Minimally invasive surgery:The evolution of fellowshipAdrian Park, MD,a Stephen M. Kavic, MD,a Tommy H. Lee, MD,a and B. Todd Heniford, MD,b

Baltimore, Md, and Charlotte, NC

Background. The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS)training has undergone substantial growth and change. To determine whether fellowships are meetinga strategic need in training, we conducted a survey to assess the current status and trends of changein MIS/GIS fellowships.Methods. A survey was distributed to fellows currently in MIS/GIS programs in the United States andCanada in 2003 and 2006. Fellows were asked to describe demographics as well as their experienceboth during fellowship and residency. We compared this with aggregate data of resident experiencethrough the Accreditation Council for Graduate Medical Education (ACGME) case logs, data trackedby industry, and program data from the Fellowship Council (FC) web site.Results. There were 54 responses to the 75 surveys distributed in 2006 (72% response rate). MISfellows performed more laparoscopic cases during their residency than the average graduating chiefresident, but did not feel competent to perform advanced laparoscopic surgery. However, combiningfellowship numbers with residency numbers does suggest that the total experience provides competency ina wide variety of procedures.Conclusions. It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgicalresidents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging tonote the improvements in fellowship structure, standards, and overall experience, brought by the effortsof the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review ofcurrent data will aid in further evaluation and improvement. (Surgery 2007;142:505-13.)

From the Department of Surgery, University of Maryland,a Baltimore, and the Carolinas Medical Center,b

Charlotte, North Carolina

The twentieth anniversary of the introductionof laparoscopic cholecystectomy to North Ameri-can surgeons is nigh upon us. Although this will stira fading memory to many established surgeons, toothers it will be observed simply as an historicalfootnote. Yet the impact of this procedure, and therevolution in surgical technique and patient carethat it spawned, is probably unparalleled in surgicalhistory.

In some regards, much has changed over thepast 2 decades. Patients referred to abdominal sur-geons of all clinical stripes now anticipate a “scar-less” procedure, with a low complication risk, andfrom which they will return to their regular activi-

Accepted for publication July 3, 2007.

Reprint requests: Adrian Park, MD, Plugge Professor of Surgery,Head, Division of General Surgery, University of Maryland Med-ical Center, 22 S. Greene Street, Room S4B14, Baltimore MD21201-1595. E-mail: apark@smail.umaryland.edu

0039-6060/$ - see front matter

© 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.surg.2007.07.009

ties at a pace not dreamed of 20 short years ago.Minimally invasive surgery (MIS) has certainlymade the transition from the experimental to theexpected.

In another sense, little has changed. Debate con-tinues to rage about the role of surgeons who per-form MIS on the surgical landscape. Is there aplace for surgical specialists who focus on tech-niques rather than on organ systems or diseasestates? Whether a patient has colon cancer re-moved laparoscopically by a general surgeon withMIS training or a colorectal surgeon with MIS train-ing is still largely determined by the culture ofpractice within an institution and by the nature ofregional and national training programs producingthe surgeons. The ongoing vigor of the debate onthe proper role and specialty assignment of MISsuggests that little has yet been resolved.

As patients increasingly demand minimally in-vasive options for their surgical problems, indi-vidual surgeons naturally want to be able toprovide these services and techniques.1 However,

the majority of surgical oncologists, as well as gas-

SURGERY 505

506 Park et al SurgeryOctober 2007

trointestinal, general, and colorectal surgeons, inpractice today have not received formal training inadvanced MIS techniques. The proliferation of allmanner of MIS short courses, proctoring, “mini”fellowships, and full fellowships over the past 15years bears testimony to the need surgeons havefelt to be trained in these new procedures.2

The most appropriate forum for training in newand established surgical techniques should be asurgical residency program. Yet it is evident on anational level that surgical residency training inMIS remains woefully inadequate or at best inho-mogeneous. A recent study surveyed 4th- and 5th-year surgical residents; 65% reported that theyneeded additional training beyond their residencyto feel competent to practice advanced laparo-scopic surgery.3 Despite the prominence of MIS,not enough has changed in surgical training overthe past 2 decades.

