Guidelines for Non-ACGME Accredited Fellowships in Surgery

The Fellowship Council

Approved by:
American Hepato-Pancreato-Biliary Association – February 27, 2003
Society for Surgery of the Alimentary Tract – February 1, 2003
Society for American Gastrointestinal Endoscopic Surgeons – March 2003
Minimally Invasive Surgery Fellowship Council – March 2003
The Fellowship Council – February 2005
The American Society for Bariatric Surgery - June 2005

Contents

I. Non-ACGME Accredited Fellowships in Surgery

A. Background
B. Objectives

II. Program Requirements for Fellowships

A. General Information
B. Program Director, Teaching Staff, and Support Personnel
C. Educational Principles
D. Educational Components
E. Research and Scholarly Activity
F. Library Facilities
G. Selection Process
H. Completion of the Fellowship
I. Evaluation of Fellows, Program Director, Teaching Staff, and Program

III. Accreditation of Fellowships

A. Curriculum Review and Approval Process
B. Site Visits
C. Re accreditation

IV. Proposed Activities of the Constituent Societies in Relation to Fellowships

A. Accreditation of Fellowships
B. Annual Meeting of Program Directors and Fellows
C. Fellowship Registry
D. Fellowship Matching Program

Appendix A

Appendix B

I. NON-ACGME ACCREDITED FELLOWSHIPS IN SURGERY

A. Background

The unprecedented growth of knowledge and technology in surgical disciplines in the past 50 years, particularly the past two decades, has had a profound effect on the training of surgeons. The increased complexity of the diagnosis and management of many conditions has led to the evolution of post-residency, non-ACGME accredited fellowships in some areas of general surgery. For example, it is now considered desirable for a surgeon entering the practice of surgical oncology or organ transplantation in a major tertiary care center to have received additional specialty training after a general surgery residency. Leading professional organizations, such as the Society for Surgical Oncology and the American Association of Transplant Surgeons, have created fellowships—without seeking approval from the Accreditation Council for Graduate Medical Education (ACGME)—to fill the need for training in fields not traditionally recognized as specialties.

Most surgeons recognize that there are specialists in certain surgical fields. Recent developments in these fields have included complex enabling technology that requires mastery of new cognitive, perceptual, and manual skills, further intensifying the need for formal post-residency training for surgeons who wish to make these areas the main focus of their careers.

However, except for a few fellowships whose quality and organization are overseen by a particular specialty society (e.g., surgical oncology and transplantation fellowships), there are no organized, uniform, carefully monitored fellowship training programs in many other areas where ad hoc fellowships have evolved (e.g., endoscopic, minimally invasive, gastrointestinal and hepato-Pancreato-Biliary surgery). This is surprising, considering the strong demand for additional training from physicians completing general surgery residency programs. Instead of a nationally organized fellowship program, senior residents interested in such fellowships find a variety of locally organized programs, ungoverned by national quality standards. Although Web sites of surgical societies provide descriptions of these opportunities, the information is often incomplete.

To address the needs of general surgery residents pursuing these recently present other fellowships, the Minimally Invasive Surgery Fellowship Council (MISFC) was established in 2001. Initially an informal organization of a small number of MIS fellowship program directors, it evolved into a legal entity and by 2003 had over 60 member fellowship programs and conducted a match where over 90 applicants matched into these programs. Coincident with the activities of the MISFC, three pre-eminent societies (the Society of American Gastrointestinal Endoscopic Surgeons [SAGES], the Society for Surgery of the Alimentary Tract [SSAT], and the American Hepato-Pancreato-Biliary Association [AHPBA]) commissioned a joint committee to establish guidelines for a fellowship in Endoscopic, Gastrointestinal and Hepato-Pancreato-Biliary surgery. The bylaws and organizational structure of the MISFC along with the guidelines document developed by this joint commission served as the basis for the evolution of the MISFC into The Fellowship Council (FC). Soon after the American Society of Bariatric Surgery [ASBS] became a member of the Fellowship Council. The Fellowship Council, by incorporating the leadership and organization of the MISFC and the guidelines established by the member societies, seeks to not only conduct practical activities around the process of managing a match and registry of fellowship programs, but also accredit programs to the standards outlined in this guidelines document.

