The Scientific Societies and the Lack of Skills: A Training Programme in Bariatric Surgery

As surgeons, the medical-legal aspects of our profession do not seem to be a priority in our daily practice; however, lawsuits for negligence are becoming more and more frequent, as discussed at the 29th National Surgery Congress, titled “Medical-legal aspects of bariatric surgery”, with the participation of two experienced attorneys. There is also a need for scientific societies to get involved in activities that provide adequate training for their members in order to reduce the adverse effects secondary to medical or surgical treatments.¹

A judge may not only assess whether a physician has committed a felony or misdemeanor, or whether he/she used the necessary means, but a judge may also find a doctor responsible for an observed “loss of opportunity”. This is a new judicial concept that is understood as any delay in diagnosis or in surgery that deprives the patient of a medical action which, if not applied within a certain timeframe, causes damage or injury.²

The World Medical Association recommends an appropriate training policy for physicians with insufficient knowledge, including the limitation of professional practice until the situation is corrected.¹ In Spain, scientific societies cannot limit a physician's professional practice, but they can develop training programs for their members.

To design a training program, the first step should be to determine the knowledge, skills and abilities necessary to treat a pathological process or perform certain surgical procedures. In the case of bariatric surgery (BS), it is well known that there is a long learning curve (>100 cases) during which morbimortality is higher and even inadmissible in some cases.^3–6 Morbidly obese patients are very complex and usually have severe comorbidities that can compromise their recovery in the post-operative period, requiring a multidisciplinary team in order to optimize the results of the BS.⁷ In addition, laparoscopic BS techniques (especially mixed or malabsorptive techniques) require intracorporeal suturing, with the added difficulty of the excessive thickness of the abdominal wall, hepatomegaly and the large volume of intraabdominal fat.

International laparoscopic BS scientific societies (IFSO, ASBS) have reiterated their concern about maintaining quality and safety standards in bariatric surgery. They have published safety rules for the procedures that specify standards for organization (intensive care units, special hospital beds and operating tables, blood banks, etc.) as well as the training and experience of surgeons, and quality standards of the process.^8,9 Furthermore, it has been demonstrated that adequate training can avoid the poor results associated with the learning curve.^10–13

In our country, the Spanish Association of Surgeons (SOS) and its Morbid Obesity Section, along with the Spanish Society of Surgery for Obesity and Metabolic Disorders (SECO) have collaborated to elaborate a BS Training Program, which establishes the requirements that a surgeon must meet to obtain the program diploma. The program began in 2009 and is made up of 5 phases that include theoretical knowledge, practical work and tutored professional experience. The theoretical part took place at the virtual campus of the SOS with the course “Basics of bariatric and metabolic surgery”. The course content deals with subjects related to obesity, associated comorbidities, multidisciplinary teams, optimization of morbidly obese treatment, technical options than can be applied (including advantages and disadvantages), the management of post-operative complications and long-term follow-up with the prevention of any possible side-effects, as well as an introduction to metabolic surgery. More than 100 healthcare professionals, including a large number of surgeons, all dedicated to the multidisciplinary treatment of obese patients, have voluntarily collaborated in preparing the subject contents and videos. The 3 editions of the course organized between 2009 and 2012 have received a high number of Continued Training credits (19–27 credits) and have been well received by the members of the SOS, with more than 600 students enrolled.

As for practical training and skill acquisition, SECO has created another 4 phases. Phase II, developed by 110 surgeons, is the most expensive as it includes surgery courses in pig models in which students perform laparoscopic gastric bypass.¹⁴ Phase III consists of a course in which several interventions are perfomed and commented on by experts; more than 400 surgeons have assisted these courses in various geographical areas in the last 3 years. Phase IV is a minimum stay of 2 months at a teaching center in which a series of requirements should be met. During this “rotation”, participants should assist in at least 12 BS procedures, participate in hospitalized patient care and patient office visits. Phase v requires the assignation of a tutor,¹⁵ the preparation of a treatment protocol for morbid obesity and the completion of 40 interventions as main surgeon.

SECO and the Obesity Section of the SOS have also established minimal requirements so that active bariatric surgeons may also apply for certification. These requirements include having perfomed more than 100 BS procedures, a minimum of 5 years’ experience in this field, regularly performing at least 20 annual interventions and having actively participated in courses and congresses.

In the year 2012, the period began for active surgeons to apply for certification declaring their competency in BS, and to date 52 diplomas have been awarded. The diploma enables bariatric surgeons to demonstrate, to whomever necessary, that they have received adequate training as determined by the SECO and SOS. This opens the way for scientific societies to contribute towards improving the quality and safety of the bariatric surgeries performed in our country.