That the field of postgraduate MIS/gastrointes-tinal surgery (GIS) training has undergone sub-stantial growth over the past several years is beyonddebate. However, it is generally agreed that thesechanges occurred largely in response to unmetneeds (for training) rather by deliberate, thought-ful design.2 Fewer than 10 programs existed foradvanced MIS/GIS training beyond residency in1993. By 2006, �120 postgraduate fellowships inMIS/GIS were operational.4 These fellowships haveremained competitive: In 2006, only 79% of appli-cants matched into MIS/GIS fellowships.5

A significant and coordinated effort over thepast 5 years has resulted in increased structure andcoordination of MIS fellowships.2 The FellowshipCouncil (FC), representing the vast majority ofMIS/GIS training programs in North America, hasestablished a matching process, standards, and anaccreditation process for these fellowships.

While recognizing that efforts must continue todevelop and standardize a national surgical resi-dency curriculum that encompasses MIS/GIS, fel-lowships may be meeting a strategic need insurgical training. Our minimal understanding ofthe composition, operation, clinical experience, ac-ademic productivity, and ultimate quality of (sur-geon) product of these fellowship programs isreflected in the paucity of literature on this subject.The focus of this study was to assess the currentstatus and trends of change in MIS fellowships.

METHODSA survey was distributed to fellows currently in

MIS/GIS programs in the United States and Can-ada. The survey was administered in person at a

conference in August 2003 and 2006, and immedi-

ately collected. Fellows were asked to describe theirexperience both during fellowship and residency.The survey described the basic fellow and fellow-ship demographics, satisfaction with fellowship,reasons for choosing a fellowship, the numbers ofcases performed as a resident, the number of casesfelt to be needed for competency, future careerplans, challenges of fellowship, and research expe-rience. All data were self-reported.

The first version of the survey was distributed in2003. The original survey was updated in 2006;most questions were adapted to Likert scales, andadditional questions probing interactions with res-idents inserted. All questions in the 2006 surveywere multiple choice except for the questions in-volving number of cases performed or expected toachieve competence.

Data were tabulated and analyzed in a MicrosoftExcel database. t-Tests were utilized to compare the2003 and 2006 data where possible. Some questionswere changed or eliminated between 2003 and2006 and therefore were not suitable for formalstatistical analysis. Questions that provided a textresponse were examined and compared for quali-tative trends.

To provide a basis for interpreting this surveydata, we collated aggregate data of resident expe-rience through the Accreditation Council for Grad-uate Medical Education (ACGME) case logs.6 Tosupplement further the fellows’ reports, we alsoobtained aggregate case experience data on 56programs tracked and collected by industry(Tyco-US Surgical, North Haven, Conn). Addition-ally, program information was collated from the FCweb site. The FC case experience is also self-re-ported, but is provided by the program directorand not the fellow. This report then represents notmerely a survey, but a comprehensive sampling ofevery major source of available data on MIS oper-ative experience.

RESULTSThere were 54 responses to the 75 surveys dis-

tributed in 2006 (72% response rate), and 31 re-sponses to the 44 surveys distributed in 2003 (70%response rate). Questions that were incompletelyor inadequately answered were excluded from anal-ysis. Most fellows reported that their overall satis-faction was high, with 85% of respondents sayingthat fellowship met their expectations.

The majority of fellows were surgical residents inacademic centers (72.5%), and similarly were en-rolled at an academic center for fellowship (87%).In 2006, 37% rated their MIS training during resi-

dency as excellent to outstanding, whereas in 2003

average

Surgery Park et al 507Volume 142, Number 4

only 9.4% of fellows rated their resident training asexcellent. Most fellows (65% in both 2003 and2006) did not perform research during residency.

The self-reported cases performed by fellows as aresident did not differ significantly from 2003 to2006, except for colectomy (Table I). On average,surgical residents who became MIS/GIS fellowshad participated in nearly 17 laparoscopic colonresections in 2006, as opposed to approximately 6cases in 2003. Laparoscopic cholecystectomy re-mained the most common laparoscopic procedureby far, with both our survey and ACGME data find-ing that residents performed in �100 cases duringresidency.

Comparison with ACGME numbers for 2004 and2005 shows that MIS fellows performed more lapa-roscopic cases during their residency than the av-erage graduating chief resident (Table I). In eachmajor category, from splenectomy to inguinal her-nia, the mean reported cases for fellows exceededthe mean numbers reported through the ACGME.