The founding societies directed that the guiding principle for establishment of a fellowship in surgery be that such a fellowship must in no way interfere with or detract from the training of residents in general surgery. In several surgical subspecialties other than those represented here, the development of fellowships, certificates of special competence, and subspecialty board examinations have limited general surgeons’ ability to practice all components of their general surgery training. To help avoid the development of franchises in Fellowship Council fellowships, the Fellowship Council will not seek an ACGME-approved certificate of special competence or establish a certifying examination. Instead, the Fellowship Council program is based on the assumption that program applicants have been fully trained in general surgery and seek exposure to an environment that will provide experience in surgical management of complex surgical problems including mastery of surgical skills. This fellowship training is not being established to exclude other surgeons in the community from performing such procedures.

B. Objectives

We propose that the guidelines herein detailed will:

1. Provide a mechanism for establishing and accrediting non-ACGME accredited fellowships in surgery.

2. Provide a mechanism to ensure that surgery fellowship programs attain and maintain a high level of quality.

3. Provide mechanisms to ensure that surgery fellowships do not interfere with residency training in general surgery.

4. Provide a central registry of approved surgery fellowships to which prospective fellows can apply.

5. Provide a central registry of data on approved surgery fellowships to assist general surgery residents in choosing the best fellowship for themselves.

6. Provide a diverse range of fellowship opportunities within the scope of general surgery.

II. PROGRAM REQUIREMENTS FOR FELLOWSHIPS IN SURGERY

A. General Information

1. In this document, a Fellowship Council fellowship (referred to as the “fellowship”) is defined as a clinical or research experience of not less than one year. Fellowship programs may be flexible in design but are required to provide a clear focus on the anatomical and functional evaluation of the diseases typically managed within the field of focus for the fellowship (e.g., GI Surgery, Bariatric Surgery, etc) as well as techniques for operative and postoperative management. In addition, it is essential that scholarly activity be integrated into the daily activities of the fellowship program.

2. Fellowship training requires adequate previous training in general surgery. Thus, fellowships will follow completion of an accredited general surgery residency program in the United States or equivalent general surgery training outside the United States.

3. Academic fellowships will be accredited primarily in institutions that sponsor a general surgery residency-training program accredited by the ACGME or are integrated by formal agreement into such a program. However, fellowships at institutions in which abundant clinical experience is combined with adequate didactic training may be approved.

4. Rotations to other institutions for a period not exceeding 25% of the total time in the fellowship program may be approved; adequate educational justification for such rotations must be provided during program review.

5. Fellowship programs will not be approved if they will have a substantial negative effect on the training of general surgery residents. Specifically, the general surgery residency-training program cannot have been cited for a deficiency in the area of the proposed fellowship.

B. Program Director, Teaching Staff, and Support Personnel

Fellowships will be approved only in institutions capable of providing a scholarly environment for acquiring the necessary cognitive and procedural clinical and research skills essential to the surgical practice of trainees. This objective can be achieved only when the program director, the program’s faculty and staff, and the institution’s administration are fully committed to the educational program being offered. It is also imperative that appropriate resources and facilities be present. Service obligations must not compromise the fellowship’s educational goals and objectives.

1. Program director

A single program director must be responsible for the fellowship program.

a. Qualifications of the program director

The program director must be a surgeon who is qualified to supervise and to educate fellows in the broad field of the fellowships focus as defined previously and must meet requirements similar to those required of program directors of ACGME-approved general surgery training programs. The director must be recognized nationally or regionally by his or her peers as a leader in some facet of the area of the program’s focus. Specifically, the program director must:

1) Be certified by the American Board of Surgery (ABS) or have equivalent qualifications.

2) Have an appointment in good standing to the medical staff of the institution anchoring the fellowship program.

3) Be licensed to practice medicine in the state in which the anchoring institution is located.

4) Maintain a cooperative working relationship with the director of the general surgery residency program (where one exists)

5) Be a member in good standing of at least one of the constituent societies.

