Oversight Organizations in Complex General Surgical Oncology - Potential Impact on Competency Based Education.

BackgroundExposure in hepatopancreatic (HP) surgery can vary among Complex General Surgical Oncology (CGSO) fellowship graduates. Real-world outcomes of fellowship graduates performing HP surgery have not been previously examined.MethodsMedicare beneficiaries undergoing HP surgery for cancer between 2016 and 2021 were identified. Surgeon-level data, including fellowship training information, were linked to patient-level Medicare data. Trends and variations in severe complications and 90-day mortality according to fellowship training were examined.ResultsOverall, 9954 HP cancer operations (pancreatectomy: 7,566, 76%; hepatectomy: 2,388, 24%) were performed between 2016 and 2021. A total of 609 CGSO fellowship graduates trained at 42 different CGSO programs in the United States or Canada were identified. Most cases (93.2%) were performed by surgeons who had completed an ACGME-accredited CGSO program. Almost half of HP operations were performed by graduates of two specific CGSO programs (n = 4,769, 47.9%), whereas 92.1% (n = 9,166) of HP operations were performed by graduates of 15 CGSO programs. After adjusting for relevant, multilevel characteristics, marked variations in outcomes by CGSO fellowship program were noted following both hepatectomy and pancreatectomy. The adjusted probability of serious complications decreased from 2016 to 2021 (16.4% vs. 12.9%; p < 0.05), however, the likelihood of 90-day mortality remained relatively stable during the study period (2016: 6.4% vs. 2021: 5.3%; p = 0.19).ConclusionsWhile outcomes of CGSO graduates improved over time, a marked variation in outcomes of graduates performing HP surgery was noted based on their fellowship training. Further efforts should be made to enhance and standardize HP surgery exposure and training in CGSO programs for fellows intending to perform HP surgery in practice.

Vascular surgery's identity

Gender Bias in Surgical Oncology Fellowship Recommendation Letters: Gaining Progress

Securing a position in a complex general surgical oncology (CGSO) fellowship requires significant academic productivity, often including dedicated research time during surgical residency. However, it remains unclear whether this research translates into continued scholarly activity post-fellowship. This study aimed to evaluate longitudinal academic productivity among CGSO fellowship graduates and assess their perspectives on the current training paradigm. The study identified 483 CGSO fellowship graduates (2006-2016) from 20 U.S. fellowship training programs. Academic productivity was assessed using publication count, h-index, and m-index. The study queried National Institutes of Health (NIH) and United States Department of Defense individual research funding through NIH reporter and Congressionally Directed Medical Research Program databases. A survey was distributed to assess career paths, practice settings, and opinions on training structure. Multivariable regression was used to identify predictors of sustained research activity. Although 71% of the CGSO graduates completed dedicated research time during residency, only 9% received extramural funding, and 60% had an m-index lower than 1, indicating limited long-term academic productivity. Multivariate regression analysis showed that fellowship training institution and attainment of advanced degrees were associated with higher m-index values, whereas residency research time was not. Survey responses (n = 181, 47% response rate) showed that most graduates devote the majority of their careers to clinical work and support restructuring the training model to align with actual practice patterns. Despite research serving as a de facto prerequisite for CGSO fellowship admission, few graduates maintain academic productivity after training. These findings underscore the need to re-evaluate the current CGSO training paradigm, with consideration for clinically focused and research-intensive fellowship tracks that better align with trainee goals and workforce needs.

Surgical oncology operative experience during general surgery residency is poorly characterized. We hypothesized that graduates pursuing the Complex General Surgical Oncology (CGSO) fellowship would have greater surgical oncology exposure and log more surgical oncology relevant (SOR) cases. Demographics, program characteristics, and Accreditation Council for Graduate Medical Education (ACGME) case logs were collected from 20 general surgery residency programs in the US Resident OPerative Experience (ROPE) Consortium spanning 2010-2020. CGSO matriculants (CGSO group) were compared with graduates entering other surgical fellowships/practice (non-CGSO group). SOR cases included liver, pancreas, breast, endocrine, laparoscopic colorectal, and abdominoperineal resection. Among 1343 graduates, 80 (6%) pursued CGSO fellowships. Demographics, including sex, race/ethnicity, and underrepresented in medicine, were similar between groups (all p > 0.05). CGSO matriculants more often graduated from university-based programs with CGSO-trained faculty (95% vs 86%), dedicated surgical oncology divisions (81% vs 66%), and National Cancer Institute (NCI)-designated Cancer Centers (85% vs 68%, all p < 0.05). Median total cases were similar between groups; however, CGSO-bound graduates logged greater SOR procedures (162 vs 141), including liver (+4), pancreas (+10), endocrine (+7), and laparoscopic colorectal (+5, all p < 0.05). In multivariable analysis, factors associated with CGSO matriculation included departmental NIH funding (OR 4.82, 95% CI 1.18-19.79, p = 0.02), dedicated research experience (OR 5.62, 95% CI 3.02-10.44, p < 0.001), and increased SOR cases (OR 1.01, 95% CI 1.001-1.01, p = 0.02). CGSO matriculants have a unique general surgery training experience and log more SOR cases, which could reflect efforts to prepare for fellowship and/or the influence of surgical oncology immersion on career interest. These data highlight opportunities to bolster CGSO recruitment and fellowship preparation.

