The Experts on Bariatric Fellowships…Where Are We?

Like to know more about bariatric fellowships? In this exclusive interview, on behalf of Bariatric Times, Dr. Daniel Jones, Associate Professor at Harvard Medical School, posed questions to the leadership of the Fellowship Council. Dr. Jones is the director of the “MIS fellowship with emphasis in Bariatric Surgery” at Beth Israel Deaconess Medical Center. The Fellowship Council is responsible for creating a curriculum for fellowships in advanced gastrointestinal surgery and standardizing the fellowship application and selection process, as well as overseeing the match process. Interviewed here are Bruce Schirmer, MD, President Elect; Michael Sarr, MD, Vice President; Raul Rosenthal, MD, Secretary/Treasurer; C. Daniel Smith, MD, Past President and Chair of the Board of Directors; Alfons Pomp, MD, Representative of the American Society for Metabolic and Bariatric Surgery Representative to the Board; Adrian Park, MD, American Board of Surgery Representative to the Board; and Founding Member/Fellowship Director Eric J. DeMaria, MD, FACS.

What are you looking for in a bariatric fellow?

Bruce Schirmer: Our main criteria for rating prospective fellows is a combination of the personal recommendation letters they have received, their academic performance to date, their experience in minimally invasive surgery (MIS), and the impression we obtain on a personal interview. While experience is a positive, it is not a dealbreaker. Our fellows are actually appointed to the faculty, so we are looking for individuals with enough experience and a track record of performance that strongly suggests to us that they will positively contribute to our program while learning. Interviews are given only to selected candidates, based on the other criteria. However, the interview is a very important component of our evaluation.

Raul Rosenthal: The qualifications vary from one program director to another. Obviously they must have finished a general surgery training program and be board-eligible. Academic interest is required in some institutions, as well as ability to publish and do oral presentations. Communication skills are crucial. This entails understandable English language. Additionally, I personally expect the fellow to be qualified and mature enough to run my clinic, do consultations, communicate with the relatives of our patients, and do rounds independently. High United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE) scores help but are not the most important aspect of an application.

Michael Sarr: There is no question that what we are looking for in a bariatric fellow would be a competent bariatric surgeon—someone who is competent in the preoperative evaluation, can have interaction in a multidisciplinary fashion, is technically adept at the operation, and is able to anticipate and take care of problems that occur postoperatively. We are also looking for an empathetic physician. This is more than just being a surgeon.

Daniel Smith: A self-starter who is committed to excellent patient care, has a passion for personal excellence, and wants to be a part of a team that also performs at the highest level possible.

Alfons Pomp: Fellows are expected to contribute to the advancement of the knowledge of obesity surgery and the treatment of obesity and related diseases. This knowledge needs to be gained by hands-on clinical experience. Fellows are usually expected to submit abstracts and complete a research project (and manuscript) during the fellowship year.

Eric J. DeMaria: Our program is combined MIS and bariatrics; therefore, we are looking for both bariatric and non-bariatric interested individuals. However, we do rely significantly on the skill development of laparoscopic Roux-en-Y gastric bypass to teach our fellows whether they have a primary career interest in bariatrics or not. Candidates must be agreeable to that training model. We also strive to train academic leaders in MIS/bariatrics and therefore look for individuals with a demonstrated track record of academic accomplishment during residency. Most successful candidates for our program are in the uppermost category in terms of scholastic success and letters of recommendation. Personal contact from the candidate’s program helps us to identify the best candidates.

Adrian Park: We are looking for bright, motivated individuals who already have a track record that demonstrates initiative and clinical acumen. I want someone whose hands work well and who is a finisher—someone who is willing, able, and motivated to see things through to completion.

Are preoperative and postoperative clinics a required part of fellowship training?

Alfons Pomp: We consider the perioperative care component of the fellowship important enough that we have mandated specific numbers; fellows should be involved in at least 50 preoperative evaluations, 100 postoperative patient encounters (i.e. hospital rounds) and 100 postoperative outpatient evaluations. We believe that this is the minimal number of clinical contacts that will allow the fellow to be adequately prepared to manage the particular aspects of care unique to a bariatric practice.

Michael Sarr: The response to this question is “absolutely.” For a bariatric fellowship to be able to train a bariatric surgeon to be able to go into practice and start a bariatric program, they absolutely have to participate in the pre- and postoperative care. To be a bariatric surgeon does not just mean you can do the operation. It means that you must understand the components of patient selection, the different types of operations, and the multidisciplinary preoperative evaluation, but also the postoperative care, problems that can occur, surveillance that is required, psychologic input, etc. The term bariatric surgery involves the word surgery. This word implies the practice of doing bariatric procedures, much of which is nonoperative, i.e. preoperative and postoperative care. The bariatric operation is the operation that is done.