6) Must have a minimum of two years experience, post training.

7) Must have published in a peer reviewed journal or presented at a national or regional meeting.

8) Demonstrated experience and/or expertise in teaching residents, fellows, or post graduate surgeons on a regional, national or international level as in a course.

b. Responsibilities of the program director

It is the responsibility of the program director to support the fellowship program by devoting his or her efforts to its management and administration. The director is also expected to be an active and recognized participant in the institution’s clinical and educational programs. This general responsibility includes the following specific activities.

1) Preparation of a written statement with the following components: an outline of the goals of the fellowship program with respect to knowledge, skills, and other attributes; a narrative description of the fellowship, including details of fellows’ involvement in clinical, research, teaching, and administrative activities; and a description of the relationship between the fellowship and the general surgery residency program. This statement must be made available to fellows, general surgery residents, the director of the general surgery residency program, and members of the teaching staff.

2) Selection of fellows for the program in accordance with institutional and departmental policies and procedures.

3) Selection and supervision of the teaching staff and other program personnel at each institution participating in the program.

4) Supervision of fellows through explicit written descriptions of supervisory lines of responsibility for the care of patients. Such guidelines must be communicated to all members of the fellowship program staff and to the general surgery staff and residents. Fellows must be provided with prompt, reliable systems for communicating and interacting with supervising physicians.

5) Organization and supervision of the research activities of fellows.

6) Organization and supervision of fellows’ participation in conferences and other educational activities.

7) Organization and supervision of fellows’ interaction with general surgery residents at the educational, research, administrative, and patient care levels.

8) Implementation of fair procedures, as established by the sponsoring institution, regarding academic discipline and complaints or grievances.

9) Monitoring of fellows’ stress level, including monitoring for mental and emotional conditions inhibiting job performance and for drug or alcohol related dysfunction. The program director and teaching staff should be sensitive to the need, where applicable, for timely provision of confidential counseling and psychological support services to fellows. Training situations that consistently produce undesirable stress on fellows must be evaluated and modified.

10) Tabulating and recording the operative logs of surgical fellows in a format similar or identical to the ACGME general surgery resident operative logs.

11) When the program director changes, the membership committee of the Fellowship Council must be promptly notified in writing.

2. Teaching staff

a. Other than the program director, additional teaching staff with documented qualifications and a commitment to instruct and supervise fellows must be available. Staff members should have a recognized record of achievement in clinical practice, teaching, research, or a combination of these. Faculty members should be primarily committed to the program’s area of focus and have a clinical practice that supports areas of special emphasis. Members of the teaching staff must be able to devote sufficient time to supervisory and teaching responsibilities.

b. When the fellowship program is located in more than one institution, a member of the teaching staff of each participating institution must be designated to assume responsibility for the day to day activities of the program at that institution, with overall coordination by the program director.

c. The teaching staff and program director must regularly and formally review each other’s performance in accordance with the goals and objectives of the fellowship.

d. The teaching staff should regularly evaluate the financial and clinical contribution of the resources available to the fellowship program, the contribution of each institution participating in the program, and the effect of the fellowship on the general surgery residency program.

3. Support Personnel

The fellowship program must be provided with the professional, technical, and clerical personnel needed for it to function smoothly and effectively.

C. Educational Principles

The principles of education enumerated in the Program Requirements for Residency Education in General Surgery published by the ACGME are also applicable to the fellowship. In particular:

1. The program director is responsible for ensuring that adequate facilities and resources are available to achieve the educational objectives.

2. The fellowship must provide advanced education such that fellows can acquire the special skills and knowledge of the field represented by the fellowship. This education should consist of both a cognitive and a technical component. The cognitive component should emphasize the scholarly attributes of self instruction, teaching, skilled clinical analysis, sound surgical judgment, and research creativity. The technical component must provide appropriate opportunity for fellows to acquire the operative skills required for the practice of advanced surgery.