BackgroundSurgical subspecialty training aims to meet the needs of practicing surgeons and their communities. This study investigates career preparedness of Complex General Surgical Oncology (CGSO) fellowship graduates, identifies factors associated with practice readiness, and explores potential opportunities to improve the current training model.MethodsThe Society of Surgical Oncology partnered with the National Cancer Institute to conduct a 36-question survey of CGSO fellowship graduates from 2012 to 2022.ResultsThe overall survey response rate was 38% (221/582) with a slight male predominance (63%). Forty-six percent of respondents completed their fellowship after 2019. Factors influencing fellowship program selection include breadth of cancer case exposure (82%), mentor influence (66%), and research opportunities (38%). Overall, graduates reported preparedness for practice; however, some reported unpreparedness in research (18%) and in specific clinical areas: thoracic (43%), hyperthermic intraperitoneal chemotherapy (HIPEC) (15%), and hepato-pancreato-biliary (15%) surgery. Regarding technical preparedness, 70% reported being “very prepared”. Respondents indicated lack of preparedness in robotic (63%) and laparoscopic (33%) surgery approaches. Suggestions for training improvement included increased autonomy and case volumes, program development, and research infrastructure. Current practice patterns by graduates demonstrated discrepancies between ideal contracts and actual practice breakdowns, particularly related to the practice of general surgery.ConclusionsThis study of CGSO fellowship graduates demonstrates potential gaps between trainee expectations and the realities of surgical oncology practice. Although CGSO fellowship appears to prepare surgeons for careers in surgical oncology, there may be opportunities to refine the training model to better align with the needs of practicing surgical oncologists.

There is significant demand for training in Complex General Surgical Oncology (CGSO) fellowships. Previous work has explored objective quantitative metrics of applicants that matriculated to CGSO fellowships; however, ambiguity remains concerning academic benchmarks and qualitative factors that impact matriculation. A web-based survey was sent to each ACGME/SSO-approved CGSO fellowship training program. The survey was comprised of 24 questions in various forms, including dichotomous, ranked, and five-point Likert scale questions. Twenty-nine of 30 program directors (97%) submitted complete survey responses, representing 64 of the 65 CGSO fellowship positions (99%) currently offered. Programs received a mean of 73 applications per cycle (range 50-125) and granted a mean of 26 interviews (range 2-45). Seventy-two percent of programs had an established benchmark for ABSITE score percentile before offering a candidate an interview, with 62% of those programs setting that benchmark above the 50th percentile. The majority of programs also had established benchmarks for quantity of first author publications (mean: 2.3) and all publications of any authorship (mean: 4.4). An applicant's interview was ranked as the most important factor in determining inclusion on the program's rank list. The ability to work as part of a team, interpersonal interaction/communication abilities, and operative skills were rated as most important applicant characteristics, whereas an applicant's personal statement was ranked as least important. After established academic benchmarks have been met, a multitude of factors influences ranking of applicants to the CGSO fellowship, most of which are assessed at the interview.

Complex general surgical oncology (CGSO) fellowships recently obtained Accreditation Council for Graduate Medical Education (ACGME) accreditation and board certification eligibility. We aimed to characterize the applicant pool and identify factors predictive of matching into our program. We conducted a retrospective review of CGSO fellowship applications to a major cancer center from 2008 to 2018. Data were analyzed for trends over time, including a comparison of pre- versus post-American Board of Surgery (ABS) certification eligibility. A total of 846 applications were reviewed. Most applicants (86.2%) trained in a US residency program; 58.4% performed ≥ 1 research year during residency; 29.6% had a dual degree. Fewer applicants (34.5%) were female, a trend which did not change over time. Post-ABS, applicants were more likely to complete ≥ 1year between residency and fellowship (20.9% versus 13.2%, p = 0.003), to be in practice at the time of application (12.2% versus 6.6%, p = 0.005), and to reapply (5.5% versus 1.0%, p < 0.001). Post-ABS applicants listed more peer-reviewed publications (8 [interquartile range (IQR) 4, 15] versus 5 [IQR 2, 10]; p < 0.001). On multivariable analysis, factors associated with matching into our program included: US allopathic medical school graduation [odds ratio (OR) 4.6, 95% confidence interval (CI) 1.8-11.7], Alpha Omega Alpha (AOA) Honor Medical Society distinction (OR 2.7, 95% CI 1.6-4.7), dual degree (OR 2.0, 95% CI 1.1-3.4), and performance of a clinical/research rotation at our institution (OR 4.9, 95% CI 2.2-10.7). After establishment of CGSO board certification eligibility, applicants were more likely to apply while in practice and to reapply. A number of factors, including having a dual degree and rotating at our institution, were associated with matriculation.

