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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 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 • Covidien: unrestricted educational grant to MIMIS • MIMIS Fellowship Faculty: • Paid consultants for rural hospitals • Surgical education - proctors
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
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
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
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
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
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
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
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
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
Dr. Howard McCollister teaches laparoscopy to Haitian surgeons
Dr. Tim LeMieur MIMIS faculty
Educating the Rural Surgeon So why develop a fellowship?
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
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
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
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
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)
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)
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)
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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?
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
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
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
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
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
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
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