Update From the American Board of Surgery 4 th Rural Surgery Symposium Mithoefer Center for Rural Surgery Cooperstown, NY May 17, 2009 Steven C. Stain, M. D.
AMERICAN BOARD OF SURGERY • History and functions of the Board • ABS Diplomates – Maintenance of Certification – Modular Exams and Recertification • Resident Training – Surgical Council on Resident Education – IOM Report on Resident Work Hours – Surgical Oncology Fellowship? – Tracking of Residents – Rural Track?
The American Board of Surgery
American Board of Surgery • Certification of Training Programs – RRC • Certification of Individuals – ABS
American Board of Surgery Flexner Report – 1910 Medical Education in the United States and Canada • Funded by Carnegie Foundation • Apprenticeships vs. Education • Fundamentally changed medical education • 166 schools By 1930, only 75
Board Movement • Certification of individual specialists • Equally Important to the safe care of patients
American Surgical Association Founded in 1880 How may a standard of knowledge be established, the attainment of which will gain men general recognition? . . . The ASA could create itself a national college of surgeons and hold annual examinations. Only those passing this examination would be eligible for fellowship. The eligibility of fellowship and the certification of having passed such an examination would at once give a man a recognized standing Dudley Allen, ASA Presidential Address 1907
American Board of Surgery • • American College of Surgeons Am Board of Ophthalmology Am Board of Otolaryngology Am Board of Obstetrics and Gyn Am Board of Orthopedic Surgery Am Board of Colon and Rectal Surg Am Board of Urology 1913 1916 1924 1927 1934 1935
American Board of Surgery ACS originally argued that ABS was unnecessary, since the ACS had championed surgical standards
AMERICAN BOARD OF SURGERY • • American College of Surgeons American Surgical Association Surgical Section AMA New England Surgical Society Pacific Coast Surgical Association Southern Surgical Association Western Surgical Association
ABS Directors American College of Surgeons (4) American Surgical Association (4) Society of University Surgeons (3) New England Surgical Society Pacific Coast Surgical Assn Western Surgical Assn American Medical Assn Southern Surgical Assn Central Surgical Assn Southeastern Surgical Congress Southwestern Surgical Congress Am Board of Colon and Rectal Surg Am Board of Plastic Surgeons Am Board of Thoracic Surgeons Am Assn Surgery of Trauma Am Pediatric Surgery Assn Academic Surgery Assn Program Directors Surgery Assn Pediatric Prog. Directors Assn Vascular Prog. Directors Am Society Transplant Surgeons SAGES SSAT Society for Surgical Oncology Society for Vascular Surgery At large Directors (3)
AMERICAN BOARD OF SURGERY Nomination Process • Each organization nominates 3 surgeons • Confidential discussion of the candidates by the Directors • Blind e-mail vote
AMERICAN BOARD OF SURGERY • Certifying Exam 3 times per year – Senior directors: 2 times per year until 65 • • Attending Directors Meetings (3) Standing Committee – Credentials, GS Residency, Advanced Surgery Education, Diplomates • Sub Boards & Advisory Councils – Vascular, Pediatric Surgery, Surgical Oncology, GI Surgery, Transplantation, Trauma/Burns/CC
The American Board of Surgery Inc. , (ABS) is a non profit, private, autonomous organization formed for the following purposes: 1. To conduct examinations of acceptable candidates who seek certification or maintenance of certification by the board
The American Board of Surgery Inc. , (ABS) is a non profit, private, autonomous organization formed for the following purposes: 1. To conduct examinations of acceptable candidates who seek certification or maintenance of certification by the board 2. To issue certificates to all candidates meeting the board’s requirements and satisfactorily completing its prescribed examinations
The American Board of Surgery Inc. , (ABS) is a non profit, private, autonomous organization formed for the following purposes: 1. To conduct examinations of acceptable candidates who seek certification or maintenance of certification by the board 2. To issue certificates to all candidates meeting the board’s requirements and satisfactorily completing its prescribed examinations 3. To improve and broaden the opportunities for the graduate education and training of surgeons
Maintenance of Certification • ABS one of 24 Boards of the ABMS ~200 “Boards” • ABMS and quality standards – Board Certification – Time limited certificates (1970’s) – Deemed Status • MOC: Automatically enrolled if certified or recertified after July 1, 2005
Why Maintenance of Certification • Board Certification is a measure of quality • Public perception of physician errors • Measurement of quality being defined for us – Are things being measured by CMS important? – If Board certification is important, how to best assure that surgeons are maintaining quality?