The program director must establish an environment that is optimal for both the education of fellows and patient care, including the responsibility for continuity of care, while ensuring that fellows can avoid undue stress and fatigue. It is the program director’s responsibility to ensure assignment of appropriate in hospital duty hours so that fellows do not have prolonged working hours.

3. During in house on-call hours, fellows should be provided with adequate sleeping, lounge, and food facilities. There must be adequate backup so that patient care is not jeopardized during or after assigned periods of duty. Support services and systems must be such that fellows do not spend an inordinate amount of time in non-educational activities that can be conducted properly by other personnel.

D. Educational Components

1. General competencies

Fellowships must become competent in the following six areas at the level expected of a surgery practitioner. Training programs must define the specific knowledge, skills, and attitudes required and provide the educational experience for fellows to demonstrate:

a. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Specifically, fellows must:

1) Demonstrate manual dexterity appropriate for their training level.
2) Be able to develop and execute patient care plans.

b. Knowledge about established and evolving issues in biomedical and clinical sciences and application of this knowledge to patient care.

Specifically, fellows are expected to:

1) Critically evaluate and demonstrate knowledge of pertinent scientific information.

c. Practice-based learning and improvement that involve investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.

Specifically, fellows are expected to:

1) Critique personal practice outcomes.
2) Demonstrate recognition of the importance of lifelong learning in surgical practice.

d. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals.

Specifically, fellows are expected to:

1) Communicate effectively with other health professionals.
2) Counsel and educate patients and families.
3) Effectively document practice activities.

e. Professionalism, as manifested by a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Specifically, fellows are expected to:

1) Maintain high standards of ethical behavior.
2) Demonstrate a commitment to continuity of patient care.
3) Demonstrate sensitivity to age, race, gender, and culture of patients and other health care professionals.

f. Systems-based practice as manifested by actions that demonstrate an awareness of and response to the larger context and system of health care and effectively call on system resources to provide optimal care.

Specifically, fellows are expected to:

1) Practice high-quality, cost-effective patient care.
2) Demonstrate knowledge of risk-benefit analysis.
3) Demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.

2. Specific competencies

a. A sufficient number of patients must be available to ensure that fellows receive appropriate experience in the management of complex problems without adversely affecting the experience of residents in the general surgery core program. Specifically, a fellowship will not be approved in an institution that has a program deficiency in the pertinent areas of general surgery. Fellows must have adequate responsibility for continuity of care, including pre-hospital and post hospital experience.

b. Conferences, including medical surgical reviews, analyses of complications and deaths, seminars, and clinical and basic science instruction, must be regularly scheduled. In most cases, these educational activities will be shared with general surgery residents. Active participation of fellows in the planning and production of these meetings is essential to the fellows’ education and should enhance the education of general surgery residents.

c. Fellows must have the opportunity to provide patient consultation with faculty supervision. They should have clearly defined educational responsibilities for other residents, medical students, and professional personnel. These teaching experiences should involve correlation of basic biomedical knowledge with the clinical aspects of the fellowship.

d. A fellow may be appointed as an instructor to fulfill the role of a junior faculty member or as a postgraduate trainee, depending on the number of years of postgraduate training completed and institutional requirements and policies. A fellow should not be associated with an excessive number of faculty members who serve as “anchors” to the specialty surgical unit.

e. There must be close interaction between the fellowship program and the general surgery residency program (where one exists). Lines of responsibility for general surgery residents and fellows must be defined clearly. Fellows may serve as teaching assistants for residents when appropriate.

f. The fellowship should include meaningful participation in the administrative activities of the department. Active learning about practice management and other administrative aspects related to the future practice of their specialty, surgical research, and surgical education of residents and medical students should be made available to fellows, as applicable. Fellowship programs are encouraged to include fellows in the departmental education committee that oversees the general surgery residency-training program, where applicable.

g. Adequate and appropriate supervision of fellows must be provided at all times, in accordance with each fellow’s level of experience and expertise and institutional rules and policies.

E. Research and Scholarly Activity

Graduate medical education must take place in an environment of inquiry and scholarship in which trainees participate in the development of new knowledge, learn to evaluate research findings, and develop habits of inquiry as a continuing professional responsibility.

