August 2013 | Volume 98 Number 8 | American College of Surgeons Bulletin Contents

August 2013 | Volume 98 NUmber 8 | american college of surgeons Bulletin Contents

Features Cover stories: ACS Resident and Associate Society: Diving into the evolving demands of resident training 11 Hold the onions: Training in an era of heightened diversity and expectations 12 Brian J. Santin, MD

The role of politics in shaping surgical training 17 Jennifer Baker, MD; Subhasis Misra, MD, MS, FACCWS; Neil J. Manimala, MD; SreyRam Kuy, MD, MHS; and Gerald Gantt, MD

Improved communication techniques enable residents to provide better care now and in the future 26 by Raphael C. Sun, MD; Afif Kulaylat, MD; Scott B. Grant, MD; and Juliet Emamaullee, MD

International surgery provides opportunities for residents to serve and learn 33 | 1 Shannon L. Castle, MD; Nicolas J. Mouawad, MD, MPH; Konstantinos Spaniolas, MD; and Daniela Molena, MD

Early surgical subspecialization: A new paradigm? Part I 38 Scott B. Grant, MD; Jennifer L. Dixon, MD; Nina E. Glass, MD; and Joseph V. Sakran, MD, MPH

Early surgical subspecialization: A new paradigm? Part II: Interviews with leaders in surgical education 43 Afif N. Kulaylat, MD; Feibi Zheng, MD;S reyRam Kuy, MD, MHS; and James G. Bittner IV, MD

Centennial reprint: Course coordinator describes purposes of ATLS® program 50

Bulletin of the American College of Surgeons online edition • All of the content in the print version • Easily read on mobile devices as well as on desktop computers • Links to “related posts” • Share content across multiple Bulletinonline social media platforms including Facebook, Twitter, and LinkedIn http://bulletin.facs.org.

AUG 2013 Bulletin American College of Surgeons Contents continued

Columns A look at The Joint Commission: NAPBC announces milestone: Preventing surgical fires 65 Accreditation of 500 breast centers 78 Looking forward 8 NTDB® data points: Geronimo 67 Procedure-Specific Consents David B. Hoyt, MD, FACS Richard J. Fantus, MD, FACS available online 78 What surgeons should know Report on ACSPA/ACS activities: about...Using S-CAHPS 53 News June 2013 80 Jill Sage, MPH Susan E. Mackinnon, MD, FACS, Lena M. Napolitano, MD, Coding and practice management FRCSC, receives 2013 Jacobson FACS, FCCP, FCCM corner: Coding for damage-control Innovation Award 69 Chapter news 90 surgery 57 CoC general session focuses on Donna Tieberg Linda M. Barney, MD, FACS; Jenny updates, lessons learned in care J. Jackson, MPH, CPC; Charles D. for cancer patients 72 Scholarships Mabry, MD, FACS; Mark T. Savarise, Plan to attend these RAS-ACS Eighteen surgeons participate in MD, FACS; and Christopher K. events during 2013 Clinical Senkowski, MD, FACS 2013 Health Policy Scholarship Congress 76 program 97 ACS Clinical Research Program: College seeks Medical Director for ACS offers two-year Resident Improving cancer care through Washington, DC, Office 77 Research Scholarships 99 quality measures: Putting evidence 2 | MOC Review: Essentials for to work with the CoC 62 Surgical Specialties to be offered Meetings Calendar Christopher M. Pezzi, MD, FACS; at Clinical Congress 77 Henry M. Kuerer, MD, PhD, FACS; Calendar of events 100 and Heidi Nelson, MD, FACS

A publiCATioN of AmE riCAN CollE g E of SurgE o NS p rofESSioNAl ASSo C i ATioN (ACSp A)

Influencing ThE ACS Health Policy in Washington ADvoCATE and the States Each month, rely on the ACS advocacy eNewsletter: To keep you informed. To learn the College’s position on pertinent issues. To see how your involvement can make a difference.

Downloadable from most digital communications devices. Also available online at www.facs.org/ahp/news/index.html.

Advocacy Summit • AMA House of Delegates/Surgical Caucus • Cancer • Chapter Advocacy • Training • Coding • Electronic Health Records • e-Prescribing • Grassroots Efforts • Health Information Technology • Legislative Action Center • Legislative Advocacy • Liability • Lobby Day Grant Program • Medicaid • Medicare • Medicare Physician Payment • Pediatric Issues • Physician Quality Reporting • Political Action Committee (SurgeonsPAC) • Quality and Patient Safety • Relative Value Update Committee (RUC) • Socioeconomics • Surgery State Legislative Action Center (SSLAC) • Surgical Quality Alliance • Trauma and EMS • Workforce

ADVOCATE ad half page Bulletin shorter.indd 1 1/14/2013 11:24:28 AM V98 No 8 Bulletin American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

Editor-in-CHIEF Letters to the Editor ! #$%^&* Diane Schneidman should be sent @ with the writer’s Director, Division of name, address, Integrated Communications e-mail address, and E-mail isn’t for everyone. Lynn Kahn daytime telephone Sdenior E itor number via e-mail to Tony Peregrin dschneidman@facs. org, or via mail to Co ntributing Editors Diane S. Schneidman, But it is for Fellows of the American Jeannie Glickson Editor-in-Chief, Katie McCauley Bulletin, American College of Surgeons who want to College of Surgeons, Graphic Designer 633 N. Saint Clair St., keep current on the latest news Tina Woelke Chicago, IL 60611. from their professional society. Editorial Advisors Letters may be edited Charles D. Mabry, MD, FACS for length or clarity. Leigh A. Neumayer, MD, FACS Permission to publish Marshall Z. Schwartz, MD, FACS letters is assumed If we don’t have your current e-mail Mark C. Weissler, MD, FACS unless the author address, you’re really missing out. Front cover design indicates otherwise. Tina Woelke We have a lot to share, so let us connect with you. Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, You can add or update your e-mail at 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical www.efacs.org. Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Go to the home page, click on My Profile, Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. and follow the prompts. The American College of Surgeons’ headquarters is located at Questions? Contact Member Services at [email protected]. 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800-621-4111; e-mail:[email protected]; website: www.facs.org. Washington, DC, office is located at 20 F If you would like to make sure all e-mail from the Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. College is promptly sent to your current e-mail 202‑337-2701; website: www.tmiva.net/20fstreetcc/home. Unless specifically stated otherwise, the opinions expressed account(s), and to ensure that we can reach you for and statements made in this publication reflect the authors’ years to come, go to http://efacs.org. Registration personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. for this service is quick, easy, and free. ©2013 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

We need your e-mail half-page 06--06-13.indd 1 6/6/2013 3:00:03 PM Officers and Staff of the American College of Surgeons

Gerald M. Fried, MD, Alliance/American FACS, FRCSC College of Surgeons Officers Montreal, QC Advisory Council Clinical Research *A. Brent Eastman, MD, to the Board Program *Barrett G. Haik, MD, FACS Heidi Nelson, MD, FACS FACS, FRCS (Ed) (Hon) Memphis, TN San Diego, CA of Regents Chair President B.J. Hancock, MD, FACS, FRCSC (Past-Presidents) Convention and Meetings R. Phillip Burns, MD, FACS Winnipeg, MB Felix Niespodziewanski Chattanooga, TN Enrique Hernandez, MD, FACS Kathryn D. Anderson, MD, FACS Director First Vice-President Philadelphia, PA Corona, CA Division of Education John M. Daly, MD, FACS Lenworth M. Jacobs, Jr., MD, FACS W. Gerald Austen, MD, FACS Ajit K. Sachdeva, MD, Philadelphia, PA Hartford, CT Boston, MA FACS, FRCSC Second Vice-President L. Scott Levin, MD, FACS John M. Beal, MD, FACS Director Courtney M. Townsend, Jr., MD, FACS Philadelphia, PA Valdosta, GA Executive Services Galveston, TX L. D. Britt, MD, FACS Barbara L. Dean Secretary *Mark A. Malangoni, MD, FACS Philadelphia, PA Norfolk, VA Director Andrew L. Warshaw, MD, FACS Finance and Facilities Boston, MA Raymond F. Morgan, MD, FACS John L. Cameron, MD, FACS Charlottesville, VA Baltimore, MD Gay L. Vincent, CPA Treasurer Director David B. Hoyt, MD, FACS *Leigh A. Neumayer, MD, FACS Edward M. Copeland III, MD, FACS Salt Lake City, UT Gainesville, FL Human Resources and Chicago, IL Talent management Executive Director Valerie W. Rusch, MD, FACS Gerald B. Healy, MD, FACS Michelle McGovern Gay L. Vincent, CPA New York, NY Boston, MA Director Chicago, IL Marshall Z. Schwartz, MD, FACS R. Scott Jones, MD, FACS C hief Financial Officer Information Technology Philadelphia, PA Charlottesville, VA Howard Tanzman Howard Snyder III, MD, FACS Edward R. Laws, MD, FACS Director Philadelphia, PA Boston, MA 4 | Division of Integrated Officers-Elect Beth H. Sutton, MD, FACS LaSalle D. Leffall, Jr., MD, FACS Communications (take officeO ctober 2013) Wichita Falls, TX Washington, DC Lynn Kahn Steven D. Wexner, MD, FACS Lloyd D. MacLean, MD, FACS Director *Carlos A. Pellegrini, MD, Weston, FL Montreal, QC Journal of the American FACS, FRCS(I)(Hon) College of Surgeons Seattle, WA Michael J. Zinner, MD, FACS LaMar S. McGinnis, Jr., MD, FACS Atlanta, GA Timothy J. Eberlein, MD, FACS President-Elect Boston, MA Editor-in-Chief Layton F. Rikkers, MD, FACS David G. Murray, MD, FACS *Executive Committee Syracuse, NY Division of Member Services Madison, WI Patricia L. Turner, MD, FACS First Vice-President-Elect Patricia J. Numann, MD, FACS Director John T. Preskitt, MD, FACS Syracuse, NY Board of PERFORMANCE IMPROVEMENT Dallas, TX Richard R. Sabo, MD, FACS Will Chapleau, RN, EMT-P Second Vice- Bozeman, MT President-Elect Governors/ Director Executive Seymour I. Schwartz, MD, FACS Division of Research and Committee Rochester, NY Optimal Patient Care Frank C. Spencer, MD, FACS CliffordY . Ko, MD, MS, FACS Board of Regents Lena M. Napolitano, MD, FACS New York, NY Director *Julie A. Freischlag, MD, FACS Ann Arbor, MI Baltimore, MD Chair Cancer: Chair Gary L. Timmerman, MD, FACS Executive Staff David P. Winchester, MD, FACS *Mark C. Weissler, MD, FACS Sioux Falls, SD Medical Director Chapel Hill, NC Vice-Chair Executive Director Vice-Chair David B. Hoyt, MD, FACS William G. Cioffi, Jr., MD, FACS Trauma: *John L. D. Atkinson, MD, FACS Providence, RI Division of Advocacy John Fildes, MD, FACS Rochester, MN Secretary and Health Policy Medical Director Margaret M. Dunn, MD, FACS James C. Denneny III, MD, FACS Frank G. Opelka, MD, FACS Dayton, OH Knoxville, TN Associate Medical Director *A. Brent Eastman, MD, Lorrie A. Langdale, MD, FACS Christian Shalgian FACS, FRCS (Ed) (Hon) Seattle, WA Director San Diego, CA Fabrizio Michelassi, MD, FACS American College of James K. Elsey, MD, FACS New York, NY Surgeons Foundation Atlanta, GA Martin H. Wojcik Sherry M. Wren, MD, FACS Executive Director Henri R. Ford, MD, FACS Palo Alto, CA Los Angeles, CA

V98 No 8 Bulletin American College of Surgeons Author bios

a b c

d e | 5

f g h i

Dr. Baker (a) is a PGY-4 general surgery Dr. Castle (d) is a PGY-5 general Dr. Fantus (g) is director, trauma resident at the University of California, San surgery resident at the University of services, and chief, section of surgical critical Diego. She is a member of the Resident and California, San Diego. She is a member of care, Advocate Illinois Masonic Medical Associate Society of the American College of the RAS-ACS Membership Committee. Center, and clinical professor of surgery, Surgeons (RAS-ACS) Issues Committee. University of Illinois College of Medicine, Dr. Dixon (e) is a PGY-4 general surgery Chicago. He is Past-Chair of the ad hoc Dr. Barney (b) is associate professor and resident, Scott and White Memorial Trauma Registry Advisory Committee associate program director for general surgery, Hospital, Temple, TX. She is a member of of the ACS Committee on Trauma. department of surgery, Wright State University the RAS-ACS Education Committee. Boonshoft School of Medicine, and in practice at Dr. Gantt (h) is a research fellow in the Wright State Surgeons, Miami Valley Hospital, Dr. Emamaullee (f) is a PGY-4 general department of colorectal surgery, Cleveland Dayton, OH. She is the ACS advisor at the surgery resident, Emory University, Clinic Foundation, OH. He is a member American Medical Association (AMA) CPT Atlanta, GA. She is the Chair of the of the RAS-ACS Issues Committee. Editorial Panel and Vice-Chair, ACS General RAS-ACS Communications Committee, Surgery Coding and Reimbursement Committee. a member of the Women in Surgery Dr. Glass (i) is a PGY-5 general surgery Committee, and the RAS Liaison to resident, New York University Langone Dr. Bittner (c) is assistant professor the Surgical Research Committee. Medical Center, New York, NY. She is Chair of surgery and co-director, Virginia of the RAS-ACS Education Committee. Commonwealth University (VCU) Minimally Invasive Surgery Center, Richmond, and continued on next page director, bariatric surgery fellowship, VCU School of Medicine, Richmond. He is Past- Chair of the RAS-ACS Education Committee.

AUG 2013 Bulletin American College of Surgeons Author bios continued

j k l m

n o p 6 |

q r s t

Dr. Grant (j) is a PGY-4 general surgery Dr. Kuy (n) is a vascular surgery D r. Misra (q) is associate professor, division resident, Robert Wood Johnson Medical fellow, Medical College of Wisconsin, of surgical oncology, department of surgery, School, New Brunswick, NJ. He is a member Milwaukee. She is a member of the RAS- Texas Tech University Health Sciences Center, of the RAS-ACS Communications, Education, ACS Education and Issues Committees. Amarillo, TX. He is a member of the RAS- Issues, and Membership Committees. ACS Education and Issues Committees. Dr. Mabry (o) is associate professor of Ms. Jackson (k) is Practice Affairs surgery, University of Arkansas for Medical Dr. Molena (r) is assistant professor Associate, ACS Division of Advocacy Sciences, Little Rock. He is Chair of the of surgery, Johns Hopkins University, and Health Policy, Washington, DC. ACS Health Policy Advocacy Council, Baltimore, MD. She is a member of the a member of the ACS General Surgery RAS-ACS Membership Committee. D r. Kuerer (l) is professor of surgery Coding and Reimbursement Committee, and program director, breast surgical and an alternate ACS advisor to the AMA/ Dr. Mouawad (s) is a fellow, division oncology fellowship training program, Specialty Society Relative Value Scale of vascular diseases and surgery, Ohio University of Texas MD Anderson Cancer Update Committee (AMA RUC). State University Wexner Medical Center, Center, Houston, and Chair, ACS Clinical Columbus. He is Chair, RAS-ACS Membership Research Program Education Committee. M r. Manimala (p) is a medical student Committee, and RAS representative to the at the University of South Florida, Morsani ACS International Relations Committee. Dr. Kulaylat (m) is a PGY-2 general College of Medicine, Tampa. He is active surgery resident, Penn State Milton S. in the RAS-ACS Issues Committee. D r. Napolitano (t) is professor of surgery, Hershey Medical Center, Hershey, PA. He University of Michigan Medical School, is a member of the RAS-ACS Education Ann Arbor, and division chief, acute care and Communications Committees. surgery, University of Michigan Hospital. She is Chair of the ACS Board of Governors. continued on next page

V98 No 8 Bulletin American College of Surgeons Author bios continued

u v w x

y z aa | 7

bb cc dd ee

Dr. Nelson (u) is Fred C. Andersen Dr. Santin (y) is a vascular surgeon in Dr. Spaniolas (bb) is assistant Professor Surgery and Chair, division of private practice, Ohio Vein & Vascular, professor of surgery, division of advanced surgery research, Mayo Clinic, Rochester, Inc., Wilmington, OH. He is Chair of the laparoscopic, gastrointestinal, and MN, and Program Director of the Alliance/ RAS-ACS. endocrine surgery, East Carolina University, ACS Clinical Research Program. Greenville, NC. He is Co-Chair of the Dr. Savarise (z) is assistant clinical RAS-ACS Membership Committee. Dr. Pezzi (v) is associate program director, professor of surgery, University of Utah, Salt general surgery residency program, and Lake City. He serves on the General Surgery Dr. Sun (cc) is a PGY-4 general surgery director of surgical oncology, Abington Coding and Reimbursement Committee and resident, University of Iowa, Iowa City. He Memorial Hospital, Abington, PA, and the Advisory Councils for General Surgery is currently a pediatric surgery research Chair of the Quality Integration Committee and Rural Surgery, and is the ACS alternate fellow at Washington University, St. of the ACS Commission on Cancer. advisor at the AMA CPT Editorial Panel. Louis. He is a member of the RAS-ACS Communications Committee as the social Ms. Sage (w) is Senior Quality Dr. Senkowski (aa) is professor of media representative and Facebook editor. Associate, ACS Division of Advocacy surgery and surgical residency program and Health Policy, Washington, DC. director at Mercer University School of MS. Tieberg (dd) is Manager of Medicine, Savannah, GA. He serves as Chapter Services, ACS Division of Dr. Sakran (x) is assistant professor of the ACS advisor to the AMA RUC. Member Services, Chicago. surgery and director of global health and disaster preparedness, Medical University Dr. Zheng (ee) is a PGY-4 general of South Carolina, Charleston. He is surgery resident at The Methodist Secretary, RAS-ACS, and RAS Liaison to Hospital, Houston, TX. She is Co-Chair the Advisory Council for General Surgery. of the RAS-ACS Education Committee.

