to ensure that “advanced” training really is that: training that is exceptional as opposed to an essential element of practice for surgeons in our communities. We do not need to create new surgical specialties based on techniques; we need to allow surgical science and disease management to drive the development of specialization.

Many surgical educators are concerned that this distinction in the field of MIS is blurred at the present time. The skills that many residents acquire in current MIS fellowships are not substantially different or new compared with those they acquire in their general surgery training programs. Indeed, in some general surgery residencies, the experience in these techniques at even the greatest complexity is equivalent to the experience gained by fellows in some MIS programs. The diseases treated are not new and management principles do not differ. Instead, many of these fellowships offer the critical volume of training for the fellow to acquire, if not mastery, then competency, in these techniques as applied to common surgical disorders: abdominal wall hernias, colonic disorders, gastroesophageal reflux disease, obesity, and bowel obstruction.

At the present time, these fellowships are filling a procedural training void (a void created initially by a now rapidly disappearing faculty gap in expertise) but now more importantly a gap created by the simple fact there is not enough time to acquire technical mastery in these skills in the current training structure. These technical skills must be acquired after 5 years of general surgical training due to current training expectations of the American Board of Surgery and RRC. Our residents must meet broad training requirements in all of the essential content areas of general surgery, which given the ever expanding complexity of general surgery limits the intensity of exposure in important areas that are central to any community based general surgeon in practice. One simply cannot fit all of the required comprehensive didactic and technical training into our 80-hour per week residencies in the current 5-year model and achieve mastery in more sophisticated areas of even common surgical disorders encountered in a community surgeon's practice. This is particularly distressing in the case of MIS fellowships for most of these fellows pursue these training programs not in preparation for restricted practices in advanced gastrointestinal surgery but rather with the intent of fully preparing themselves for a community-based nontertiary setting general surgery practice. They simply want to be well prepared to take care of patients with common surgical disorders and feel that additional training in MIS is needed. One could reasonably propose that this is due, at least in part, to the fact that current training requirements include inordinate depth of training in areas that will not ultimately be part of their practice repertoire, complex areas of trauma care, hepatobiliary and pancreatic surgery, vascular or and pediatric surgery, for example.

I hope the fellowship review council will take the next step and take a renewed look at what the optimal training pathway to become a skilled gastrointestinal surgeon should be. Consider what the role of fellowship training should be in this discipline. Where do we draw the line between advanced surgical training in gastrointestinal surgery as a discipline and that body of surgical skill, technology, and disease management that should be part of the portfolio of all community based surgeons who practice abdominal surgery as part of their general surgery practice?

For those surgeons who will practice exclusively gastrointestinal surgery in tertiary care environments, consider as well the optimal pathway to that endpoint. Is it essential for that surgeon to complete a 5-year general surgery residency in all of the essential content areas of general surgery? How much trauma, head and neck, breast, pediatric, or vascular surgery do these surgeons really need? We all agree that a core platform with broad exposure is valuable, but does that core mean the same comprehensive 5-year residency in general surgery for all surgical specialists? Perhaps the gastrointestinal surgery training pathway would be better focused if built upon a core that led to a GI surgery track that included more training in body imaging, gastroenterology, endoscopy, and gastrointestinal pathology and less training in trauma or head and neck or breast surgery.

The maturation of the FC and the implementation of a match process are a positive operational step. I am optimistic that the council will continue its work in collaboration with gastrointestinal surgery societies, the American Board of Surgery, and the RRC to advance not only the process of securing fellowship training and reviewing these training programs, but also to introduce fundamental innovation in surgical training that will prove to be efficient and optimal for the next generation of surgeons. The FC has an opportunity to set an example for the other advanced and evolving surgical disciplines to develop focused and efficient training pathways that will produce the new leaders in the field of gastrointestinal surgery as a discipline while also ensuring that state-of-the-art technical training is incorporated within the body of training of community-based surgeons who practice abdominal and gastrointestinal surgery. I hope this accomplished group, known for their “independence,” will indeed take on this leadership opportunity.