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The MIMIS Fellowship. Educating the Rural Surgeon. Paul Severson, MD, FACS Howard McCollister, MD, FACS Timothy LeMieur, MD, FACS Shawn Roberts, MD. Disclosures. Paul Severson, MD Stryker Endoscopy: International Advisory Council MIMIS Fellowship

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The MIMIS Fellowship


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    1. The MIMIS Fellowship Educating the Rural Surgeon Paul Severson, MD, FACS Howard McCollister, MD, FACS Timothy LeMieur, MD, FACS Shawn Roberts, MD

    2. Disclosures • Paul Severson, MD • Stryker Endoscopy: International Advisory Council • MIMIS Fellowship • Covidien: unrestricted educational grant to MIMIS • MIMIS Fellowship Faculty: • Paid consultants for rural hospitals • Surgical education - proctors

    3. Sunrise on Serpent LakeCrosby, Minnesota

    4. The MIMIS Fellowship • The first rural fellowship • The first fellowship in a “critical access” rural hospital • Cuyuna Regional Medical Center, Crosby, Minnesota • The first fellowship to be triple accredited in the United States and Canada • MIS + Bariatric + Flexible Endosurgery

    5. The MIMIS Fellowship • The first rural fellowship • The first fellowship in a “critical access” rural hospital • Cuyuna Regional Medical Center, Crosby, Minnesota • The first fellowship to be triple accredited in the United States and Canada • MIS + Bariatric + Flexible Endosurgery

    6. The MIMIS Fellowship • The first rural fellowship • The first fellowship in a “critical access” rural hospital • Cuyuna Regional Medical Center, Crosby, Minnesota • The first fellowship to be triple accredited in the United States and Canada • MIS + Bariatric + Flexible Endosurgery

    7. Background – Surgical Education • MIMIS – Minnesota Institute for Minimally Invasive Surgery • Created by our rural surgical group in 2002 to reflect our mission • History of educating regional surgeons in advanced laparoscopy and endoscopy since 1995 • Laparoscopic Burch bladder neck suspension (urinary incontinence in women) • Laparoscopic Nissen fundoplication • Endoscopy training (FP Residents, surgeons in private practice) • Additional courses offered after forming MIMIS • Bariatric mini-fellowships • Trivex faculty for varicose vein surgery • Stapled hemorrhoidopexy regional training center

    8. Background – Surgical Education • MIMIS – Minnesota Institute for Minimally Invasive Surgery • Created by our rural surgical group in 2002 to reflect our mission • History of educating regional surgeons in advanced laparoscopy and endoscopy since 1995 • Laparoscopic Burch bladder neck suspension (urinary incontinence in women) • Laparoscopic Nissen fundoplication • Endoscopy training (FP Residents, surgeons in private practice) • Additional courses offered after forming MIMIS • Bariatric mini-fellowships • Trivex faculty for varicose vein surgery • Stapled hemorrhoidopexy regional training center

    9. Background – Surgical Education • MIMIS – Minnesota Institute for Minimally Invasive Surgery • Created by our rural surgical group in 2002 to reflect our mission • History of educating regional surgeons in advanced laparoscopy and endoscopy since 1995 • Laparoscopic Burch bladder neck suspension (urinary incontinence in women) • Laparoscopic Nissen fundoplication • Endoscopy training (FP Residents, surgeons in private practice) • Additional courses offered after forming MIMIS • Bariatric mini-fellowships • Trivex faculty for varicose vein surgery • Stapled hemorrhoidopexy regional training center

    10. Background – Surgical Education • Regional Surgical Leadership • Upper Midwest Bariatric Forum (Severson, McCollister) • Founded by MIMIS in cooperation with UM and Mayo • Hitchcock Surgical Society Presidents (Severson, LeMieur) • Minnesota Surgical Society leadership (Severson, McCollister, LeMieur) • Minnesota Trauma Task Force (Severson, LeMieur, Roberts) • National leadership opportunities emerge • SAGES Program Committee – rural liaison (Severson) • Fellowship Council Program Directors (Severson) • Global education efforts are recognized • Severson and McCollister develop courses in Laparoscopy and Endoscopy for surgeons in Pignon, Haiti – 13 years and running • ACS Executive Director Dr. Tom Russell visits Pignon, awards granted • Severson appointed to Global Health Education Committee at UM • Incorporation of global health into medical school curriculum

