New Column! The Foundation for Surgical Fellowships: Impacting the Future of Surgical Training

This column aims to educate individuals and organizations about the importance of the work that the Foundation for Surgical Fellowships is doing to ensure the funding that leads to the innovative training for surgeons to apply the principles of advanced surgical techniques in patient care.

by Adeena N. Bleich, MAOM, and Dennis L. Fowler, MD, MPh

Adeena N. Bleich, MAOM, is the Executive Director of The Foundation for Surgical Fellowships.
Dennis L. Fowler, MD, MPH, is the President of The Foundation for Surgical Fellowships

FUNDING: No funding was provided for this article.
FINANCIAL DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

In the early 1900s, the first human diagnostic laparoscopy occurred. Since then, surgical innovation has grown by leaps and bounds. With each generation of progress, the need for advanced training for surgeons has also grown. The need for specialized surgical skills for general surgeons created a large demand for training that was not included in residency or ACGME-accredited Fellowships.[1]

In 1991, there were three self designated Minimally Invasive Surgery (MIS) Fellowships in the United States that were developed to meet this need and formally teach laparoscopic surgery. These pioneering fellowships were the first attempt to formalize training of this new approach.[2] Until then, most surgeons were learning laparoscopy at brief courses on specific techniques that, at the time, residency programs could not routinely teach. The need for advanced training in laparoscopic surgery resulted in the rapid development of fellowships for which there was no oversight. Different groups stepped up to try to bring order to the training process, including Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society for Surgery of the Alimentary Tract (SSAT), American Hepato-Pancreato-Biliary Association (AHPBA) and American Society for Metabolic and Bariatric Surgery (ASMBS) and American Society of Colon and Rectal Surgeons (ASCRS).

By 1993, there were nine programs. The program directors felt that once enough surgeons were trained and returned to residency programs to teach that MIS Fellowship programs would become obsolete. Yet, as the benefits of laparoscopic surgery became apparent during the 1990s, increasing numbers of surgery residents began seeking additional training in laparoscopic techniques. In 1997, the MIS Fellowship Council was organized by a group of these pioneering surgeons who championed the use of laparoscopy and endoscopy in the realm of General Surgery. This was done to bring order to the rapidly developing fellowships to assure that fellows received a good experience and to provide guidance to the existing and prospective programs. By 2004, the different groups working to coordinate training formed one new organization called the Fellowship Council and the number of programs increased to 80. Today, two decades after the first MIS Fellowship, there are 156 programs and 210 fellowship positions in advanced GI Surgery, Endoscopy, MIS, Bariatric/Metabolic, HPB (Hepato, Pancreas and Biliary), Colorectal, and Thoracic with potential for incorporating other surgical disciplines.[2]

For more than 15 years, an informal and unplanned coalition of hospitals, surgeon practices, and industry funded such fellowship training in these non ACGME accredited fellowship programs. Then in 2010, The Foundation for Surgical Fellowships (FSF) was founded. The Foundation was formed when economic and political changes made it increasingly complicated for medical industry to support advanced surgical training programs. This created the need for an independent institution to administer and distribute fellowship funds free of industry influence. For the past four years, the FSF has managed a merit-based, blinded-application and review process and distributed funds to qualified organizations throughout the United States based on objective and fair criteria of excellence.

Although the initial focus of these fellowships was minimally invasive surgery (MIS), the non ACGME accredited fellowships now provide expert training in many types of complex surgery, including hepato-pancreatic and biliary surgery, bariatric and metabolic surgery, colorectal surgery, non-cardiac thoracic surgery, flexible surgical endoscopy, as well as other types of complex gastrointestinal surgery. With the exception of colorectal and non-cardiac thoracic surgery, advanced training in these types of surgical care is available only through these non ACGME accredited fellowships. In the past four years, the FSF has been able to provide the funding for fellows to receive state of the art, life-saving training at more than 600 fellowship programs nationwide.

The availability of high-quality complex surgical care throughout the United States in the future will be dependent on sustaining these fellowships. Despite the training provided by these fellowships, some forms of complex surgical care are still not available to many patients. For example, we know that MIS is underutilized in many hospitals. A study published in the July 2014 British Medical Journal by a team of researchers from Johns Hopkins University found that of the 1,000 US hospitals surveyed, MIS procedures were not offered as an option to hundreds of thousands of patients, at times because the surgeons had not received training for those complex surgical procedures.[3] Sustaining fellowship training for complex surgical care will increase the availability of this care to more patients.

Currently, 70 to 80 percent of general surgery residents are seeking post residency fellowships.4 The FSF provides essential financial support for sustaining these non ACGME accredited fellowships in which surgeons acquire the expertise to deliver these types of complex surgical care. The need for training continues to increase while the funding to support training continues to decrease. Our industry partners continue to work in a volatile and uncertain economic environment, and the level of support from industry in the future is unclear. In addition, unlike some foundations that have a base of individual support, most patients treated by fellowship trained physicians have no idea that their health benefitted from the efforts of the FSF.

The problem for the FSF and for the non ACGME accredited fellowships is serious. The FSF needs input and support from the surgical community at large to develop new sources of funding that will sustain the critical training currently being received by fellows. Individuals and organizations alike should understand the importance of sustaining this type of life saving surgical training that benefits us all in some way, perhaps even as patients ourselves.

For more information please visit www.surgicalfellowships.org.

References
1.    Fowler DL, Hogle NJ. The Fellowship Council: a decade of impact on surgical training. Surg Endosc. 2013;27(10):3548–3554.
2.    Arregui.M. About the Fellowship Council. (2012, January 10). https://fellowshipcouncil.org/about/. Accessed October 1, 2014.
3.    Cooper M, Hutfless S, Segev DL, et al. Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review. BMJ. 2014;349:g4198.
4.    Numann, PJ. Presidential Address, 97th Clinical Congress, American College of Surgeons, San Francisco, California. October 23, 2011.

Tags: bariatric surgery

Category: Past Articles, Spotlight on Surgical Fellowships