AUG 2013 Bulletin American College of Surgeons Executive Director’s report

Looking forward

by David B. Hoyt, MD, FACS

his month’s Centennial reprint from a past issue of the Bulletin, which appears on page 50, The pilot [ATLS] course Tcenters on the roots of one of the American was presented in Auburn, College of Surgeons’ (ACS) most successful educational programs—the Advanced Trauma Life Sup- NE, in 1978 at the request port® (ATLS®) course. Since the ACS began pre- of several physicians and senting the course more than 30 years ago, more than 1 million physicians in more than 60 nations nurses in nearby Lincoln. have trained in the lifesaving techniques presented This appeal came on the in this program. heels of an airplane crash in a rural Nebraska cornfield Modest beginnings in February 1976. ATLS has humble roots. The pilot course was presented in Auburn, NE, in 1978 at the request of several physicians and nurses in nearby Lincoln. This appeal came on the heels of an airplane crash in a rural Ne- braska cornfield in February 1976. Piloting the plane 8 | was J.K. Styner, MD, FACS, an orthopaedic surgeon. Dr. Styner sustained serious injuries, three of his children sustained critical injuries, and one child sustained minor injuries. His wife died on impact. Dr. Styner maintained that the care he and his family received was inadequate, stating, “When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed.”* Soon after the pilot course was presented in Auburn, Paul E. “Skip” Collicott, MD, FACS, Past-Director of the ACS Division of Member Services and a recipient of the College’s Distinguished Service Award, introduced the concept of the ATLS program to the ACS Commit- tee on Trauma (COT) at their 1979 annual meeting in Houston, TX. The COT enthusiastically endorsed the proposal and called upon its Region Chiefs to meet in Lincoln for an introduction to the course.† With that, in January 1980, the College initiated the promulgation of ATLS as an educational program to teach health care professionals about the initial care of injured patients. Later that year, the course was presented in Denver, CO; Dallas, TX; San Diego, CA; Washing-

*Fildes J. History of the ATLS® Program. Available at: http://www.facs. org/trauma/atls/history.html. Accessed June 28, 2013. †Collicott PE. ATLS® celebrates 25th anniversary. Bull Am Coll Surg. 2005;90(5)18-21.

V98 No 8 Bulletin American College of Surgeons Executive Director’s report

ton, DC; Philadelphia, PA; Newark, NJ; Opelika, AL; with other surgeons and physicians to develop three and Milwaukee, WI. The course spread to Canada in editions of the ATLS manual. “All viewpoints were al- 1981 and was introduced to the international commu- lowed and vetted until true agreement was reached. nity beginning with Latin America in 1986.† Such cooperation simply strengthens the ATLS content and truly makes it a common language for the care of the injured patient. Fellows’ perspectives “My other fond memory of ATLS is when we took As we reflect on the College’s litany of efforts to pro- the first course to Hong Kong and Beijing,” Dr. Wei- mote quality patient care, many Fellows would agree gelt added. “In Beijing we presented parts of the course that the ATLS course ranks high on that list with re- using a translator, which was challenging. It was ter- spect to success—both nationally and internationally. rific to watch our audience attempt to capture every I recently contacted several prominent trauma sur- word and concept that we presented. I am not sure I | 9 geons who have been involved in presenting and fos- have ever had as attentive an audience for our ATLS tering the ATLS course and asked them to share their principles.” experiences and insights. Here’s what they had to say: The international experience is one that resonates “Starting in 1974–1975 the COT took on a number particularly strongly with other ATLS leaders as well. of projects to improve trauma care and outcome in “As President, I’m finding in country after country trauma patients. The ones that were very successful ATLS is our most successful outreach program and included ATLS, verification, and theN ational Trauma has won us friends all over the world,” said ACS Presi- Data Bank®, to name a few,” said Donald Trunkey, MD, dent and Past-Chair of the COT A. Brent Eastman, MD, FACS, Past-Chair of the COT. “ATLS has been a clear FACS. He attributes some the course’s successful prom- winner. First, it allows surgeons to develop their own ulgation internationally to the efforts of former TA LS criteria, which is very important to get better outcomes. Committee Chair Brent Krantz, MD, FACS, whom Dr. In many centers, ATLS can salvage up to 30 percent of Eastman appointed. “Brent Krantz did a spectacular job major injuries where cardiac function has ceased. Clear- always with his strong rural background and sense of ly, Dr. Styner, who founded this resuscitation model humor,” he said. after he had a plane accident and his wife was killed “To further promote the program international- and the children very severely injured, deserves ku- ly, I was involved in a seminal meeting with Stephen dos, as does Skip Collicott for bringing it to the COT.” Deane [MB, BS, FACS] and Peter Danne [MB, BS, FACS, John A. Weigelt, MD, FACS, Past-Chair of the COT, FRACS] from Australia when I was Chair of the COT,” said, “I remember my first TA LS course vividly. Skip Dr. Eastman said. “The Royal Australasian College of Collicott and other Nebraska surgeons were present Surgeons wanted to adopt ATLS but felt there needed for the first instructor course in Dallas, TX. I was a se- to be some flexibility to make it relevant to their needs. nior resident and was impressed with the dedication The situation had reached a critical impasse. Howev- of the faculty and especially the educator, which was er, in an evening meeting in a lounge in San Antonio, John George [MD, FACS],” he said. TX, Drs. Deane, Danne, and I managed to work out “I have never seen a more dedicated group of doctors an agreement that moved things forward. This was an from around the world come to consensus on difficult important bit of international diplomacy, because the issues,” Dr. Weigelt said of his experience in working Royal Australasian College of Surgeons has gone on

AUG 2013 Bulletin American College of Surgeons Executive Director’s report

Now in its ninth edition, ATLS has become the gold standard in care for injured patients throughout the world.

to have one of the strongest ATLS—they call it Early Course Manual, released at the 2012 Clinical Congress, Management of Severe Trauma, EMST—programs in has a companion app. The mobile app is available for the world.” download at MyATLS.com and is being continually up- Also addressing ATLS’ effect on improving trauma dated for use in the field. care internationally, Past ATLS Committee Chair John The College couldn’t be more proud of the B. Kortbeek, MD, FACS, said, “I witnessed firsthand success that ATLS has experienced. As ACS Past- the difference TA LS made in my home province of President L. D. Britt, MD, MPH, DSc(Hon), FACS, Alberta, Canada. Referring centers as well as our in- FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), house trauma teams now provide standardized, safe, FRCSI(Hon), FCS(SA)(Hon), said, “There has been no high-quality care. The program has evolved from its program that has been as effective as TA LS in saving humble beginnings to a global partnership supported lives and decreasing the morbidity of injuries. It is one 10 | by experts across cultures and disciplines,” added Dr. of the greatest medical innovations—worldwide—in Kortbeek, who received the ATLS Meritorious Service the last 75 years!” Award in 2012 and is presently involved in international The College looks forward to building on this promulgation of the program. achievement as we move into the next 100 years.  “It’s hard to put into words what the opportunity to lead ATLS has meant to me,” said current ATLS Com- mittee Chair Karen Brasel, MD, FACS. “To see people who might agree on little else put aside personal and political differences to invest countless hours (and in many cases, their own money and other resources) to improve the program, and to bring trauma education to their own countries speaks to the value of the program and to what can be accomplished when the focus is truly on the patient and doing the right thing,” she noted. “The recent adoption of ATLS by countries in the Middle East, where there are both political and safety hurdles, is truly a triumph of the regional structure and international ATLS family in addition to the triumph of right over politics,” Dr. Brasel added.

A program for the next century Now in its ninth edition, ATLS has become the gold standard in care for injured patients throughout the world. To ensure that health care professionals have easier access to the latest information and techniques If you have comments or suggestions about this or other issues, please in trauma care, the newest edition of the ATLS Student send them to Dr. Hoyt at [email protected].

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

ACS Resident and Associate Society:

Diving into the evolving demands of resident training

| 11 RAS-ACS: Evolving demands of resident training

Hold the onions: Training in an era of heightened diversity and expectations

by Brian J. Santin, MD

12 | Highlights • Compares the recent dramatic changes in surgical practice and training to the increased diversity in culinary techniques now seen in restaurants throughout the U.S. • Provides an overview of the history of GME • Emphasizes transformations that have occurred in GME in the last 20 years, including the implementation of work-hour restrictions and a focus on the delivery of patient-centered, coordinated care • Notes surgeons’ concerns regarding how these changes will affect their role in the future delivery of health care

n a recent interview published in Delta Sky magazine, Anthony Bourdain, author, chef, and host of the Trav- Iel Channel’s No Reservations, explained how the U.S. culinary scene has experienced a multitude of changes throughout the past 60 years—essentially a culinary explo- sion.1 He recalled the complete absence of sushi or most other “non-American” foods in the Manhattan, NY, restaurants of his childhood; it was “ham with a pineapple ring” back then.1 This is in stark contrast to the now commonplace appearance of sashimi, Vietnamese noodle bowls, tableside guacamole, or any other so-called non-American dishes on menus across the country. In not so many words,

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

As the American College of Surgeons celebrates its Centennial year, now is an appropriate time to reflect on just how much has changed with regard to medical education and surgical practice over the past 100 years—and how much it continues to evolve.

the food culture in America has likely adapted and in- confines of their training institution, barely able to see corporated more variety in the past few decades than sunlight through panes of glass—almost an eerie re- in all of human history combined. semblance to penitentiary life. The mantra of “see one, Mr. Bourdain described how this culinary revo- do one, teach one” was commonplace in the surgical lution has resulted in a much more inclusive, world- training environment for decades. ly, and extensive array of tantalizing treats to spread Resident work hours are monitored more closely across our palates. A few Sundays ago, as I was reading than ever; not only are trainees not to work more than the interview and enjoying the most amazing French 80 hours per week, but first-year residents are banned macaroons made fresh just two blocks away from my from spending more than 16 hours straight in a hospi- home, I thought of how the changes in medical educa- tal. Case logs are carefully entered into complex online tion and patient-centered care have exploded in recent databases with the capabilities to constantly update years as well. Current Procedural Terminology codes. Expensive, high-tech computer simulators are now used as substitutes for live patients when interns perform their | 13 History of medical education first case. Many of the changes in academic medicine date back In the late 1840s, when a cholera epidemic was to 1910, when Abraham Flexner conducted an observa- sweeping through the U.K., the scholars and physi- tional study and later published a report on the state of cians of the time believed that the transmission of the medical education in the U.S. and Canada. Mr. Flexner nearly always fatal disease was via a respiratory route. essentially described the state of affairs to be equiva- Fortunately, a surgeon named John Snow, MD, who lent to a Wild West show featuring a man with a mon- later became recognized as the father of modern epi- key head trying to ride a unicycle while juggling flam- demiology, wrote the landmark book On the Mode of ing bowling pins. Many medical schools were termed Communication of Cholera. In his book, Dr. Snow argued “diploma mills.”2 There was a complete lack of infra- against the accepted dogma of a respiratory transmis- structure and no standards for schools to follow to en- sible route for one favoring the gastrointestinal tract.3 sure medical trainees were being adequately taught. Despite widespread opposition to his theory and public Not since Flexner’s landmark findings more than 100 dismissal of it, Dr. Snow persevered, and eventually, years ago have such dramatic changes in medical edu- history proved his logic to be correct. It is with time cation and training in this country occurred than as in and increased breadth of knowledge that the medical the past 20 or so years. profession has gained a far better appreciation for the As the American College of Surgeons (ACS) cele- work of Dr. Snow and countless other physicians and brates its Centennial year, now is an appropriate time surgeons who faced similar difficulties in going against to reflect on just how much has changed with regard the norm, attempting to see a problem from a different to medical education and surgical practice over the perspective, or simply doing things differently. past 100 years—and how much it continues to evolve. Take for example, graduate medical education (GME) and even more specifically surgical education. Embracing change Within just the past 20 years, the entire landscape of Why are so many people resistant to change? I am the GME has changed. Surgical folklore recounts stories product of the work-hour restriction era in GME. My of case logs being inscribed on rolls of toilet paper and internship year, albeit seven years ago, was the first residents spending an entire week straight within the in which residents were mandated to work no more

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

To date, there remains a paucity of data to actually support the fact that work-hour changes have a clinical benefit. Yet some would argue that there has been a positive effect, if none other than to make the choice of pursuing surgery more appealing to residents—men and women alike.

