3/7/2015 Endocrine Surgery The Different Ways People are An estimated 80,000 endocrine Trained in Endocrine Surgery procedures performed in the USA in 2004 Projected that 97,700 endocrine Nancy D. Perrier, MD, FACS procedures will be performed in 2020 MDACC UCSF Post Graduate Course March 7, 2015 Sosa J, et al. Surgery 2007; 142(6):876-83. Graduate Education in General Surgery Endocrine Surgery and its Subspecialties • 1000 medical students enter General Surg • Large proportion of procedures are done – Proliferation of fellowships in subspecialties by high-volume endocrine surgeons – Increasing desire for subspecialties to have recognition as specialties in their own right • Many are performed by general surgeons – As a consequence- Gen Surg has become less attractive as a specialty – ABS developed a defined curriculum in Gen • Increase in percentage of procedures being done by otolaryngologists Surgery – SCORE-national curriculum - Endocrine 15% Saunders B, et al. Surgery 2003; 134(6):924-31. Terris D, et al. Laryngoscope 2007; 117(6):1009-12. Bell, Richard. WJS (2008) 32:2178-2184 Terris D, et al. Laryngoscope 2006; 116(6):911. Harness J, et al. World J Surg 2000; 24(8):976-82. 1
3/7/2015 Educational Pathways General Surgery and OTO Programs Year # Prog # Res # Cases VASCULAR THORACIC PED SURG TX PLASTIC PGY 7 SURGERY SURGERY SURG ONC SURGERY 2004–2005 250 1022 26,926 END BRS SCC MIS,UGI, VASCULAR PLASTIC COLO- HPB,BAR PGY 6 THORACIC SURGERY SURGERY RECTAL General SURGERY 2005–2006 250 1008 27,895 surgery VASCULAR GENERAL SURGERY PGY 5 SURGERY 2006–2007 248 1004 30,154 (GS) OTOLARNGOLOGY PGY 4 2007–2008 246 1020 31,562 PGY 3 2004–2005 101 255 14,561 PGY 2 2005–2006 102 272 15,986 ENT PGY 1 2006–2007 102 259 15,950 MEDICAL SCHOOL (4YRS) 2007–2008 100 253 17,019 Bell, Richard. WJS (2008) 32:2178-2184 Zarebczan, Sipple (2010) Surgery Dec Thyroid and Parathyroid Cases Case Numbers are Increasing General Surgery and OTO Resident Year Total Thyroid Parathyroid % Thyroid & Average # of Thyroids and Parathyroids Cases Cases Cases Parathyroid 70 General 2004-2005 920090 18236 8690 1.98 Surgery 60 (GS) Average # of Cases 2005-2006 915728 19279 8616 2.10 50 GS 2006-2007 913778 20956 9198 2.29 40 OTO 2007-2008 932475 22258 9304 2.34 30 Otolaryn- 2004-2005 11876 2685 20 p<0.001 gology 10 2005-2006 12899 3087 (OTO) 0 2006-2007 12942 3008 '04-'05 '05-'06 '06-'07 '07-'08 2007-2008 13755 3264 Year Zarebczan, Sipple (2010) Surgery, Dec 2
3/7/2015 Training the Endocrine Surgeon Training the Endocrine Surgeon General Surgery • Too Confined Otolaryngology • Technical not medical 1. General Surgery Residency • Volume of index cases? 2. Endocrine Surgery (23 Training Programs) General Surgery • Complexity of care? • Lacks multidisciplinary? 3. Surgical Oncology (22 Training Programs) • Operative Experience Endocrine Surgery • Sustainability of Jobs • Extensive time in non ENT Surgical Oncology contributory disease sites • Efficiency of training 1. Otolaryngology Residency 2. Head and Neck Surgery (2 Training Programs) The American Association of Endocrine Surgeons Complexity of Training Fellowship Programs University of Calgary Brigham and Women's Hospital University of California – LA Cleveland Clinic HB/Panc Columbia University University of California – SF Duke University University of Chicago Johns Hopkins University University of Miami Minimal Massachusetts General University of Pittsburgh General Invasive Mayo Clinic Surgery University of Texas (MDACC) Medical College of Wisconsin Endocrinology University of Wisconsin – Mount Sinai Medical Center Madison Genetics NIH / NCI Weill Cornell Medical College Head & Radiology Northshore University Path Neck Yale University Scott and White Clinic Oncology Instituto Nacional Sydney Melbourne 3