Fellows were also asked to estimate the numberof cases of a given procedure that were necessary toachieve competence in that procedure, and theresults are reported in Table II. Comparing thenumber of cases thought to be needed for compe-

Table I. Mean number of laparoscopic cases perfo

Operation ACGME 2004-2005 2003

Cholecystectomy 100.6 � 40.5 115.0 � 89.3Nissen 4.7 � 5.1 8.3 � 5.8Inguinal hernia 12.7 � 11.9 20.4 � 20.8Ventral hernia — 12.9 � 14.4Colectomy 6.5 � 7.1 5.9 � 9.2Splenectomy 1.5 � 1.6 3.6 � 3.4Nephrectomy — 1.2 � 3.7Adrenalectomy — 1.8 � 2.8Thoracoscopy — 13.9 � 13.1

t - Test; P - values are shown.

Table II. Mean number of cases needed for comp

Operation 2003 2

Cholecystectomy 33.2 � 20.6 35.6Nissen 22.7 � 9.2 22.0Inguinal hernia 20.6 � 11.4 26.7Ventral hernia 12.4 � 6.4 18.4Colectomy 23.4 � 14.3 27.0Splenectomy 11.2 � 6.9 13.6Nephrectomy 21.6 � 11.2 18.0Adrenalectomy 12.1 � 7.9 15.1Thoracoscopy 14.2 � 7.5 15.1

t - Test; P - values are shown. Also shown are industry data representing

tency (Table II) with the number cases performed

in residency (Table I), the data suggest that fellowsin 2006 are completing residency feeling they arecompetent to perform only a handful of laparo-scopic cases (cholecystectomy, ventral hernia, andthoracoscopy.) In all other procedures, from ne-phrectomy to Nissen fundoplication, the data iden-tify that the fellows’ experience is not sufficient inquantity to meet their own definition of compe-tence.

Fellows’ top reasons for selecting a fellowship in2006 are shown in Table III. Principally, fellowsselected training programs based on the mentorand the operative experience. No fellow reported

as a resident

2006 P (ACGME to 2006) P (2003 to 2006)

7.8 � 48.3 .240 .0757.3 � 6.6 .001 .4350.0 � 22.8 .000 .9531.0 � 18.3 — .1786.9 � 19.3 .000 .0004.0 � 7.6 .000 .3721.2 � 3.2 — .8452.1 � 2.8 — .7785.4 � 13.7 — .892

y

P Industry data 2005 fellows

9 .893 32.7 � 52.75 .676 16.8 � 14.18 .080 21.6 � 27.7

.268 14.4 � 14.04 .600 14.6 � 18.2

.361 2.7 � 2.92 .963 1.7 � 3.60 .429 3.5 � 4.6

.463 1.0 � 3.4

case numbers of the 2005 fellows.

Table III. Answers to the question in 2006:“What is the most important factor in selecting afellowship?”

Answer %

Types of procedures 60.0Preceptor reputation 20.0Clinical experience of previous fellows 15.6Job opportunity at the center 2.2Research opportunities 2.2Flexible endoscopy 0

rmed

10

221

1

etenc

006

� 20.� 10.� 15.� 9.7� 14.� 9.0� 13.� 10.� 8.7

the expectation that, after fellowship, his or her

508 Park et al SurgeryOctober 2007

practice would be predominantly bariatric surgery.No fellow listed flexible endoscopy as the primaryreason for pursuing fellowship.

Fellows were asked to estimate the percentage ofbariatric surgery that they anticipated to be per-forming at the completion of fellowship. In 2003,the majority of fellows anticipated performing bari-atric surgery: 45% of fellows anticipated at least onequarter of their practice would be bariatrics, and20% expected more than half of their cases to bebariatrics. In 2006, 8% of fellows reported that theywould not perform any bariatric surgery, and only9% reported that between 50% and 75% of theircases would be bariatric. No fellow anticipated�75% of his or her practice would be bariatricsurgery.

The relationship between fellows and residentswas also explored. In 2003, 39% of respondentsreported that the greatest challenge during fellow-ship was relations with residents. By 2006, the great-est challenge reported was maintaining adequatecase volumes and case mix. The manner in whichrelations with residents have been best managed in2006 are shown in Table IV.

DISCUSSIONFellowship in MIS has undergone significant

changes in recent years. Our survey of the majorityof 2006 fellows provides a snapshot of the currentconditions in fellowship, and the 2003 survey rep-resents the conditions before the most recent ma-jor changes of the fellowship match, and theimplementation of the 80-hour resident work week.

The American Surgical Association Blue RibbonCommittee issued its 2004 Report on Surgical Ed-ucation, and described subspecialty fellowship inthe following terms: “largely unregulated, unsuper-vised, nonuniform, and uncertified.”7 In fact, agrassroots movement was already growing at thattime, with a view to addressing the lack of regula-

Table IV. Answers to the question in 2006:“Which of the following strategies have beenmost effective in managing the relationships withthe residents?”