than an average of 80 hours in a single week. Since This example of human nature adapting under the then, countless articles, editorials, surveys, and opin- auspice of awareness has been observed in multiple ion pieces have been published by everyone from the venues since the 1950s. Should we as physicians and youngest of medical students to the eldest of surgeons, surgeons expect anything different from the general all surrounding this radical change in the way physi- public’s increasing observation of our professional re- cians are taught in this country. Some of these individu- sults? HealthGrades.com, UCompareHealthCare.com, and als have been quite critical of these changes. Herbert Vitals.com are three of the most prominent websites Fred, MD, in an editorial from 2007, criticized work- that rate patient satisfaction. (For more information hour restrictions, claiming that “we are exchanging about these sites, see the upcoming article in the Sep- sleep-deprived healers for a cadre of wide-awake techni- tember issue of the Bulletin.) The claim that these sites cians.”4 He wasn’t alone in expressing this sentiment.5-7 provide “outcomes” remains to be justified, as they are Are these commentators really just concerned about technically opinions and not verified outcomes mea- change or have they created an environment similar to sured against a standardized set of benchmarks. Our 14 | the one Dr. Snow encountered? To date, there remains very own patients are taking the time to complete sur- a paucity of data to actually support the fact that work- veys online about how well we did: Was the physician’s hour changes have a clinical benefit.Y et some individu- bedside manner poor, good, or great? How was the als would argue that there has been a positive effect, if promptness of scheduling an appointment? These are none other than to make the choice of pursuing surgery just some of the criteria and measures upon which we more appealing to residents—men and women alike.8 I are being compared; whether we choose to participate hope surgical educators 100 years from now don’t look in these measures or not, the public will continue to back at the past 20 years in medical education and think report on their experiences. we were similarly irresponsible for not more readily embracing the changes in the training paradigm. Role of public perception Should patient feedback affect our pay and delivery The Hawthorne Effect of care? I suspect that the Hawthorne Effect may not In 1950, Henry Landsberger was analyzing previous hold true in this realm as the equation for quality care studies conducted outside of Chicago, IL, at the Haw- is far more complex than public observation. How- thorne Works factory when he coined a now familiar ever, physicians’ attempts to solve the equation must term: the Hawthorne Effect.9 In the original series of still place appropriate emphasis on this confounding studies dating back to the 1920s, workers in a factory variable. The role of public perception on physicians were observed to see whether the installation of new and hospitals has gained increasing ground. A 2010 light bulbs in the warehouse affected their productiv- article in the Journal of the American College of Surgeons ity. Productivity did increase during the study peri- is among the accumulating evidence that popular me- od; however, upon completion of the study, when the dia and Internet-based quality ratings are increasingly workers were no longer being observed, productiv- important to patients.10 ity slowed to its pre-study pace even with the brighter The simplistic or propagandistic model of online bulbs. Thus, Mr. Landsberger hypothesized that the reporting, outcomes, and survey-driven websites are workers were becoming more productive simply be- forms of democracy at play within the natural con- cause they were being watched, not because of the light text and scope of society, termed social media. The amplitude overhead. antagonistic or, arguably, the theoretical model con-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: EvolvingHea lthdem caandres reofform resident training

tends that these sites are attempting to change the hi- organizations be the ones handling the issue or should erarchal model of the medical profession.11 Is it really the issue be permitted to perseverate on the Internet? just the profession of medicine getting in line behind Could self-regulation really turn this issue around? the celebrities, book authors, amazon.com sellers, and The old adage “Trust me. I’m a Doctor” seems almost pretty much anyone or anything else that has come antiquated in today’s environment. In fact, Chantler under the scrutiny of the public on the Internet? Ev- and Ashton have suggested “a need to redefine medi- eryone has the right to voice their opinion, and, to con- cal professionalism given the changing roles of physi- tinue the culinary metaphor mentioned earlier, “hold cians and the increasing expectations of the public, the onions” in the current state of affairs in the online and this in turn will have an effect on regulation.”12 kitchen. But is the medical profession held to a different standard inherent in a heightened sense of ethical and moral concerns in caring for a human being’s life? The automaton theory Herein lies a great discrepancy between medicinal care The increasing role of the health care consumer and thumbs up/down from a food critic. raises the question of how the medical profession | 15 Medical decision making is built upon a founda- is truly being run. Matthew Wynia, MD, MPH, a tion of evidence-based literature and scientific conclu- physician working for the Institute of Ethics of the sions, not on an opinion regarding whether or not a Le American Medical Association, addressed the very Plat Principal was too fishy tasting. David O’Connor, real possibility that medicine is being transformed PhD, a scholar in bioethics at Johns Hopkins University, into a more commercial system. “Professionalism Baltimore, MD, wrote, “In this online environment is a distinct ideology from consumerism, in which personal experience (that of the patient) is sometimes regulation of medical practice would be based primar- valued more highly (more authentic and less mediated ily on expectations established by medical ‘consum- by professional stricture) than the expertise of the phy- ers’ and implemented through competitive market- sician.”11 Fueling the fire is the finding that many of place mechanisms,” noted Dr. Wynia in 2010.13 The these patient satisfaction websites are without an over- results of various consumer-driven programs to rate seeing, editorial review process—allowing defaming and grade surgeons may be tied to the likelihood of comments to be posted and mar a physician’s record whether a surgical practice will thrive or not. Jain and without any objective evidence to support the claim. Cassel argue that physicians are becoming “automa- But why do patients run to these websites to vent their tons” whose actions are defined by external forces frustrations regarding a physician’s poor bedside manner and public opinion.14 Is that why we have all traveled and not report their concerns to a representative/authori- this long, and, at times, self-depriving road—just to tative medical body? Do patients have a sense of futility become an automaton? when they do complain to a state medical board or Public policy is increasingly supportive of the au- surgical society and feel that their voice isn’t being tomaton theory. “Rather than being counted on to heard? Is this an area in which the ACS could play maintain their knowledge and expertise on their own a proactive role? Could the ACS develop a national accord, they [physicians] are subject to periodic exam- marketing campaign to increase the awareness of the inations to demonstrate continued proficiency.”14 Are importance of the physician-patient relationship or increased regulations for credentialing and recertify- offer an official “postprandial” satisfaction survey? ing really just a way to replace the self-motivation of If consumers are disenfranchised with a surgeon, surgeons to pursue continuing education and lifelong should the surgeon’s peers, colleagues, and trusted learning opportunities?

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The increasing role of the health care consumer raises the question of how the medical profession is truly being run.

While I may be at an early stage in my career, I References know that I will continue to seek knowledge to help 1. Zimmerman A. Guts, glory, and growing up. Interview with care for my patients and remain at the forefront of de- Anthony Bourdain. Delta Sky Magazine. April 2013. Available livery of quality patient care. I don’t simply owe this to at: http://deltaskymag.delta.com/Sky-Extras/Favorites/ GutsGlory—Growing-Up.aspx. Accessed June 11, 2013. my patients, but I have an internal drive to continue to 2. Rohack JJ. 100 years after Flexner, AMA is still a force in med honing my skills. Even without the increased require- ed. Am Med News. February, 8 2010. Available at: http://www. ments for recertification and continuing medical edu- amednews.com/article/20100201/opinion/302019957/5/. cation documentation, I am responsible to myself and Accessed June 3, 2013. my patients to maintain and improve my proficiency. 3. Markel H. Happy Birthday, Dr. Snow. JAMA. 2013;309(10):995-996. Other surgeons who I have encountered in my train- 4. Fred H. These are the days: The internship revisited. Tex ing have been tough on me at times, but, like so many Heart Inst J. 2007;34(1):3-5. other surgeons, no one is ever tougher on me than I am 5. Wexner S. Resistance to change in medicine: Dogma persists on myself. If this mind-set were to ever change, that is through the ages. Gen Surg News. August 2008. Available at: the day I would stop practicing the fine art of surgery. http://www.generalsurgerynews.com/ViewArticle.aspx?d_ 16 | id=77&a_id=11219. Accessed June 3, 2013. In contrast to the increasing scrutiny surgeons are 6. Hyman NH, Kozol RA, Kirton OC, Berger DL. Attending coming under from their patients, some have asked surgeon work hour restrictions. Arch Surg. 2008;143(5):443. the reciprocal question: “When patients call, will phy- 7. Anderson J. ACS-RAS weighs in on 80-hour workweek. sicians respond?”15 With the projected continual de- Surg News. December 2008. Available at: http://www. cline of physician reimbursements and the suspicion acssurgerynews.com/fileadmin/content_pdf/sn/past_ issues/1208.pdf. Accessed June 3, 2013. that surgical subspecialists will be the hardest hit in 8. Davis EC, Risucci DA, Blair PG, Sachdeva AK. Women in the pocketbook, will surgeons be willing and in some surgery residency programs: Evolving trends from a national cases even financially able to care for the increased de- perspective. J Am Coll Surg. 2011;212(3):320-326. mand for services that is imminent when the Afford- 9. Landsberger HA. Hawthorne Revisited: Management and the able Care Act is fully implemented? This conundrum Worker, Its Critics, and Developments in Human Relations in Industry. Ithaca, NY: Cornell University; 1958. is yet another ingredient in the recipe for medical care 10. Osborne NH, Nicholas LH, Ghaferi AA, Upchurch GR, in the 21st century. Dimick JB. Do popular media and internet-based hospital So tonight, as I make sure to not forget to add the ex- quality ratings identify hospitals with better cardiovascular tra pinch of Hawaiian Alaea Red Sea Salt to the chicken surgery outcomes? J Am Coll Surg. 2010;210(1):87-92. paprikash, I will be reminded of the increasing array of 11. O’Connor D. Rated negatively online? What’s a physician to do? Am Med News. August 22, 2011. Available at: http://www. changes and adaptations we continue to appreciate in amednews.com/article/20110808/profession/308089945/5/. medicine, surgery, and GME. And while it may be a bit Accessed June 3, 2013. time-consuming and out of the way to stop by my local 12. Chantler C, Ashton R. The purpose and limits to professional Sur La Table for that red sea salt, I will thank myself self-regulation. JAMA. 2009;302(11):2032-2033. for doing it—for taking the time to educate residents 13. Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA. under new guidelines and spend appropriate time with 2010;304(2):210-212. patients and their families. I’ll even go so far as to en- 14. Jain SH, Cassel CK. Societal perceptions of physicians: courage my patients to fill out those online surveys.  Knights, knaves, or pawns? JAMA. 2010;304(9):1009-1010. 15. Zinberg JM. When patients call, will physicians respond? JAMA. 2011;305(19):2011-2012.

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The role of politics in shaping surgical training

by Jennifer Baker, MD; Subhasis Misra, MD, MS, FACCWS; Neil J. Manimala, MD; SreyRam Kuy, MD, MHS; and Gerald Gantt, MD

Highlights defining quality of professionalism is commitment to a core set of val- • Discusses how various ues, regardless of divergent external pressures. The external forces political and socioeconomic Aaffecting surgical training and practice have grown in recent years. factors have affected Fortunately, the values and professional commitments of surgeons have not surgical training necessarily been in conflict with these outside demands. However, over the past century, the profession has morphed in such a way as to be able to better • Examines the effect of respond to these pressures, and in turn, the training pathways have changed government funding for as well. It is unclear whether this metamorphosis will have a positive or neg- GME on training programs ative effect in the long term, but it clearly will have an impact on issues that • Addresses surgical workforce affect surgical training, including finance and health care policy, workforce shortages and the factors shortages, work-hour restrictions, informed consent, and attending supervi- | 17 that may prevent medical sion in the operating room (OR). students from pursuing surgical training • Analyzes the effects Finance and health care policy of resident work- The health care delivery system and health care policy have had significant hour restrictions influence on the surgical training environment since the formal residency • Considers the role of model was adopted in the early 20th century. Under this system, the resident patient consent in limiting is both a government employee and student; and teaching hospitals serve a opportunities for patients dual mission of providing medical education and charitable care while oper- to attain hands-on training ating in a competitive marketplace.1,2 Until the 20th century, surgeons trained via informal pathways, including apprenticeships, training abroad, or short graduate courses. The length and quality of training varied and the financial arrangements between the apprentice and the “master surgeon” were made in a free-market environment.3 William S. Halsted, MD, FACS, developed the first formal surgical residency model in 1889. In the true Halstedian model, residents trained in a teaching hospital and attended to ward and OR tasks under graduated levels of supervision in exchange for room and board and a small salary.4,5 Teaching hospitals at this time served patients who were largely receiving charitable care and who generally accepted that training physicians would be providing some of their hospital care.6 Fueled by the growing safety and sophistication of modern surgery, by the 1920s, a new kind of patient sought hospital services: middle- and upper-class Americans who were willing and able to pay for increasingly elective care.7 This population did not last long because the costs of health care quickly rose to an unaffordable height. However, these private-payment patients played a significant role in shaping the view that medical care was a product that

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

could be purchased and should be provided by fully and educational facility costs—and indirect medical trained physicians and surgeons—not residents.8 Sur- expenses (IME), which include the increased costs gical residents necessarily assumed less independent teaching hospitals incur due to increased lab tests and roles, and hands-on learning was replaced with increas- increased complexity of disease and care. DME is cal- ingly menial tasks.9 culated on a per-resident basis with the amount varying To address the problem of increasing medical costs, between hospitals based on the proportion and number the nation turned to prepaid insurance plans, and by of Medicare patients treated.10 the early 1960s, most Americans had employer-based Simultaneously with the PPS came managed care health care insurance.7 This payor solution served to trends with payment based diagnosis-related groups increase the “paying” patient population, heightening (DRGs), which reimburse hospitals a fixed amount of competition between hospital systems. Teaching hos- money for a specific diagnosis rather than for actual pitals were not protected from these market forces and costs. Managed care reimbursement rewards volume because resident care and teaching activities are eco- and lower prices, which not only increases pressure nomically inefficient, these realities further restrained for teaching hospitals to run in a commercial fashion, the educational mission. but puts pressure on faculty to concentrate on treat- In 1965, Medicare and Medicaid were established to ing more patients faster.2 This environment increas- 18 | support the two populations that had been left out of es the number of admissions with quicker turnover/ the employee-based system: the elderly and indigent. discharges, essentially increases administrative work While this was an important and just payor solution, for residents, and dampens opportunities for bedside the legislation only worsened the commercial pres- learning.11 sure on teaching hospitals. Recognizing this conflict, Historically, surgical training has benefited the federal government pledged financial support of from—but has also and tragically been impeded graduate medical education (GME) by increasing re- by—political and financial forces. After all, federal imbursement to teaching hospitals with greater fund- policymakers control reimbursement of hospitals for ing than nonteaching hospitals on a per-patient ba- activities related to GME, which stands to fund ap- sis under Medicare Part A.5 Training physician costs propriate facilities and competent faculty for teach- were initially covered in Medicare Part B, but a major ing. They also dictate the financial pressures of the movement in 1969—in which Medicare refused to pay health care marketplace, which affects the balance for services performed by residents—affected teach- between commercialism and the educational mis- ing hospitals in a negative way. The next decades saw sion of academic medical centers. Furthermore, the political battles over reimbursement for resident ser- delivery system indirectly influences cultural trends vices, and although some deals were worked out, the in patient expectations, which affects the ability of a ultimate consequence was a steep downturn in the surgeon-in-training to participate in providing mean- number of operations that residents performed. The ingful patient care. In an era of health care reform issue largely remains unresolved today.7 and ongoing debate about federal funding of GME, it New reimbursement regulations were put in place is important to understand how the political climate in 1984 in an effort to respond to increasing GME costs has influenced surgical training throughout history with the enactment of Medicare’s prospective payment and its potential impact moving forward. system (PPS). Under this system, which is still in use today, hospitals are reimbursed for GME based on number of residents, estimated costs based on Medicare pa- Surgeon shortages tient volume, and other factors. Medicare pays hospitals National politics has long played a significant role in for direct medical education expenses (DME), which determining the distribution of the medical and sur- covers resident salaries, funding for faculty teaching, gical workforce. Within a span of more than three de-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training New reimbursement regulations were put in place in 1984 in an effort to respond to increasing GME costs with the enactment of Medicare’s prospective payment system. Under this system, which is still in use today, hospitals are reimbursed for GME based on number of residents, estimated costs based on Medicare patient volume, and other factors. cades, from the late 1970s and early 1980s to the present time, the pendulum has swung Surgical training timeline from a perceived excess of physicians and • 1889: William S. Halsted, MD, FACS, institutes surgeons to an acknowledgment of severe first formal surgical residency model at Johns shortages of physicians, particularly in sur- Hopkins University, Baltimore, MD. gery and primary care. Among the many • 1914: Judge rules that patients have the statutes affecting GME and, as a result, the right to refuse medical care. surgical workforce, perhaps the most sig- • 1920s: Patients begin seeking out elective procedures nificant piece of legislation has been the Bal- from fully trained attending surgeons. anced Budget Act of 1997, which capped the • 1950s: Employer-based health insurance number of residency training positions that coverage becomes the norm. Medicare would fund.12 Fast-forwarding to 2009, the American • 1957: Court rules that patients must be informed of potential College of Surgeons (ACS) Health Policy risks and complications associated with a procedure in Research Institute (HPRI) revealed some order to make medical decisions in their best interests. startling statistics in its report Surgical • 1965: Medicare and Medicaid Act expands coverage to elderly and indigent patients—dramatically Deserts in the U.S.: Places without Surgeons. | 19 In 2006, 30 percent (925) of the 3,107 U.S. affecting the funding model for GME. counties lacked a single surgeon, had a total • 1969: Medicare moves resident reimbursement out of Part B. population of nearly 9.5 million Americans, • 1984: Medicare institutes a prospective payment 13 and had 433 critical access hospitals. A system to reimburse hospitals, under which study by Etzioni and colleagues in 2003 not- hospitals are paid for DME and IME. ed that due to an expanding/aging popula- • 1984: Libby Zion dies in a New York hospital due tion, there would be a 31 percent increase in in part to misdiagnosis by two residents who had 14 surgical services between 2001 and 2020. been working for 18 continuous hours. Sparks This combination of circumstances will calls for resident work work-hour restrictions. likely result in a 9 percent shortage in the • 1992: Medicare begins using relative value general surgical workforce, with greater units to determine physician payment. shortages in other surgical specialties.15 The Dartmouth model used to benchmark re- • 1997: Balanced Budget Act caps the number gional procedures and specialist variations of Medicare-funded residency positions. also shows that the degree of the variation • 2000s: Multiple studies indicate growing shortages in in regional physician supply is significant. the number of general surgeons available to care for The number of physicians per capita was an aging population, particularly in rural areas. 1.6 times higher in high-supply versus low- • 2003: ACGME issues work-hour restrictions supply regions.16 for interns and residents. Other issues that have affected the sur- • 2008: Institute of Medicine recommends residency geon shortage include the declining num- training programs increase on-site supervision. ber of medical student applications for • 2010: Affordable Care Act is enacted, requiring general surgery residency; a desire among all Americans to have health insurance, current trainees for a more balanced life- thereby likely increasing patient load. style; increased subspecialization; the liability crisis; and declining reimbursement.17 Whereas the implementation of the 80-