3/7/2015 AAES Fellowship Endocrine Surgery Fellowships 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 AAES Sponsored Match Defined Curriculum • First performed 8/06 for positions 7/07 – By hand • Disease Site Specific – 12 clinical spots at 11 institutions • Demonstrate knowledge and understanding of – 1 research position endocrine gland anatomy, physiology, normal and pathologic states • 26 clinical spots at 22 institutions • Diagnose disease – 4 research, 3 international positions • Understand inherited syndromes • Appreciate current controversies • Electronically executed match day • Demonstrate ability to safely perform appropriate • > 50 applicants in 2014 operations 4
3/7/2015 Endocrine Surgery Fellowship Oversight Fellowships • Institutional GME – Description and objectives, performance evaluations, Aligns with SSO and Fellowship Council yearly updates, graduation attestments Completion of a U.S. General Surgery residency - ABS Eligibility • AAES-Sponsored Match No accreditation • AAES Curriculum Topics No ACGME approval • AAES Fellowship Council • AAES Accreditation Committee 2013 Match Current Fellows Endocrine Surgery Fellow Caseloads • 40 candidates registered for match Year Total Thy/Para Adr LND Islet • 30 submitted rank lists • 25 positions in 23 programs 250 85 20 6 8 2006-7 • 22 candidates matched, 8 did not match 300 97 11 5 14 2007-8 331 98 24 10 2 2009-10 • 3 programs had unfilled spots, all have 376 109 30 15 9 subsequently filled 2010-11 342 117 12 10 7 2011-12 – 10 candidates matched to first choice – 18 candidates matched one of top 3 choices – 6 programs matched 1 st choice * Compliments of Program #5 – 14 programs matched one of top 3 choices 5
3/7/2015 Endocrine Surgery Program Directors Poll Surgical Oncology 2011 Parathyroidectomy Survey Results • 22 Programs in North America • 95% obtain US for concurrent thyroid nodules – Includes 3 in Canada – All use FNA if found • US Programs are accredited by the Accreditation • All obtain 1 imaging study and 89% obtain >1 Council for Graduate Medical Education (ACGME) • Canadian Programs are accredited by the Royal • 70% use outpatient calcium supplementation College of Physicians and Surgeons of Canada • 100% define cure=durable eucalcemia (median 6 mo) – Complex General Surgical Oncology Exam- ABS – SOSAP (Society of Surgical Oncology Self Assessment Program) Carty, Wang, Pasieka (2014) Am J of Surg E ;Telerik.Si 17B13F71 /wEdAAYb n /wEPDwU tir e S ite ... ? Complex General Surgery Oncology Surgical Oncology Training Programs • Memorial Sloane-Kettering-NYC • Ohio State University- Columbus • Complex Surgical Oncology Certification • Roger Williams- Providence • Cedars Sinai- LA • Endocrine/ H and N Curriculum (13%) • Roswell Park- Buffalo • City of Hope- Duarte • Univ of Calgary- Calgary • Pancreatic Endocrine- HPB ( 10% of 18%) • Dana-Farber-Boston • Univ of Chicago- Chicago • Fox Chase- Philadelphia • SOSAP 16 (239 questions) • Univ of Louisville- Louisville • H.Lee Moffit- Tampa • Univ of Miami- Miami • John Wayne – Santa Monica • Univ of Pitts- Pittsburgh � Surg Onc Fellowship Curriculum Outline • Johns Hopkins- Baltimore • Univ of Texas- Houston – 75% broad topics • Univ of North Carolina-Chapel • Univ of Toronto- Toronto – 25% complex Hill • Virginia Commonwealth- • McGill Univ- Montreal Richmond • Wake Forest- Winston Salem 6
3/7/2015 Training of a Thyroid Surgeon 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 Shaha, A. Surgery, Volume 152, Issue 6, 2012, 943 - 952 Head and Neck Endocrine Surgery The Endocrine Surgery Job Market A Survey of Fellows Programs • 90% are in academic jobs • Medical College of Georgia • Avg # of job interviews 3.2 • M.D. Anderson Cancer Center • 98% happy • 57% believe that there are not enough job opportunities • 50% believe there are too many fellowships Shin, J. J of Surg Educ May 2013 7
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