What I Know Now That I Didn’t Know Then: Advice for Future Fellows

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.

This month:
by Matthew O. Hubbard, MD, MS, and Caitlin Halbert, DO, MS

Dr. Matthew Hubbard is currently working to complete a Bariatric Fellowship under the direction of Ronald H. Clements, MD, at Vanderbilt University in Nashville, Tennessee. Dr. Halbert is currently working to complete a Bariatric Fellowship under the direction of Aurora D. Pryor, MD, at Stony Brook University Medical Center, Stony Brook, New York.

Bariatric Times. 2015;12(6):16.

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Entry #1:
Caitlin A. Halbert, DO, MS
As this year has progressed, my personal interpretation of the term minimally invasive surgery or “MIS” has changed dramatically. I remember telling my surgical attendings from residency that I was going to do a MIS fellowship after graduation. One of those surgeons then asked me, “Why are you learning a technique when you should be learning about a disease process?” I was not sure how to answer this very important question. It resonated with me. How could I build a practice on the basis that I know how to operate laparoscopically? Are not most graduating residents proficient to some level in basic and sometimes advanced laparoscopy? And, if someone does not consider themselves a MIS surgeon, are they then, by default, an “open” surgeon?

The term, minimally invasive surgery is defined as surgery done through small incisions, or none at all. I can tie intra- and extracorporeal knots and I am proficient in using the EndoStitch suturing device (Covidien, Mansfield, Massachusettes). I can mobilize the hiatus and dissect into the preperitoneal space. I can endoscopically diagnose a marginal ulcer and dilate a stricture. But more importantly, I have learned from this year that I am treating morbid obesity, sleep apnea, hypertension, diabetes, reflux, achalasia, and much more. My career is not defined by my technical ability but rather my impact on a patient’s health.

The fellowships are shifting their perception of MIS in a similar fashion. The MIS fellowship is a broad title that has been replaced with the hepatobiliary, bariatrics, advanced gastrointestinal surgery, thoracic, and colorectal MIS fellowships. There is even a proposal to roll out upper gastrointestinal (GI)/foregut surgery as a category in the near future. My advice to residents interested in MIS is to carefully review the disease process that appeals to them. Techniques will inevitably change overtime, but the diseases will persist. When asked what I am doing this year, I more appropriately tell people that I am completing an advanced GI fellowship in bariatric and foregut disease with a focus on MIS techniques.

Entry #2:
Matthew O. Hubbard, MD, MS
Starting this summer, I will be an attending surgeon in Bariatric and Minimally Invasive Surgery in an academic practice. Just saying that to myself 12 months ago would have given me pause for many reasons. My advice to the incoming fellows is as follows: Even though you may be just graduating from a difficult residency and are eligible to sit for your general surgery boards, you should not assume that you know everything. If you approach fellowship as a chance to rapidly gain knowledge and experience in a supportive and educational environment, then you can make the most of the last training experience of your life.

First of all, I do not believe that I had the requisite surgical skills after completing a general surgery residency to complete an advanced minimally invasive operation by myself. By focusing my training during my fellowship year toward the perfection of technique of a few advanced cases related to bariatric and foregut surgery, I have gained confidence and ability that allows me to feel confident in operating independently when I leave my training program.

The second reason that I would not have felt comfortable entering into an academic practice after residency is that I did not have the experience in running an outpatient office. After residency, a resident has only come into contact with a small portion of the administrative duties required to efficiently organize an office, a clinic schedule, and a staff of dedicated personnel. My fellowship training required didactic courses on building a practice. Additionally, being involved with the same group of surgeons in the same practice day after day was as though I was a junior partner in the group. Much of what I learned in practice management came from the comfort derived from working with the same people for 12 months in a row.

Finally, one thing that I was not prepared for after residency was dealing with many of the unusual patient cases that are out there. As a resident I might have been involved in some peculiar operations that I learned quite a bit from, but this was not the norm, and I’m sure that I did not experience many types of surgical issues (re-operative surgery, unusual anatomy, rare complications) just due to the limited time I spent on each rotation. After fellowship I can think of any number of patients that have come to our clinic, been worked up, and have received operations and subsequent follow up care that would not be considered “run of the mill.”

Fellowship in Advanced Minimally Invasive and Bariatric Surgery has trained me to not just be a safe and competent surgeon, but has also given me invaluable experience in how to run a practice and treat my patients with world-class care inside and outside of the operating room. I think every surgeon would like to say this about their practice, but in this age of residency education I don’t think this would be possible without the support of organizations like 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.

Tags: surgical fellowships

Category: Past Articles, Spotlight on Surgical Fellowships