The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the program director and the teaching staff of the fellowship. Therefore, the staff as a whole must demonstrate broad involvement in scholarly activity. This activity should include:

1. Active participation of the teaching staff in clinical discussions, rounds, and conferences in a manner that promotes inquiry and scholarship. Scholarship implies an in depth understanding of basic mechanisms of normal and abnormal conditions and the application of current knowledge, techniques and technology to clinical practice.

2. A leadership role in journal clubs and research conferences with an emphasis on the fellowship’s area of focus.

3. Active participation in regional and national professional and scientific societies, particularly through presentations at the organizations’ meetings and publication in their journals.

4. Active participation in basic science or clinical investigations, or both, particularly in projects that are funded after peer review or that result in publications or in presentations at regional and national scientific meetings.

5. Provision of guidance and technical support as needed (for example, research design and statistical analysis) to students, residents, and fellows involved in research and other scholarly activities.

6. Provision of the opportunity for fellows to become involved in scientific or clinical investigations so that they may become familiar with the design, implementation, and interpretation of research studies.

7. Participation in the management of the general surgery residency program in the anchoring institution.

8. A systematic review of current and evolving techniques and new and evolving technologies.

F. Library Facilities

1. Fellows must have ready access to a major medical library, either at the institution where they are located, through arrangement with nearby institutions, or by means of appropriate computer access to Web portals.

2. The library services available to fellows should include electronic retrieval of information from medical databases.

G. Selection Process

Fellows should be selected in a fair and nondiscriminatory manner in accordance with the Equal Opportunities Act. The selection process may vary according to institution. Each program must make the details of the process known to applicants. During the selection process, applicants should be made familiar with the faculty’s experience, ongoing research, publications, and potential conflicts of interest (as defined by ACGME standards). It is essential that applicants have the opportunity to meet and question current fellows in the absence of the program director, faculty, and staff. If requested, a list of previous fellows with their current positions and contact information should be made available to applicants. Ultimately, selection of a fellow by an institution (and vice versa) will be done with use of a computerized matching program with logic identical to that of the National Resident Matching Program used by the Association of American Medical Colleges. This matching program will be overseen by the Communications Committee.

H. Completion of the Fellowship

At completion of the fellowship, fellows will be required to supply the program director with their clinical case log; lists describing their research experience, grants, and publications; and curriculum vitae. These documents should be collected in a completion file for each fellow. The institution should maintain documentation on each fellowship for 10 years after its completion. On successful completion of fellowship, fellows should receive a certificate signed by the program director and department chair, where applicable.

I. Evaluation of Fellows, Program Director, Teaching Staff, and Program

1. Fellows

There must be regular evaluation of the fellows’ knowledge, skills, and overall performance, including the development of professional attitudes consistent with being a physician. Evaluation should be provided in a timely and constructive manner and be used primarily as a stimulus for improvement. To that end, the program director, with the participation of the teaching staff, general surgery residents, and students will:

a. Evaluate the knowledge, skills, and professional growth of fellows, using appropriate criteria and procedures, at least quarterly.

b. Communicate each evaluation to fellows in a timely manner.

c. Advance fellows to positions of higher responsibility only on the basis of evidence of satisfactory progressive scholarship and professional growth. Maintain a permanent record of evaluation for each fellow that is accessible to the fellow and other individuals authorized by the fellow or fellowship program director.

A written final evaluation is required for all fellows who have completed a fellowship program. The evaluation must include a review of the fellow’s performance during the final period of training and should verify that the fellow has demonstrated sufficient professional ability to practice independently with the highest standard of competence. This final evaluation should be part of the fellow’s permanent record maintained by the institution.

2. Program director and teaching faculty

The fellowship program director should be evaluated annually by the director of the general surgery core program or the chief of surgery at the primary hospital with respect to teaching effectiveness, scholarly research productivity, patient care activities, and administrative ability. On completion of the fellowship, fellows should submit a formal evaluation of the teaching faculty to be kept on file and made available to site reviewers.

