Raising the Standard: Current Quality Standards in Bariatric Surgical Fellowship Training

| January 1, 2022

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health in Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(1):12–13

“Education is what remains after one has forgotten what one has learned in school.”

-Albert Einstein

In this month’s column, we would like to review the current state of bariatric fellowship training. Bariatric fellowship training programs began in the 1990s. These fellowships were nonstandard training programs, meaning they were not under the domain of the Accreditation Council for Graduate Medical Education (ACGME). The Minimally Invasive Fellowship Council was formed in 2004 in an effort to create training standards and impose some order on the selection process for surgical residents seeking additional training in minimally invasive and endoscopic procedures. As the number of nonstandard specialty fellowships grew, the name was changed to The Fellowship Council. 

The Fellowship Council now oversees advanced gastrointestinal (GI) and related postgraduate specialty training for 185 fellowship programs and 238 fellowship positions.1 There are currently 70 accredited bariatric training programs in the United States.2 Most of these programs are affiliated with universities or medical schools, but several remain based in community hospitals. Their mission is to uphold uniformly high standards and produce well-trained surgeons.

After completing fellowship, the American Society for Metabolic and Bariatric Surgery (ASMBS) currently offers trainees the opportunity to obtain an ASMBS fellowship certificate. The purpose of this ASMBS certification is “to add merit to surgeons beginning their careers in the field by emphasizing their ability to adequately perform metabolic and bariatric surgery.”3 Trainees wishing to obtain ASMBS certification must submit a summary of Fellowship Council case logs, patient evaluation case logs, and an outline of the educational curriculum of the applicant’s fellowship program.

The standardization of the curriculum in bariatric training has been one of the key contributions of the Fellowship Council and ASMBS. Core curriculum must include comprehensive didactic educational sessions covering epidemiology, physiology, and psychology as they relate to obesity. A didactic review of all procedures, as well as endoscopy, is required. The educational program must also cover the management of bariatric patients before and after surgery, which includes the management of complications. Fellows are expected to participate quarterly in morbidity and mortality (M&M) conferences, including quality improvement conferences, perioperative management conferences, and bariatric multidisciplinary conferences. They also must attend at least one patient support group and one patient educational seminar. Certification also requires that fellows complete at least one clinical and/or research project and submit to a National or Regional Society.

Standardization of bariatric training focuses heavily on documentation of all the aforementioned fellowship activities. In addition to surgical case logs, documentation of nonoperative patient encounters includes preoperative evaluations, inpatient encounters, and outpatient evaluations. Bariatric fellowships must provide training in more than one type of weight loss operation. Minimum standards have been set for the designation of comprehensive training, which are as follows: 

  1. Participation in more than 100 weight loss operations
  2. Primary surgeon, which is defined as having performed the key components of the operation, in more than 51 percent of cases. 
  3. Participation in more than 50 intestinal bypass operations 
  4. Combined total of more than 10 restrictive operations
  5. Combined total of more than five revisional procedures
  6. Exposure to and/or extensive teaching of bariatric-specific emergency procedures 
  7. Endoscopy exposure (no case or procedure-specific minimum)
  8. Nonprocedural standards
    1. 50 preoperative evaluations
    2. 100 postoperative inpatient management encounters
    3. 100 postoperative outpatient evaluations

Some flexibility was provided for trainees in 2020-21 due to the impact of the COVID-19 pandemic on bariatric case volumes. Finally, to obtain ASMBS certification, the program director must provide the ASMBS with a brief synopsis of at least two fellow performance assessment interviews.4 

The evolution of bariatric training programs has added significant costs and work effort to what were mostly mentorship programs in the 1990s, but has all this effort added “merit to surgeons beginning their careers?” We can begin to answer this question by addressing the learning curve. While there is no one definition of the learning curve, a systematic review of the literature for laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG) attempted to characterize the key aspects since the impact of learning curves on operative outcomes has been repeatedly demonstrated. An analysis of 28 publications related to learning curves for 27,770 RYGB and LSG procedures was completed. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. The learning curve case range was wide and heterogeneous. However, learning phases were identified that described the number of procedures necessary to achieve predefined skill levels. These levels are reached for RYGB after 30 to 70 cases (competency), 70 to 150 cases (proficiency), and up to 500 cases (mastery) and for LSG after 30 to 50 cases (competency), 60 to 100 cases (proficiency), and 100 to 200 cases (mastery). Training curricula, previous laparoscopic experience, and high procedure volume were associated with successful outcomes during the learning curve.5 

Several reports have described better bariatric outcomes after completion of one-year fellowship training. Training in an accredited bariatric fellowship was associated with operative times, conversion to open rates, length of stay, and 30-day complications similar to national benchmarks in a surgeon’s first year of independent practice for gastric bypass,6 as well as LSG and biliopancreatic diversion.7 There were no mortalities in either study. Thus, there is good evidence that the efforts to standardize bariatric training have led to better patient outcomes for fellowship-trained bariatric surgeons early in their career.

References

  1. The Fellowship Council. https://www.fellowshipcouncil.org/. Accessed 28 Dec 2021.
  2. The Fellowship Council. Directory of fellowships. https://www.fellowshipcouncil.org/directory-of-fellowships/. Accessed 28 Dec 2021.
  3. American Society for Metabolic and Bariatric Surgery. ASMBS fellowship certificate. https://asmbs.org/professional-education/fellowship. Accessed 1 Jan 2022.
  4. American Society for Metabolic and Bariatric Surgery. Core curriculum for American Society for Metabolic and Bariatric Surgery fellowship training requirements. https://asmbs.org/app/uploads/2014/05/CoreCurriculumASMBSFellowshipTraining.pdf. Accessed 28 Dec 2021.
  5. Wehrtmann FS, de la Garza JR, Kowalewski KF, et al. Learning curves of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in bariatric surgery: a systematic review and introduction of a standardization. Obes Surg. 2020;30(2):640–656.
  6. Agrawal S. Impact of bariatric fellowship training on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass in the first year as consultant surgeon. Obes Surg. 2011;21(12):1817–1821.
  7. Sucandy I, Antanavicius G. Impact of minimally invasive/bariatric surgery fellowship on perioperative complications and outcomes in the first year of practice. N Am J Med Sci. 2013;5(7):419–421.

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Category: Past Articles, Raising the Standard

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