AMERICAN BOARD OF SURGERY American Board of Medical Specialties • Board movement of the 20 th century • Kevin Weiss, M. D. – Hired as CEO in 2005 – Initiative to Enhance the Public Trust – Develop Common MOC Tools
AMERICAN BOARD OF SURGERY • Maryland Blue Cross/Blue Shield now accepts MOC as Pay for Performance Indicator – Participation in Part IV of MOC – Effectiveness points for additional reimbursement • Met with National Blue Cross/Blue – Can list MOC participation in Directory – Working towards additional reimbursement
Four Components of MOC • Professional Standards – License, Hospital Privileges and Reference • Lifelong Learning and Self-Assessment – 50 hours per year (30 hrs Category I) • Cognitive Expertise – Secure Exam (Recert Exam) every 10 years • Evaluation of Performance in Practice – Outcomes Database or QA Program
Part IV of MOC: Evaluation of Practice • Numerous options • Not onerous on the Diplomates – Meaningful assessment • Disease Focused • Verifiable Reporting • True Evaluation of Surgeon’s Practice
Practice Assessment Resources • • • ACS Case Log Bariatric Database ABA Burn Registry Children Oncology Group CMS PQRI Mastery of Breast Surgery Nat’l Cancer Database NSQIP NTDB NTRACS NICHD Neonatal Network SCOAP (State of WA) SAGES Outcome Initiative STS Database Surgical Care Improvement Program • SVS Vascular Registry • New England Vascular Study Group • UNOS • • •
MOC Timeline for an ABS Diplomate Who Recertifies in 2009 YEAR MOC REQUIREMENT 2010 Yearly CME 2011 Yearly CME 2012 Yearly CME, Self-Assessment, Reference Letters 2013 Yearly CME 2014 Yearly CME, Practice Performance 2015 Yearly CME, Self-Assessment, Reference Letters 2016 Yearly CME 2017 -2019 Secure Recertification Examination
Current ABMS Issues • Committee on Certification, Subcertification and Recertification (COCERT) – Hospitalist Certificate – Radiology Primary Certificate • Committee on Oversight and Monitoring of Maintenance of Certification (COMMOC) • Method of true practice assessment – Surgical Outcomes Registry
Committee on Oversight and Monitoring of Maintenance of Certification • Proposed Methods of Assessment – Consumer Assessment Healthcare Providers and Systems (CAHPS) – Patient Safety Self Assessment Program – Communication Assessment (3600 evaluation)
Consumer Assessment Healthcare Providers and Systems (CAHPS) • Developed by AHRQ – National Reporting Database – Survey Instrument (16 pages) – Letters mailed out to patients – 36 questions – Developed for Ambulatory Primary Care
Consumer Assessment Healthcare Providers and Systems (CAHPS) 5. In the last 12 months, did you phone this doctor’s office to get an appointment for an illness, injury or condition that needed care right away? 1 Yes 2 No If No, go to #7 6. In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed? 1 Never 2 Almost never 3 Sometimes 4 Usually 5 Almost always 6 Always
Consumer Assessment Healthcare Providers and Systems (CAHPS) 19. In the last 12 months, how often did this doctor show respect for what you had to say? 1 Never 2 Almost never 3 Sometimes 4 Usually 5 Almost always 6 Always 20. In the last 12 months, how often did this doctor spend enough time with you? 1 Never 2 Almost never 3 Sometimes 4 Usually 5 Almost always 6 Always
Patient Safety Self Assessment
3600 Evaluation of Communication • American Board of Orthopedics • Letters to – – – – Chief of Surgery Chief of Staff Chief of Anesthesia Chief of Emergency Department OR Manager Nurses in OR, ED, ICU, wards Referring Doctors • Average of 15 letters • Identify 5 -6 of 250 Orthopedists per year
Current ABMS Issues • Mandatory MOC Standards – Consumer Assessment Healthcare Providers and Systems (CAHPS) – Patient Safety Self Assessment Program – Communication Assessment (3600 evaluation) • All Opposed by ABS – Agreed to 5 year voluntary “pilot” program
Current ABMS Issues • ABIM Hospitalist Certificate (Defeated) • Radiology Primary Certificate (Defeated) • Surgical Outcomes Registry • Support ACS Development – NSQIP light
Modular Exams and Recertification • Why should a breast surgeon recertify in “general surgery” • Could we develop a modular exam? – 200 questions w/ 150 in focused area – Subspecialist perform well on exam anyway – They may decide to change their practice
Modular Exams and Recertification • Why should a breast surgeon recertify in “general surgery” • Could we develop a modular exam? – 200 questions w/ 150 in focused area – Subspecialist perform well on exam anyway – They may decide to change their practice • ABS voted the proposal down
Draft Definition of a General Surgeon Comprehensive • Alimentary Tract • Abdomen • Breast, skin, soft tissue • Endocrine system • Critical care • Surgical Oncology • Trauma/Burns/Acute Care
Definition of a General Surgeon Familiar with: • Transplantation • Pediatric Surgery • Thoracic Surgery • Vascular Surgery
Definition of a General Surgeon Should general surgeons do: – Pancreaticoduodenectomy – Hepatectomy – Esophagectomy
Definition of a General Surgeon • Statewide Regionalization of Pancreaticoduodenectomy and its Effect on In. Hospital Mortality Gordon et al, Ann Surg 1998 • Should Hepatic Resections be Performed at High Volume Centers Choti, et al, J GI Surg 1998
Draft Definition of a General Surgeon Comprehensive • Alimentary Tract • Abdomen • Breast, skin, soft tissue • Endocrine system • Critical care? • Surgical Oncology? • Trauma/Burns/Acute Care?
