Providing complex GI surgical care with minimally invasive approaches: a survey of the practice patterns of Fellowship Council alumni

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases

INTRODUCTION

Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships.

METHODS

We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis.

RESULTS

For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001).

CONCLUSIONS

FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

Thriving or surviving? A critical examination of funding models for fellowship council fellowships

BACKGROUND

Since 1997, the Fellowship Council (FC) has evolved into a robust organization responsible for the advanced training of nearly half of the US residency graduates entering general surgery practice. While FC fellowships are competitive (55% match rate) and offer outstanding educational experiences, funding is arguably vulnerable. This study aimed to investigate the current funding models of FC fellowships.

METHODS

Under an IRB-approved protocol, an electronic survey was administered to 167 FC programs with subsequent phone interviews to collect data on total cost and funding sources. De-identified data were also obtained via 2020-2021 Foundation for Surgical Fellowships (FSF) grant applications. Means and ranges are reported.

RESULTS

Data were obtained from 59 programs (35% response rate) via the FC survey and 116 programs via FSF applications; the average cost to train one fellow per year was $107,957 and $110,816, respectively. Most programs utilized departmental and grants funds. Additionally, 36% (FC data) to 39% (FSF data) of programs indicated billing for their fellow, generating on average $74,824 ($15,000-200,000) and $33,281 ($11,500-66,259), respectively. FC data documented that 14% of programs generated net positive revenue, whereas FSF data documented that all programs were budget-neutral.

CONCLUSION

Both data sets yielded similar overall results, supporting the accuracy of our findings. Expenses varied widely, which may, in part, be due to regional cost differences. Most programs relied on multiple funding sources. A minority were able to generate a positive revenue stream. Although fewer than half of programs billed for their fellow, this source accounted for substantial revenue. Institutional support and external grant funding have continued to be important sources for the majority of programs as well. Given the value of these fellowships and inherent vulnerabilities associated with graduate medical education funding, alternative grant funding models and standardization of annual financial reporting are encouraged.