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

hour workweek has resulted in significant improve- included provisions that would give specific prefer- ments in the current quality of life of residents, many ence for increasing direct GME funding and indirect concerns have been expressed with regard to the po- medical education slots to hospitals that submit ap- tentially negative effects on professional develop- plications for new primary care and general surgery ment, including young surgeons feeling less com- residency positions.12 This important piece of legis- fortable starting out in solo practices, especially in lation was reintroduced in 2013 by Senator Nelson rural areas, where they may be the sole surgeon in and the bill’s other co-sponsors and is currently in the county.18 the Senate Finance Committee. In the early 1990s, Medicare introduced the rel- Rural areas in particular are known to have a sur- ative value unit (RVU),and it is now a prominent geon-to-population ratio that is significantly lower component in determining physician reimburse- than non-rural areas.23,24 If the goal is to alleviate ment.19 Because the health care system could no lon- shortages, simply increasing the number of general ger support the “historical fees” general surgeons surgeons will not necessarily lead to an increased sup- charged, Medicare developed a list of procedures ply of surgeons in the areas where the need is great- it deemed overvalued and downwardly adjusted est. Research has shown that new physicians prefer- payment accordingly.20 The early 1990s also saw a entially settle in areas where supply is already high.12 redistribution of funds from surgeons to primary Political support is imperative to achieve geographi- care physicians as Congress shifted its focus to the cally focused recruitment/retention with immigra- 20 | management of chronic illness. The primary care tion visas, loan forgiveness, improved reimburse- fee schedule was readjusted upward at the expense ment, and other incentives to optimize the delivery of “proceduralists.” All of these changes in payment of care in underserved areas. undoubtedly discouraged surgeons from remaining Other recent changes on the political front will af- in practice any longer than necessary and medical fect surgical training in the near future, directly and students and residents from pursuing surgical train- otherwise. The Affordable Care Act of 2010 increases ing. Some studies have noted that the attrition rate access to insurance coverage for Americans, which among general surgery residents ranges from 14 to theoretically will increase patient load. Additionally, 32 percent nationally, and the economics of the pro- on March 1, the budget sequestration cuts took ef- fession have had a role in this high drop-out rate.21,17 fect, which will reduce Medicare spending by 2 per- The cost of practicing surgery, in operational ex- cent. This funding cut is likely to affect the creation penses and liability insurance premiums, has a ma- of more surgical training positions. jor impact on the decision to enter the profession. Political support similar to that for encouraging Limiting liability and potential economic disaster surgeons to practice in underserved areas could likely could attract more graduating students to a surgical be the tipping point for medical students to consider career. Damage caps, which directly limit the mag- surgical residency. nitude of a liability award and thereby theoretically lower liability insurance premiums, are one means of protection. Legislative reform has resulted in non- Work-hour restrictions and public pressure economic damage caps in many states.22 The health care landscape was categorically differ- Recognizing that the residency caps from the Bal- ent in the U.S. before World War II, as many illnesses anced Budget Act need to be repealed if the number of were untreatable, hospital length of stay was exten- U.S. physicians is to increase, Sen. Bill Nelson (D-FL) sive, procedures were less technically complex, and and eight other co-sponsors introduced the Resident the volume and nature of surgical practice was quite Physician Shortage Reduction Act of 2009. This bill different.25 When the resident training system origi- proposed a 15 percent increase in the number of resi- nated in 1889, trainees were expected to reside at dency positions funded through Medicare. Of great hospitals, always be on call, and not marry. Though interest to general surgeons was the fact that the bill these expectations changed somewhat over the years,

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The cost of practicing surgery, in operational expenses and liability insurance premiums, has a major impact on the decision to enter the profession.

in spirit they remained relatively constant until re- care, residents applied work-arounds, such as swip- cently, with physicians self-regulating work hours ing cards and returning to work, and underreporting without much input from the rest of society. Even actual work hours, to avoid loss of their program’s in 1975, when residents at New York City hospitals accreditation. Before the ACGME mandate, surgical went on a one-day strike for a reduction in on-call residents easily experienced weeks of more than 100 frequency, their concerns were addressed directly by actual work hours, and some reported on-call shifts area training institutions.26 of up to 60 consecutive hours.28 Although surgical National attention to resident work hours dra- residents report better quality of life and reduced matically increased in the late 1980s when 18-year-old burnout since the work-hour restrictions went into Libby Zion, the daughter of a prominent journalist, effect, the realities of patient care are unchanged.18 died at New York Hospital, partly due to misdiagnosis Residents need to be at the hospital both for the well- by two exhausted emergency room residents. Work- being of their patients and for the sake of their educa- ing for 18 continuous hours, the first- and second- tion. The volume and quality of work performed in year residents attempted treatment that resulted in those 100 hours must in some way benefit the patient. a lethal drug interaction with Ms. Zion’s outpatient Unfortunately, the correlation between work medication.26 In the years following her death in 1984, hours and patient outcomes is dubious. Long work New York State’s Bell Commission was formed in re- hours can undoubtedly make residents tired, but no sponse to the public perception that residents were statistically significant evidence is available to show overworked and undersupervised. The commission that their reduction actually leads to fewer adverse | 21 evaluated resident work hours and ultimately recom- events. Data from the College’s National Surgical mended restricting residents to 80 hours of work per Quality Improvement Program (ACS NSQIP®) indi- week averaged over four weeks with a maximum of cate no significant improvement in quality of patient 24 consecutive hours per shift.27 care after the work-hour restriction, and there is no New York codified the recommendations of the conclusive evidence that decreased sleep deprivation Bell Commission Report in 1989. Residents contin- leads to decreased medical error.18,29,30 ued to work long hours, though it wasn’t until 10 Perhaps the biggest problem with connecting years later that New York State mandated an 80-hour work-hour restrictions to better patient outcomes is workweek enforced through fines on noncompliant the fragmentation of patient care that results from teaching hospitals. The issue of work-hour limits cat- caps.25 The trade-off between reducing work hours apulted to the national stage. The U.S. Department and increasing hand-offs may be impossible to by- of Health and Human Services found that long work pass. Errors are prone to occur during care transitions hours may impair physician performance, but the fed- due to miscommunication and are likely to result in eral government hesitated to adopt a national policy poor outcomes for the patient.31 An increased num- on resident work hours. The department deferred ber of residents in programs or a higher reliance on this responsibility to the Accreditation Council for mid-level providers may be needed to approximate Graduate Medical Education (ACGME), which in 2003 the same level of care that can be achieved with a mandated nationally what the Bell Commission Re- single resident working long hours. Either way, risky port recommended a decade earlier for New York.26 hand-offs are more likely to occur. Furthermore, the The ACGME’s restrictions applied to all specialties physician-patient relationship may be fragmented be- in all residency programs across the country. The cause residents must often leave the hospital rather ACGME further restricted interns to 16-hour shifts than provide continual care to the same patient.29 in 2011, in line with the Institute of Medicine’s qual- The concerns of decreased continuity of care point ity improvement recommendations. to another drawback of work-hour caps: their nega- These regulatory measures failed to change actu- tive effect on surgical residency training independent al work hours, as residents continued to work more of patient outcomes. It stands to reason that reduced than 80 hours per week. To maintain continuity of time in the hospital may result in fewer opportuni-

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

National attention to resident work hours dramatically increased in the late-1980s when 18-year-old Libby Zion, the daughter of a prominent journalist, died at New York Hospital partly due to misdiagnosis by two exhausted emergency room residents.

ties for hands-on training. Many hours of practice Patient safety and informed consent are required to achieve expertise in any field.I t has Patient consent has been an important topic since Plato been forecast that longer residency programs may be made the distinction between physicians and physi- required to maintain training quality. Lengthening cian assistants in his dialogues, “Laws,” and since he residency may further deter medical students from discussed the concept of medical consent and coercion entering surgical residency.32 Another fear regarding in “The Statesman.”37 However, the first legal decision the effect of work-hour restrictions on resident educa- addressing informed consent in the U.S. was the 1914 tion is that they may prevent residents from receiving ruling Mary E. Schloendorff v. the Society of the New York critical instruction in morning reports and attending Hospital—the first case upholding a patient’s right to rounds and other conferences.33 refuse medical care.38 Ms. Schloendorff agreed to an A counterpoint to this claim is that residents have exam under anesthesia to determine if a fibroid tumor more time for independent study; junior residents was malignant. Even though Ms. Schloendorff stated at a New York hospital experienced a significant im- she was not consenting to resection of the tumor, the provement in American Board of Surgery In-Training surgeon removed the mass. In his final ruling, the judge Examination scores after the state restricted work in the New York Court of Appeals found the surgeon hours.34 The ACGME’s work-hour restrictions pro- guilty of battery and wrote, “Every human being of tect six hours of time for education and hand-offs. adult years and sound mind has the right to determine Additionally, data from multiple studies suggest no what shall be done with his own body.”38 That opinion 22 | significant change in resident operative case volume became the basis for subsequent cases involving a pa- after the work-hour cap.18 One year after the restric- tient’s right to autonomous decision making. tion was implemented, 39 percent of surveyed surgi- The term “informed consent” first appeared in the cal residents felt that although it worsened the qual- case of Martin Salgo v. Leland Stanford Jr. University Board ity of their training, it raised their quality of life.35 of Trustees in 1957. 39 Mr. Salgo awoke paralyzed after an Raising resident quality of life and maximizing angiogram and had never been informed that the pro- patient safety are not conflicting goals, so it is unfor- cedure involved the risk of paralysis. The ruling in favor tunate that the health care system’s structure created of the plaintiff stated that sufficient disclosure of risks the illusion that they are. The best way to approach and complications—informed consent—was necessary scarcity of surgical residents’ time is to find efficient for patients to make appropriate autonomous decisions. evidence-based ways to make the most of it. Fabri Today, informed consent and the role of surgical suggested that reducing redundancies, promoting trainees remains an important topic in surgical train- collaboration, improving hand-offs, and establishing ing. The three major ethical requirements of informed solid clinical mentorship are appropriate strategies consent are disclosure, patient understanding, and pa- to accomplish this goal.25 The long-term effects of tient decision making.40 The role of surgical trainees work-hour restrictions on both the training of surgi- during the patient’s procedure and how it affects patient cal residents and the health of their patients remain informed consent is another frontier in the evolution of to be seen. Public demand for these restrictions is general surgical training that is still being elucidated. overwhelming since the Libby Zion case and demon- Knifed and colleagues surveyed surgeons (n=274) strates the effect of social pressure on how physicians at the University of Toronto, ON, to determine what are trained.36 Most likely, these restrictions are here surgeons tell patients about the role of residents in their to stay. Teaching hospitals will have to implement care and found that only 17 percent explicitly inform creative scheduling solutions to achieve the best out- patients—without being asked by the patient—that comes for everyone. Additionally, as society takes an residents may do portions of their operation.41 During indirect role in influencing residency training, it is qualitative interviews with surgeons, several themes important to provide nonphysicians with evidence- emerged, which were that surgeons are comfortable based reasoning so that their opinions about work- allowing residents to operate with graded responsi- hour restrictions and other matters are well-informed. bility, see residents as important assets beneficial to

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The best way to approach scarcity of surgical residents’ time is to find efficient evidence-based ways to make the most of it.

patient care, and recognize the trust patients place in References them. However, another theme emerged from these 1. Bell RH Jr, Banker MB, Rhodes RS, Biester TW, Lewis FR. qualitative interviews, which is that surgeons do not Graduate medical education in surgery in the United States. routinely voluntarily inform patients about the role Surg Clin North Am. 2007;87(4):811-23, v-vi. 2. Mechanic R, Coleman K, Dobson A. Teaching hospital of residents in the OR. Researchers also qualitatively costs: Implications for academic missions in a competitive interviewed patients undergoing elective neurosur- market. JAMA. 1998;280(11):1015-1019. gical procedures about the role of residents in their 3. O’Shea JS. Becoming a surgeon in the early 20th century: surgery.42 Most patient respondents had a low level of Parallels to the present. J Surg Educ. 2008;65(3):236-241. knowledge about what residents are and do, but also 4. McClure RD, Szilagyi E. Halsted, teacher of surgeons. Am J Surg. 1951;82(1):122-131. had some anxiety about the involvement of residents. 5. Rich EC, Liebow M, Srinivasan M, Parish D, Wolliscroft Most of these patients were unaware that residents JO, Fein O, Blaser R. Medicare financing of graduate have medical degrees and did not know the differ- medical education. J Gen Intern Med. 2002;17(4):283-292. ence between medical students, junior residents, and 6. Ludmerer KM. The rise of the teaching hospital in senior residents. However, they understood that resi- America. J Hist Med Allied Sci. 1983;38(4):389-414. 7. O’Shea JS. Individual and social concerns in American dents would be present in the OR, supported residents’ surgical education: Paying patients, prepaid health educational needs, and overall stated they trusted the insurance, Medicare and Medicaid. Acad Med. medical system. These respondents understood and 2010;85(5):854-862. accepted that hands-on training is essential for resi- 8. Ludmerer KM, Stevens R. Charities or businesses? dents to become competent surgeons, with at least one American hospitals in the twentieth century. Rev Am Hist. 1990;18(2):267-273. | 23 respondent stating, “It’s better for them and just for 9. Ludmerer KM, Johns MM. Reforming graduate medical the future of medical practice that they’re in surgery.” education. JAMA. 2005;294(9):1083-1087. However, most patients thought surgeons should be 10. Association of American Medical Colleges. Medicare responsible for informing them about resident involve- payments for graduate medical education: What every ment in their operation and indicated that they would medical student, resident, and advisor needs to know. Available at: https://members.aamc.org/eweb/upload/ like to meet the residents involved before the opera- Medicare%20Payments%20For%20Graduate%20Med%20 tion. Only 24 percent of surgeons surveyed require Ed.pdf. Accessed March 6, 2013. that residents meet the patients before operating on 11. Ludmerer KM. The history of calls for reform in graduate them.42 medical education and why we are still waiting for the right Cowles and colleagues also surveyed general sur- kind of change. Acad Med. 2012;87(1):34-40. 12. Etzioni DA, Finlayson SR, Ricketts TC, Lynge DC, Dimick gery patients (n=200) regarding their perceptions of JB. Getting the science right on the surgeon workforce resident involvement in their surgical procedure.43 In issue. Arch Surg. 2011;146(4):381-384. contrast to the study by Knifed et al, most of these 13. Belsky D, Ricketts T, Poley S, Gaul K, Fraher E, Sheldon G. patients, 70 percent, knew that residents had complet- Surgical Deserts in the U.S.: Places Without Surgeons. Chapel ed medical school. Among these patients, 91 percent Hill, NC: American College of Surgeons Health Policy Research Institute; July 2009. believed resident involvement in their care was im- 14. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging portant to help in the education of future surgeons, population and its impact on the surgery workforce. Ann and 86 percent were comfortable with resident in- Surg. 2003;238(2):170-177. volvement.43 However, only 64 percent were willing 15. Williams TE Jr, Satiani B, Thomas A, Ellison EC. The to allow residents to perform some of the procedure. impending shortage and the estimated cost of training the future surgical workforce. Ann Surg. 2009;250(4):590-597. When examining patient expectation and association 16. Goodman DC, Fisher ES. Physician workforce crisis? with patient attitudes regarding resident involvement, Wrong diagnosis, wrong prescription. N Engl J Med. the awareness that there would be multiple physicians 2008;358(16):1658-1661. involved in their care was positively correlated with continued on next page positive patient attitudes toward the role of residents in their care. When patients anticipated that several physicians would be involved in their medical care,

