2015 Application for Certificate of Acknowledgement of Satisfactory Training in Bariatric Surgery Application Deadline: August 1, 2015 A. Basic Information Applicant Name Address Telephone Email Fellowship Program Academic Year Institution Name Program Director Address Telephone Email Date of Last Accreditation by Fellowship Council Duration of Accreditation from Fellowship Council B. Clinical & Technical Experience Required Minimum Number Total Number of Clinical Fellows in the Program *Quarterly M & M, including quality improvement & peri-operative management conferences Patient Preoperative Evaluations Postoperative in-patient management encounters Postoperative out-patient evaluations Support Group Meetings attended Patient Educational Seminar Intestinal bypass operations (Roux-en-Y Gastric Bypass or Biliopancreatic Diversion +/- Duodenal Switch Restrictive Cases Performed (Sleeve Gastrectomy and/or Adjustable Gastric Banding procedures) Total Number of Bariatric Cases as Primary Surgeon Revisional Procedures Total Number of Bariatric Surgeries Applicant’s Reported Numbers 4 per year 50 100 100 1 1 50 10 51 5 100 Page | 1 of 2 C. Research and Publications Abstract title submitted during Fellowship (one title is required) Society Submitted Date Completed Clinical and/or Research Manuscript or Research Project Poster title completed during Fellowship (one title is required) Society Submitted Date Completed D. Cognitive and Didactic Requirements It is mandatory that the Fellow attend at least one session of each of the following topics with at least one mentor. Opportunities for didactic interactions include specially designated bariatric textbook review sessions, journal clubs, peer-review conferences, and resident teaching rounds. 1. Epidemiology of Obesity 2. History of Bariatric Surgery 3. Physiology and Interactive Mechanisms in Morbid Obesity 4. Preoperative Evaluation of the Bariatric Patient 5. Psychology of the Morbidly Obese Patient 6. Essentials of a Bariatric Program 7. Postoperative Management of the Bariatric Patient 8. Laparoscopic versus Open 9. Laparoscopic Adjustable Banding 10. Other Restrictive Operations 11. Gastric Bypass 12. Biliopancreatic Diversion/Duodenal Switch 13. Revisional Weight Loss Surgery 14. Managing Postoperative Complications 15. Nutritional Deficiencies 16. Obesity in Childhood and Adolescence 17. Outcomes of Bariatric Surgery 18. Role of Endoscopy in Bariatric Surgery E. Other Required Documents 1. 2. 3. 4. Applicant’s Curriculum Vitae Summary of Fellowship Council Case Logs Patient Evaluation Case Logs Educational Curriculum of the Fellowship Program Signature of the Program Director Date By signing this form, the Program Director verifies that the Fellow has completed all necessary Fellowship Council requirements, including the Core Curriculum for ASMBS Fellowship Training. Please submit the completed application form and all accompanying documentation electronically, in a single PDF document, by August 1, 2015, to [email protected]. Applicants will receive an electronic confirmation within 48 hours of submission. If you do not receive this email confirmation, please call the ASMBS office at 352-331-4900. Page | 2 of 2
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