The demand for training in complex general surgical oncology (CGSO) fellowships currently exceeds the number of positions offered; however, there are scarce data defining the applicant pool or characteristics associated with successful matriculation. Our study described the applicant population and to determine factors associated with acceptance into the fellowship. Data were extracted from the Electronic Residency Application System for applicants in 2015 and 2016 and stratified based on matriculation status. Applicant demographics, including medical education, residency, and research achievements, were analyzed. Academic productivity was quantified using the number of peer-reviewed publications as well as the journal with the highest impact factor in which an applicant's work was published. Data were gathered on a total of 283 applicants, of which 105 matriculated. The overall population was primarily male (63.2%), Caucasian (40.6%), educated at a U.S. allopathic medical school (53.4%), and trained at a university-based General Surgery residency (55.5%). Education at a U.S. allopathic school (OR = 5.63, p < 0.0001), university-based classification of the applicant's surgical residency (OR = 4.20, p < 0.0001), and a residency affiliation with a CGSO fellowship (OR = 2.61, p = 0.004) or National Cancer Institute designated Comprehensive Cancer Center (OR = 3.16, p < 0.001) were found to be associated with matriculation. Matriculants published a higher number of manuscripts than nonmatriculants (median of 10 vs. 4.5, p < 0.0001) and more frequently achieved publication in journals with higher impact factors (p < 0.0001). This study represents the first objective description of the CGSO fellowship applicant pool. Applicants' medical school, residency, and research data points correlated with successful matriculation.

Residents entering Complex General Surgical Oncology fellowship lack confidence with pelvic MRI for rectal cancer: Results of a needs assessment survey

Entrustable professional activities (EPAs) are familiar to academic surgeons since their adoption by the American Board of Surgery in 2023. Complex general surgical oncology (CGSO) fellowships have been required to adopt EPAs as part of the goal of competency-based education. This report describes the results from the initial creation of an EPA set for CGSO. Three separate groups are involved in the creation of an EPA set. The first group is the oversight group or "owner" of the process. This group takes responsibility for defining the need and for final approval of the EPA set. In the reported case, the CGSO Board comprised this group. The second group defines the EPA set, defines the scope of each, and provides direct oversight of the writing process. A group of senior volunteers assumed this task. The third group performed the detailed writing and included the attending surgeons as well as the surgical residents and CGSO fellows. To encompass the core of surgical oncology, 12 EPA topics were selected. To these EPAs were mapped 19 of 23 CGSO milestones to provide clinically applicable assessment tools for the majority of the milestones. Creation of an EPA set for CGSO entailed several challenges described in this report. The methods used by the authors are described in detail to serve as a potential template for other specialties. Because most individuals will have only one opportunity to develop similar programs, the authors present their experience with the hope that it will be useful to others as they embark on creation of EPAs for their own specialty.

BackgroundIn the era of coronavirus disease 2019 (COVID-19), many Complex General Surgical Oncology (CGSO) fellowship programs implemented virtual interviews (VI) during the 2020 interview season. At our institution, we had the unique opportunity to conduct an in-person interview (IPI) prior to the pandemic-related travel restrictions, and a VI after the restrictions were in place.ObjectiveThe goal of this study was to understand how the VI model compares with the traditional IPI approach.MethodsOnline surveys were distributed to both groups, collecting feedback on their interview experience. Responses were evaluated using a two-sample t test assuming equal variances.ResultsTwenty-three of 26 (88%) applicants completed the survey. Most applicants reported that the interview gave them a satisfactory understanding of the CGSO fellowship (100% IPI, 92% VI) and the majority in both groups felt that the interview experience allowed them to accurately represent themselves (92% and 82%, respectively). All participants in the IPI group felt they were able to get an adequate understanding of the culture of the program, while only 64% in the VI group agreed with that statement (p = 0.02). IPI applicants were more likely to agree that the interview experience was sufficient to allow them to make a ranking decision (92% vs. 54%; p = 0.04).ConclusionsWhile the VI modality offers several advantages over the IPI, it still falls short in conveying some of the more subjective aspects of the programs, including program culture. Strategies to provide applicants with better insight into these areas during the VI will be important moving forward.

