MIS Fellowship: Clinical Activities

The major emphasis of clinical training is close mentorship by attending faculty in caring for surgical patients with problems requiring an MIS approach. Over the course of the year, the fellow establishes a relationship with each of the attendings that will allow a graduated level of responsibility in caring for patients at all levels including outpatient evaluation, inpatient care and surgical technical skills.

The goal of the clinical aspect of the fellowship is to develop a high level of competence in advanced laparoscopic techniques spanning a wide variety of diseases and, thereby, develop the trainee’s confidence in his or her abilities to manage similar complex cases after completion of the fellowship. Fellows are expected ultimately to demonstrate their abilities to independently evaluate and manage foregut disorders, morbid obesity, abdominal hernias, and endocrine and solid organ disorders using minimally invasive techniques.

Schedule

On each day, the fellow is responsible for rounding on all patients on whom he or she has operated. The fellow’s daily operative and outpatient clinic responsibilities are based on a fixed rotation of attending coverage.



Monday

Surgery with Dr. Eagon at Barnes -Jewish West County Hospital (BJWCH)

Tuesday a.m.

Tuesday p.m.

Surgery w/ Dr. Eagon at BJWCH

Dr. Eagon clinic at Center for Advanced Medicine, Barnes-Jewish Hospital (BJH)

Wednesday

Laparoscopic surgery with Dr. Brunt at BJH

Thursday

Surgery at BJH and BJWCH

Friday a.m.

Friday p.m.

Research

Dr. Brunt clinic at Center for Advanced Medicine, BJH

This schedule is consistent throughout the year except that the fellow spends two weeks in the last quarter of the academic year rotating on the colorectal service at Barnes-Jewish Hospital and Barnes-Jewish West County Hospital. During this period, the fellow works exclusively with one of the Washington University colorectal faculty members on laparoscopic colectomy procedures. During this period, it is anticipated that the fellow will perform approximately 12 laparoscopic colectomies.

Case Volume and Mix

The case volume and mix of cases vary slightly from month to month and year to year on the basis of the attending surgeons’ practice patterns. However, an estimate can be obtained from the activities of the first two fellows. Ramon Rivera, M.D. (2003-04), completed 225 operations during his fellowship, of which 95 percent were laparoscopic and 72 percent were advanced laparoscopic cases. Forty-nine percent of cases were laparoscopic gastric bypass procedures. Projecting forward from midway through his fellowship to estimates of final numbers at the end of the year, Abdelrahman A. Nimeri, M.D. (2004-2005), will have completed 219 operations.

Interactions with Attendings

A strength of the fellowship is the opportunity to work with a number of different attendings on a regular basis. This fosters greater understanding of the variety of acceptable techniques in minimally invasive surgery. In addition, the attending staff selects difficult advanced laparoscopic cases to perform with the fellow and maintains a close level of supervision during these difficult cases.

Fellows are employed as instructors in surgery and generally are board eligible. As such, they have a higher standing than chief residents and are treated in the collegial manner afforded to junior attendings. In theory, they can manage patients independently. On occasion at Barnes-Jewish West County Hospital, they may be called upon to manage simple cases independently; however, this is rare. The emphasis is on mentoring the fellow in complex cases in which the presence of the attending is required to complete the operation.

Interactions with Surgical Residents

Surgical residents do not rotate at Barnes-Jewish West County Hospital, but at Barnes-Jewish Hospital the fellow and the surgical residents interact. The fellow rounds on the patients on whom he or she operates. The fellow and the R1 and R3 also communicate with each other directly on a daily basis to discuss any particular concerns regarding the patient’s surgical procedures or perioperative course. Concerning decision-making about patients, the responsibilities of the fellow and the chief resident do not overlap. Outside of this schedule, if the resident team cannot meet coverage of either laparoscopic or open cases, the chief resident will contact the fellow to ask whether he or she can cover such cases.

Teaching interactions between the fellow and residents are encouraged. On Wednesdays and Thursdays, the R1 or R3 are encouraged to scrub alongside the fellow on cases at the appropriate level. For example, the R3 could scrub for a laparoscopic cholecystectomy or straightforward lap Nissen and have the fellow assist him or her with the case with the attending providing supervision.