Journal of Surgical Oncology 2008;98:3

GUEST EDITORIAL

Board Certification in Surgical Oncology:

ABS Certification Is Not the Answer for Surgical Oncology

MARSHALL M. URIST, MD*University of Alabama at Birmingham, Birmingham, Alabama

In 1998 the American Board of Surgery (ABS) changed its policy

toward specialization by establishing advisory councils for areas of

general surgery not currently granting a certificate. In so doing, it

sought to foster the development of these specialties. This new forum

has promoted significant advances in the development of our specialty.

The importance of this event was described in two editorials publish-

ed the following year. In the first, Dr. DavidWinchester [1] emphasized

the pivotal role of the Society for Surgical Oncology (SSO) in advising

and recommending changes in surgical oncology training and exa-

mination questions. The second editorial, by Dr. Walter Lawrence [2]

addressed the question of board certification for surgical oncologists,

a concept that had first been proposed over 20 years earlier. He

reviewed the history of the controversy and concluded there was

no need to do so if the role of the surgical oncologist was one of

providing advanced level care, teaching and investigating new areas

of knowledge and therapy rather than claiming exclusive domain over

the broad range of our discipline. In the 8-year interval, the Advisory

Council for Surgical Oncology has fulfilled its role by advising the

board on surgical oncology issues (especially fellowship training)

and continuously updating the cancer-question banks for all examina-

tions given by the ABS. To further improve this communication the

SSO has established the American Board of Surgery Advisory Task

Force.

As a species of surgeon, the population of surgical oncologists

is thriving but its range is being threatened by environmental

pressures. The SSO has been highly successful in developing new

training programs and graduating record numbers of fellows. Surveys

of graduates confirm that they are able to establish successful

practices, focus their care on cancer patients and maintain a wide

range of operative procedures. The graduates now practice in the

community and many academic medical centers. These faculty

members teach advanced knowledge, skills and decision-making

to an increasing number of general surgery residents. The SSO recently

announced an all time high number of members and the organization

is seeking to broaden its base among community surgeons who

share an interest in cancer care. The competing pressure comes from

a proliferation of specialists (within and outside of general surgery)

largely based upon anatomic site or organ system, for example,

breast, head and neck, hepatobiliary-pancreatic and endocrine

surgery. An additional threat comes from hospital credentialing

committees and from outcome studies that associate superior results

with high surgeon- or institution-volume. All of these pressures will

continue.

Would ABS certification for surgical oncologists solve these issues?

I do not believe so. In fact, the solution to some of these problems is

already available to us.

The definition of a surgical oncologist remains unchanged. Essentially,

he/she is an ABS certified general surgeon with advanced training and

experience in awide range of oncologic diseases and procedures including

those in the affiliated oncologic disciplines. Building on skills acquired in

a broad-based residency, the fellow efficiently learns advanced techniques

but is unlikely to acquire extensive experience in all areas after 2 years.

While all approved programs meet the standards set by the SSO, they

differ in their resources and patient mix. Advanced training gives the

surgical oncology fellow important knowledge, especially in decision-

making.

Establishing board certification through the ABS is a complex process

that would first require a precise definition of that body of knowledge

which differentiates the surgical oncologist from a general surgeon. Once

defined, this level of knowledge must be measurable in a validated

examination process. At the present time these two essentials do not exist.

Assuming that the certification process could be developed, it would bring

additional regulations and would not reduce the challenge by others with

specialty training and experience. Verification of training and experience

by training programs is commonly accepted by credentialing bodies

without the requirement for board certification. Case number requirements

often appear to be arbitrarily set by individual institutions.

I believe a better answer to this problem is found in the positive

energy and resources of the SSO. Along with its members and their

institutions, the SSO provides the training, educational programs,

scientific meetings and research which will best define and support the

surgical oncologist. The Surgical Oncology Advisory Council and the

SSO’s Advisory Task Force can provide the guidance for expansion

and improvement of training programs while maintaining a strong

relationship with the ABS. If the standards for training are high, then a

SSO certificate will carry all the value of board certification without the

need for oversight by the Accreditation Council for Graduate Medical

Education.

REFERENCES

1. Winchester DP: Surgical Oncology and The American Board ofSurgery: A new and promising relationship. J Surg Onc 1999;72:183.

2. Lawrence W, Jr.: Are we ready to certify surgical oncologists?J Surg Onc 1999;71:74–75.

*Correspondence to: Dr. Marshall M. Urist, MD, Section of SurgicalOncology, 321 Kracke Building, University Station, 1922 Seventh AvenueSouth, Birmingham, AL 35233; Fax: 205-975-5971.E-mail: mmurist@ccc.uab.edu

Received 4 January 2008; Accepted 7 January 2008

DOI 10.1002/jso.20990

Published online in Wiley InterScience(www.interscience.wiley.com).

� 2008 Wiley-Liss, Inc.