Board certification in surgical oncology: Does it make sense?

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  • Journal of Surgical Oncology 2008;98:12


    Board Certication in Surgical Oncology: Does it Make Sense?

    RAPHAEL E. POLLOCK, MD*Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, Texas

    The issue of board certication status for the specialty of surgical

    oncology has remained a source of controversy for more than 25 years.

    This is partly because it has been difcult to dene a sufciently broad

    and deep corpus of knowledge that distinguishes the subspecialty of

    surgical oncology from the parent specialty of general surgery. The

    reality is that community-based general surgeons will typically

    devote at least 2530% of their efforts engaged in cancer patient

    care. Another concern has been a genuine desire to avoid the type of

    destructive internecine warfare that occurred with the creation of board

    certication in vascular surgery. And so long as there were adequate

    numbers of general surgeons to care for the population at large, the

    pressure to create specialty certication in surgical oncology was

    moderate, and seemingly ran at odds with the putative interests of our

    parent general surgery specialty.

    However, I would like to respectfully suggest that the times are

    certainly changing, and in light of some recent developments, not all

    good, we must respond by proactively changing ourselves or run the

    risk of being forced to react in a manner that may be counter to our

    perceived interests as well as those of the solid tumor patients whom

    we seek to serve.

    What are the underlying developments that support establishing

    board certication mechanisms in surgical oncology? First is the

    reality that a distinct and extensive corpus of knowledge has developed

    that describes the natural history of solid tumors from their molecular

    inception on through their behaviors as macroscopic malignancies

    capable of metastasis. Based on the acquisition of this specialized

    knowledge, surgical oncologists are uniquely equipped to integrate

    non-surgical therapies into the neoadjuvant as well as post-surgical

    contexts of primary tumor management. By virtue of their training,

    surgical oncologists are particularly adept at orchestrating con-

    temporary multidisciplinary care of recurrent malignancy and also

    exert control over situations where uncommon operations, (e.g.,

    hemipelvectomy, hepatic trisementectomy, etc.) are indicated. Mature

    attributes such as these unequivocally distinguish surgical oncology as

    a distinct surgical discipline based on, but separate from, general

    surgery. And in the 80 hr work week era, it is clear that this specialized

    surgical oncology knowledge and experience clearly exceeds the

    training content of most, if not all, general surgery residencies in the

    United States.

    A second factor underlying the need for board certication in

    surgical oncology can be found in the conuence of several profound

    forces: the aging of our population coupled with anticipated manpower

    shortages in the ranks of general surgeons from which the surgical

    oncologists emerge. The overall number of general surgeons in the

    U.S. has been stagnant for the past 30 years, during which our

    residency programs have trained approximately 1,000 new general

    surgeons annually. Unfortunately, this stably sized community of

    general surgeons is confronted by a population in which the number of

    Americans aged 65 or greater (the largest single purveyor of general

    surgical services) will double over the next 10 years. And during this

    same time frame, cancer will replace cardiovascular disease as the

    number one killer in our population. Compounding these demo-

    graphics, the rate of general surgical growth is also less in absolute

    terms than that of our referring non-surgical specialties. In addition, for

    some candidates the appeal of a general surgery career is negatively

    affected by the length of training vis-a`-vis education debt load

    (frequently in excess of $250,000 by the end of medical school),

    unfavorable and deteriorating reimbursement schedules, the increased

    costs of remaining compliant with ever changing medical documenta-

    tion requirements, unrelenting exposure to liability claims and the cost

    of liability insurance, and the lack of control over time allocated to

    work versus time allocated to family [1].

    If nothing is done in response to these forces, within a decade we

    may be confronting a crisis precipitated by a relatively if not absolute

    smaller number of surgeons capable of offering contemporary

    oncology care to a rapidly expanding solid tumor patient population.

    The availability of board certication in surgical oncology would be a

    concrete step towards enhancing the appeal of our specialty as a career

    outlet for residents in general surgery who now struggle in this perfect

    storm of demographic and professional challenges.

    There is a third major factor that may facilitate the emergence

    of board certication in surgical oncology. Important discussions

    about prospective changes in residency training are engaging depart-

    ments of surgery that have residency programs, the American Board

    of Surgery (ABS), the American College of Surgery, and other relevant

    stakeholders. To address concerns about the time length of relevant

    surgical training, appropriate use of clinical material, challenges to

    continuity of surgical care in the 80 hr work week mileau, etc., a model

    in which trainees would undergo 23 years of basic surgery training,

    followed by fellowship training of 46 years in a surgical subspecialty

    (i.e., rural surgery, transplantation surgery, surgical oncology, etc.) is

    receiving attention. Certication would be in the fellowship training

    specialty under the aegis of the ABS.

    In anticipation of these possible changes, now is the time to

    consider how this might be accomplished. The ABS, a leading driver of

    improvement in surgical training, established the Surgical Oncology

    Advisory Council (SOAC) more than a decade ago to provide

    assistance and advice. SOAC has recently been asked to make

    recommendations to the ABS regarding certication in surgical

    *Correspondence to: Dr. Raphael E. Pollock, MD, Department of SurgicalOncology, UT MD Anderson Cancer Center, 1515 Holcombe Blvd., Box444, Houston, TX 77030. Fax: 713-792-0722.E-mail:

    Received 2 January 2008; Accepted 4 January 2008

    DOI 10.1002/jso.20991

    Published online in Wiley InterScience(

    2008 Wiley-Liss, Inc.

  • oncology, which is now perceived by the ABS as meriting serious

    consideration in light of the issues discussed above. For this to happen,

    there are many procedural and political hurdles that must be overcome;

    a certication process will need to be crafted that is consonant with

    these possible changes in residency and fellowship training platforms,

    yet avoids antagonizing our colleagues in the general surgery


    Currently, for a board certication mechanism to be recognized by

    the American Board of Medical Specialties (ABMS), the educational

    programs in which candidates are trained must be accredited by

    the American Council of Graduate Medical Education (ACGME).

    ACGME accreditation is based on a multifactorial process where one

    of the key criteria is that the constituent training programs do not make

    direct or indirect use of clinical revenues generated by trainees to

    cover trainee salaries. A survey of Society of Surgical Oncology

    (SSO)-accredited surgical oncology fellowship programs conducted in

    2007 revealed that approximately one-third depended on trainee-

    generated revenues as part of their compensation structure such that

    adhering to ACGME requirements would create signicant difculties.

    As an alternative, the American College of Surgeons, working in

    conjunction with the SSO, may be willing and able to serve as an

    accrediting agency for surgical oncology fellowships in a manner

    acceptable to the ABS and the ABMS, a possibility that is currently

    being explored.

    Assuming that these preliminary accreditation processes can be

    successfully negotiated, a next step will be the creation of the

    certication process per se. One can anticipate that the current SSO

    accreditation of fellowships would be replaced by a process potentially

    under the direction of the American College of Surgeons, with

    further standardization of surgical oncology training curricula as

    a necessary and logical by-product. The ABS clearly has the

    track record of psychometric testing experience needed to design,

    administer, and maintain certication examinations. It remains to be

    determined whether such an examination would have a written and oral

    component, and what would be the structure and content of the

    maintenance of certication and re-certication processes, especially

    given the reality of emerging sub-specialization within surgical

    oncology (e.g., breast, hepatobiliary, colorectal, etc.). To avoid

    problems that occurred with the creation of the American Board of

    Vascular Surgery, it will be imperative to allow a period of time,

    perhaps a decade, in which any surgeon holding active certication

    from the ABS will be allowed to sit for a certifying examination in

    surgical oncology, even without formal