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

References (continued) they were more likely to feel it was important to 17. Sanchez M, Sariego J. The general surgeon shortage: Causes, help in the education of future surgeons, to know consequences, and solutions. South Med J. 2009;102(3):291-294. who was in charge of their care, to feel that surgical 18. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, residents helped them better understand their plan Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. of care, and to have positive responses to resident 2006;243(6):864-875. involvement. 19. Hsiao WC, Braun P, Becker ER, Causino N, Couch NP, Porta and colleagues surveyed patients (n=316) DeNicola M, Dunn D, Kelly NL, Ketcham T, Sobol A, Verrilli specifically about disclosure of resident participation D, Yntema DB. A National Study of Resource-based Relative and its effect on patient informed consent.44 They Value Scales for Physician Services: Phase I Final Report to the Health Care Financing Administration. Boston, MA: Harvard found that 94 percent of patients had consented to School of Public Health; 1988. having a resident participate in their operation, and 20. Fischer JE. The impending disappearance of the general 91 percent believed that their care at a teaching hos- surgeon. JAMA. 2007;298:2191-2193. pital was equivalent to or better than that of a private 21. Rao M. The surgical workforce shortage: In search of hospital. Most patients believed that they received answers. Gen Surg News. 2008;35:8-9. 22. Kilgore ML, Morrisey MA, Nelson LJ. Tort law and medical personal benefit from participating in resident train- malpractice insurance premiums. Inquiry. 2006;43:255-270. ing and that their participation would benefit other 23. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart patients. However, most patients wanted to be in- LG. A longitudinal analysis of the general surgery workforce formed if a resident was going to be involved in their in the United States, 1981–2005. Arch Surg. 2008;143(4):345-351. operation (87 percent for a minor procedure and 95 24 | 24. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural percent for a major procedure). Additionally, 92 per- America. Arch Surg. 2005;140(1):74-79. cent wanted to be informed if this was the first time 25. Fabri PJ. Fragmented care: A practicing surgeon’s response. the trainee was performing a particular procedure, BMJ Qual Saf. 2012;21:i13-15. with 55 percent stating that this information would 26. Rosenbaum L, Lamas D. Residents’ duty hours—toward an make them less likely to consent. Patient belief that empirical narrative. N Engl J Med. 2012;367(21):2044-2049. 27. Douglas RG Jr, Hayes JG, Roberts RB, Bardes CL. Bell there was a societal or personal benefit associated Commission requirements: Doctors or factory workers? with the participation of residents in their procedure Trans Am Clin Climatol Assoc. 1990;101:91-98. correlated with their willingness to consent to resi- 28. Gurjala A, Lurie P, Haroona L, Rising JP, Bell B, Strohl KP, dent involvement. Wolfe SM. Petition Requesting Medical Resident Work Hour These studies show that, in general, patient Limits. Public Citizen. April 30, 2001. Available at: http:// www.citizen.org/Page.aspx?pid=614. Accessed July 18, 2013. knowledge about surgical trainee involvement in 29. Kramer, M. Sleep loss in resident physicians: The cause of an operation is low but has a large impact on patient medical errors? Front Neurol. 2010;1:128. informed consent. Also, when patients anticipate that 30. Ellman PI, Law MG, Tache-Leon C. Sleep deprivation does their care will be provided through a team approach, not affect operative results in cardiac surgery. Ann Thorac are given the opportunity to meet the resident mem- Surg. 2004;78:906-911. 31. Wachter RM. Understanding Patient Safety. New York, NY: bers of their surgical team before the procedure, and McGraw Hill Professional; 2008. understand the personal and societal benefits of resi- 32. American College of Surgeons Task Force on the resident dent participation, they are more likely to consent to 80-Hour Work Week. Position of the American College of having a trainee assist in their operation. Surgeons on restrictions on resident work hours presented to the Institute of Medicine Consensus Committee, March 4, 2008. Bull Am Coll Surg. 2009;94(1):11-8. 33. Fins JJ. Professional responsibility: A perspective on the Bell Supervision in the OR Commission reforms. Bull NY Acad Med. 1991;67(4):359-364. While surgical trainees in the past were free to in- 34. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ III. dependently manage the care of indigent patients, Effects of limited work hours on surgical training. J Am Coll today’s training programs require an increasing Surg. 2002;195(4):531-538. continued on next page amount of attending supervision due to economic and social pressures, including an increasing num-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The role of surgical trainees during the patient’s procedure and how it affects patient informed consent is another frontier in the evolution of general surgical training that is still being elucidated.

ber of paying patients and a social trend toward References (continued) a single standard of care.45 In 2008, the Institute 35. Irani JL, Mello MM, Ashley SW, Whang EE, Zinner MJ, Breen of Medicine recommended that residency train- E. Surgical residents’ perceptions of the effects of the ACGME ing programs increase the amount of supervision duty hour requirements 1 year after implementation. Surgery. 46 2005;138(2):246-253. of trainees through on-site supervisors. In addi- 36. Blum AB, Raiszadeh F, Shea S, Mermin D, Lurie P, Landrigan tion, the ACGME has instituted requirements for CP, Czeisler CA. U.S. public opinion regarding proposed limits general surgery residency training programs that on resident physician work hours. BMC Med. 2010;8(6):33. include specific recommendations for resident su- 37. Dalla-Vorgia P, Lascaratos J, Skiadas P, Garanis-Papadatos T. pervision.47 These requirements contain guidelines Is consent in medicine a concept only of modern times? J Med Ethics. 2001;27(1):59-61. for senior resident supervision of junior residents, 38. Osman H. History and development of the doctrine of informed as well as attending supervision of all residents. consent. Int Electron J Health Educ. 2001;4:41-47. The stated goals of attending supervision include 39. Green D, MacKenzie C. Nuances of informed consent: The ensuring patient safety, resident education, and paradigm of regional anesthesia. HSS J. 2007;3(1):115-118. fostering professionalism. While the intended pur- 40. Childers R, Lipsett P, Pawlik T. Informed consent and the surgeon. J Am Coll Surg. 2009;208(4):627-634. pose of increased faculty supervision is lauded, the 41. Knifed E, Taylor B, Bernstein M. What surgeons tell their effects of these policies have, in some instances, patients about the intraoperative role of residents: A qualitative been perceived as negative. study. Am J Surg. 2008;196(5):788-794. Theoretically, greater attending involvement 42. Knifed E, July J, Bernstein M. Neurosurgery patients’ feelings has led to less resident autonomy and consequently about the role of residents in their care: A qualitative case study. J Neurosurg. 2008;108(2):287-291. | 25 ill-prepared residents. Many residents report feel- 43. Cowles RA, Moyer CA, Sonnad SS, Simeone DM, Knol JA, 48 ing under-trained. This perception is reflected in Eckhauser FE, Mulholland MW, Colletti LM. Doctor-patient the increased number of residents pursuing fellow- communication in surgery: Attitudes and expectations of ship training.49 It is likely that this sentiment stems general surgery patients about the involvement and education of from a combination of less resident autonomy and surgical residents. J Am Coll Surg. 2001;193(1):73-80. 44. Porta CR, Sebesta J, Brown T, Steele S, Martin M. Training reduced duty hours. This concern is less common- surgeons and the informed consent process: Routine disclosure ly expressed among other nonsurgical specialists of trainee participation and its effect on patient willingness and who report that increased attending involvement consent rates. Arch Surg. 2012;147(1):57-62. has proven to be beneficial to their education and 45. O’Shea JS. Individual and social concerns in American surgical patient care.50 However, the unique procedural education: Paying patients, prepaid health insurance, Medicare and Medicaid. Acad Med. 2010;85(5):854-62. and acute nature of surgery requires a gradation 46. Borman KR, Fuhrman GM, Association of Program Directors of responsibility to fully develop an independent in Surgery. Resident duty hours: Enhancing sleep, supervision, surgeon. and safety: Response of the Association of Program Directors Loss of resident autonomy has been a conse- In Surgery to the December 2008 Report of the Institute of quence of social, economic, and political pressures. Medicine. Surgery. 2009;146(3):420-427. 47. Nasca TJ, Day SH, Amis ES Jr, ACGME Duty Hour Task Force. Although the effects of increased attending involve- The new recommendations on duty hours from the ACGME ment in the operating room are not well studied, it task force. N Engl J Med. 2010;363(2):e3. is imperative that technical skills and intraopera- 48. Veazey Brooks J, Bosk CL. Remaking surgical socialization: tive decision making are taught through alternative Work hour restrictions, rites of passage, and occupational methods to ensure the continued development of identity. Soc Sci Med. 2012;75(9):1625-1632. 49. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing skilled surgeons.  demographics of residents choosing fellowships: Longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206(5):782:788; discussion 788-789. 50. Sox CM, Burstin HR, Orav EJ, Conn A, Setnik G, Rucker DW, Dasse P, Brennan TA. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998;73(7):776-782.

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

Improved communication techniques enable residents to provide better care now and in the future

by Raphael C. Sun, MD; Afif Kulaylat, MD; Scott B. Grant, MD; and Juliet Emamaullee, MD

Highlights • Spotlights the important role effective communication plays in delivering high-quality, well-coordinated, patient-centered care • Describes how certain tools, such as checklists and the development of multidisciplinary teams, can be used to improve communication and quality of care • Explains how resident work-hour restrictions have added to the 26 | necessity of effective communication in training institutions to avoid potential problems resulting from more frequent hand-offs

ffective communication is a key component and common de- nominator in successful organizations and businesses, and med- Eical practices are no exceptions to this rule. Studies have con- sistently demonstrated that effective communication is essential to delivering safe and high-quality patient care.1,2 Until recently, residents have not been required to complete standardized courses in communication, and the subject has never been a formal component of graduate medical education. However, the emphasis placed on communication has increased since the Accreditation Council on Graduate Medical Education (ACGME) has identified it as one of the six core competencies for physicians.3 Consequently, many surgical training programs are teaching residents to become more effective communicators and developing processes to improve care coordination and provide more patient-centric care. As surgical training continues to evolve, renewed focus and innovative approaches in communication across disciplines ultimately will enhance the quality of patient care. Health care documentation has advanced from paper charts to electronic health records (EHR). This new method of communication between health care providers eliminates many potential errors. Il- legible handwriting, misplaced orders, and delays in the processing of orders are all less likely to pose problems because of the new system. RAS-ACS: Evolving demands of resident training

As medicine has evolved over the last few decades, for one man to fly.” A group of test pilots evaluated so has surgery. Historically, patients who required sur- the incident and instead of abandoning the plane or gery were brought into the operating room (OR), and requiring longer training, they created a checklist. the procedure began when the surgeon made the in- This checklist resulted in the Model 299 flying nearly cision. Times have changed. Currently, a number of 2 million miles without an accident.5 systematic protocols are implemented prior to patients Health care practitioners have been using check- undergoing surgery. With the advent of surgical checklists to improve patient safety and quality of care lists to confirm variables, such as patient’s consent, site for at least 20 years. The Northern New England of surgery, and procedure performed, morbidity and Cardiovascular Disease Study Group developed a mortality have declined. checklist for all cardiac surgery patients in the early Furthermore, as health care has become increas- 1990s, which decreased the number of patient deaths ingly specialized, it has concordantly become more by almost 300.6 In 1998, the American Academy of fragmented. Patients with complex diseases may of- Orthopedic Surgeons made it standard practice for ten encounter multiple specialized health care teams surgeons to initial, with a marker, the operative site during their hospital stay, each with its own manage- before bringing a patient to the OR.6 In 2003, The ment priorities and treatment plans. Communication Joint Commission approved the Universal Protocol failure among different health care providers is one of for Preventing Wrong Site, Wrong Procedure, and | 27 the most frequently cited causes of preventable harm Wrong Person Surgery. to patients, and The Joint Commission has reaffirmed In the medical literature, checklists have shown the relevance of improving the effectiveness of com- successful reduction of morbidity and mortality. One munication among care providers as a national patient memorable demonstration was by Peter Pronovost, safety goal.4 MD, PhD, FCCM, senior vice-president for patient In addition to the communication challenges ad- safety and quality and director, Armstrong Insti- dressed here, it is important to note that the 80-hour tute for Patient Safety and Quality, Johns Hopkins workweek has completely changed surgical training. In Medicine, Baltimore, MD, who created a five-item order to abide by this rule, residents are engaged in the checklist for preventing infection during insertion practice of sign-outs. These sign-outs place responsibil- of a central venous line.5 Although the five steps are ity on the resident on call. Although the continuity of simple and obvious—wash hands; clean the patient’s care by the same resident is compromised, the overall skin with chlorhexidine; put sterile drapes over the care of the patient should not be. Thorough and accu- entire patient; wear a mask, hat, sterile gown, and rate sign-outs between residents ensure that everyone gloves; and put a sterile dressing over the insertion is reading off the same page and that the safety and site—Dr. Pronovost found that even experienced cli- quality of patient care remains intact. nicians skipped at least one step in more than one- third of patients. After several years of implementing the checklist during central venous line insertion, his Checklists—a tool for enhanced hospital and other hospitals in the U.S. successfully communication and teamwork reduced infections and deaths, and there was a dem- The aviation sector developed the first checklist af- onstrated reduction in costs. At Johns Hopkins, the ter pilot Maj. P. Hill piloted a Boeing Model 299 that checklist decreased the 10-day line-infection rate from took off in Dayton, OH, on October 30, 1935, but then 11 percent to only two line infections in more than stalled and crashed. An investigation concluded that two years, resulting in $2 million in savings. When Maj. Hill forgot to release the elevator lock before the checklist was implemented in Michigan intensive taking off. The crash was classified as “pilot error,” care units (ICUs), hospitals saved more than 1,500 lives and newspapers reported it was “too much airplane and approximately $175 million in the first 18 months.5

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

In surgery, communication in the OR is complicated by having multiple team members who often have never worked together, including the circulating nurse, scrub nurse, anesthesia assistant, anesthesiologist, surgeon, and surgical assistant.