Do fellows do research during their fellowship year?

Michael Sarr: Almost all bariatric fellowships strongly advocate a component of academia into the fellowship. Some fellowships are obviously much more academically oriented, while others are much less so, but all suggest some form of participation in an academic mission usually through SAGES or through the ASMBS. Some of the fellowships actually “require” submission of an abstract, but it doesn’t necessarily mean they have to be accepted or they have to have a paper accepted. The Fellowship Council as a whole  supports the concept of promoting academia in these fellowships and strongly encourages it.

How does the fellowship match work?

Adrian Park: The match is set up to protect both the fellowship applicant and the fellowship program director. Those seeking fellowships can interview wherever they desire to attain a fellowship, and those seeking fellows can interview all candidates. The objective is to be as fair as possible so that a match happens on an even playing field. There are no backroom deals. Once interviews are conducted, both parties rank in order of their preference. After all applications, interviews,  and rankings are complete, we match applicants’ top choices to programs’ top choices based on those rankings.

Do bariatric fellows need to take the SAGES FLS exam?

Bruce Schirmer: If the bariatric fellow has not already taken the Fundamentals of Laparoscopic Surgery (FLS) exam, they most certainly must do so. The FLS exam is now a requirement for all finishing residents in surgery before they can sit for the Qualifying Examination given by the American Board of Surgery. If a resident should have documentation of this body of knowledge and manual skills, then a fellow should certainly do so also. In addition, I believe the Fellowship Council has now made it a mandatory part of completing an accredited Fellowship Council GI fellowship.

If an applicant does not receive an offer on Match Day, can he or she still find a program?

Adrian Park: The day after Match Day is Scramble Day. At the Fellowship Council, we know which fellowships did not get filled and which applicants did not yet get matched, and the executive director facilitates a scramble—where open positions/fellowships are worked through with our list of unmatched fellows. Currently, 15 to 20 percent of fellowship applicants do not secure a spot via match.

Do patients know when a fellow is participating in their care or doing their operation?

Bruce Schirmer:  While I cannot speak for all institutions, at our institution we have a specific paragraph in the standard consent form that details the fact that operations often involve the participation of multiple people besides the surgeon. When I am explaining that paragraph to all of my patients, I make clear that there will be three people doing a laparoscopic procedure. One person will point the telescope and one other person will do the surgery with me. If the patient asks specifically who will be doing the operation, I inform them that the operation is a two-person procedure, and that it is basically necessary for both of us to perform certain parts of the operation in order to successfully complete it. Whether I am putting the stitch in or making it possible for the fellow to do it is not as important as ensuring it is done correctly, which I will do by being there.

Michael Sarr: This should be evident to the patient via communication. Whenever a trainee does an operation or participates in it, this must be communicated to the patient. All of us with these fellowships are directly responsible for the care of the patient. The patients are under the care of the bariatric surgeon and the faculty in the fellowship. The fellow is a trainee and, although he or she may do much of or maybe all of the operation, the direct responsibility for the patient lies with the faculty. It would not be right to not inform the patient that the fellow will be participating in some or all parts of the operation.

How do you balance the line between allowing trainees to learn and reassuring patients that you are their doctor?

Daniel Smith: Nearly every patient asks me that question. The answer is simple.
I am their surgeon. I remain actively involved in all aspects of care and do not delegate their care to unsupervised trainees. On the other hand, I do teach and have an obligation to train the surgeons of the future, so these trainees will be involved in all aspects of patient care.

Bruce Schirmer: One does that by being their doctor. Taking the time to converse with them in clinic beforehand, getting to know them, explaining the procedure, answering questions, obtaining the consent form myself, and then seeing them every day that I am in town while they are in the hospital, as well as of course performing their surgery and directing their care with our resident staff daily. These are the main components of my patient care that, I believe, leave little doubt in my patients’ minds that I am indeed their doctor. We also must live the care portion of patient care.

Raul Rosenthal: Patients are made aware of that surgical treatment is a complex and around-the-clock task. To achieve the highest standards, treatment must be a team effort. I personally tell patients that fellows are fully trained surgeons and that they work under my direct supervision. I believe that independent work, in the OR and outside of it, is a gradual process that varies from one fellow to the next depending on skills, knowledge, and complexity of the case. There are still cases when I personally need advice from my senior mentors.