Answer %

Intraoperative teaching 31.8Didactic teaching 18.2Attending as mediator 18.2“Sounding board” or resident resource 13.6Changing pattern of rounds 6.8Other 11.4

tion, supervision, and accreditation of MIS fellow-

ships. A group of fellowship directors cametogether to found the MISFC in 1997. The goal ofthe MISFC “was to develop guidelines for highquality fellowship training, to provide a forum forthe directors of minimally invasive and gastrointes-tinal fellowships to exchange ideas, formulate train-ing curricula; to establish uniform application andselection dates and to create an equitable comput-erized match system for applicants.”2

The MISFC was later incorporated in 2003 with77 member programs. The first match occurred inDecember 2003, for 2004 fellowship selection. Notsurprisingly, one of the greatest concerns of the2003 fellows identified in our initial survey wasthe angst and vulnerability they felt while enduringthe largely unregulated selection process. This is-sue was resolved by the time of the 2006 fellowsurvey and the contribution of the MISFC to thatend must be recognized.

It also bears mentioning that the MISFC joinedwith representatives of the Society for Surgery ofthe Alimentary Tract, Society of American Gastro-intestinal and Endoscopic Surgeons (SAGES),American Hepato-Pancreato-Biliary Association,and American Society for Bariatric Surgery to formthe FC in late 2004. Quality guidelines for fellow-ship programs were established and promulgatedamong the member programs. Further, one of thefirst actions of the newly formed FC was to createan independent accreditation committee chargedwith surveying all programs for the purposes ofcertifying compliance with the accepted guidelines.The first round of this gargantuan task has nowbeen completed, addressing comprehensively theissues raised by the Blue Ribbon Committee.

From our survey, we can state that fellows in MIShad greater experience in advanced laparoscopicprocedures during their residency compared withtheir peers, as reflected in their 2006 self-reportednumbers and the ACGME 2004 and 2005 statistics.Despite this, current fellows do not feel equippedto perform these cases based on their residencyexperience alone. The fellows’ estimation of thenumber of cases needed for competency consis-tently exceeds the number reported during theirresidency experience. Comparison to the industrydata from 2005 demonstrates that even 1 year ded-icated to minimally invasive fellowship alone doesnot provide adequate experience to achieve com-petency. However, combining fellowship numberswith residency numbers does suggest that the totalexperience provides competency in a wide varietyof procedures. Additionally, there is some indica-tion of progress from 2003. In 2006, 37% of fellows

rated their laparoscopic training in residency as

Surgery Park et al 509Volume 142, Number 4

excellent or better, compared with 9.4% in 2003,suggesting that there is already some improvementin laparoscopic training in residency.

In the fellowship survey administered in 2006,approximately 3 in 4 fellows trained at an academiccenter for residency, with 87% participating in afellowship at an academic institution. However,�38% intended to practice in an academic setting.In other words, these fellows did not feel ade-quately trained to engage in clinical practice out-side of a tertiary care center at the completion oftheir formal residency training. It is not that fellowsare generally pursuing mastery of the complexitiesof advanced laparoscopic techniques; rather, theyrepresent the motivated residents who are, by theirown account, ill-equipped to provide the servicesrequired by their future patients in the community.

With respect to bariatrics, there was an interest-ing and significant trend between 2003 and 2006.In 2003, when asked what percent of their futurepractices will involve weight loss surgery, nearly20% reported that bariatric surgery would consti-tute more than half. By 2006, this number hadfallen to just �9%. This may represent a waninginterest among fellows in surgery for morbid obe-sity, or it may reflect market saturation in the de-mand for bariatric surgeons.

Despite the recent surge in interest concerningNatural Orifice Transgastric Endoluminal Surgery,flexible endoscopy was not seen as a primary focusamong fellows. No fellow listed flexible endoscopyas the main reason that attracted them to fellow-ship. Flexible endoscopy holds great promise andimportance for general surgery, and for MIS inparticular. However, this message has not yet fil-tered to the level of the fellowship applicant.