Despite the obvious benefits of using checklists, they FACS, who led the WHO Safe Surgery Saves Lives pro- were met with some resistance. Some physicians believe gram and authored The Checklist Manifesto. The WHO their jobs were far too complicated to be reduced to a group agreed on a 19-item checklist in spring 2007.5 checklist or that clinical judgment was superior to pro- This checklist decreased the rate of death from 1.5 per- tocol. Some physicians were offended by the suggestion cent to 0.8 percent, the rate of complications from 11 that they needed checklists, and viewed checklists as be- percent to 7 percent, the rate of surgical site infection neath them and an embarrassment.5 Tom Piskorowski, from 6.2 percent to 3.4 percent, and the rate of un- MD, an ICU physician, said, “Forget the paperwork. planned reoperation from 2.4 percent to 1.8 percent (all Take care of the patient.”5 Others were concerned that p <0.05).7 The WHO checklist has been translated into the checklist had been developed by nonphysicians with- 11 other languages, and it has been studied, adapted, out their input. Some surgeons saw it as an irritation and applied in various different countries.8,9 or an interference with their turf. They feared that the The WHO Safe Surgery Saves Lives team had 10 checklist broke with the surgical tradition of the vir- objectives they hoped the checklist would address, and tuoso surgeon who could do it all himself. one was, “The team will effectively communicate and In surgery, communication in the OR is compli- exchange critical information for the safe conduct of cated by having multiple team members who often the operation.”8 The checklist was designed to enhance 28 | have never worked together, including the circulat- communication and calls for all members of the OR ing nurse, scrub nurse, anesthesia assistant, anesthesi- team to introduce themselves by name and role.9 ologist, surgeon, and surgical assistant.5 Studies have Checklists are designed to address (1) the fallibility shown that nearly half the time the operating staff did of memory, (2) the fallibility of attention (for exam- not know each other’s names, but the silver lining was ple, distraction), and (3) the minimum necessary steps. that when they did, communication ratings improved Checklists can protect anyone, even the skilled and ex- substantially.5 perienced surgeon, against failure. They ensure people Recognizing the dangers in surgical care, health communicate, coordinate, and accept responsibility. care professionals met at the World Health Organiza- Checklists revolutionized aviation and prevented tion (WHO) headquarters in 2007 to initiate the WHO pilots from making human errors while flying. Like Safe Surgery Saves Lives Campaign.5 At this meeting, pilots, surgeons are susceptible to making mistakes leading experts identified problems, such as unsafe an- while performing complicated tasks. Fortunately, the esthesia, infections, and the surgeon’s lack of communi- American College of Surgeons (ACS) acknowledges the cation and respect for anesthetists and nurses.5 Several benefits of combining communications team training surgeons had experience with OR checklists, and with with an international recognized surgical checklist.10 their input, the WHO group came to a consensus on Currently, more than 3,000 hospitals participate in the several checkpoints important in surgery. WH O Safe Surgery Saves Lives Campaign and use the A WHO working group took these checklists and organization’s checklist.9,10 condensed them into one document with three pause points where the team must stop to run through the checks before proceeding5: Coordination of care Communication and coordination of care are two sig- 1. Before induction of anesthesia nificant challenges currently facing the delivery of sur- 2. Before skin incision gical care and are critical to its success. Patients with 3. Before the patient leaves the OR multiple, complex comorbidities that require attention from numerous providers with distinct areas of exper- Much of the recent attention on surgical checklists tise frequently find themselves navigating through di- evolved from the work of Atul Gawande, MD, MPH, agnoses and treatments from an often disjointed and

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

loosely associated group of providers.11 In U.S. hospi- daily mid-day bedside rounds with multiple providers, tals, where resources are abundantly available, one including residents, nurses, social workers, and care would expect care to be better coordinated and com- coordinators. Morning plans are reassessed; new data munication to be more effective. However, failures in are reviewed; and patient questions, concerns, and these two essential components of care continue to future plans are addressed from the patient’s perspec- contribute to the shortcomings of the nation’s health tive. Educational elements are emphasized as these care system and have been underscored by the Insti- collaborative care rounds provide an opportunity to tute of Medicine.4 reinforce lifestyle and behavioral modifications in a To meet the challenges of communication and co- concerted and unified fashion. As a result of these ordination of care, health care must be delivered in an bedside rounds, patients have reported feeling they environment of collaboration with a focus on delivering are at the center of their care and are primary partici- patient-centered, high-quality surgical care. In her book pants in the interaction, discussion, and formulation of High Performance Healthcare: Using the Power of Relation- their care plans. Six months into implementation, unit ships to Achieve Quality, Efficiency and Resilience, Gittell and service-based Hospital Consumer Assessment of observes that “when doctors, nurses, therapists, case Healthcare Providers and Systems (HCAHPS) scores managers, social workers, other clinical staff and ad- improved dramatically. ministrative staff are connected by shared goals, shared The literature on multidisciplinary rounding, as | 29 knowledge, and mutual respect, their communication a basis for collaborative care, is limited—particularly tends to be more frequent, timely, accurate, and fo- for surgical patients.14,15 Multidisciplinary rounding has cused on problem solving, enabling them to deliver been implemented in many different forms with vary- cost-effective, high quality patient care.”11 This intricate ing levels of success with respect to cost savings, length interdependency between relationships, communica- of stay (LOS), and quality outcomes.16-19 In a model that tion, and coordination in the setting of shared goals, used regularly scheduled multidisciplinary rounds in a shared knowledge, and mutual respect defines rela- conference room setting, Felten and colleagues demon- tional coordination.11 Because surgeons spend a signifi- strated cost savings and decrease in LOS in general sur- cant portion of their day in the OR away from inpatient gery patients with participants reporting improvements care activities, successful and well-developed relational in communication and teamwork.14 Even in studies that coordination can help bridge the gaps in patient care. failed to support benefit in LOS and hospital costs, the High levels of relational coordination among care benefit of multidisciplinary rounds on teamwork, col- providers have been associated with shorter hospital laboration, and efficiency of the workday persisted.20 stays, greater patient-perceived quality of care, and Observational studies have demonstrated that higher improved clinical outcomes.11 A successful multidisci- ratings of collaboration and teamwork have been as- plinary and collaborative approach has been reported sociated with better patient outcomes.15,20-22 Further- in the surgical oncology literature and was shown to more, higher nurse retention and greater job satisfac- affect patient treatment plans.12,13 Expanding the con- tion among team members has also been shown.23 A cept of relational coordination into the realm of sur- recent Cochrane review addressing the impact of in- gical rounding with different disciplines may provide terprofessional collaboration and the effects of practice- an opportunity to improve communication, as well based interventions on professional practice and health as patient care and satisfaction. Some health care in- care outcomes described these efforts as “promising” stitutions and providers have experimented with dif- and recommends further dedicated research.24 ferent models to achieve these aims.14-19 At Penn State Notably, surgical care is undergoing a paradigm in Pittsburgh, a multidisciplinary process known as shift from a physician-centered model to one that is “collaborative care rounds” was instituted based on patient-centric. The emerging model embraces a part- the aforementioned principles. This process includes nership between the patient and health care providers

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

Patient-centered care requires successful relational coordination, deliberate collaboration, and communication between health care teams and their members.

and is guided by the principles of patient autonomy by As the frequency of patient sign-outs increases, par- allowing patients to make informed decisions based on ticularly among complex surgical patients, concern that the expert knowledge of providers to guide their care. communication breakdowns may lead to medical errors Patient-centered care requires successful relational co- is on the rise. The effects of sign-outs on patient care ordination, deliberate collaboration, and communica- has been challenging to study, as it involves a quali- tion between health care teams and their members. tative evaluation of the sign-out process and longitu- Health care is changing. Delivering high-quality, dinal follow up of patient outcomes. Recently, Yeung cost-effective care with high patient satisfaction is an and colleagues examined the effect of frequent patient imperative. Successful outcomes in surgical patients sign-outs on a busy trauma service to determine wheth- will no longer be defined solely on operative success. er they affected patient outcomes.26 In a retrospective The coordinated efforts between health care provid- review of more than 4,000 patients, they observed no ers with different but equally important skills will be difference in time spent in the emergency department, essential to achieving these goals. I CU length of stay, ventilator days, or mortality when patients were admitted during shift change periods (6:00 to 8:00 am and 6:00 to 8:00 pm) versus those ad- Effects of work-hour restrictions mitted during other times of the day. However, they 30 | While the implementation of checklists and multidis- observed a small but significant increase in overall ciplinary rounds represents a significant improvement length of stay (five versus four days) in patients admit- in health care delivery over the past decade, there have ted during shift change periods. Although these data been sweeping changes related to regulation of resident are encouraging, more studies designed to evaluate the duty hours. In 2003, the ACGME implemented a series impact of frequent patient sign-outs need to be carried of resident work-hour rules, including the controversial out to fully understand the true effect on patient care. 80-hour workweek, which was intended to reduce resi- Traditionally, one of the tenets of surgical residency dent fatigue and thus improve patient safety. training has involved pre-rounding as a junior resident. More recently, a series of additional restrictions were This process typically involves arriving at the hospital implemented, including a new rule that limits interns early, reviewing patient data, and assembling this infor- to no more than 16 hours of continuous duty. This mation into a patient list for the surgical team. In the policy has led to the widespread adoption of shift cov- context of resident duty hours, this process consumes 10 erage among junior residents. Although the impact of percent or more of an intern’s assigned shift. Also, the these changes is still being evaluated, they do not ap- integrity of patient data may be compromised during pear to have resulted in a measurable improvement in the transcription process. The enactment of the Health patient outcomes. However, as these rules have been Information Technology for Economic and Clinical implemented, a number of issues have been identified, Health (HITECH) Act of 2009 has led to the widespread particularly in surgical residency training programs. adoption of the EHR in hospitals across the U.S. With the limitation on resident work hours, it has been Despite the variety of high-quality EHR products challenging to optimize the service-to-education ratio available, few suppliers have developed software to fa- in order to maximize time spent involved in direct pa- cilitate patient sign-off among health care providers. tient care and the OR. As a result, many programs have Recognizing that patient data are largely maintained expanded service coverage by hiring mid-level provid- in an electronic record, a number of surgical training ers to offset the resident workload and hours regula- programs have developed computerized database pro- tions. For these reasons, there has been an increase in grams to seamlessly translate patient data into a work- the number of sign-outs among residents and midlevel ing patient list and sign-out tool. The leader in this providers, leading to more than 300 patient sign-outs area has been the University of Washington, Seattle, for the typical intern over a one-month period.25 which developed a computerized rounding and sign-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

out instrument (CORES) in 2003.27 This pro- References gram was designed with three goals: improve 1. Leonard M, Graham S, Bonacum D. The human factor: The critical workflow efficiency, enhance sign-out com- importance of effective teamwork and communication in providing munication quality, and increase the time safe care. Qual Saf Health Care. 2004;13(10):Suppl 1:i85-90. 2. Leonard MW, Frankel AS. Role of effective teamwork and spent in direct patient-care activities. As the communication in delivering safe, high-quality care. Mt Sinai J Med. program was implemented, some individuals 2011;78(6):820-826. expressed concern that medical errors may 3. Accreditation Council for Graduate Medical Education. Global arise because residents were not directly re- resident competency rating form. Available at: http://www.acgme. viewing patient information, medications, org/acgmeweb/Portals/0/PFAssets/ProgramResources/380_ SummativeEvaluation_GPM_AA_04_10_2008.pdf. Accessed June 4, and other data in the patient’s electronic chart 2013. before rounding because the information was 4. Kohn LT, Corrigan J, Donaldson MS (eds). To Err Is Human: Building a automatically populating in the report on Safer Health System. Committee on Quality of Health Care in America, rounds. To study this potential problem, a Institute of Medicine. Washington, DC: National Academy Press; randomized crossover cohort study was per- 2000. 5. Gawande A. The Checklist Manifesto: How To Get Things Right. 1st ed. formed, comparing residents (internal medi- New York, NY: Metropolitan Books; 2010. cine and general surgery) who rounded in the 6. Gawande A. Complications: A Surgeon’s Notes On an Imperfect Science. 1st ed. New York: NY: Metropolitan Books; 2002. traditional way versus using the new comput- | 31 erized rounding report. Researchers found 7. Haynes AB, Weiser TG, Berry WR,Lipsitz SR, Breizat AH, Dellinger that adoption of the CORES program resulted EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. Safe Surgery Saves in reduced pre-rounding time, improved the Lives Study Group. A surgical safety checklist to reduce morbidity quality of patient sign-out, and did not in- and mortality in a global population. N Engl J Med. 2009;360(5):491-499. crease medical error.27 A number of surgical 8. World Health Organization. Safe Surgery Saves Lives. Available at: residency programs have followed the Uni- http://www.who.int/patientsafety/safesurgery/tools_resources/en/ versity of Washington’s lead and developed index.html. Accessed June 4, 2013. 9. World Health Organization. Surgical Safety Checklist 2009. Available their own computerized sign-out tool. These at: http://whqlibdoc.who.int/publications/2009/9789241598590_eng_ range from a simple Excel spreadsheet model Checklist.pdf. Accessed June 4, 2013. to a formalized, custom-built program via 10. American College of Surgeons. Press release. December 5, 2012. collaboration between the residents, program Surgical teams can reduce expensive postoperative complications by directors, and hospital administration.25,28 In combining communications team training with an internationally recognized surgical checklist. Available at: http://www.facs.org/ each system, the authors observed a measur- news/jacs/teams1212.html. Accessed June 4, 2013. able decrease in time spent pre-rounding and 11. Gittell JH. High Performance Healthcare: Using The Power of Relationships an improvement in communication and pa- to Achieve Quality, Efficiency and Resilience. New York, NY: McGraw- tient sign-out. Hill; 2009. Moving forward, it is clear that changes 12. Lamb B, Green JS, Vincent C, Sevdalis N. Decision making in surgical oncology. Surg Oncol. 2011;20(3):163-168. in resident duty-hour regulations will require 13. Blazeby JM, Wilson L, Metcalfe C, Nicklin J, English R, Donovan constant adaptation to maintain educational JL. Analysis of clinical decision-making in multi-disciplinary cancer standards and to optimize delivery of qual- teams. Ann Oncol. 2006;17(3):457-460. ity patient care. Present challenges include 14. Felten S, Cady N, Metzler MH, Burton S. Implementation of transitioning to a shiftwork schedule among collaborative practice through interdisciplinary rounds on a general surgery service. Nurs Case Manag. 1997;2(3):122-126. junior residents, which has resulted in more 15. Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM, Jr. frequent patient sign-outs. The rounding and Risk-adjusted morbidity in teaching hospitals correlates with reported sign-out process can be integrated with the levels of communication and collaboration on surgical teams but not data in the EHR, which would streamline with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg. 2007;205(6):778-784. these tasks and increase resident efficiency, continued on next page

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

As the frequency of patient sign-outs increases, particularly among complex surgical patients, concern that communication breakdowns may lead to medical errors is on the rise.

resulting in more time spent in direct patient care References (CONTINUED) and the OR. Development of a high-quality electron- 16. o’Mahony S, Mazur E, Charney P, Wang Y, Fine J. Use of ic sign-out tool requires the support of the hospital multidisciplinary rounds to simultaneously improve quality administration and collaboration among residency outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med. 2007;22(8):1073-1079. programs. As these instruments are developed and 17. Cowan MJ, Shapiro M, Hays RD, Afifi A, Vazirani S, Ward sign-out procedures are standardized, continued CR, Ettner SL. The effect of a multidisciplinary hospitalist/ research into their effects on patient safety and out- physician and advanced practice nurse collaboration on comes needs to be conducted to identify methods hospital costs. J Nurs Adm. 2006;36(2):79-85. to improve these tasks. 18. Curley C, McEachern JE, SperoffT . A firm trial of interdisciplinary rounds on the inpatient medical wards: An intervention designed using continuous quality improvement. Med Care. 1998;36(8 Suppl):AS4-12. Conclusion 19. Wild D, Nawaz H, Chan W, Katz DL. Effects of This year, the ACS commemorates its 100th anni- interdisciplinary rounds on length of stay in a telemetry unit. versary. Since its establishment in 1913, the ACS has J Public Health Manag Pract. 2004;10(1):63-69. 20. O’Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, continued to make efforts in starting committees, Williams MV. Improving teamwork: Impact of structured initiatives, and setting the standard for surgeons to interdisciplinary rounds on a medical teaching unit. J Gen 32 | improve quality in hospitals and, most importantly, Intern Med. 2010;25(8):826-832. patient care. The ACS’s goal of Inspiring Quality: 21. Baggs JG, Schmitt MH, Mushlin AI, Mitchell PH, Eldredge Highest Standards, Better Outcomes remains con- DH, Oakes D, Hutson AD. Association between nurse- physician collaboration and patient outcomes in three stant as health care delivery changes. intensive care units. Crit Care Med. 1999;27(9):1991-1998. Many aspects of communication in surgery have 22. Wheelan SA, Burchill CN, Tilin F. The link between received particular attention in the past decade in teamwork and patients’ outcomes in intensive care units. Am an effort to advance quality improvement. Surgery J Crit Care. 2003;12(6):527-534. checklists have undoubtedly revolutionized stan- 23. Chapman KB. Improving communication among nurses, patients, and physicians. Am J Nurs. 2009;109(11 Suppl):21-25. dards of practice and prevented errors. Patients un- 24. Zwarenstein M, Goldman J, Reeves S. Interprofessional dergoing surgery 100 years ago were more suscep- collaboration: Effects of practice-based interventions on tible to infection and other preventable morbidities. professional practice and healthcare outcomes. Cochrane Although complications may be inevitable, checklists Database Syst Rev. 2009(3):CD000072. have yielded concrete results, including decreases 25. Wohlauer MV, Rove KO, Pshak TJ, Raeburn CD, Moore EE, Chenoweth C, Srivastava A, Pell J, Meacham RB, Nehler in infection rates and preventable errors. Another MR. The computerized rounding report: Implementation communication transformation is the increased fre- of a model system to support transitions of care. J Surg Res. quency of collaboration and coordination among 2012;172(1):11-17. health care providers. These types of relational co- 26. Yeung L, Miraflor E, Garcia A, Victorino GP. Effect of ordination are a key component of patient-centered surgery resident change of shift on trauma resuscitations and outcomes. J Surg Educ. 2013;70(1):87-94. care. Lastly, changes in duty-hour regulation have 27. Van Eaton EG, McDonough K, Lober WB, Johnson EA, required residency programs to adopt better sign- Pellegrini CA, Horvath KD. Safety of using a computerized out methods. rounding and sign-out system to reduce resident duty hours. The ACS will always have a strong commit- Acad Med. 2010;85(7):1189-1195. ment to ensuring that the surgical patient receives 28. Clark CJ, Sindell SL, Koehler RP. Template for success: Using a resident-designed sign-out template in the handover of quality care. These current and future communi- patient care. J Surg Educ. 2011;68(1):52-57. cation initiatives will provide young surgeons and surgeons in training with the skills they need to provide optimal care to surgical patients for the next 100 years. 