Eric J. DeMaria: We run a busy program with high surgical volumes. Patients are educated that we have fellows intimately involved in their care, including the surgical procedure as it is a “two-surgeon” operation, which requires high-level assistance. I follow the principles of “graded responsibility” during the fellowship year—with the goal of complete independent performance of the gastric bypass operation by mid-year followed by what I like to call “progressive interference” with the fellows’ ability to perform, in which I simulate an untrained assistant frequently during the procedure. This helps to train the fellow to the level of mastery in my view. I also emphasize the fellows’ primary role in all aspects of patient care and my expectation that the fellow assumes comprehensive responsibility for the patients—yet keeps me informed at every step and particularly when a patient is not following the expected pathway. Fellows must demonstrate exemplary patient care, and I take patient complaints about their care as a signal that the fellow is not doing his or her job to the level of my expectations. Our program has a lot of responsibility for the fellows in their care of our patients. It hasn’t been my experience that our patients do not know who their doctor is—and if a fellow somehow gives a patient that impression (i.e. that the attending is not aware and involved in their care) we would move to correct that fellow’s behavior and remedy the situation promptly.

Alfons Pomp: Patients are aware that in a teaching institution part of their care is provided by surgeons who are in training and are being closely supervised by an attending professor. I personally let each patient know that the fellow is a board-eligible surgeon and I have confidence in his or her clinical abilities. Every patient is reassured that I am present throughout his or her surgery and I personally oversee my fellow’s activity in the operating room.

Michael Sarr: First of all, you have to win the respect of the patient, communicating that you are the person controlling their preoperative, operative, and postoperative care. For instance, what I often do is talk about playing tennis right-handed or left-handed. If you are right-handed, you don’t want to have to hit a ball left-handed or “back-handed” and if it is right-handed for you and you are right-handed and left-handed for the fellow and he/she is right-handed, then you should be doing that part of the operation. If, on the other hand, it would be left-handed or “back-handed” for you but right-handed or forehanded for the fellow and the fellow is competent to do that, it would be better for the fellow to do it. That’s one of the ways that I describe it. We also say that it is a training program but that there will be direct hands-on supervision of everything that is done.

Adrian Park: This is an age-old issue, and the same can be said with residents. I am of the firm conviction that patients come to me for the best care, not as an educational opportunity for a fellow or resident. My first commitment is to the patient and the best outcome. In the vast majority of cases, we can give the best care and allow for learning and teaching. I communicate to any patients who have concerns that I am their surgeon, but that we function as a surgical team in the OR. The fellow is an integral part of that team, and this is a learning center. The patient’s wish is, however, always honored.

What are some of the goals of teaching adult learners?

Eric J. DeMaria: Incoming fellows are average age 30 to 33, with experience to bring to the table. They are often married and with children. Of Duke’s most recent 12 fellows, 10 were married, all of those with children, and including two children born during the year of fellowship training. They are graduates of general surgery residency, and we are meeting them 5 to 8 years after medical school graduation. They are goal- and relevancy-oriented, and they’re practical. They need to be shown respect. When we train fellows, we are training adults, and therefore we need to understand how to optimize adult learning. Motivation to learn is important and enhanced by fellows’ interest in learning what you know for their own future. Self-directed study is good, but may have the potential to become unproductive if unstructured. We as trainers have to beware of spoon feeding—adults do better with self direction in a structured environment with responsibility; they need to be free to direct themselves. Experiential learning, derived from adult learning theory, seems to be the best model, and is a cyclic process involving setting goals, thinking, planning, experimenting, making decisions, and, finally, action, followed by observing, reflecting, and reviewing. As mentioned, our typical fellows are in their early 30s and have experience on which to draw. Experiential learning uses participants’ own experience and their own reflection about that experience, rather than lecture as the primary approach to learning. Experiential learning theory allows for the generation of understanding and transfer of skills and knowledge through the fellows doing something and discovering what it is like through their experience rather than someone else’s. This concept is particularly effective in adult education as it addresses the cognitive, emotional, and physical aspect of the learner. Training fellows in a way that incorporates these values ensures that learning takes place through direct involvement and reflection, and the “hands-on” aspect increases motivation and material retention. Goals of teaching adult learners are stressing that the fellow IS the surgeon, and as such, has direct patient care responsibility and the charge of mastering technical skills. This kind of learning is not a remedial training experience. Again, the fellows actually want to learn what you do so they can practice your specialty. Their efforts should be guided by high expectations from the program faculty, but they should always be treated with respect and be valued for their role.

Is there a defined number or type of cases a bariatric fellow should participate in during training?

Eric J. DeMaria: Our expectation is the fellow will be the primary surgeon on at least 100 anastomotic bariatric MIS procedures during the fellowship year.

