around 2012 and implemented in the residents’ portfolio.30 In this version of the OSATS, the GRS is combined with an Overall Performance Scale (OPS) and Alphabetic Summary Scale (ASS). An example is found in Appendix A of this thesis. In laparoscopic training next to the OSATS the Global Operative Assessment of Laparoscopic Skills (GOALS) is used in the Netherlands. Both OSATS and GOALS are generic assessment, they do not focus on specific surgical tasks or procedures. The validity of these GRS in grading or granting privileges is uncertain, as is their role in fellowship training.31 With curricula based on EPAs it is important to support entrustment with well-grounded, valid, assessments. Lifelong Learning After successful completion of general surgical training, the trainee is certified as a surgeon. However, training does not stop there. It is an ongoing process throughout the whole surgical career. Some surgical procedures are, due to their complexity or relatively low prevalence, part of an additional fellowship training program, often less formally described than the resident programs. Moreover, as new operative techniques will emerge throughout any surgical career, the ability to update skills and innovate techniques is an essential part of lifelong learning. METABOLIC BARIATRIC SURGERY TRAINING When new techniques or procedures are added to the surgical armamentarium, history shows that firstly the surgeons, and next the trainees adapt this new technique. After the introduction of laparoscopic surgery in the Netherlands, for example, minimally invasive surgery fellowships -as the LIMIS program-, were introduced to teach this novelty to attending surgeons.32 Nowadays, these laparoscopic techniques are adopted by residents from the first days of training practice. Residency programs include laparoscopic training courses such as the Fundamentals of Laparoscopic Surgery (FLS) program in the United States and specific courses in the Dutch curriculum.20,33 In 2015 Mostaedi et al. published an evaluation of the procedures in the Faculty Practice Solution Center (FPCS) database of the University Health System Consortium and Association of American Medical Colleges.34 In the most performed procedures in general surgical practice in 2006-2011 the laparoscopic RYGB (LRYGB) consistently ranked top 10, representing 18.2 - 24.6% of all cases. A more recent review of Jog et al. shows MBS fellows in the US performed 14 1
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