3. Program

The educational effectiveness of a fellowship program must be evaluated in a systematic manner. In particular, the quality of the curriculum and the extent to which fellows have met its educational goals must be assessed regularly by the program director and either the general surgery program director, the surgery department chair, or the chief of surgery at the fellowship’s primary hospital. In addition, fellows should be provided the opportunity to evaluate the fellowship on a regular basis, offer constructive feedback, identify deficiencies, and address problems or potential problems without fear of retribution. These evaluations should be circulated to the faculty and discussed with site reviewers. Written evaluations should be kept on file for 10 years.

III. ACCREDITATION OF FELLOWSHIP COUNCIL FELLOWSHIPS

A. Curriculum Review and Approval Process

A surgery department wishing to have a Fellowship Council fellowship accredited must submit the following documents.

1. Application (see Appendix)

2. Mission statement regarding the fellowship

3. Policy on fellows’ interaction with general surgery residents

4. A narrative description of the fellowship that includes the following should be available for all fellowship applicants:

a. The intended goals, objectives, and curriculum of the fellowship experience, with details about the nature of its clinical activities, including the types and approximate numbers of procedures to be performed and assisted by fellows.

b. The intended nature and scope of the research program or opportunities, with specific details regarding the resources available.

c. The intended scope of the educational involvement of fellows in the general surgery program and the education of students.

d. A narrative description of current research activities and specific research interests of the program director and faculty.

e. Descriptions of the primary and affiliated hospitals, clinics, or ambulatory centers at which fellows will work. This section should include a description of the environment affecting the fellowship (number of beds, size of the surgical department, space allocated to fellows, access to a medical library, number of operating rooms, and access to and cost of parking and other required fees).

f. A description of the kind of appointment, salary, benefits, insurance, and other fringe benefits to which fellows will be entitled. It is expected that salary and benefits will be equivalent to ACGME regional standards appropriate for the level of training.

5. A statement from the chief of surgery and the director of graduate medical education, or hospital chief executive officer, indicating that the fellowship fits into the internal plans of the institution and will be appropriately integrated with existing educational programs.

6. Where available, the operative logs for general surgery residents submitted to the Residency Review Committee (RRC) for the previous three years.

7. Sample certificate given on completion of the fellowship.

8. Curriculum vitae of program director and faculty members.

Completed applications will be reviewed by the accreditation committee with representation from the constituent societies. Provisional approval will be granted to all fellowship programs initially meeting the requirements. Within one year after this approval is given, an initial site visit will be conducted and if all components outlined in this document are verified, and there has been a review of the case logs and interviews with the existing Fellows, full accreditation (max three years) will be conferred if performance is satisfactory. If not, the program will not be accredited and will need to reapply. Programs that are not offered full accreditation after three reviews will be dropped from the Fellowship Council. A majority vote of the accreditation committee will be required for full approval of a program. The accreditation committee will consider programs for approval twice a year. The application for program approval must be received eight weeks before the committee meets. Copies of the application will be distributed to committee members for review. An application fee is required for the accreditation committee to consider initial approval of the program. Approved programs will be charged an amount approved by the board to cover costs of monitoring their programs and communication with other constituencies, such as the ABS, RRC, and American College of Surgeons.

B. Site Visits

Site visits will be the mechanism for ensuring that fellowship programs meet the highest possible standards of quality. Site visitors will be appointed by the Accreditation Committee and will serve under their guidelines. Recommendations regarding accreditation are made to the Fellowship Council Board of Directors and the Board grants final approval.  As part of the initial application process, the site visitor will perform a comprehensive review of the program and provide constructive feedback to the program director to ensure full compliance with fellowship guidelines. After this initial visit, site visits may occur at the request of a program director for the purpose of mediation, to provide administrative recommendations concerning the relationship between the fellowship program and the parent institution, or to help in other ways to ensure the continuity and quality of the fellowship program. Requests for such site visits should be addressed to the Membership and Accreditation Committees, with the reasons for the request and the time frame in which such a visit is desired specified. The cost of a site visit will be borne by the requesting institution. Site visits may also be requested by the accreditation committee for programs that are in questionable compliance with fellowship guidelines. In all cases, site visitors must present a report to the chair of the accreditation committee no later than three weeks after the site visit.

