Endocrine Surgery’s Status as a Specialty

Gaining momentum, but more work to do

By Allan Siperstein, MD

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Just two decades ago, only a handful of surgeons practiced endocrine surgery exclusively. With the maturation of the field and a growing recognition that volume and specialization are linked to better outcomes, endocrine surgery has evolved into a very specialized area — so specialized, in fact, that the American Association of Endocrine Surgeons (AAES) launched a formal fellowship program approximately nine years ago.

Prior to AAES establishing its program, some centers such as Cleveland Clinic offered ad hoc, apprentice-type fellowships. However, the AAES program — which is open to board-certified/-eligible members of the American Board of Surgery (or equivalent in other countries) — includes a one-year, intensive  curriculum with goals and objectives, matching, and more recently, a formal accreditation process for endocrine surgery fellowship programs.

Official status

The start of AAES’ fellowship program marked endocrine surgery’s official status as one of the newest boarded surgical specialties in the country. Yet our center has conducted studies that have found there is still an underrecognition of endocrine surgery as a discreet specialty. In addition, we found that only half of large academic medical centers have fellowship-trained endocrine surgeons on staff. And if you ask physician recruiters if they recruit endocrine surgery specialists, they tend to ask — not infrequently — “What’s that?”

What this tells us is that our work is just beginning when it comes to creating widespread recognition of endocrine surgery — both within the medical community and in the public — as an important and distinct specialty area.

Endocrine surgery needs ‘brand recognition’

Complicating the issue of awareness is the fact that endocrine surgery is performed not only by endocrine surgeons and general surgeons, but also by some otolaryngologists. However, the only group performing endocrine surgery as a dedicated practice (other than those who specialized prior to the AAES fellowship program) is the new generation coming out of fellowship.

While other specialties such as bariatric and vascular surgery also have evolved as an outgrowth of general surgery, they seem to be more widely recognized. As endocrine surgery as a burgeoning specialty edges its way out of infancy and into adolescence, there’s a clear opportunity for increased marketing and education about the value of advanced training and certification of surgeons who treat diseases of the thyroid, parathyroid and adrenal glands, as well as neuroendocrine tumors of the pancreas and GI tract.

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Essentially, endocrine surgery as a specialty needs what marketers refer to as “brand recognition.” To do that, it’s important to identify where gaps exist so that we can address them. At the AAES’ 2015 Annual Meeting, my AAES fellow Vikram D. Krishnamurthy, MD, presented our department’s recent analysis of the endocrine surgery workforce over the past six decades.3 The “Mapping Endocrine Surgery: Modern Workforce Analysis,” which is scheduled for publication as a full paper in the January 2016 issue of Surgery, revealed some helpful insights and opportunities relevant to the goal of greater awareness.

‘Mapping Endocrine Surgery’: New insights

Our innovative study pulled data from the 2012 Medicare provider database to identify high-volume endocrine surgery providers (defined as > 50 endocrine operations per year), with an evaluation of trends over time. We focused on 14 CPT codes for thyroid and parathyroid surgery.

Some of the key findings included:

  • There were 395 high-volume surgeons in 47 states who performed an estimated 48,745 thyroid and parathyroid operations in 2012.

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  • The majority of recent high-volume surgeons were general surgeons, non-fellowship-trained, and not AAES members.

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  • Despite a perceived saturation of high-volume surgeons for thyroidectomy and parathyroidectomy in certain states and regions, when compared to the populations they serve, there was still demand for more surgeons across the country.

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Based on the analysis, we identified some opportunities and areas for additional development:

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  • The map showing the distribution of high-volume providers provides insights into where there’s an opportunity for the growth of endocrine surgery specialists, as well as geographic targets for fellows looking for jobs. Despite the fact that the AAES fellowship program is producing 25 specialized surgeons per year, there’s still a tremendous opportunity out there, especially in the Western United States.
  • There’s an excellent opportunity available to engage the 65 percent of non-AAES members who are high-volume surgeons to join the AAES — especially in the Southeast, western Midwest, Pacific Northwest, Southwest and West. This would allow more cohesive representation as a specialty. As members, they would benefit from interaction with colleagues, as well as perks such as the Find a Member Directory on the AAES website that can be accessed by patients and referring physicians.
  • This data can be shared with hospital leadership and physician recruiters, along with information about the expertise and background of AAES-trained surgeons, to increase awareness and market demand.

Our center’s experience with the AAES program

At Cleveland Clinic, we have a long history of recognizing the importance of endocrine surgery specialization. We developed the country’s first graduate medical education-sponsored endocrine surgery fellowship, which birthed the concept of AAES’ formal fellowship program. When AAES launched its curriculum, our program was moved under AAES’ auspices as a formal fellowship. For the first seven years of AAES’ fellowships, I oversaw development and ran matches.

In a set-up that’s unique to Cleveland Clinic, our surgical and medical endocrine fellows are co-located (instead of the surgeons being embedded in the general surgery or surgical oncology departments) to set the stage for a multidisciplinary approach to care.

Cleveland Clinic has trained more AAES fellows than anyplace else in the country — an even 20 so far, with two trained per year due to our high volume of endocrine surgeries. We recognize the value of the expertise that these fellowship-trained surgeons bring to their roles — within our Endocrine Surgery Department, and at centers across the country. Due to the expertise of our surgeons and our focus on practicing endocrine surgery exclusively, we handle a large volume of referral cases, including complex and reoperative surgeries.

It’s clear that advanced training and an exclusive focus on endocrine surgery make a difference. Now we need to spread the word about endocrine surgery as a recognized specialty — together.

Dr. Siperstein is Chair of Endocrine Surgery at Cleveland Clinic. He also serves as Program Director for the General Surgery Residency Program and the Endocrine Surgery Fellowship. For more information contact Dr. Siperstein at sipersa@ccf.org or 216.444.5664.