Tension and problems between fellows and res-idents seems to have become less of an issue be-tween 2003 and 2006. In 2003, 39% of fellowsreported that their greatest challenge was the rela-tionship with the residents. By 2006, only 14% offellows described moderate or disruptive tensionwith the residents. Perhaps as programs matured,MIS/GIS fellows now have an accepted role that isbetter defined and delineated from that of theresidents. The FC effort in setting standards andpromoting accreditation certainly helped this pro-cess. The most commonly listed strategy for man-aging relations with residents is that of the fellow asteacher, both intraoperative as well as didactic. Inother words, fellows ideally serve to augment resi-dent education rather than displace residents fromthe operating theater. Although there is some ten-sion inherent in the fellow–resident relationship, it

is cooperation with direct interaction between fel-

low and resident that seems to provide the optimalarrangement.

One persistent concern is that the presence of afellow may interfere with resident training and per-petuate the need for ongoing fellowships. Again,the available data are limited. A survey among res-idents was conducted at the end of the first yearthat a gynecologic laparoscopic fellowship was in-stituted.8 The residents experienced no change incase volumes, and gave the fellow a positive ap-proval rating, likely related to the fellow’s involve-ment in resident education and training. Ingeneral surgery, the only available data suggest thatprograms with a fellowship have an increased num-ber of advanced laparoscopic cases logged perchief resident.9

For training of residents, we believe that thebenefits of maintaining strong fellowship programswill become even more apparent. Fellowships arebetter suited to evaluate and adopt new techniquesand technologies in a more nimble way than ispossible for residency programs. One might ulti-mately imagine a system in which fellowships serve,among other things, as the vanguard of surgicaladvancement and innovation. As techniques movefrom being “cutting edge” to “mainstream,” theywould then transition in a coordinated way fromfellowship to residency curricula. Because there isevery indication that we will continue in this seasonof innovation in surgical technology and tech-niques for some time, fellowships may provide thisunanticipated benefit.

There are few other published reports on grad-uate and postgraduate training in MIS/GIS. In2002, a survey was sent to surgical residency pro-grams involved in MIS training.10 The survey founda surprisingly low operative exposure to MIS. Thepaper concluded that “American surgical residencyprograms do not meet the suggested MIS caserange or volume required for competency.” In thepresent study, this is still the case.

Only one other survey of MIS fellowship hasbeen published, dating from a survey administeredin 2002.11 This study was hampered by its poorresponse rate (32%). The authors found that fel-lowships were competitive, and provided a variablebut adequate experience. They also found that56% of fellows pursued a career in private practiceafter fellowship. It is difficult to compare the surveyresults directly, because there were different issuesand concerns in the pre-FC era. Indeed, it was thesedevelopments that prompted us to change our sur-vey between 2003 and 2006.

MIS/GIS fellowship remains a highly sought af-

ter position among graduating residents, as illus-

510 Park et al SurgeryOctober 2007

trated by the 79% match rate. The majority ofresidents (71% of residents graduating in 2004)report that they intend to pursue a fellowship.2 Fewobjective data exist on the clinical impact of fellow-ship training. One study examined the first 75 bari-atric cases performed by 2 surgeons, only one ofwhich had received fellowship training.12 The fel-lowship-trained surgeon had shorter operativetimes and fewer major complications, providing atleast some objective demonstration of the clinicalbenefits of fellowship. The benefits of fellowshiptraining have also been seen in colorectal surgery,where newly trained surgeons have been found tohave outcomes comparable to their mentors.13

Naturally, there are limitations inherent in ourdescriptive survey methodology. Some bias mayhave been written into the survey itself. There mayalso be an element of selection bias in that thesurvey was not administered to all fellows, nor wasthere a 100% response rate. However, we believethat the cohort is representative of MIS/GIS fellowsin North America.

Self-reported data must always be interpretedwith some degree of caution, with the potential formisunderstanding the questions, memory con-founds, or deception. This seems unlikely given thenature of this particular survey. We have buttressedour survey instrument with all independent, avail-able data—from the ACGME, the FC, and thatderived from industry.

In 2006, our survey permits us to draw a pictureof the average MIS/GIS fellow in North America.The fellow is a 34-year-old man who completedtraining at an academic center but did nottake time away from residency to do research. Heseeks training at an academic center with a mentorwho has a national reputation and an adequatecase mix. Flexible endoscopy, like bariatric surgery,is not a priority. After fellowship, he plans on per-forming MIS/GIS in a community setting.

