The Different Ways People are An estimated 80,000 endocrine Trained - - PowerPoint PPT Presentation

3/7/2015 1

The Different Ways People are Trained in Endocrine Surgery

Nancy D. Perrier, MD, FACS MDACC UCSF Post Graduate Course March 7, 2015

Endocrine Surgery

An estimated 80,000 endocrine procedures performed in the USA in 2004 Projected that 97,700 endocrine procedures will be performed in 2020

Sosa J, et al. Surgery 2007; 142(6):876-83.

Endocrine Surgery

• Large proportion of procedures are done

by high-volume endocrine surgeons

• Many are performed by general surgeons
• Increase in percentage of procedures

being done by otolaryngologists

Saunders B, et al. Surgery 2003; 134(6):924-31. Terris D, et al. Laryngoscope 2007; 117(6):1009-12. Terris D, et al. Laryngoscope 2006; 116(6):911. Harness J, et al. World J Surg 2000; 24(8):976-82.

Graduate Education in General Surgery and its Subspecialties

• 1000 medical students enter General Surg

– Proliferation of fellowships in subspecialties – Increasing desire for subspecialties to have recognition as specialties in their own right – As a consequence- Gen Surg has become less attractive as a specialty – ABS developed a defined curriculum in Gen Surgery – SCORE-national curriculum - Endocrine 15%

Bell, Richard. WJS (2008) 32:2178-2184

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Educational Pathways

PGY 7 THORACIC SURGERY VASCULAR SURGERY PED SURG SURG ONC TX PLASTIC SURGERY PGY 6 PGY 5 PGY 4 PGY 3 PGY 2 PGY 1 THORACIC SURGERY VASCULAR SURGERY VASCULAR SURGERY GENERAL SURGERY

MEDICAL SCHOOL (4YRS)

PLASTIC SURGERY COLO- RECTAL END BRS SCC MIS,UGI, HPB,BAR

Bell, Richard. WJS (2008) 32:2178-2184

OTOLARNGOLOGY

General Surgery and OTO Programs

Year # Prog # Res # Cases

General surgery (GS)

2004–2005 250 1022 26,926 2005–2006 250 1008 27,895 2006–2007 248 1004 30,154 2007–2008 246 1020 31,562

ENT

2004–2005 101 255 14,561 2005–2006 102 272 15,986 2006–2007 102 259 15,950 2007–2008 100 253 17,019

Zarebczan, Sipple (2010) Surgery Dec

Average # of Thyroids and Parathyroids

10 20 30 40 50 60 70 '04-'05 '05-'06 '06-'07 '07-'08

Year Average # of Cases

GS OTO

Thyroid and Parathyroid Cases are Increasing

p<0.001

Case Numbers General Surgery and OTO Resident

Year Total Cases Thyroid Cases Parathyroid Cases % Thyroid & Parathyroid

General Surgery (GS) 2004-2005 920090 18236 8690 1.98 2005-2006 915728 19279 8616 2.10 2006-2007 913778 20956 9198 2.29 2007-2008 932475 22258 9304 2.34 Otolaryn- gology (OTO) 2004-2005 11876 2685 2005-2006 12899 3087 2006-2007 12942 3008 2007-2008 13755 3264

Zarebczan, Sipple (2010) Surgery, Dec

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Training the Endocrine Surgeon

General Surgery

• 1. General Surgery Residency
• 2. Endocrine Surgery (23 Training Programs)
• 3. Surgical Oncology (22 Training Programs)

ENT

• 1. Otolaryngology Residency
• 2. Head and Neck Surgery (2 Training Programs)

Training the Endocrine Surgeon

Otolaryngology General Surgery Endocrine Surgery Surgical Oncology

• Too Confined
• Technical not medical
• Volume of index cases?
• Complexity of care?
• Lacks multidisciplinary?
• Operative Experience
• Sustainability of Jobs
• Extensive time in non

contributory disease sites

• Efficiency of training

Complexity of Training

Genetics Path Radiology Endocrinology Head & Neck General Surgery HB/Panc

Minimal Invasive

Oncology

Brigham and Women's Hospital Cleveland Clinic Columbia University Duke University Johns Hopkins University Massachusetts General Mayo Clinic Medical College of Wisconsin Mount Sinai Medical Center NIH / NCI Northshore University Scott and White Clinic University of Calgary University of California – LA University of California – SF University of Chicago University of Miami University of Pittsburgh University of Texas (MDACC) University of Wisconsin – Madison Weill Cornell Medical College Yale University Instituto Nacional Sydney Melbourne The American Association of Endocrine Surgeons Fellowship Programs

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Endocrine Surgery Fellowships

AAES Fellowship Training Requirements

• Duration of fellowship/ # fellows
• Funding mechanism
• Faculty CV
• Curriculum- rotations, didactic, teaching, multidisciplinary

conferences, tumor board

• Operative volumes (fellow/other): thy, lateral neck

dissection, parathyroid, adrenal NET

• Research curriculum
• Academic productivity
• GME oversight
• Non Operative experience

Defined Curriculum

• Disease Site Specific
• Demonstrate knowledge and understanding of

endocrine gland anatomy, physiology, normal and pathologic states

• Diagnose disease
• Understand inherited syndromes
• Appreciate current controversies
• Demonstrate ability to safely perform appropriate
• perations