Draft Definition of a General Surgeon Should a general surgery resident require a fellowship to perform? • Pancreatectomy • Hepatectomy • Esophagectomy • Rectal Cancer Resection
My Definition of a General Surgeon Comprehensive • Alimentary tract – (HPB, Esoph, Rectal) • • Abdomen Breast, skin, soft tissue Endocrine system Acute care surgery Knowledge of: • Critical care? • Surgical Oncology? • Trauma/Burns? Familiar with: • • Transplantation Pediatric Surgery Thoracic Surgery Vascular Surgery
How do we train residents to be competent? • • • Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems Based Practice Based Learning and Improvement Approved by ACGME and ABMS in 1999
Resident Training in Patient Care How many procedures are necessary to perform to be competent in a procedure?
Resident Training How many procedures are necessary to perform to be competent in a procedure? • ABS data on graduating residents
Resident Operative Data Mean Median LAP CHOLECYSTECTOMY 102. 4 95 OTHER PROCEDURES 60. 1 45 OPEN INGUINAL HERNIA 50. 1 48 OPEN COLECTOMY 43. 5 42 NON-OPERATIVE TRAUMA 43. 2 27 VENTRAL HERNIA 41. 4 40 LAPAROSCOPIC APPENDECTOMY 36. 0 33 COLONOSCOPY 33. 7 23 BREAST BIOPSY 31. 2 28 OPEN APPENDECTOMY 24. 5 21 THYROIDECTOMY, PARTIAL OR TOTAL 23. 2 20. 0
Resident Operative Data Mean Median UPPER ENDOSCOPY 20. 2 15 PEDIATRIC HERNIA 19. 8 17 OTHER MAJOR SKIN /SOFT TISSUE 19. 7 17 A-V FISTULA 18. 6 16 SMALL BOWEL RESECTION 18. 1 17 LAP INGUINAL HERNIA 17. 4 14 CAROTID ENDARTERECTOMY 16. 2 14 TRACHEOSTOMY 14. 1 12 NON TRAUMA LAPAROTOMY 13. 5 11 LAPAROSCOPIC COLECTOMY 12. 9 11 OPEN CHOLECYSTECTOMY 12. 0 11 LYSIS OF ADHESIONS 10. 9 8 VENTILATORY MANAGEMENT 10. 1 7
Resident Operative Data Lap Chole Open inguinal hernia Open colectomy Ventral hernia Lap appy Colonoscopy Breast biopsy Open appy Thyroidectomy EGD Peds Hernia Major skin/soft tissue Small bowel resection Lap inguinal hernia Tracheostomy Non trauma laparotomy Lap colectomy Open appy Lysis of adhesions
Knowledge of: Critical care? Surgical Oncology? Trauma/Burns? Familiar with: Transplantation Pediatric Surgery Thoracic Surgery Vascular Surgery Subspecialists General Surgeons Alimentary tract (HPB, Esoph, Rectal) Abdomen Breast, skin, soft tissue Endocrine system Acute care surgery
• Surgical Council on Resident Education – ABS, ACS, ASA, APDS, ASE, RRC • Website Portal for Resident Curriculum – Beta Test at 33 sites – 117 modules – Didactic knowledge – online textbook links – Video library – SAGES – Goal: Available by July 1
• Diseases – Broad: Comprehensive knowledge – Focused: Initial Management / Stabilization • Operations – Essential – Common – Essential – Uncommon – Complex
• Diseases – Broad Knowledge – Limited Knowledge for Initial Management • Procedures – Common: Core procedures – Unusual (but necessary knowledge) – Rare (subspecialty training)
• Broad – – Jaundice Cholangitis Gallstone Disease Iatrogenic CBD injury? • Focused – – – GB Cancer Bile duct cancer Choledochal cyst Sclerosing cholangitis Ampullary Stenosis
Common Unusual Rare Lap Cholecystostomy Lap CBDE Open Chole CBDE GB cancer resection Choledochojejunostomy Klatskin resection Incidental GB cancer Choledochal cyst Repair Acute CBD injury Sphincteroplasty
How to Train Surgical Residents in 2009 • How to assess competency? • Institute of Medicine Report • Effect of fellowships on training – Surgical Oncology Certificate