In reviewing the commentary from the fellows,several recurring themes were evident, and allow usto highlight some traits of successful fellowshipprograms. First, and not surprisingly, a good men-tor is essential, both for drawing residents to thefellowship as well as for providing an adequateexperience. Second, the goals of the fellowshipmust be clearly articulated at the beginning, andthen met. It is also of utmost importance to main-tain a balance between residents and fellows. Thismay be accomplished through strict delineation ofroles and encouraging open communication, butgenuine interest in resident training and educationby the fellow was identified as the most important

strategy for success.

CONCLUSIONSIt seems that MIS/GIS Fellowship is meeting a

real need among graduating surgical residents.This study revealed that most MIS/GIS fellows planto practice surgery in a nonacademic environmentregardless of whether they trained in a communityor academic program. Furthermore, these fellowscompleted residency with a higher number of lapa-roscopic cases on average than the national expe-rience, yet still felt unprepared for clinical practice.Combining their fellowship operative experiencewith residency cases appeared to provide the fel-lows a volume and breadth of experience that wasadequate, in their view, to achieve competence.

Thus, 20 years after the introduction of laparo-scopic cholecystectomy, MIS/GIS fellowship con-tinues to play an important role in the training ofsurgeons in North America. It is encouraging tonote the improvements in fellowship structure,standards, and overall experience over the pastseveral years brought about in large part by theefforts of the FC.

Work is afoot to develop a national curriculumfor MIS/GIS fellowship training, which would fur-ther standardize the training experience. It is likelythat some form of national curriculum for surgicalresidency training will also soon evolve. In themeantime, efforts must continue in parallel to en-sure adequate clinical exposure, standards, and co-ordinated curricular development for MIS/GIStraining at the residency and fellowship level. It ishoped that this report of the state of MIS fellowshipwith its comprehensive review of current data willaid in this process.

REFERENCES1. Anonymous. Surgical innovation under scrutiny. Lancet

1993;342:187-8.2. Swanstrom LL, Park A, Arregui M, Frankling M, Smith CD,

Blaney C. Bringing order to the chaos: developing a match-ing process for minimally invasive and gastrointestinal post-graduate fellowships. Ann Surg 2006;243:431-5.

3. Rattner DW, Apelgren KN, Eubanks WS. The need fortraining opportunities in advanced laparoscopic surgery.Surg Endosc 2001;15:1066-70.

4. The Fellowship Council [homepage on the Internet]. Avail-able: www.fellowshipcouncil.org. Accessed 14 February2007.

5. Stitzenberg KB, Sheldon GF. Progressive specializationwithin general surgery: adding to the complexity of work-force planning. J Am Coll Surg 2005;201:925-32.

6. General surgery: national resident report C, reporting pe-riod: 2004-2005 academic year. Chicago, Ill: AccreditationCouncil for Graduate Medical Education; 2005.

7. Debas HT, Bass BL, Brennan MF, et al. American SurgicalAssociation Blue Ribbon committee report on surgical ed-ucation: 2004. Ann Surg 2005;241:1-8.

8. Einarsson JI, Timmins A, Young AE, Zurawin RK. Does a

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minimally invasive surgery fellowship impact surgicalexperience among gynecology residents? J Am Assoc Gy-necol Laparosc 2004;11:464-6.

9. Marks JM, Nussbaum MS, Pritts TA, Scheeres DE. Evalua-tion of endoscopic and laparoscopic training practices insurgical residency programs. Surg Endosc 2001;15:1011-5.

10. Park A, Witzke D, Donnelly M. Ongoing deficits in residenttraining for minimally invasive surgery. J Gastrointest Surg2002;6:501-7.

11. Madan AK, Frantzides CT, Deziel DJ. Survey of minimallyinvasive surgery fellowship programs. J Laparoendosc AdvSurg Tech 2006;16:99-104.

12. Oliak D, Owens M, Schimidt HJ. Impact of fellowship on thelearning curve for laparoscopic gastric bypass. Obes Surg2004;14:197-200.

13. Schlachta CM, Mamazza J, Grégoire R, Burpee SE, Pace KT,Poulin EC. Predicting conversion in laparoscopic colorectalsurgery. Surg Endosc 2003;17:1288-91.

DISCUSSIONDr Nathaniel Soper (Chicago, Illinois): You did

a survey of fellows in minimally invasive programsand you give us a snapshot of their current con-cerns and experience. You have shown that therehave been increasing numbers in residency in se-lected cases during this 3-year window between2003 and 2006. And for those of us who are fellow-ship directors, I think you have given us good in-formation regarding what we ought to include aspriorities in our program.