Michael Sarr: The Fellowship Council strongly believes that these bariatric and MIS fellowships should expose the fellow to all aspects of bariatric surgery—both restrictive procedures, such as the laparoscopic band or the sleeve gastrectomy, as well as the more conventional bypass procedures, such as a Roux-en-Y gastric bypass or a duodenal switch with biliopancreatic diversion. The Fellowship Council believes that although many of the MIS/bariatric programs may not give direct, hands-on experience in all of these types of procedures to the fellow, the true bariatric fellowship should have a component of both restrictive and bypass procedures incorporated into their fellowship. So, yes, the fellows are expected to do at least 100 cases as a primary surgeon in a year, with some mix of restrictive and bypass procedures.

What are job opportunities after fellowship training?

Michael Sarr:  There are many types of job opportunities, either in a primary bariatric practice or in a practice that involves some bariatric surgery. These practices can be community-based, university-based, hospital-based, or we would hope that the bariatric surgeon—when he/she finishes the fellowship—would be able to partner up with some other surgeons in the community to help start a practice like this. There are some practices that are solely bariatric that work in a group of other physicians. It is almost impossible to be a sole bariatric surgeon because the patients need 24-hour care and it is hard for one person independently to do this. Many of these practices now are going to “Centers of Excellence” that are accredited programs either by the ASMBS or by the American College of Surgeons (ACS).

Are fellowships open to foreign medical graduates? If so, what type of visa or license is required?

Raul Rosenthal: Fellowships are open to medical graduates only if they have passed the USMLE examination—Step 1 through Step 3 and provided they can be integrated in an ACGME program as PGY 7. If applicants want to train in private or semi-private institutions without an approved ACGME training program, they must be board-eligible and qualified in order to obtain an unrestricted medical license in the state they are applying for training. An H1 VISA is the minimum required for this last option.

Alfons Pomp: This is an interesting and pertinent question; Adrian, Raul, and myself have all completed a significant part of our training outside the United States. Fellowship requirements vary from program to program. In New York state, for example, licensing requirements are difficult for fellows who need to take attending calls and therefore candidates who do not have at least a registered alien (“green card”) status may not be offered interviews. The majority of fellowship programs offer employment to foreign medical graduates.

If a trainee is interested in a bariatric fellowship, where should he or she look to learn more?

Alfons Pomp: A trainee who is interested in a bariatric fellowship should consult the Fellowship Council’s website. Once they have evaluated the programs that appear interesting, they should further investigate the programs through the web and research other publications/presentations by the program’s faculty. If interviewed by the program, candid questions to the existing fellows and pointed questions about the current appointments of past fellows are very pertinent.

Does the Fellowship Council distinguish between MIS fellowships and bariatric fellowships?

Alfons Pomp: The fellowship council has over 120 fellowship programs, among which there are 58 MIS/bariatric and 15 bariatric fellowships. In order to be accredited a bariatric fellowship, the council mandates that the fellow be the primary surgeon in 51 cases that involve stapling or anastomosis of the gastrointestinal tract (bypass) and 10 restrictive operations (band). There are some fellowships where the candidate has exposure to this volume of bariatric procedures as well as a significant number of other minimally invasive procedures, and these are considered MIS/bariatric fellowships.

What do you do if a fellow has weak technical skills?

Bruce Schirmer: Repetition. Repetition. Repetition. Some individuals take longer to master the skills of surgery than others. So patience on your part and repetition on the part of the fellow are essential to achieving adequate skill levels. The fellow may have had a relatively poor experience during residency in performing minimally invasive surgery. While weak technical skills are definitely a detractor, I would rather have that than a character, work ethic, or communication deficit in the fellow. Technical skills can almost always be improved to a satisfactory level with adequate repetition.

Is there a written board exam in bariatric surgery?

Eric J. DeMaria: Not yet, but it is coming… no doubt at all about that.

What is the benefit of an MIS fellowship after resident training? Better jobs?

Adrian Park: From a data standpoint, it is hard to be definitive. The perception is that the salary after fellowship is 10- to 15-percent higher. Residents who seek fellowship training do so because of a self-assessed deficit, and have determined that they need further training and improvement in skills. With this further training and advanced skills acquisition, the fellow develops a focus of expertise, and perhaps increased marketability.

What does it mean for a fellowship to be accredited by the Fellowship Council?

Adrian Park: To be accredited by the Fellowship Council, an institution has applied and gone through the rigorous application process, which involves review of curricula, caseload and mix of cases, infrastructure, site visit feedback, etc. Site viewers make a detailed, metrics-based assessment involving the relevant components, and the Fellowship Council then makes a final decision after further review of all information. Accreditation can be given in one-year and three-year terms, or is not granted.

Category: Interviews, Past Articles