Institute of Medicine Report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (Dec 2008)
Institute of Medicine Report • Leaves intact 80 hr per week limit • NO shifts longer than 16 hours – Followed by 5 hrs of uninterrupted sleep break – No call from home – Effectively ends night call • Night float – NO more than 4 consecutive nights – Followed by 48 hours off duty
ABS Response to IOM Report • ACGME conference – Phil Nasca – Invited Commentary by Boards • Patient Safety – No evidence that 80 hours has improved – Do residents sleep if work reduced? • Continuity of Care – Surgery is different • Does not prepare residents for real practice
ABS Response to IOM Report • IOM report is not binding • Representative John Dingle (D-Michigan) – SEIU – unionization of residents? • GME funding in jeopardy? Sentiment of Directors We will not certify that residency graduates are competent to practice
Subspecialty in Surgical Oncology • ABS domain over non ACGME fellowships – Surgical oncology, breast fellowships, minimally invasive surgery, Transplant, GI / HPB, Acute Care • Influenced by ABIM and hospitalists – Defeated by ABMS • Legal opinion regarding ABS certificates for non ACGME fellowships
Subspecialty in Surgical Oncology • 19 SSO training programs – 8 in free standing cancer centers – 3 are in Canada – Only 8 are US Department of Surgery with concomitant Gen Surg training programs – Graduate 55 trainees per year – 95% of cancer care delivered by general surgeons
Is Surgical Oncology Training Different? Procedure Gen Surg Chief Resident SSO Trainees Retroperitoneal lymph node dissections 0. 6 +/-2 1. 98 +/- 3. 05 Liver Resections 3. 9 +/- 4 16. 82 +/- 12. 68 Pancreaticoduodenectomy 4. 0 +/- 4 45. 2 +/- 57. 28 Total Pancreatectomy 0. 2 +/- 1 1. 8 +/- 1. 79 Distal Pancreatectomy 2. 3 +/- 2 13 +/- 2. 29 Esophagectomy 1. 1 +/- 2 1. 53 +/- 3. 78 Esophagogastrectomy 0. 9 +/- 1 2. 84 +/- 3. 86
Is Surgical Oncology Training Different? Procedure Gen Surg Chief Resident SSO Trainees Partial gastrectomy 4. 3 +/-3 6. 6 +/- 5. 64 Total gastrectomy 1. 0+/- 1 3. 2 +/- 2. 59 Laparoscopic gastric resection 2. 3 +/- 7 0. 41 +/- 0. 94 Abdominoperineal Resection 3. 1 +/- 3 6. 87 +/- 6. 37 Stereotactic breast biopsy 1. 5 +/- 4 5. 6 +/- 10. 43 Adrenalectomy 1. 9 +/- 2 2. 81 +/- 3 Major lymphadenectomy 4. 1 +/- 4 19. 23 +/- 14. 09 Soft tissue sarcoma resection 2. 7 +/- 3 15. 13 +/- 15. 99 Radical neck dissections 1. 4 +/- 2 6. 12 +/- 6. 37
Do Surgical Oncologists Practice Differ Procedure SSO NON P value Cholecystectomy Hernia repair (all) Colon (all) Pancreas (all) Breast (all) Major lymphadenectomy Major excision skin neoplasm Melanoma sentinel node biopsy a Radical excision for soft tissue tumors 24. 3 22 17. 6 9. 5 98. 8 7. 3 12. 5 11. 1 11. 5 56. 1 59 20. 1 1. 6 55. 8 2. 6 1. 2 1. 8 0. 002 0. 275 0. 0001 0. 04 0. 002 0. 006 0. 001
Will Surgical Oncologists Take Call On Call Schedule Number Percent No Call 78 13. 7 Surg Oncology Only 162 28. 4 Oncology and General Surgery 196 34. 4 Oncology, General Surgery and Trauma Missing 85 14. 9 49 8. 6
Subspecialty in Surgical Oncology • Leaders in Cancer Care – Division Chiefs – Cancer Center Directors • • Cancer Education and Prevention Research Requirements Will not grandfather previous trainees Under ABS Domain – Explosion of surgical oncology fellows?