At the conclusion of my presidential address describing the events that led to a subspecialty certificate in Advanced Surgical Oncology at the 63rd Annual Cancer Symposium of the Society of Surgical Oncology (SSO) in March 2010, I stated: ‘‘It is fair to say that the goal is in sight, yet it is prudent to remind ourselves that we have not crossed the finish line yet’’. 3 years later, I have realized how prophetic that statement was. The events that followed the submission of a formal request by the American Board of Surgery (ABS) to the American Board of Medical Specialties (ABMS) to establish a certificate for Advanced Surgical Oncology and the subsequent steps that led to its approval by the ABMS have been detailed in a previous editorial. This was an historical event for the discipline of surgical oncology, which was recognized as deserving of a formal training and a unique certificate. This was also a significant moment for the ABS in that this certificate is the first new certificate offered by the ABS in more than 20 years. The process then continued with the Accreditation Council on Graduate Medical Education (ACGME). The ACGME asked the Residency Review Committee in Surgery (RRC-S) to specify the training requirements for surgical oncology programs. A subcommittee of the RRCS was established with Drs. Peter Fabri, Mark Wallack, and Thomas Whalen (chair). The SSO was asked to name a representative, and Dr. Russell Berman joined the subcommittee. Once defined, the proposed program requirements were then sent to the GME constituency on February 6, 2012, for the statutory 45-day comment period. After the RRC-S collated and answered all comments received, it submitted the final document to the Requirement Development Committee of the ACGME Board of Directors for review. Finally, the full Board of Directors of the ACGME approved the program requirements at the June 10, 2012, meeting. By the first week in July, both the program requirements and the program information form (PIF) were available on the ACGME Web site. In recognition of the high quality of program supervision that the Training Committee of the SSO had provided to SSO-accredited programs, the RRC-S, which has oversight responsibility for the fellowships, agreed that current SSOapproved programs would not require a site visit as a part of the initial accreditation review. Non-SSO-approved programs would require a site visit to verify and confirm the information provided in the PIF. In accordance with ACGME policy, programs accredited in the 2012–2013 academic year could request a retroactive effective date of accreditation to July 1, 2012, making graduates of these ACGME-accredited fellowships eligible to participate in the ABS certification process upon graduation on June 30, 2013. In the meantime, changes also occurred at the ABS. The name of the Surgical Oncology Advisory Council (SOAC) was changed to Surgical Oncology Board. In addition, its composition was defined (Table 1). I was elected the first chair of the Surgical Oncology Board (2011–2012) and was then followed by Dr. Selwyn Vickers, who is currently serving a 2-year mandate. The newly established Surgical Oncology Board decided to award the certificate of Complex General Surgical Oncology to eligible candidates after successfully passing a qualifying examination (QE) and a certifying examination (CE), very much like the process leading to a certificate in surgery. The first order of business therefore became to establish a sizable multiplechoice question bank for the qualifying exam. In order to expeditiously attend to this task, the Surgical Oncology Board created a group of 12 consultants, two for Society of Surgical Oncology 2013

Palliative care is an important component of global oncology care, and palliative surgical oncology is becoming an increasingly significant part of surgical oncology practice. Fellows in complex general surgical oncology (CGSO) can anticipate palliative surgical oncology to represent approximately 25-30% of their practice. As such, education in this area is critical during CGSO Fellowship to properly prepare the trainees to enter their practice. Unfortunately, there is evidence to suggest the training in surgical palliative care is not as deliberate as necessary to achieve these training goals. We have developed a palliative surgical oncology rotation that is meant to address gaps in the training of CGSO Fellows. We have followed Kern's six-step approach to curriculum development. This manuscript outlines our steps and the approach we have used in this rotation. The rotation outline is aligned with competencies and learning objectives. Implementation of a structured palliative care rotation can be implemented in a CGSO training program. This rotation outline is a starting point for our program and can stimulate innovation to address this important learning opportunity.

With the first qualifying examination administered September 15, 2014, complex general surgical oncology (CGSO) is now a board-certified specialty. We aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation. A 29-question anonymous survey was distributed to fellows in surgical oncology fellowship programs and applicants interviewing at our fellowship program. There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66%. Ninety-percent of the respondents were aware that completing an ACGME-accredited fellowship leads to board eligibility in CGSO. However, the majority (80%) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the ACGME accreditation. The fellows in training were concerned about the cost of the exam (90%) and expressed anxiety in preparing for another board exam (83%). However, the majority of the respondents believed that CGSO board certification will be helpful (79%) in obtaining their future career goals. Interestingly, candidate fellows appeared more focused on a career in general complex surgical oncology (p=0.004), highlighting the impact that fellowship training may have on organ-specific subspecialization. The majority of the surveyed surgical oncology fellows and candidates believe that obtaining board certification in CGSO is important and will help them pursue their career goals. However, the decision to specialize in surgical oncology does not appear to be motivated by ACGME accreditation or the new board certification.