Board certification in surgical oncology: Does it make sense?

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Journal of Surgical Oncology 2008;98:12GUEST EDITORIALBoard Certication in Surgical Oncology: Does it Make Sense?RAPHAEL E. POLLOCK, MD*Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, TexasThe issue of board certication status for the specialty of surgicaloncology has remained a source of controversy for more than 25 years.This is partly because it has been difcult to dene a sufciently broadand deep corpus of knowledge that distinguishes the subspecialty ofsurgical oncology from the parent specialty of general surgery. Thereality is that community-based general surgeons will typicallydevote at least 2530% of their efforts engaged in cancer patientcare. Another concern has been a genuine desire to avoid the type ofdestructive internecine warfare that occurred with the creation of boardcertication in vascular surgery. And so long as there were adequatenumbers of general surgeons to care for the population at large, thepressure to create specialty certication in surgical oncology wasmoderate, and seemingly ran at odds with the putative interests of ourparent general surgery specialty.However, I would like to respectfully suggest that the times arecertainly changing, and in light of some recent developments, not allgood, we must respond by proactively changing ourselves or run therisk of being forced to react in a manner that may be counter to ourperceived interests as well as those of the solid tumor patients whomwe seek to serve.What are the underlying developments that support establishingboard certication mechanisms in surgical oncology? First is thereality that a distinct and extensive corpus of knowledge has developedthat describes the natural history of solid tumors from their molecularinception on through their behaviors as macroscopic malignanciescapable of metastasis. Based on the acquisition of this specializedknowledge, surgical oncologists are uniquely equipped to integratenon-surgical therapies into the neoadjuvant as well as post-surgicalcontexts of primary tumor management. By virtue of their training,surgical oncologists are particularly adept at orchestrating con-temporary multidisciplinary care of recurrent malignancy and alsoexert control over situations where uncommon operations, (e.g.,hemipelvectomy, hepatic trisementectomy, etc.) are indicated. Matureattributes such as these unequivocally distinguish surgical oncology asa distinct surgical discipline based on, but separate from, generalsurgery. And in the 80 hr work week era, it is clear that this specializedsurgical oncology knowledge and experience clearly exceeds thetraining content of most, if not all, general surgery residencies in theUnited States.A second factor underlying the need for board certication insurgical oncology can be found in the conuence of several profoundforces: the aging of our population coupled with anticipated manpowershortages in the ranks of general surgeons from which the surgicaloncologists emerge. The overall number of general surgeons in theU.S. has been stagnant for the past 30 years, during which ourresidency programs have trained approximately 1,000 new generalsurgeons annually. Unfortunately, this stably sized community ofgeneral surgeons is confronted by a population in which the number ofAmericans aged 65 or greater (the largest single purveyor of generalsurgical services) will double over the next 10 years. And during thissame time frame, cancer will replace cardiovascular disease as thenumber one killer in our population. Compounding these demo-graphics, the rate of general surgical growth is also less in absoluteterms than that of our referring non-surgical specialties. In addition, forsome candidates the appeal of a general surgery career is negativelyaffected 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 increasedcosts of remaining compliant with ever changing medical documenta-tion requirements, unrelenting exposure to liability claims and the costof liability insurance, and the lack of control over time allocated towork versus time allocated to family [1].If nothing is done in response to these forces, within a decade wemay be confronting a crisis precipitated by a relatively if not absolutesmaller number of surgeons capable of offering contemporaryoncology care to a rapidly expanding solid tumor patient population.The availability of board certication in surgical oncology would be aconcrete step towards enhancing the appeal of our specialty as a careeroutlet for residents in general surgery who now struggle in this perfectstorm of demographic and professional challenges.There is a third major factor that may facilitate the emergenceof board certication in surgical oncology. Important discussionsabout prospective changes in residency training are engaging depart-ments of surgery that have residency programs, the American Boardof Surgery (ABS), the American College of Surgery, and other relevantstakeholders. To address concerns about the time length of relevantsurgical training, appropriate use of clinical material, challenges tocontinuity of surgical care in the 80 hr work week mileau, etc., a modelin 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.) isreceiving attention. Certication would be in the fellowship trainingspecialty under the aegis of the ABS.In anticipation of these possible changes, now is the time toconsider how this might be accomplished. The ABS, a leading driver ofimprovement in surgical training, established the Surgical OncologyAdvisory Council (SOAC) more than a decade ago to provideassistance and advice. SOAC has recently been asked to makerecommendations 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: rpollock@mdanderson.orgReceived 2 January 2008; Accepted 4 January 2008DOI 10.1002/jso.20991Published online in Wiley InterScience( 2008 Wiley-Liss, Inc.oncology, which is now perceived by the ABS as meriting seriousconsideration 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 withthese possible changes in residency and fellowship training platforms,yet avoids antagonizing our colleagues in the general surgerycommunity.Currently, for a board certication mechanism to be recognized bythe American Board of Medical Specialties (ABMS), the educationalprograms in which candidates are trained must be accredited bythe American Council of Graduate Medical Education (ACGME).ACGME accreditation is based on a multifactorial process where oneof the key criteria is that the constituent training programs do not makedirect or indirect use of clinical revenues generated by trainees tocover trainee salaries. A survey of Society of Surgical Oncology(SSO)-accredited surgical oncology fellowship programs conducted in2007 revealed that approximately one-third depended on trainee-generated revenues as part of their compensation structure such thatadhering to ACGME requirements would create signicant difculties.As an alternative, the American College of Surgeons, working inconjunction with the SSO, may be willing and able to serve as anaccrediting agency for surgical oncology fellowships in a manneracceptable to the ABS and the ABMS, a possibility that is currentlybeing explored.Assuming that these preliminary accreditation processes can besuccessfully negotiated, a next step will be the creation of thecertication process per se. One can anticipate that the current SSOaccreditation of fellowships would be replaced by a process potentiallyunder the direction of the American College of Surgeons, withfurther standardization of surgical oncology training curricula asa necessary and logical by-product. The ABS clearly has thetrack record of psychometric testing experience needed to design,administer, and maintain certication examinations. It remains to bedetermined whether such an examination would have a written and oralcomponent, and what would be the structure and content of themaintenance of certication and re-certication processes, especiallygiven the reality of emerging sub-specialization within surgicaloncology (e.g., breast, hepatobiliary, colorectal, etc.). To avoidproblems that occurred with the creation of the American Board ofVascular Surgery, it will be imperative to allow a period of time,perhaps a decade, in which any surgeon holding active certicationfrom the ABS will be allowed to sit for a certifying examination insurgical oncology, even without formal surgical oncology fellowshiptraining. Note that this is different than grandfathering in which apractitioner is awarded certication solely on the basis of havingperformed a specied number of specialty procedures. The principle ofawarding certication to any general surgeon who can pass theexamination will hopefully go a long way towards assuaging concernsof the general surgery community. Handled carefully, deliberately, andwith sensitivity it is quite possible that board certication in surgicaloncology can become a reality sometime over the next interval,hopefully to the benet of the solid tumor patients whom we all seek toserve with the highest level of expertise.REFERENCE1. Fisher, JE. The impending disappearance of the general surgeon.JAMA 2007;298:21912193.Journal of Surgical Oncology2 Pollock