Residency Training General Surgeons vs. Subspecialty General Surgery • Rural surgery need • Shortage of general surgeons • Effect of fellowships Subspecialty • Resident choice • Focused practice • Improved quality
The Impending Disappearance of the General Surgeon • 1000 surgical residents per year – 70% go into fellowships – Competency in a limited field – Increased compensation – “Lifestyle considerations” Fischer, JAMA. 2007; 298(18): 2191 -2193
Specialty as Percentage of Total Physician Workforce Fischer, J. E. JAMA 2007; 298: 2191 -2193. Copyright restrictions may apply.
The Surgeon: A Changing Profile • 35, 400 general surgeons in the US – 80% full time • 1 surgeon / 10, 000 people – 38 million currently > 65 yrs of age – 78 million by 2040 > 65 yrs of age Stabile, Arch Surg 2008
The Surgeon: A Changing Profile • • > 1000 general surgeons retire or die /yr 1000 residency graduates 70% go into fellowships 600 potentially practice “general surgery” – Min invasive, colorectal, surgical oncology, trauma, critical care, acute care surgery Will subspecialists practice general surgery? Stabile, Arch Surg 2008
The Surgeon: A Changing Profile • • > 1000 general surgeons retire or die /yr 1000 residency graduates 70% go into fellowships 600 potentially practice “general surgery” – Min invasive, colorectal, surgical oncology, trauma, critical care, acute care surgery Will subspecialists practice general surgery? Who will practice in rural areas? Stabile, Arch Surg 2008
The Surgeon: A Changing Profile • • Long work hours Poor compensation Declining prestige Fragmentation of the specialty Stabile, Arch Surg 2008
Fragmentation of General Surgery • Is subspecialization inevitable? • General surgeon role models? • Is Acute Care Surgery the answer?
Early Specialization in Surgery: The New Frontier Has the general surgery graduate changed? • • Advances in technology Spectrum and complexity of disease Environment of independence Duty hour restrictions Longo, Udelsman et al, Yale J Biol Med 2008
Early Specialization in Surgery: The New Frontier • Surgical specialization is here to stay • Tracking of residents • Potentially shorten basic surgical training Longo, Udelsman et al, Yale J Biol Med 2008
Resident Training in 2009 • Solution is to strengthen general surgery • May not be able to broadly train general surgeon in 5 years • Need to give the general surgeon some aspect of training that the colorectal, cardiac, MIS, endocrine, breast or oncologic do not have.
Restructuring of Surgical Residency • How many years are necessary? • Breadth of training • Are we wasting cases on those who won’t ever be performing them
Resident Training in 2009 • Solution is to strengthen general surgery • May not be able to broadly train general surgeon in 5 years • Need to give the general surgeon some aspect of training that the colorectal, cardiac, MIS, endocrine, breast or oncologic do not have.
Minimum Operative Requirements? LAP CHOLECYSTECTOMY 50 PEDS HERNIA 15 OPEN INGUINAL HERNIA 25 A-V FISTULA? ? 15 OPEN PARTIAL COLECTOMY 25 SB RESECTION 15 VENTRAL HERNIA 25 LAP INGUINAL HERNIA 25 LAP APPENDECTOMY 25 CAROTID TEA? ? COLONOSCOPY 50 TRACHEOSTOMY 10 BREAST BIOPSY 25 NON TRAUMA LAPAROTOMY 10 OPEN APPENDECTOMY 25 LAP COLECTOMY 25 THYROIDECTOMY 15 OPEN CHOLECYSTECTOMY 5 EGD 25 ENTEROLYSIS 5
Resident Training in 2009 Rural Surgery Acute Care Trauma Critical Care General Surgery MIS / GI / HPB Surgical Oncology Colorectal Plastic Transplant Vascular Pediatric Cardiac CORE SURGICAL TRAINING 4 yrs
Changing Resident Training in 2009 Potential Concerns • ABS Directors • General surgery certificate holders • Residents • Subspecialty Societies? – Vascular – Cardiac – Plastics
What About Rural Surgery? What is the solution for providing more, and better trained rural surgeons?
What About Rural Surgery? What is the solution for providing more, and better trained rural surgeons? • Existing vs. expansion of programs • Separate track? • Separate certification?
What About Rural Surgery? What is the solution for providing more, and better trained rural surgeons? • Existing vs. expansion of programs • Separate track? • Separate certification? Can ABS and RRC help?
Albany Medical Center
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