Transcript American Board of Surgery

Update From the
American Board of
Surgery
4th 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
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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
1935
American Board of Surgery
ACS originally argued that ABS was unnecessary,
since the ACS had championed surgical
standards
AMERICAN BOARD OF SURGERY
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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
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
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Certifying Exam 3 times per year
– Senior directors: 2 times per year until 65
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Attending Directors Meetings (3)
Standing Committee
– Credentials, GS Residency, Advanced Surgery
Education, Diplomates
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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 the 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 20th 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
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ACS Case Log
Bariatric Database
ABA Burn Registry
Children Oncology Group
CMS PQRI
Mastery of Breast Surgery
Nat’l Cancer Database
NSQIP
NTDB
NTRACS
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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?
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Yes
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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?
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Never
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Almost never
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Sometimes
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Usually
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Almost always
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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?
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Never
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Almost never
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Sometimes
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Usually
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Almost always
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Always
20. In the last 12 months, how often did this doctor spend enough time with you?
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Never
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Almost never
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Sometimes
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Usually
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Almost always
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Always
Patient Safety Self Assessment
3600 Evaluation of Communication
• American Board of Orthopedics
• Letters to
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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 InHospital 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)
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Abdomen
Breast, skin, soft tissue
Endocrine system
Acute care surgery
Knowledge of:
• Critical care?
• Surgical Oncology?
• Trauma/Burns?
Familiar with:
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Transplantation
Pediatric Surgery
Thoracic Surgery
Vascular Surgery
How do we train residents to be
competent?
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Patient Care
Medical Knowledge
Interpersonal and Communication Skills
Professionalism
Systems Based Practice
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
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Jaundice
Cholangitis
Gallstone Disease
Iatrogenic CBD injury?
• Focused
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GB Cancer
Bile duct cancer
Choledochal cyst
Sclerosing cholangitis
Ampullary Stenosis
Common
Unusual
Rare
Lap Chole
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
2.6
1.2
1.8
0.008
0.002
0.275
0.005
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
Oncology, General
Surgery and Trauma
196
34.4
85
14.9
Missing
49
8.6
Subspecialty in Surgical Oncology
• Leaders in Cancer Care
– Division Chiefs
– Cancer Center Directors
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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
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> 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
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> 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
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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?
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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