C. Re-accreditation

Every three years or sooner, the Accreditation Committee will review the yearly reports submitted by the director of the fellowship program. Re-accreditation of the program will be based on the committee’s findings during the review. Programs that do not meet the requirements described in this document will either be accredited with citation or placed on probation. A letter detailing the committee’s reasons for assigning probation status to a program will be sent to the program director. A similar letter will be sent to directors of programs accredited with citations. Program directors may submit a written appeal of the assigned status within 30 days. A subcommittee of the accreditation committee will consider the appeal and, if its findings warrant, recommend revoking the probation status. Otherwise, the program director must address the problems cited in the letter specifically and present an acceptable plan for correction within 180 days of receipt of the letter. For programs given accreditation with citations, submission of such a plan is not required; however, failure to correct the cited deficiencies by the time of a subsequent review may result in probation.

On receipt of an acceptable plan for correction of a program placed on probation, the accreditation committee will notify fellows currently in the program of its probationary status and will be given a copy of the program’s correction plan. At the same time, the program will be identified in all registries as being on probation. If, at the next review, the committee finds that a program is still deficient, approval for the program will be withdrawn and the program will be deleted from all registries.

IV. PROPOSED ACTIVITIES OF THE CONSTITUENT SOCIETIES IN RELATION TO THE FELLOWSHIP COUNCIL

The member societies will nominate members to the Accreditation Committee and encourage participation of fellows at their annual meetings.

A. Accreditation of Fellowships

The constituent societies will nominate members to the Accreditation Committee, whose purpose will be to review all applications for accreditation of fellowship programs, make recommendation of approval of fellowship programs to the board, and monitor evolution of the fellowship programs in general. The intent is to establish a process similar to that currently carried out by the RRC for general surgery.

B. Annual Meeting of Program Directors and Fellows

The Fellowship Council will sponsor an annual meeting of program directors of member programs. The purpose of this meeting will be to provide a forum for discussing program issues, recommending ways of promoting high-quality fellowship education, reviewing the matching process, advising the Accreditation Committee on grievance and approval issues, recommending creation of special programs or projects for advancing surgical, and supplying members with program advice. The societies will be encouraged to offer fellows the opportunity to meet during their annual scientific meetings and to actively solicit research and clinical papers by fellows.

C. Fellowship Registry

The Membership Committee will act as a registry and clearinghouse for fellowship programs and prospective fellows. Efforts will be made to assist in the recruitment and placement of candidates for fellowship. Such efforts will include placing advertisements in appropriate journals, sponsoring program director and resident events at national meetings, and informing society members of fellowship opportunities by mail. A directory of approved fellowship programs will be maintained by the Fellowship Council. This directory will be made available on request to eligible applicants or residency program directors, and each society will provide a link to the directory on its Web site. For each fellowship program, the directory will include the name of the program, program director, program coordinator, and primary institution; the focus and duration of the fellowship; and the salary range, when appropriate. The Fellowship Council will also maintain an updated and confidential file on each approved program that includes the original application form; a statement regarding the program’s approval status; letters of grievance; letters of recommendation; site visit reports; list of past fellows; list of past fellows’ research activities and publications, past fellows’ case logs; and documentation of the operative experience of the previous year’s fellows. A confidential record of noncompliance or problems will also be maintained by the membership committee. A copy of individual files, including a summary of grievances filed, will be made available to the fellowship program director on request.

D. Fellowship Matching Program.

The Communications Committee will work with the National Resident Matching Program (NRMP) to establish a fair and equitable matching program similar to that used jointly by the AAMC, the ACGME, and the ABMS.