We are now in the 20th year since the introduc-tion of laparoscopic cholecystectomy in France. Inabout 1993, the SAGES organization approachedthe American Board of Surgery and asked whetherwe could weigh in on the development of the fel-lowships that were just springing into being. Wewere told that we could not because there was a fearthat we would create a franchise, so this was put torest. The FC then sprung up primarily to look atminimally invasive fellowships, but later then devel-oped into an all-encompassing, noncolorectal GIfellowship mechanism. It has brought order tochaos; specialty fellowships were largely unregu-lated, unsupervised, nonuniform, and uncertified.The FC is going out to accredit these fellowshipsand a curriculum is currently being developed.

How was your survey administered? Was itmailed out? Was this at a meeting? In what time ofyear was it given?

You said that 87% of those surveyed were inacademic programs. Overall, of these GI fellow-ships, what percentage are in academic centersversus in private practice settings?

The fellow–resident interaction continues to bea concern for all of us. Were the fellows asked withwhat level of residents they interacted primarily in

their programs? I think that makes a big difference.

It looks as though the residency and fellowshipnumbers combined are adequate to meet whatthese fellows believe are enough for competence.As I recall, there have been some articles written byexperts saying what they think are the minimumnumbers for competence. How do the numbersmatch between the fellows’ and the experts’thoughts?

Finally, I thought it was very interesting to seethat these fellows had more laparoscopic experi-ence during their residency than the average grad-uating residents.

Dr S.M. Kavic (Baltimore, Maryland): The sur-vey was distributed at a conference of MIS and GIsurgical fellows held in Arizona in August. So thiswas toward the beginning of fellowship, which iswhy we focused on analyzing residency numbers. Iwould suggest that the numbers from residencywere fresh in the minds of the fellows at that time.Their numbers for fellowship would be less validand were not asked. The survey was administeredand collected on site.

The next question was concerning the bias to-ward academic centers. At this conference, no in-stitution was represented by �1 fellow. Someacademic centers may have 3 or even 4 fellows, butwere represented by a single one. So although mostat the conference were academics, there was a sub-stantial community representation as well, the de-tails of which are in our paper. In terms of theoverall numbers of the breakdown between com-munity and academic programs, I do not havethose numbers at my fingertips.

With regard to the level of residents that fellowsinteract with, the Residency Review Committeerules would preclude having a chief resident or a5th-year resident on the same service with the fel-lows. However, there are a number of means ofdividing cases between a fellow and a chief resi-dent. We did not specifically ask the fellows abouttheir interactions with junior residents versus chiefresidents. However, the tension that is reported isalmost exclusively that of operative competition—competition for the same cases—which simply doesnot exist between an intern and a fellow as it doesbetween a 4th- or 5th-year resident.

In terms of what are expert levels of compe-tence, the only data that I have seen come from asurvey from the University of Kentucky, publishedin the Journal of Gastrointestinal Surgery in 2002,which criticized residency programs for being vari-able in their exposure to laparoscopic surgery andsaying that overall the training did not meet theminimum needs. I think what the minimum needs

are for competence are a matter largely of opinion.

512 Park et al SurgeryOctober 2007

Dr Gerald M. Fried (Montreal, Quebec, Can-ada): I think the 2 major accomplishments of theFC are the institution of the match and the accred-itation process, both of which were put in place toprotect the best interests of the applicant. I thinkthe reduced stress that is reflected in your surveyreflects the fairness of the process. Dr Park and hiscolleagues that instituted this council really deservean enormous amount of credit.

The accreditation process is really directed atensuring that there is a good match betweenwhat is posted or advertised for the fellowship andwhat the fellow actually gets. And when you look atthe FC listing, you realize that there is a largevariety in the composition of the fellowships. Al-though the numbers have increased enormously,the breadth of the fellowships has perhaps reducedas many fellowships have become very focused, forinstance, in bariatrics.

So looking at the numbers of average number ofcases is not a very good way of really looking at howwell the fellowships meet the needs. For instance, if50% of the fellowships were exclusively bariatrics,that is not going to be reflected in the averagenumber of Nissens or inguinal hernias that a fellowwill do. It really needs to match their needs orexpectations.

My questions really relate to the drift of fellow-ship graduates into private practice as opposed toacademic surgery. For me it is a bit of concern. Ifone of our goals is to try to increase the number ofcases residents are exposed to, then I would hopethat we would increase the number of people thatgraduate from these programs that then go on toteach residents so that their education can perpet-uate the education of the next generation of resi-dents.

