Test Required for Laparoscopy Privileges in Boston


In a move that sponsors believe is the first of its kind in the United States, attending general surgeons at several Boston-area hospitals will be required to prove basic motor skills outside an operating room before obtaining laparoscopic surgery privileges.

And as an incentive toward completion of the Fundamentals in Laparoscopic Surgery (FLS) exam, CRICO/RMF, the Harvard medical community's professional liability insurer, is providing a one-time $500 patient safety incentive to general surgeons who pass the exam.

The new requirement—which is going into effect at Beth Israel Deaconess Medical Center, Cambridge Health Alliance, and Massachusetts General Hospital, all of which are in Boston—could portend adoption of the FLS standards in many hospitals, said Dr. Steven Schwaitzberg, chief of surgery at the Cambridge Health Alliance.

“I expect it to spread,” Dr. Schwaitzberg said in an interview. “I think this is going to become quite viral in terms of its impact and rate of spread, and pick up dramatically.”

The FLS program, which includes hands-on skills training and assessment tools, took almost a decade to develop, and is a joint educational offering of the American College of Surgeons and the Society of Gastrointestinal and Endoscopic Surgeons.

The test is a two-part, proctored 75-question multiple choice exam administered by computer, plus an evaluation of skills based on speed and accuracy of the surgeon's maneuvers using the FLS Laparoscopic Trainer Box.

The skills test consists of five nonprocedure-specific simulation exercises incorporating most of the psychomotor skills necessary for basic laparoscopic surgery. Surgeons are tested on their proficiency at suturing, cutting in a circle, and moving objects from one location to another.

Beth Israel Deaconess was the first U.S. hospital to require general surgeons performing laparoscopic surgery to pass the FLS exam, said Dr. Daniel Jones, the hospital's chief of minimally invasive surgery.

The hospital started requiring residents to prove competency in laparoscopy about 10 years ago, Dr. Jones said in an interview. “Finally we said: Why should we hold trainees to a higher level than surgeons in practice? Would you let a truck driver drive after only a written exam?”

Dr. Jones said surgeons can elect to simply take the test without taking the course first. “I did that,” he said. “But it's a real test, and it's better to study and practice first. It's nothing less than a patient would expect their surgeon to do effortlessly.”

In the Boston area, professional liability insurer CRICO/RMF sponsored the FLS course in January, and about 60 people signed up, said Dr. Schwaitzberg. Beth Israel Deaconess and Cambridge Health Alliance have already adopted the FLS exam as a requirement for laparoscopic privileges, and Massachusetts General Hospital will do so in the near future, said Dr. David Rattner, chief of the division of general and gastrointestinal surgery at Massachusetts General.

Surgeons insured by CRICO/RMF who pass the exam will receive a one-time $500 patient safety incentive from the insurer, as well as continuing medical education credits through SAGES and ACS. But “it's not about the money,” said Dr. Jones. “It's about sending the signal that the bar has been raised.”

Dr. Jones said he expects the FLS to become the new minimal standard for all surgeons offering basic laparoscopy to patients. And Dr. Schwaitzberg agreed, saying the FLS, like the Advanced Trauma Life Support (ATLS) curriculum in trauma surgery, indicates a move toward more testing of skills and competency in surgery in general.

“You wouldn't work in a trauma [emergency department] without the ATLS,” said Dr. Schwaitzberg. “Will this be a model for other aspects of surgery? I think so.”

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