APPENDIX A -- ETHICAL GUIDELINES FOR INDUSTRY SUPPORT OF POSTGRADUATE FELLOWSHIP PROGRAMS

The medical device and pharmaceutical industries have long played an important role in the training of surgeons. Through contributions of time, money, facilities and products these companies have enabled and encouraged the rapid growth of postgraduate training programs in the disciplines represented by the Fellowship Council. This in turn has contributed to the availability and quality of MIS and GI specialty surgery to the public. The Fellowship Council (FC) recognizes these substantial contributions and the role that Industry plays in the promulgation of fellowship programs. One of the primary tasks of the FC is to ensure the quality of fellowship training programs in order to assure applicants and the public that accredited programs meet a high standard of excellence in training. This accreditation process is a serious and critical one and must be performed in the most stringently ethical manner to maintain the trust and respect of all parties involved. Guidelines for ethical behavior have been developed by both Industry (1) and Physicians (2) and the Fellowship Council has referenced these to create the following code of conduct to ensure proper ethical behavior between Industry, the FC and member FC programs:

Fellowship Council

The FC recognizes the critical role that Industry plays in the support (financial and otherwise) of postgraduate training programs and wishes to keep interested Industry supporters fully informed of processes and developments in Fellowship programs. It is part of the mission of the FC to accredit programs and to represent the specialty societies represented by the FC to the governing bodies of surgery. As such, it is necessary that the FC holds itself to the highest ethical standards and avoids any conflicts of interest, perceived or actual. The following guidelines are therefore presented to ensure a good working relationship between Industry and the FC while avoiding the appearance of impropriety:

• Requests or acceptance of Industry contributions require a majority vote of the FC Board of Governors and should only be accepted if there is absoluteagreement that there is no potential conflict of interest.
• Individual members of the FC shall not solicit contributions from Industry on behalf of the FC.
• Industry contributions should be accepted only if they benefit the general membership or the constituency of the FC.
• Industry supported events should be oriented towards education, research or annual meetings for the membership.
• Industry supported events and projects must be clearly labeled as such.
• An Industry representative may be invited to present a report to the Board of Governors or FC committees but shall have no vote and should not attend non-related portions of the meetings.

Member Programs

The Fellowship Council recognizes that many fellowship programs belonging to the FC receive financial or other support from Industry. The benefits of this support are widely recognized and appreciated and it is acknowledged that this support has contributed greatly to the dissemination of advanced MIS and GI surgery and that many programs would not or could not exist without such support. The Fellowship Council believes that such arrangements can exist with no conflict of interest, but there may be situations where conflict of interest might cause harm to the program involved, its constituents and the public. Member programs belonging to the FC should, therefore, adhere to the following guidelines in order to avoid the appearance of non-ethical behaviors.

• Industry support of a FC program shall not be contingent on or tied to purchasing agreements between the sponsoring institution and the sponsoring company.
• Industry sponsors may be directly involved in fellow education (e.g., supporting a fellow to attend an industry sponsored course), but such exposure should be minimized and occur only under the supervision of faculty members.
• Fellow education curricula and research efforts should be designed and administered by the fellowship program director
• Industry sponsorship and involvement in the program must be fully disclosed to fellows, both existing and applicants.
• Efforts should be made to expose fellows to a broad spectrum of available devices and drugs beyond that of any sponsoring company.
• Research sponsored by Industry should not be subject to revision or other influence by the Industry sponsor which might compromise its scientific validity

Industry

Industry has valuable and relevant offerings in research and training that can legitimately be made available to the FC and its member programs. Many industry potential supporters of FC or member program efforts are already voluntarily following strict guidelines regarding their interactions and support of healthcare professionals (3). Specific to the FC the following guidelines should be followed.

• Proposals for support from Industry to the FC should be made in writing to the President of the FC.
• For any Industry seeking to support the FC and its activities who is not already voluntarily participating with AdvaMed or one of the other established guidelines groups, then the AdvaMed guidelines will be used to aid the FC in its deliberations regarding the appropriateness of such support.

1. Code of Medical Ethics. Council on ethical and judicial affairs: American Medical Association. AMA Press, Chicago. 2004.

2. Code of Ethics on Interactions with Health Care Providers. Advanced Medical Technology Association (AdvaMed). Internet publication. www.advamed.org. 2003.

Appendix B: Application for Accreditation