Endocrine Surgery Fellowship Training

Although most surgeons in the USA who perform endocrine operations do so in the context of a broad general surgery practice, many believe that additional training in endocrine surgery is required for those who will serve as experts in the field. Endocrine surgery fellowships of variable duration add clinical, operative, and research experiences onto the standard surgical residency training. The duration and curriculum for such programs have not been formally established. Current fellowships in the USA, Canada, Australia, Europe, and Asia range from 3 months to 4 years in duration and may include clinical practice, clinical research, basic science research or combinations thereof. As per the International Association of Endocrine Surgeons (IAES) website [17], there are 85 centers that have or are planning to create endocrine surgery fellowships and this number will continue to increase. No formal certification process currently accompanies this fellowship training in the USA, but it is generally agreed that an endocrine surgery fellowship should prepare the surgeon for all elements of a career in this subspecialty. To date, there have been no specific studies on the impact of endocrine surgery fellowship programs on clinical outcomes.

Surgical endocrinology does not merely involve technical skill. The additional clinical experience of a fellowship program builds in-depth knowledge in the areas of prevention, diagnosis, natural history, treatment options, preoperative preparation, operative technique, and management of surgical complications in patients with a broad range of endocrine disorders. A firm understanding of endocrine biology and pathophysiology is mandatory. Knowledge of investigative options, including their indications and limitations, allows accurate and timely diagnosis while minimizing invasiveness and cost. The use of novel and experimental treatment options not yet found in textbooks is an important aspect of fellowship training because these future endocrine surgeons will help dictate the ultimate role these therapeutic options will play. Surgical technique, including preoperative and intraoperative decision-making, must be taught by those who are experienced in the field. Appropriate postoperative and long-term follow-up care including hormone substitution therapy and surveillance for disease recurrence are vital aspects of patient management. Knowledge of the indications for and potential complications of adjuvant oncological treatment is also required. Because of advances in molecular genetics, screening for familial disease or detecting genetic markers to predict tumor behavior will play an increasing role in patient evaluation, treatment, and follow-up care. A key element of fellowship training involves achieving greater clinical and operative experience while under the guidance of endocrine surgeon mentors.

The emerging specialist should be competent in the operative and nonoperative components of surgical endocrinology. For this reason, it has been suggested that the clinical aspect of a fellowship program include nonsurgical skills such as neck ultrasonography, fine-needle aspiration biopsy, and direct laryngoscopy. Clinical experience should include nonoperative rotations in endocrinology, endocrine pathology, and related radiology and nuclear medicine investigations and treatments. Achieving this competency is an important component of specialty training.

Endocrine surgery fellowships should include a research component - basic science, clinical or both. Regardless of the type of research, development of the associated skills is a vital tool that the graduating endocrine surgeon takes from their fellowship to their professional practice. The contributions from original research are one of the yardsticks by which academic surgeons are measured. More importantly, such contributions are mandatory for the continued improvement in patient care, because advances and innovations in technique and knowledge are the products of these research efforts. In addition to the increased volume and depth of clinical experience, the research element of an endocrine surgery fellowship also differentiates it from the residency training on which they are building.

With the range and depth of clinical and research experience an endocrine fellowship program can provide, it is possible to visualize how one begins to make the transformation from general surgery graduate to specialized endocrine surgeon.

Clinical Practice -Maintaining the Skills and Knowledge and Building on Them

Surgeons who perform endocrine surgery must ensure that they maintain their level of practice at an acceptable standard, regardless of whether they have additional fellowship training or not.

The maintenance of these standards should include a critical self-appraisal of patient outcomes as they relate to clinical decision-making, timing and accuracy of diagnosis, indications for and choice of operation, postoperative follow-up care and adjuvant treatment. Since medicine is a dynamic profession, this clinical competency must reflect past training and experience while incorporating any changes in clinical practice guidelines and treatment modalities. Any surgeon caring for patients with endocrine disorders such as thyroid cancer must remain up to date on the advances in the multidisciplinary care (operative and nonoperative) that these diseases require. The specialist surgeon should play an active role in the development of these advances and in the promotion of the multidisciplinary approach.

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