Dr S.M. Kavic (Baltimore, Maryland): Person-ally, I found that to be one of the more alarmingfindings of our survey in that only 38% were de-claring their interest in an academic center,whereas from my own experience I had thoughtthat the vast majority sought fellowship to pursueteaching, training, and advanced laparoscopicpractice in an academic center. I do not have aclear answer for the reason behind that.

Fellows are in general seeking the fellowship toachieve competence, which may mean that theyjust feel ill-equipped to go out and practice. If theywish to call themselves a bariatric surgeon, for in-stance, they need to pursue a fellowship first.

That is not an inappropriate role for a fellow-ship, but it would be hoped that there would bemore trainers or educators coming out of the pro-

cess than there apparently are.

Dr L. Michael Brunt (St. Louis, Missouri): Wereyou able to look at case numbers in fellowships thathave a very heavy bariatrics focus versus those thathave less bariatrics and are more broad based?

Dr S.M. Kavic (Baltimore, Maryland): Most ofthe programs that participated in the FC matchprocess do not claim to do exclusively bariatrics. Insearching through the web site at what the pro-grams themselves report, only a handful—approx-imately 5 of the 127 programs—list themselves asbeing almost exclusively bariatrics. So within theoverall numbers of the 127 programs, I think thosenumbers washed out to a good degree.

Dr Mark A. Malangoni (Cleveland, Ohio): Be-cause the fellowships alone do not provide ade-quate experience as you have defined it, why noteliminate the fellowships and incorporate thosecases into the general surgical residency and there-fore produce a competent, adequately qualifiedindividual when they finish their 5 years of generalsurgery residency rather than to have these fellow-ships go on?

Second, I would like your opinion aboutwhether you think these fellowships would existwithout industry sponsorship.

Finally, it is one thing to talk about perception ofthe trainees regarding their feelings about compe-tence and number of cases. It is very different for usto develop some measures of whether or not thismakes any difference in taking care of patients.The individual may feel more comfortable, andthat is nice. The question is, does it make a differ-ence? Do you have any outcome measures, or arethere any plans that you have to develop outcomemeasures as to how this impacts patient care?

Dr S.M. Kavic (Baltimore, Maryland): The firstquestion concerning shifting all cases down to theresidents’ level is certainly a good one. It is a pointthat is well taken. However, can we ensure that eachexperience among the residents is uniform? It ispossible that there would be a nonuniform experi-ence—not entirely a bad thing, but something wewould have to consider at an administrative level.

With regard to industry sponsorship, it seems anecessary part of the process. It may be difficult totease out whether or not that is inherently good orbad.

Last, in terms of your comment as to what thequality of the graduating fellow is, we do not havevery good markers of standardization or of sayingwhat a minimum level of competence is objectively.There are things such as the FLS and some SAGESinitiatives that have come out and may help us toquantify competence, but at present we do not have

good markers. There is only 1 study in the litera-

Surgery Park et al 513Volume 142, Number 4

ture about fellowship training in bariatric surgeryin Orange County in which 2 surgeons, 1 fellowshiptrained and 1 not fellowship trained, began ad-vanced laparoscopic gastric bypass procedures.And not surprisingly, the fellow had mounted thelearning curve a little sooner and had an overalldecreased rate of complications. Beyond that, wedo not know much.

Dr Gerald M. Larson (Louisville, Kentucky):The FC is interested in a balanced curriculum,minimum standards, and teaching opportunitiesfor the fellows. So far, have any programs been puton probation or disapproved?

Dr S.M. Kavic: As I am not part of the FC, Icannot comment with 100% certainty on that. How-ever, I can tell you that if you look at the FC web site

you will see that not all programs have been accred-

ited. Some have withdrawn and some have appar-ently not been accredited.

Dr Keith D. Lillemoe (Indianapolis, Indiana): Ihave been on the Accreditation Committee of theFC for 2 years. Bruce Schirmer did a great job forthe first year. We site visited about 85 programs. Ofthose, 17 did not receive full accreditation. Nonewere shut down. They were given a 1-year proba-tionary period to try to turn things around. And wewill be site visiting those programs within the next6 to 8 months. So there have been some actions bythe accreditation committee and not just rubber-stamped approval.

Dr Terence P. Wade (Belleville, Illinois): If 75%of these fellowships are industry sponsored, can theJohnny Walker Liver Transplant Fellowship be far

away?