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

International surgery provides opportunities for residents to serve and learn

by Shannon L. Castle, MD; Nicolas J. Mouawad, MD, MPH; Konstantinos Spaniolas, MD; and Daniela Molena, MD

he surgeon’s character is one of a natural leader with a zest for exploring new opportunities and Highlights Tfurthering one’s knowledge and experience. In an • Globalization has increased the era of increasing globalization, the dramatic advances | 33 need for surgeons and surgical in transportation methods and social media have truly trainees to provide care beyond transformed the world into a veritable “global village.” the borders of North America. As such, increasing numbers of surgical trainees are • Surgical residents are seeking to include international experience as a com- responding and showing ponent of their surgical education. Many of these train- greater interest in international ees will choose a residency based upon a program’s es- training opportunities. tablished rotations abroad, or upon the flexibility of the • The benefits of international program in allowing a foreign surgical experience. training experiences for International surgical involvement within residency residents and patients include, training often occurs in a setting with few medical and respectively, opportunities surgical resources and requires a dedicated effort on the to learn a broad range of part of the trainee to manage his or her time effectively, procedures and techniques and be cognizant of legal documentation requirements, and better access to sustainable care. to become familiar with culturally competent care and practices. In fact, it is usually the cultural environment • Medical students who are that heightens the experience for a visiting team of vol- interested in global surgery should seek out programs that unteers. There are several reasons to pursue these op- include international rotations/ portunities, and this article provide an overview of the electives. Suggestions on benefits of international training experiences. appropriate questions to ask program directors are offered. Benefits of international training First, foreign surgical experience may enrich a surgical trainee’s personal education. This time away from home provides exposure to situations and medical conditions rare in North America. Dedicated ancillary staff and auxiliary high-technology radiological facilities are far

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

Although the Internet and other forms of telecommunication have greatly expedited our capabilities to transmit knowledge to one another with relative ease, and simulation has been developed recently to enhance learning of procedural skills, the traditional method of “hands-on” experience from experts in various fields can never be underestimated.

less common in many countries, and consequently, reported informal programs in place for international a greater emphasis and reliance on surgical clinical rotations for residents.2 A similar study in 2009 with examination and diagnosis is essential. Residents en- 73 respondents reported 33 percent of U.S. programs counter more advanced disease and have to assimilate with educational opportunities in global surgery, 86 treatment plans with scarce resources. Furthermore, percent of which offer rotations abroad.3 it is timely during this era of health care reform that Most surgical residents have an expressed inter- trainees be exposed to differing health care delivery est in international educational opportunities. A 2009 models and practices from around the world. survey of 724 general surgery residents found that 92 International experiences also ensure that peo- percent were interested in an international elective.4 ple in need throughout the world have access to In fact, more than half of them were willing to use necessary medical and surgical services. Many less- allotted vacation time to pursue this elective, and 74 developed countries have an overwhelming disease percent would have participated even if cases did not burden, and this situation is often compounded by a count toward residency requirements. Furthermore, paucity of trained surgeons. Many residents plan to the interest in global surgical electives extends beyond spend significant time abroad at the faculty level, help- general surgery into the surgical subspecialties, with 34 | ing to train surgeons in areas of the world that have a most trainees in plastic surgery, otolaryngology, and limited supply of trained surgeons or specialty-trained other disciplines expressing a desire for such experi- surgeons per capita. To this end, some surgical pro- ences.5,6 The most frequent barrier for these residents, grams have successfully built in a supplementary year understandably, was logistics. As such, a concerted ef- to train residents in rural and international surgery, fort to gain a wider awareness and acceptance of this and the graduating residents are now on staff as ad- need is important. junct faculty working in underdeveloped areas of the U.S. and other parts of the world.1 Another benefit of overseas training is that it helps Volunteerism and education to encourage international collaboration. Although The American College of Surgeons (ACS) Operation the Internet and other forms of telecommunication Giving Back program defines volunteerism as provid- have greatly expedited our capabilities to transmit ing “prospective, planned care or services to patients knowledge to one another with relative ease, and outside of the routine practice environment with no simulation has been developed recently to enhance anticipation of reimbursement or economic gain.”7 learning of procedural skills, the traditional method The value of volunteerism is often in providing much- of hands-on experience with experts in various fields needed medical expertise and care in resource-poor can never be underestimated. A big part of surgical settings. Whether provided by a single surgeon vis- training is still based on an apprenticeship model and iting a rural hospital or by a group of medical pro- a continued fostering of the collaboration within our fessionals in an organized fashion, this care often specialties and transference of concepts and techniques includes necessary operations and services for pa- remains imperative. tients who otherwise would not have access. Areas Unfortunately, published data on the availability of of the world with a paucity of general surgeons or of international training opportunities within residency surgical subspecialists may benefit from time given programs are limited. In a 2011 survey of U.S. general by visiting volunteers. surgery program directors, Mitchell and colleagues In contrast, educational experiences place empha- found that 12 percent of U.S. programs had a formal sis on the training of those visiting the country or international elective in place, with only 20 percent of the training of surgeons who reside in that country. these programs having a formal curriculum; 60 percent Visiting physicians who are on international educa-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The value of volunteerism is often in providing much-needed medical expertise and care in resource-poor settings.

tion rotations, often medical students or residents, formal general surgery residencies and a single pediat- have valuable opportunities to see pathology that ric surgery training program.9 Numerous secular U.S. is less common in their own country or to obtain institution-sponsored surgical residencies have been more experience in less commonly performed pro- established in African nations as well, including one cedures. Imperative in such situations is adequate in Eritrea10 and one in Malawi.11 trainee supervision during the rotation to ensure that The desired outcome of these collaborations is residents practice within the parameters and usual the training of surgeons who will then go on to train limitations of the home training program. To act oth- other health care professionals within their country erwise would be unethical.8 and culture, obviating the need for short-term missions. Once this aim is accomplished in a particular area, North American surgical residents can continue Training of international surgeons to benefit from training in these locations by rotat- The education that U.S. surgeons can provide to health ing through now self-sustaining training programs care professionals in limited resource areas of the world abroad. is an area that continues to evolve. For many Western surgeons, participation in | 35 medical missions historically was tied to their reli- Getting involved gious principles—part of an effort to fulfill their faith’s The benefit of the surgical volunteerism experience doctrine of serving others. Organized religions often is a lifelong reward, and multiple opportunities are supported these programs with the recognition that available to surgeons, including programs sponsored providing needed health care may lead to acceptance by Operation Giving Back. And, for students and resi- within the populations to which they hoped to spread dents who are interested in the experience of training their faith. abroad, many residency programs around the country This trend continued in the 20th century; however, now have an established curriculum involving inter- many governmental and non-governmental secular or- national rotations. ganizations started to become involved as international Medical students applying for general surgery travel made the containment and eradication of disease residency frequently inquire about the availability a global concern. Today, many organizations focus of these opportunities, and the authors support this on short-term trips to provide care. Critics note that practice. However, it is important to query program without proper planning, these trips may become self- directors regarding the details about their rotations serving and “provide value for visitors without meet- abroad. Important questions or topics to discuss with ing the local community’s needs” or be ineffective, these individuals include whether the program has providing only temporary and short-term therapies.9 an established affiliation with an institution in the A logical response to these concerns and a more ef- visiting country, the number of residents who are fective means of providing care to a large population allowed to participate per year, whether the institu- is to train the people living in that society. An exam- tion has a structured curriculum for that time, and ple is the collaboration between U.S. surgeons and the whether the program provides residents with the Pan-African Academy of Christian Surgeons (PAACS). ability to count cases performed abroad toward the PAACS formed in 1996 when a group of general sur- Accreditation Council on Graduate Medical Educa- geons from mission hospitals in Africa partnered with tion case log requirements. Applicants also are en- the Christian Medical and Dental Association in the couraged to contact residents from each program U.S. Since then, it has grown to encompass eight hos- who have already participated in these rotations to pitals in Africa that serve as the training sites for seven get their feedback and perspectives.

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

The factor that traditionally has inhibited residents from pursuing international experience has been the fact that the operative case volume from these rotations has not counted toward the ACGME case log requirements.

Exploring your options • Program’s accreditation status and cycle length (must be International training can be obtained in sever- continued accreditation with at least a four-year cycle) al ways. The most common is an elective rotation abroad, wherein a resident spends a predetermined • Statement that the American Board of Medical Special- time (usually four to eight weeks) at a structured ties-certified faculty will supervise the resident (the RRC medical facility. This is mostly limited to first through may be able to accept non-certified faculty if their re- fourth postgraduate year (PGY) residents; chief resi- view finds these professors acceptable, but this often dents may be allowed if their PGY-4 curriculum in- translates to even further time until approval) cluded chief-level rotations as all of these rotations must be completed in integrated institutions. The • Description of the goals and objectives of the rotation Residency Review Committee (RRC) has specific requirements that must be met in order for this time • Educational rationale for the rotation to count toward the required 48 weeks of clinical practice per year. A second option—more applicable • Verification of the process of resident evaluation during to subspecialty and integrated residencies—involves the rotation 36 | participation in a mission under the supervision of a U.S.-based faculty. It is important to note that this • Detailed description of the clinical experience experience may not count as clinical practice, and residents may need to use vacation time to participate. • Verification of salary, expenses, and travel/evacuation As mentioned previously, general surgery resi- insurance dents as a group are interested in international training experiences.4 Residents in programs with • Verification of access to educational resources (library already established electives need to discuss with or Web-based) their program director their interest as early as possible to allow for mandatory planning. The resi- • A copy of the program’s Letter of Agreement dency administration may require clearance both by the institutional graduate medical education Only programs in good standing are allowed to offer office and the RRC on an individual basis, so tim- such an elective. Deficiencies in operative case volumes, ing is important. duty-hour compliance, and board pass rates are likely Surgery residents who are enthusiastic about to inhibit the development of an international rota- international rotations and enrolled in a program tion, as the residency program’s goals should first aim without an established elective may still be able to at improving the already established experience. The arrange for such experience, but early planning and clinical setting needs to be well-defined.T he type of communication are key to success. The RRC has de- institution, referral pattern, and scope of practice must veloped the following list of requirements:12 be identified, and the institution’s operative volume, type, and mix must be assessed. The same is true for the • Name and location of the international site ancillary, anesthetic, radiologic, and laboratory support. The list of requirements may appear lengthy, but the • PGY level of the resident rationale behind it is sound. The RRC is interested in enhancing resident education. To that end, the require- • Dates of the rotation ments are meant to ensure that residents will obtain valuable experience in a safe environment. The educa- • Verification that the rotation is an elective tional standards and supervision should be similar to

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

that of any approved training program in the U.S., and the References residency program must meet these mandates. 1. Fader JP, Wolk SW. Training general surgeons to The factor that traditionally has inhibited residents from practice in developing world nations and rural areas pursuing international experience has been the fact that the of the United States—One residency program’s model. J Surg Educ. 2009; 66(4):225-227. operative case volume from these rotations has not counted 2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. toward the ACGME case log requirements. However, be- Elective global surgery rotations for residents: A cause the RRC now recognizes that the operative experi- call for cooperation and consortium. World J Surg. ence obtained abroad can be unique and valuable, credit 2011;35(12):2617-2624. may be allowed for cases performed under the supervision 3. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery of a U.S.-appointed teaching faculty, after appropriate com- residency: A national survey. J Am Coll Surg. munication with the RRC. 2009;208(3):426-433. Program directors must exert significant effort to de- 4. Powell AC, Casey K, Liewehr DJ, Hayanga A, James velop and maintain international experience as part of their TA, Cherr GS. Results of a national survey of surgical curriculum. However, with residents’ increasing interest resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312. in this training and the ability to count the operative cases 5. Javidnia H, McLean L. Global health initiatives for ACGME case logs, more programs are getting involved and electives: A survey of interest among Canadian | 37 with international training. For residents who are enthu- otolaryngology residents. J Otolaryngol Head Neck Surg. siastic and committed to expanding their training in this 2011;40(1):81-85. domain, early recognition and communication are essential. 6. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. The RRC must be intimately involved in the process, and, Plast Reconstr Surg. 2010;126(1):295-302. therefore, we encourage all interested parties to contact 7. American College of Surgeons. American College of their RRC and obtain updated material in terms of require- Surgeons Giving Back Report: Phase 3. September 2002. ments and guidelines before initiating a plan. Available at: http://www.facs.org/about/governors/ phase3givingback.pdf. Accessed June 5, 2013. 8. Ramsey KM, Weijer C. Ethics of surgical training in developing countries. World J Surg. 2007;31(11):2067- Conclusion 2069. U.S. surgical training programs need to undergo remodel- 9. Pollock JD, Love TP, Steffes BC,T hompson DC, ing to meet the needs of a globalizing world with dramatic Mellinger J, Haisch C. Is it possible to train surgeons health care disparities. Surgical trainees recognize these for rural Africa? A report of a successful international program. World J Surg. 2011;35(3):493-499. needs and relish the opportunity both to provide clinical 10. Khambaty FM, Ayas HM, Mezghebe HM. Surgery services to people in underdeveloped countries and as a in the Horn of Africa: A 1-year experience of an means of broadening their educational experience. The ACS American-sponsored surgical residency in Eritrea. has been supportive of the booming interest in creating pro- Arch Surg. 2010;145(8):749-752. grams that address the surgical needs in underserved areas 11. Qureshi JS, Samuel J, Lee C, Cairns B, Shores C, Charles AG. Surgery and global public health: The of the U.S. and abroad. As natural leaders, surgeons need UNC-Malawi surgical initiative as a model for to overcome the challenges of an over-regulated training sustainable collaboration. World J Surg. 2011;35(1):17- system and embrace a leadership role in forming interna- 21. tional partnerships.  12. Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham E. A model for sustainable short- term international medical trips. Ambul Pediatr. 2007;7(4):317-320.