    11. Background – Surgical Education • Regional Surgical Leadership • Upper Midwest Bariatric Forum (Severson, McCollister) • Founded by MIMIS in cooperation with UM and Mayo • Hitchcock Surgical Society Presidents (Severson, LeMieur) • Minnesota Surgical Society leadership (Severson, McCollister, LeMieur) • Minnesota Trauma Task Force (Severson, LeMieur, Roberts) • National leadership opportunities emerge • SAGES Program Committee – rural liaison (Severson) • Fellowship Council Program Directors (Severson) • Global education efforts are recognized • Severson and McCollister develop courses in Laparoscopy and Endoscopy for surgeons in Pignon, Haiti – 13 years and running • ACS Executive Director Dr. Tom Russell visits Pignon, awards granted • Severson appointed to Global Health Education Committee at UM • Incorporation of global health into medical school curriculum

    12. Background – Surgical Education • Regional Surgical Leadership • Upper Midwest Bariatric Forum (Severson, McCollister) • Founded by MIMIS in cooperation with UM and Mayo • Hitchcock Surgical Society Presidents (Severson, LeMieur) • Minnesota Surgical Society leadership (Severson, McCollister, LeMieur) • Minnesota Trauma Task Force (Severson, LeMieur, Roberts) • National leadership opportunities emerge • SAGES Program Committee – rural liaison (Severson) • Fellowship Council Program Directors (Severson) • Global education efforts are recognized • Severson and McCollister develop courses in Laparoscopy and Endoscopy for surgeons in Pignon, Haiti – 13 years and running • ACS Executive Director Dr. Tom Russell visits Pignon, awards granted • Severson appointed to Global Health Education Committee at UM • Incorporation of global health into medical school curriculum

    13. Dr. Paul Severson proctors Haiti’s surgery professors

    14. The Ride Across Haiti 2008

    15. Dr. Howard McCollister teaches laparoscopy to Haitian surgeons

    16. Dr. Howard McCollister

    17. Dr. Tim LeMieur MIMIS faculty

    18. Dr. Shawn RobertsOur first fellowMIMIS faculty

    19. Educating the Rural Surgeon So why develop a fellowship?

    20. The Problem with Surgical Education • Many residency programs poorly prepare graduates • Endoscopy • Gastroenterology control • Limited exposure to therapeutic “endosurgery” • Lack of commitment to endoscopy despite directives • Advanced laparoscopy • Failure to develop “the laparoscopic mentality” • Faculty still learning – residents don’t get enough experience • Bariatric surgery • Failure to recognize obesity as America’s #1 health problem • Surgery is currently the only and most effective treatment • Failure to accept bariatric surgery as “mainstream” general surgery

    21. The Problem with Surgical Education • Many residency programs poorly prepare graduates • Endoscopy • Gastroenterology control • Limited exposure to therapeutic “endosurgery” • Lack of commitment to endoscopy despite directives • Advanced laparoscopy • Failure to develop “the laparoscopic mentality” • Faculty still learning – residents don’t get enough experience • Bariatric surgery • Failure to recognize obesity as America’s #1 health problem • Surgery is currently the only and most effective treatment • Failure to accept bariatric surgery as “mainstream” general surgery

    22. The Problem with Surgical Education • Many residency programs poorly prepare graduates • Endoscopy • Gastroenterology control • Limited exposure to therapeutic “endosurgery” • Lack of commitment to endoscopy despite directives • Advanced laparoscopy • Failure to develop “the laparoscopic mentality” • Faculty still learning – residents don’t get enough experience • Bariatric surgery • Failure to recognize obesity as America’s #1 health problem • Surgery is currently the only and most effective treatment • Failure to accept bariatric surgery as “mainstream” general surgery

    23. The Problem with Surgical Education • Many residency programs poorly prepare graduates • Endoscopy • Gastroenterology control • Limited exposure to therapeutic “endosurgery” • Lack of commitment to endoscopy despite directives • Advanced laparoscopy • Failure to develop “the laparoscopic mentality” • Faculty still learning – residents don’t get enough experience • Bariatric surgery • Failure to recognize obesity as America’s #1 health problem • Surgery is currently the only and most effective treatment • Failure to accept bariatric surgery as “mainstream” general surgery

