Journal of Surgical Oncology 2008;98:1–2

GUEST EDITORIAL

Board Certification in Surgical Oncology: Does it Make Sense?

RAPHAEL E. POLLOCK, MD*Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, Texas

The issue of board certification status for the specialty of surgical

oncology has remained a source of controversy for more than 25 years.

This is partly because it has been difficult to define a sufficiently broad

and deep corpus of knowledge that distinguishes the subspecialty of

surgical oncology from the parent specialty of general surgery. The

reality is that community-based general surgeons will typically

devote at least 25–30% of their efforts engaged in cancer patient

care. Another concern has been a genuine desire to avoid the type of

destructive internecine warfare that occurred with the creation of board

certification in vascular surgery. And so long as there were adequate

numbers of general surgeons to care for the population at large, the

pressure to create specialty certification in surgical oncology was

moderate, and seemingly ran at odds with the putative interests of our

parent general surgery specialty.

However, I would like to respectfully suggest that the times are

certainly changing, and in light of some recent developments, not all

good, we must respond by proactively changing ourselves or run the

risk of being forced to react in a manner that may be counter to our

perceived interests as well as those of the solid tumor patients whom

we seek to serve.

What are the underlying developments that support establishing

board certification mechanisms in surgical oncology? First is the

reality that a distinct and extensive corpus of knowledge has developed

that describes the natural history of solid tumors from their molecular

inception on through their behaviors as macroscopic malignancies

capable of metastasis. Based on the acquisition of this specialized

knowledge, surgical oncologists are uniquely equipped to integrate

non-surgical therapies into the neoadjuvant as well as post-surgical

contexts of primary tumor management. By virtue of their training,

surgical oncologists are particularly adept at orchestrating con-

temporary multidisciplinary care of recurrent malignancy and also

exert control over situations where uncommon operations, (e.g.,

hemipelvectomy, hepatic trisementectomy, etc.) are indicated. Mature

attributes such as these unequivocally distinguish surgical oncology as

a distinct surgical discipline based on, but separate from, general

surgery. And in the 80 hr work week era, it is clear that this specialized

surgical oncology knowledge and experience clearly exceeds the

training content of most, if not all, general surgery residencies in the

United States.

A second factor underlying the need for board certification in

surgical oncology can be found in the confluence of several profound

forces: the aging of our population coupled with anticipated manpower

shortages in the ranks of general surgeons from which the surgical

oncologists emerge. The overall number of general surgeons in the

U.S. has been stagnant for the past 30 years, during which our

residency programs have trained approximately 1,000 new general

surgeons annually. Unfortunately, this stably sized community of

general surgeons is confronted by a population in which the number of

Americans aged 65 or greater (the largest single purveyor of general

surgical services) will double over the next 10 years. And during this

same time frame, cancer will replace cardiovascular disease as the

number one killer in our population. Compounding these demo-

graphics, the rate of general surgical growth is also less in absolute

terms than that of our referring non-surgical specialties. In addition, for

some candidates the appeal of a general surgery career is negatively

affected by the length of training vis-a-vis education debt load

(frequently in excess of $250,000 by the end of medical school),

unfavorable and deteriorating reimbursement schedules, the increased

costs of remaining compliant with ever changing medical documenta-

tion requirements, unrelenting exposure to liability claims and the cost

of liability insurance, and the lack of control over time allocated to

work versus time allocated to family [1].

If nothing is done in response to these forces, within a decade we

may be confronting a crisis precipitated by a relatively if not absolute

smaller number of surgeons capable of offering contemporary

oncology care to a rapidly expanding solid tumor patient population.

The availability of board certification in surgical oncology would be a

concrete step towards enhancing the appeal of our specialty as a career

outlet for residents in general surgery who now struggle in this ‘‘perfect

storm’’ of demographic and professional challenges.

