In continuing with the series, An Update in Acute Care Surgery, the following section highlights the evolution of the training process for the Acute Care Surgery fellowship.
Grace S. Rozycki, MD, FACS
The Willis D. Gatch Professor of Surgery
Associate Chair, Department of Surgery, Indiana University
Chief of Surgery, IUH-Methodist Hospital, Indianapolis
Acute Care Surgery: The Training Paradigm
BY CLAY COTHREN BURLEW, MD, FACS, AND GREGORY J. JURKOVICH, MD., FACS
The acute care surgery fellowships are designed to follow core training in general surgery (J. Trauma 2007;62:553-6). Currently, this means the acute care surgery fellowship follows the completion of an Accreditation Council for Graduate Medical Education general surgery residency program and is in alignment with the core competencies of the general surgery residency. The 2-year curriculum was defined by the AAST, and incorporates the requirements of an ACGME-approved surgical critical care fellowship.
Although there are mandatory components of this fellowship, a certain amount of latitude and creativity are encouraged so to capitalize on the strength of the individual program as well as to meet the individual needs of the fellow.
The basic principles of the training paradigm include the followi
1. The program is 2 years in length.
2. The acute care surgery fellowship programs must have the ACGME approved surgical critical care residency.
3.The fellowship must include specific surgical technical training in hepatobiliary disorders, thoracic surgery, and vascular surgery.
4. Trainees should participate in acute care surgery call for at least 12 months and 52 nights of acute care surgery call (trauma and emergency general surgery).
5. Flexibility in the rotations should be used to optimize the fellow’s training.
6. The rationale for out-of-system rotations and the structure of the 24-month training should be used to optimize the fellow’s training.
7. Participation in elective surgery, both to supplement general surgery training and experience and to serve in a supervisory role to residents, is an essential component of this fellowship training.
8. An academic environment is necessary and the fellows should be trained to teach others and conduct research in acute care surgery.
The rationale for the rotations of Thoracic Surgery, Transplant/Hepatobiliary/ Pancreatic, and Vascular (including vascular interventional) is twofold: 1) Many complex operative cases in these areas are infrequently encountered in modern trauma centers; and, 2) experts in these areas can provide mentorship and operative expertise and teaching for the fellow who obtains a focused, quality operative experience in these areas. Further, these rotations have specific competency related goals so that the fellow has specific requirements to meet. The AAST is currently revising its method of confirming this training expertise by examining specific components of operative technique and exposure as well as length of time on specific rotations (see below).
Program Application and Approval
The required background and expectations for the acute care surgery fellowship include the following: 1) Fellows must have successfully completed the core training requirements of an RRC-approved residency in General Surgery; and 2) the acute care surgery fellowship programs must provide the necessary education to qualify the fellow as an acute care surgical specialist in clinical, education, and research areas. Each program must have support from its parent institution, including administrative personnel, the chairman of the department of surgery, division chief, and participating acute care surgery faculty. The program should have all of the necessary resources to fulfill the training requirements and create an environment of inquiry and scholarship while allowing for progressive responsibility throughout the training period.
The process of becoming an approved acute care surgery fellowship program can be divided into the following steps:
1. The Program Director completes the Program Information Form (PIF) form (downloaded from the AAST website, http://www.aast.org).
2. The PIF is reviewed by three members of the AAST Acute Care Surgery Committee to determine whether it is complete and if it meets the essential requirements. If the initial review is successful, then a site visit of the program is scheduled.
3. The site visit is conducted by two members of AAST Acute Care Surgery Committee. The site visit consists of an evening business dinner meeting with the following personnel: the program director for the acute care surgery fellowship, the program director for the general surgery residency program, select administrators, and division chiefs. Current fellows in the program are also invited to participate. The following day, the site visitors tour the institution, and conduct one-on-one interviews with the personnel who were present at the site visit dinner. A chart review is conducted to assess the operative case load and the involvement of the faculty, residents, and fellows in the care of the patients. At the conclusion of the day, a summation interview is conducted with the acute care surgery fellowship program director.