    24. The Problem with Surgical Education • Rural surgeons need to be broadly trained • Endoscopy – therapeutic dilations, polypectomy, bleeds, ablations • Advanced laparoscopy – lap Nissen, colon, hernia • Gynecology – lap hysterectomy, lap ectopic pg, C-sections • Orthopedics – fractures and hand • ENT – tubes and tonsils • General Surgery residencies are not providing adequate training to prepare the surgeon for rural America • Fellowships are needed until residencies do the job • Even then, additional education is needed due to narrow training focus both in residency AND in fellowships • Cooperstown surgery residency training is a model for success (JACS 2003, Reynolds)

    25. The Problem with Surgical Education • Rural surgeons need to be broadly trained • Endoscopy – therapeutic dilations, polypectomy, bleeds, ablations • Advanced laparoscopy – lap Nissen, colon, hernia • Gynecology – lap hysterectomy, lap ectopic pg, C-sections • Orthopedics – fractures and hand • ENT – tubes and tonsils • General Surgery residencies are not providing adequate training to prepare the surgeon for rural America • Fellowships are needed until residencies do the job • Even then, additional education is needed due to narrow training focus both in residency AND in fellowships • Cooperstown surgery residency training is a model for success (JACS 2003, Reynolds)

    26. The Problem with Surgical Education • Rural surgeons need to be broadly trained • Endoscopy – therapeutic dilations, polypectomy, bleeds, ablations • Advanced laparoscopy – lap Nissen, colon, hernia • Gynecology – lap hysterectomy, lap ectopic pg, C-sections • Orthopedics – fractures and hand • ENT – tubes and tonsils • General Surgery residencies are not providing adequate training to prepare the surgeon for rural America • Fellowships are needed until residencies do the job • Even then, additional education is needed due to narrow training focus both in residency AND in fellowships • Cooperstown surgery residency training is a model for success (JACS 2003, Reynolds)

    27. The Problem with Surgical Education • Urban surgeons have limited themselves to very few procedures • Primarily gallbladder and hernia - maybe breast, maybe trauma • No colo-rectal • No endoscopy • There is an ever increasing divergence between the urban and rural surgical repertoire • We need to educate rural surgeons to expand their capabilities • Revenue from procedures lost to regional centers is needed to keep our rural hospitals healthy (43% of rural hospital revenue is surgical) • Educating the practicing rural surgeon in advanced laparoscopy and endoscopy is almost impossible without proctoring relationships

    28. The Problem with Surgical Education • Urban surgeons have limited themselves to very few procedures • Primarily gallbladder and hernia - maybe breast, maybe trauma • No colo-rectal • No endoscopy • There is an ever increasing divergence between the urban and rural surgical repertoire • We need to educate rural surgeons to expand their capabilities • Revenue from procedures lost to regional centers is needed to keep our rural hospitals healthy (43% of rural hospital revenue is surgical) • Educating the practicing rural surgeon in advanced laparoscopy and endoscopy is almost impossible without proctoring relationships

    29. The Problem with Surgical Education • Urban surgeons have limited themselves to very few procedures • Primarily gallbladder and hernia - maybe breast, maybe trauma • No colo-rectal • No endoscopy • There is an ever increasing divergence between the urban and rural surgical repertoire • We need to educate rural surgeons to expand their capabilities • Revenue from procedures lost to regional centers is needed to keep our rural hospitals healthy (43% of rural hospital revenue is surgical) • Educating the practicing rural surgeon in advanced laparoscopy and endoscopy is almost impossible without proctoring relationships

    30. The Problem with Surgical Education • Current educational models are inadequate • Weekend courses, major meetings • Cadaver labs, inanimate labs, “hands-on” training • Invitations to observe at tertiary centers • Patient safety and proper credentialing are not possible without numerous cases monitored by an experienced proctor • MIMIS surgeons provide long-term consulting relationships with rural hospitals to solve their problems • Advanced laparoscopy • Endoscopy • Surgical education for all the physicians • Administrative support, systems based protocols, credentialing