There is a third major factor that may facilitate the emergence

of board certification in surgical oncology. Important discussions

about prospective changes in residency training are engaging depart-

ments of surgery that have residency programs, the American Board

of Surgery (ABS), the American College of Surgery, and other relevant

stakeholders. To address concerns about the time length of relevant

surgical training, appropriate use of clinical material, challenges to

continuity of surgical care in the 80 hr work week mileau, etc., a model

in which trainees would undergo 2–3 years of basic surgery training,

followed by fellowship training of 4–6 years in a surgical subspecialty

(i.e., rural surgery, transplantation surgery, surgical oncology, etc.) is

receiving attention. Certification would be in the fellowship training

specialty under the aegis of the ABS.

In anticipation of these possible changes, now is the time to

consider how this might be accomplished. The ABS, a leading driver of

improvement in surgical training, established the Surgical Oncology

Advisory Council (SOAC) more than a decade ago to provide

assistance and advice. SOAC has recently been asked to make

recommendations to the ABS regarding certification in surgical

*Correspondence to: Dr. Raphael E. Pollock, MD, Department of SurgicalOncology, UT MD Anderson Cancer Center, 1515 Holcombe Blvd., Box444, Houston, TX 77030. Fax: 713-792-0722.E-mail: rpollock@mdanderson.org

Received 2 January 2008; Accepted 4 January 2008

DOI 10.1002/jso.20991

Published online in Wiley InterScience(www.interscience.wiley.com).

� 2008 Wiley-Liss, Inc.

oncology, which is now perceived by the ABS as meriting serious

consideration in light of the issues discussed above. For this to happen,

there are many procedural and political hurdles that must be overcome;

a certification process will need to be crafted that is consonant with

these possible changes in residency and fellowship training platforms,

yet avoids antagonizing our colleagues in the general surgery

community.

Currently, for a board certification mechanism to be recognized by

the American Board of Medical Specialties (ABMS), the educational

programs in which candidates are trained must be accredited by

the American Council of Graduate Medical Education (ACGME).

ACGME accreditation is based on a multifactorial process where one

of the key criteria is that the constituent training programs do not make

direct or indirect use of clinical revenues generated by trainees to

cover trainee salaries. A survey of Society of Surgical Oncology

(SSO)-accredited surgical oncology fellowship programs conducted in

2007 revealed that approximately one-third depended on trainee-

generated revenues as part of their compensation structure such that

adhering to ACGME requirements would create significant difficulties.

As an alternative, the American College of Surgeons, working in

conjunction with the SSO, may be willing and able to serve as an

accrediting agency for surgical oncology fellowships in a manner

acceptable to the ABS and the ABMS, a possibility that is currently

being explored.

Assuming that these preliminary accreditation processes can be

successfully negotiated, a next step will be the creation of the

certification process per se. One can anticipate that the current SSO

accreditation of fellowships would be replaced by a process potentially

under the direction of the American College of Surgeons, with

further standardization of surgical oncology training curricula as

a necessary and logical by-product. The ABS clearly has the

track record of psychometric testing experience needed to design,

administer, and maintain certification examinations. It remains to be

determined whether such an examination would have a written and oral

component, and what would be the structure and content of the

maintenance of certification and re-certification processes, especially

given the reality of emerging sub-specialization within surgical

oncology (e.g., breast, hepatobiliary, colorectal, etc.). To avoid

problems that occurred with the creation of the American Board of

Vascular Surgery, it will be imperative to allow a period of time,

perhaps a decade, in which any surgeon holding active certification

from the ABS will be allowed to sit for a certifying examination in

surgical oncology, even without formal surgical oncology fellowship

training. Note that this is different than ‘‘grandfathering’’ in which a

practitioner is awarded certification solely on the basis of having

performed a specified number of specialty procedures. The principle of

awarding certification to any general surgeon who can pass the

examination will hopefully go a long way towards assuaging concerns

of the general surgery community. Handled carefully, deliberately, and

with sensitivity it is quite possible that board certification in surgical

oncology can become a reality sometime over the next interval,

hopefully to the benefit of the solid tumor patients whom we all seek to

serve with the highest level of expertise.

REFERENCE

1. Fisher, JE. The impending disappearance of the general surgeon.JAMA 2007;298:2191–2193.

Journal of Surgical Oncology

2 Pollock