AAES Sponsored Match

• First performed 8/06 for positions 7/07

– By hand – 12 clinical spots at 11 institutions – 1 research position

• 26 clinical spots at 22 institutions

– 4 research, 3 international positions

• Electronically executed match day
• > 50 applicants in 2014

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Fellowship Oversight

• Institutional GME

– Description and objectives, performance evaluations, yearly updates, graduation attestments

• AAES-Sponsored Match
• AAES Curriculum Topics
• AAES Fellowship Council
• AAES Accreditation Committee

Endocrine Surgery Fellowships

Aligns with SSO and Fellowship Council Completion of a U.S. General Surgery residency - ABS Eligibility No accreditation No ACGME approval

2013 Match Current Fellows

• 40 candidates registered for match
• 30 submitted rank lists
• 25 positions in 23 programs
• 22 candidates matched, 8 did not match
• 3 programs had unfilled spots, all have

subsequently filled

– 10 candidates matched to first choice – 18 candidates matched one of top 3 choices – 6 programs matched 1st choice – 14 programs matched one of top 3 choices

Endocrine Surgery Fellow Caseloads

Year 2006-7 2007-8 2009-10 2010-11 2011-12

* Compliments of Program #5

Total Thy/Para Adr LND Islet 250 85 20 6 8 300 97 11 5 14 331 98 24 10 2 376 109 30 15 9 342 117 12 10 7

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Endocrine Surgery Program Directors Poll 2011 Parathyroidectomy Survey Results

• 95% obtain US for concurrent thyroid nodules

– All use FNA if found

• All obtain 1 imaging study and 89% obtain >1
• 70% use outpatient calcium supplementation
• 100% define cure=durable eucalcemia (median 6 mo)

Carty, Wang, Pasieka (2014) Am J of Surg

Surgical Oncology

• 22 Programs in North America

– Includes 3 in Canada

• US Programs are accredited by the Accreditation

Council for Graduate Medical Education (ACGME)

• Canadian Programs are accredited by the Royal

College of Physicians and Surgeons of Canada

– Complex General Surgical Oncology Exam- ABS – SOSAP (Society of Surgical Oncology Self Assessment Program)

Complex General Surgery Oncology Programs

• Ohio State University- Columbus
• Cedars Sinai- LA
• City of Hope- Duarte
• Dana-Farber-Boston
• Fox Chase- Philadelphia
• H.Lee Moffit- Tampa
• John Wayne – Santa Monica
• Johns Hopkins- Baltimore
• Univ of North Carolina-Chapel

Hill

• McGill Univ- Montreal
• Memorial Sloane-Kettering-NYC
• Roger Williams- Providence
• Roswell Park- Buffalo
• Univ of Calgary- Calgary
• Univ of Chicago- Chicago
• Univ of Louisville- Louisville
• Univ of Miami- Miami
• Univ of Pitts- Pittsburgh
• Univ of Texas- Houston
• Univ of Toronto- Toronto
• Virginia Commonwealth-

Richmond

• Wake Forest- Winston Salem

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Surgical Oncology Training

• Complex Surgical Oncology Certification
• Endocrine/ H and N Curriculum (13%)
• Pancreatic Endocrine- HPB ( 10% of 18%)
• SOSAP 16 (239 questions)

Surg Onc Fellowship Curriculum Outline

– 75% broad topics – 25% complex

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Ideal Thyroid Surgeon?

Has been appropriately trained

• Can evaluate vocal cords and voice
• Can make treatment decisions regarding radioactive iodine and

external radiation therapy

• Can make intraoperative decisions related to extent of

thyroidectomy, invasive disease, and neck dissection

• Can manage complications
• Participates in audit and research
• Can take care of the patient from A to Z
• Can provide the best chance of cure by the best first surgical

procedure

• Has knowledge of clinical trials and basic research

(surgeon/scientist)

• Is a good surgeon/teacher/researcher and leader

Shaha, A. AAES 2012 Dec Surgery

Training of a Thyroid Surgeon

Shaha, A. Surgery, Volume 152, Issue 6, 2012, 943 - 952

Head and Neck Endocrine Surgery Programs

• Medical College of Georgia
• M.D. Anderson Cancer Center

The Endocrine Surgery Job Market A Survey of Fellows

• 90% are in academic jobs
• Avg # of job interviews 3.2
• 98% happy
• 57% believe that there are not enough job
• pportunities
• 50% believe there are too many fellowships

Shin, J. J of Surg Educ May 2013

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Job Market

• 49% of academic centers polled have an

Endocrine Surgery section

• 39% of chairs feel that they need to recruit

another endocrine surgeon within 2 years

• 3 of 10 medical recruiters were familiar with

Endocrine Surgery

Joyce J. Shin , Mira Milas , Jamie Mitchell , Eren Berber , Jesse Gutnick , Allan Siperstein Journal of Surgical Education, Volume 70, Issue 3, 2013, 377 - 383

Endocrine Surgery Fellowship

• Have something to teach- algorithmic care,

practice development, ethics

• Be an expert
• Have an infrastructure
• Institutional support- regional expansion?
• Don’t detract from other fellows or residents
• Confirm job market for graduates?
• Enjoy teaching and mentoring