    31. The Problem with Surgical Education • Current educational models are inadequate • Weekend courses, major meetings • Cadaver labs, inanimate labs, “hands-on” training • Invitations to observe at tertiary centers • Patient safety and proper credentialing are not possible without numerous cases monitored by an experienced proctor • MIMIS surgeons provide long-term consulting relationships with rural hospitals to solve their problems • Advanced laparoscopy • Endoscopy • Surgical education for all the physicians • Administrative support, systems based protocols, credentialing

    32. The Problem with Surgical Education • Current educational models are inadequate • Weekend courses, major meetings • Cadaver labs, inanimate labs, “hands-on” training • Invitations to observe at tertiary centers • Patient safety and proper credentialing are not possible without numerous cases monitored by an experienced proctor • MIMIS surgeons provide long-term consulting relationships with rural hospitals to solve their problems • Advanced laparoscopy • Endoscopy • Surgical education for all the physicians • Administrative support, systems based protocols, credentialing

    33. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in MIS, Bariatric, and Flexible Endosurgery in December, 2007 • The first program to achieve triple accreditation in the US and Canada

    34. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in MIS, Bariatric, and Flexible Endosurgery in December, 2007 • The first program to achieve triple accreditation in the US and Canada

    35. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in MIS, Bariatric, and Flexible Endosurgery in December, 2007 • The first program to achieve triple accreditation in the US and Canada

    36. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in MIS, Bariatric, and Flexible Endosurgery in December, 2007 • The first program to achieve triple accreditation in the US and Canada

    37. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in MIS, Bariatric, and Flexible Endosurgery in December, 2007 • The first program to achieve triple accreditation in the US and Canada

    38. The MIMIS Fellowship • We were encouraged by the Fellowship Council to join in the effort to educate at the fellowship level (Dr. Dan Smith - 2001) • 3 years to develop MIMIS, investigate fellowships, and prepare • Hired Dr. Shawn Roberts as new partner and “test” fellow, 2004 • Applied to Fellowship Council for MIS fellowship in 2005 • Entered the match in 2006 as a new program “pending accreditation” • Granted full 3 year accreditation in December, 2007 in MIS, Bariatric, and Flexible Endosurgery • The first program to achieve triple accreditation in the US and Canada

    39. Fellowship Councilwww.fellowshipcouncil.orgHistory • 2001: “MIS Fellowship Council” established • “to advance high quality surgical education in MIS, GI, HPB, and bariatric surgery” • 2003: SSAT, SAGES, AHPBA join together to organize fellowships for GI, MIS, and HPB surgery • Non-ACGME accredited fellowships • First match (NRMP) held for 60 programs, 90 applicants • 2005: ASBS joins to support bariatric surgery fellowships • Name changes to “Fellowship Council” • 2008: Fellowship Council holds its own match • 130 programs, 217 applicants(165 US, 15 Canada, 37 Foreign)

    40. Fellowship Councilwww.fellowshipcouncil.org • The Fellowship Council has accredited 107 fellowships: • Minimally Invasive Surgery (26) • Bariatric (12), and MIS/Bariatric (51) • Flexible Endoscopy (3), and MIS/Flex Endo (3) • Hepato-Pancreato-Biliary (7) • MIS/Colorectal (4) and • MIS/Bariatric/Flexible Endosurgery (1)* *The MIMIS Fellowship

    41. Fellowship Councilwww.fellowshipcouncil.org • Notable programs that did not match • Penn State • University of Miami • Brigham and Women’s (0 of 2) • Cleveland Clinic (research fellow) • University of Iowa • Fresno Bariatrics • Columbia/Cornell (1 of 2) • New York Hospital Queens • SUNY Brooklyn • University of Illinois Chicago • So how does a private practice program in a critical access hospital in rural Minnesota match excellent candidates year after year after year?

    42. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    43. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    44. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    45. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    46. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    47. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse

    48. The MIMIS FellowshipSurvey of fellows – Why MIMIS? • More cases in a lot less time (864 total - 535 Endo, 329 OR) • Large endoscopic experience, preparation for NOS • GI Lab – expertise in pH and manometry, PillCam • Opportunity to join faculty in teaching MIS surgery in Haiti • Respect for the fellow as a surgeon, autonomy • Excellent quality of life in the rural setting • Favorable call schedule • No research abuse