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training Early surgical subspecialization: A new paradigm? Part I by Scott B. Grant, MD; Jennifer L. Dixon, MD; Nina E. Glass, MD; and Joseph V. Sakran, MD, MPH

arly specialization in surgical training is a concept that has been evolving for as long as surgical train- Eing has been in place. It started with early specialists who provided only one procedure, such as lithot- omy for bladder stones, to the point that now surgical trainees may have early systematic exposure in the field of their choice, with options including colorectal, pediatric, or transplant surgery.1 The American Highlights Board of Surgery’s (ABS) Flexibility in General Sur- gery Residency Specialty-Specific Guidelines allow • Provides background residents to spend up to 12 months of time on flexible on the evolution of surgical subspecialties rotations during their last 36 months of general surgery training to offer an opportunity for “early track- • Describes traditional and 1 38 | ing” into the resident’s preferred subspecialty. emerging approaches to The paradigm of a residency program that would training in the surgical provide advanced training emerged in the 19th cen- specialties, including tury and was formalized in the early 20th century by vascular, plastic and William Osler, MD, in medicine and later William S. reconstructive, and Halsted, MD, FACS, in surgery, both at Johns Hop- cardiothoracic surgery kins University in Baltimore, MD.2 Prior to that time, all individuals with medical degrees were considered “physicians and surgeons.” Ophthalmologists, otolar- yngologists, gynecologists, orthopaedists, and genito- urinary surgeons comprised 43 percent of the first class of Fellows of the American College of Surgeons (ACS) in 1913. However, the term “general surgery” was not a category in the ACS directory until 1965.3 Since then, the practice of surgery has become increasingly specialized, so that orthopaedic surgeons often practice on only one particular joint, general surgeons on a particular organ, or neurosurgeons on a particular disease. The course of study to become subspecialized traditionally proceeded through medical school, internship, general surgery residency, and often into a subspecialty of general surgery. Trainees and educators have asked whether all those years of background training are required for residents who plan to practice a single subspecialty, and there has been a move toward earlier subspecialization. One advantage of shorter training is that physicians can repay their educational debt earlier. Several subspecialties have already devel-

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

Several subspecialties have already developed well-formed paradigms for training programs independent of general surgery residency programs. These programs are the focus of this article.

oped well-formed paradigms for training programs and development of new training paradigms to prepare independent of general surgery residency programs. competent future leaders in vascular surgery. These programs are the focus of this article. The training pathways may be divided into two categories: independent and integrated. The independent category consists of the following pathways: 5+2, 4+2, Vascular surgery and 3+3 (see Table 1, page 40). The integrated program, Over the last 50 years, the training of vascular surgeons also known as the 0+5 pathway, consists of two years has gone from apprenticeships in the early 1960s to the of core surgical education followed by three years of development of fellowships certified by the ABS.I n this concentrated vascular surgery. This new training para- century, a new training model for vascular surgeons has digm allows residents to participate in a variety of ro- emerged and more changes are likely on the horizon. tations related to vascular surgery that are difficult to During the 1960s and 1970s the norm was a five- incorporate in the traditional 5+2 model. year general surgery residency followed by one year In 2007, the inaugural year of the integrated (0+5) of specialization with pioneers in vascular surgery. As pathway, three institutions participated in this model. time passed, the need for more formalized vascular fel- Since then, the number of individuals training in vas- lowships became apparent. Edwin J. Wiley, MD, was cular surgery has increased rapidly, and 40 integrated one of the key contributors to the development and programs are now in place nationwide. The paradigm promotion of training in vascular surgery.4 The Society shift is probably a multi-factorial response related to: for Vascular Surgery (SVS) and the North American (1) the technological advancement within the specialty, | 39 Chapter of the International Society of Cardiovascular such as the rapid expansion of endovascular surgery; Surgery spearheaded these efforts under the leader- (2) the increase in overall trainee debt; (3) residents’ ship of Dr. Wiley and other pioneers in the field. The desire to curtail length of training; and (4) the societal collaboration between both societies continued with obligation to provide well-rounded competent vascular the development of the Joint Council (JC) in the early surgical care.7 Although a number of different training 1970s. Over the next decade, the governing bodies for pathways still exist, the integrated pathway is gaining graduate medical education agreed on guidelines for the greatest momentum. essentials in the training of vascular surgeons. By 1982, the JC had credentialed 52 programs in vascular training; 1982 also marked the inception of a certificate of Plastic and reconstructive surgery special qualifications in vascular surgery by the ABS.5 Plastic and reconstructive surgery training in the U.S. In these early years, vascular training consisted of has become quite competitive. Medical student applica- a one-year fellowship after a five-year general surgery tions to plastic surgery residency programs increased residency. The requirement for ABS special certifica- 34 percent from 2002 to 2005.8 An online survey of 49 tion consisted of a written examination in 1983 and programs found that only 4.7 percent had a residency subsequently incorporated an oral examination in 1986. spot go unfilled in the last 10 years.9 Nonetheless, 10 As the requirements of certification changed, so did programs (23.3 percent) were less than satisfied with the training, with expansion into a two-year fellow- the selection process.9 ship program. The second year was initially tailored to The American Society of Plastic Surgeons (ASPS) bolster research efforts; however, a more clinical com- was founded in 1931 and is the largest plastic surgery ponent was incorporated in 1995 as the endovascular organization in the world.10 The American Board of aspect of vascular surgery began to flourish. From 1982 Plastic Surgery (ABPS) began in 1938 as a subsidiary through 2007, the ABS certified 2,676 diplomats.6 The of the ABS and achieved status as a major specialty key turning point took place on July 1, 2006, when the board in May 1941.11 In 1958, S. Milton Dupertuis, MD, ABS converted the subspecialty certificate of special president of the ASPS, noted that there were 36 resi- qualifications in vascular surgery to a primary spe- dency programs in plastic surgery with an additional cialty certificate.T his move allowed for the creation 28 preceptorships that provided training for 140 plastic

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training Tabas le 1. V cular surgery training pathways Years of Pathway training Board certification 5+2 (traditional) 7 General surgery and vascular surgery 4+2 6 General surgery and vascular surgery 3+3 6 Vascular surgery 0+5 (integrated) 5 Vascular surgery

surgeons.11 Dr. Dupertuis recommended a gradual con- sity School of Medicine, CA, graduates from 1966 to version from preceptorships to residency programs, 2009 found that career outcomes between integrated noting that “all other surgical specialty boards have and traditional plastic surgery graduates appear to either discontinued preceptorships or now permit pre- be similar.14 Of the integrated Stanford graduates, 86 ceptor training only to supplement approved residen- percent were in clinical practice.14 All of the gradu- cies.”11 Since then, plastic surgery training programs ates were either board certified (82 percent), board- have continued to evolve. eligible (recent graduates, 9 percent), or retired.14 Al- The plastic surgery program at Columbia- though most of these plastic surgeons were in private Presbyterian Medical Center, New York, NY, is practice, at least 82 percent had been academically considered the oldest continuously running plastic productive, whether through contributing to peer- surgery training program in the nation.12 Shortly af- reviewed publications and book chapters, or serving ter the formation of the ABPS, a certified two-year as program directors.14 residency program was established at Columbia, one Plastic surgery training has evolved over the last of the first of its kind, with Dr. Dupertuis as the first century. The rise of the three models of training has plastic surgery resident in 1938.12 In 1958, the ABPS raised the question about which one is best, which begs 40 | officially increased the requirement of approved resi- the larger question of the pros and cons of early surgi- dency training in “basic surgery” from two to three cal subspecialization. Although an argument may be years effective in 1960.11 In 1994, the Association of made in favor of each model, and each model produces Academic Chairmen of Plastic Surgery reported that successful graduates, only time will tell which pathway approximately 4,300 fully trained plastic surgeons becomes preferred. were actively practicing in the U.S.13 As a result, the ratio of plastic surgeons to population was 1:59,302, with 200 plastic surgery trainees per year.13 Further- Cardiothoracic surgery more, the report suggested lengthening all two-year Cardiothoracic surgery training first began at the Uni- plastic surgery programs to three years and reducing versity of Michigan, Ann Arbor, in 1928, mainly for prerequisite training to three years.13 surgical treatment of empyema and tuberculosis. It Plastic surgery trainees now follow one of three subsequently developed more formally after World War pathways, as summarized in Table 2, page 41.14 II, propelled by the invention of the cardiopulmonary Both the combined and integrated models are bypass machine. Finally, in 1971, the American Board recognized by the ABPS, but the integrated model of Thoracic Surgery (ABTS) was established.19 Despite is also recognized by the Accreditation Council for the high rate of general surgery graduates pursuing Graduate Medical Education (ACGME), whereas the fellowship, the number of candidates for traditional ACGME does not recognize the combined model.14 cardiothoracic surgery fellowship has been declining. Roughly half of all plastic surgery training programs From 1994 to 2003 the candidate pool decreased at a have adopted the integrated model, which accounts rate of 4 to 5 percent per year but then dropped pre- for approximately 50 percent of all training spots.17-18 cipitously thereafter, leading to unfilled positions every However, four programs stopped taking residents year since 2004.20-21 In 2012, 24 percent of fellowship through the integrated model within the last 10 years, positions remained unfilled, despite an approximate and nearly half of the integrated and combined pro- 20 percent reduction in available positions over the grams surveyed also take residents via the traditional last five years.22 pathway.9 Decreasing interest in cardiothoracic fellowships A recent 40-question survey looking at 130 gradu- was thought to be due to the decreased exposure to ates of the integrated program at Stanford Univer- the specialty, especially since these rotations are no

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training Table 2. Plastic surgery training pathways Years of Board Pathway training certification Created Other Independent/ 7–10 (complete General surgery and 1938—Columbia12 Model through which most practicing traditional/ surgical residency plastic surgery plastic surgeons received their training fellowship followed by fellowship) Combined/ 5–6 (3 years Plastic surgery 1989 via meeting First three years trainees are coordinated/ general surgery, of Association of considered general surgery residents transition 2-3 years plastic Program Directors in and are under the general surgery surgery) Surgery and AACPS15-16 program director’s purview Integrated 5–7 Plastic surgery 1992—Loma Trainees are always considered plastic Linda, first ACGME- surgery residents and are always under accredited; the plastic surgery program director’s Early 1960s—Stanford purview

longer a mandatory requirement for general surgery board References certification. Only an estimated 70 percent of general sur- 1. American Board of Surgery. Flexibility in General gery residents have a cardiothoracic surgery rotation as a Surgery Residency: Specialty-Specific Guidelines. required part of their curriculum, and this training may 2011. Available at: http://www.absurgery.org/xfer/ 20 flexiblerotations.pdf. Accessed March 28, 2013. be on the general thoracic service only. Cited drawbacks 2. Halsted WS. The training of the surgeon. Bulletin of of specializing in cardiothoracic surgery include the work Johns Hopkins Hospital. 1904;15:267-275. schedule and length of training.19-20 Therefore, the aim be- 3. Nahrwold D, Kernahan P. A Century of Surgeons and came to pique interest in students earlier in the career path Surgery: The American College of Surgeons 1913–2012. and to decrease the onerous length of training. Chicago, IL: American College of Surgeons; 2012:26. 4. Goldstone J, Wong V. New training paradigms To alleviate the impending shortage of cardiothoracic and program requirements. Semin Vasc Surg. surgeons, in 2003, the ABTS revised the available pathways 2006;19(4):168-171. | 41 for cardiothoracic surgery board certification by retract- 5. DeWeese J. Accreditation of vascular training ing the mandate of general surgery board certification. See programs and certification of vascular surgeons. J Table 3, page 42, for the three currently available pathways Vasc Surg. 1996;23(6):1043-1053. 6. Mills J. Vascular surgery training in the United to ABTS certification. States: A half-century of evolution. J Vasc Surg. Thus, integrated six-year (I-6) programs began develop- 2008;48(6):Supplement.90S-97S. ment at institutions with an existing cardiothoracic residency 7. Sidawy A. Presidential address: Generations apart— program in place. They first entered the National Resident bridging the generational divide in vascular surgery. Matching Program in 2007, and the first graduate completed J Vasc Surg. 2003;38(6):1147-1153. 23 8. Greene A, May JW. Applying to plastic surgery training two years ago, in 2011. Based on the most recent residency: Factors associated with medical student match data from 2012, 13 I-6 programs are in place, with 20 career choice. Plast Reconstr Surg. 2008;121(3):1049- positions filled by graduating medical students.24 The same 1053. year, 72 programs and 102 positions were available for the 9. Janis J, Hatef D. Resident selection protocols traditional cardiothoracic fellowship offered after comple- in plastic surgery: A national survey of plastic 22 surgery program directors. Plast Reconstr Surg. tion of general surgery residency. Ratios of candidates to 2008;122(6):1929-1941. available positions were 27:1 and 131:1 for traditional and 10. American Society of Plastic Surgeons. About us. integrated programs respectively, and like other subspe- Available at: http://www.plasticsurgery.org/about- cialties, candidates for the integrated programs have high- asps.html. Accessed April 15, 2013. er United States Medical Licensing Examination (USMLE) 11. Dupertuis SM. Residency training in plastic surgery. 23 Plast Reconstr Surg Transplant Bull. 1958;21(3):163-168. scores than candidates for traditional programs. It is hard 12. McLaughlin MJ. The origin of the Plastic Surgery to say whether the field is attracting high-quality applicants Program at Columbia-Presbyterian Medical Center. due in part to the highly competitive nature of this newly Plast Reconstr Surg. 1997;99(2):576-582. formed track with only 20 positions available, and if this 13. Association of Academic Chairmen in Plastic trend would persist with an increase of available I-6 positions. Surgery. The future of graduate medical education in plastic surgery. Ann Plast Surg. 1994;32(1):65-88. The future of cardiothoracic training is still variable, especially considering the rapidly diverging tracks of thoracic and cardiac surgery and the unique requirements for board continued on next page certification in both branches of the specialty.

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training Table 3. Cardiothoracic surgery training pathways Years of Pathway training Board certification 7 or 8 (5 general surgery + Traditional General surgery and cardiothoracic surgery 2 or 3 cardiothoracic) 7 (4 general surgery + 3 Joint General surgery and cardiothoracic surgery cardiothoracic) Integrated/I-6 6 (all cardiothoracic) Cardiothoracic surgery

Discussion References (continued) Surgical training has been rapidly changing and developing 14. Noland S, Lee G. Plastic surgery residency graduate over the past 30 years, especially within certain subspecial- outcomes: A 43-year experience at a single institution and the first “integrated” training program in the ties as described in this article. The optimal training para- United States. Ann Plast Surg. 2012;68(4):404-409. digm for each remains the source of ongoing debate. The 15. Luce E. A survival plan. Plast Reconstr Surg. integrated and combined pathways are shorter (and thus 2001;108(3):776-782. cheaper) and have increased training time spent focused in 16. Ruberg R. Plastic surgery training—past, present each specialty, but some argue that more general surgery and future. Ann Plast Surg. 2003;51(3): 330-331. 17. American Board of Plastic Surgery. Mission training is necessary to fulfill patient needs.I ndependent statement. Available at: http://www.abplsurg.org. pathway trainees may be at a more mature point in life with Accessed April 15, 2013. more subspecialty experience when they make their career 18. Association of Academic Chairmen of Plastic choice than the typical medical student. The counterpoint Surgery. Resident and student resources. Available is that integrated programs lock in quality candidates early. at: http://www.aacplasticsurgery.org. Accessed April 15, 2013. Overall, it appears that applicants for integrated programs 19. Crawford F. Thoracic surgery education— may have stronger applications. A study by Guo and col- Past, present, and future. Ann Thorac Surg. 2005;79(6):S2232-2237. 42 | leagues examining the plastic surgery training program at Harvard University School of Medicine, Boston, MA, showed 20. Vaporciyan AA, Reed CD, Erickson C, Dill MJ, that when comparing integrated to independent programs, Carpenter AJ, Guleserian KJ, Merrill W. Factors affecting interest in cardiothoracic surgery: Survey trainees applying to integrated residencies graduated from of North American general surgery residents. J more highly ranked medical schools, had higher USMLE Thorac Cardiovasc Surg. 2009;137(5):1054-1062. step 1 scores (mean 235, versus 220 p = 0.015), had higher 21. Gasparri MG, Tisol WB, Masroor S. Impact of a six- pre-residency publication scores, and included more MD/ year integrated thoracic surgery training program at PhDs (33 percent versus 4 percent).25 Researchers at the Medi- the Medical College of Wisconsin. Ann Thorac Surg. 2012;93(2):592-597. cal College of Wisconsin, Milwaukee, compared the demo- 22. National Resident Matching Program. Results and graphics and applications of cardiothoracic candidates from data. Specialties matching service 2012. Available at: their traditional program and their newly formed I-6 training http://www.nrmp.org/data/resultsanddatasms2012. program. They found a much higher candidate-to-position pdf. Accessed March 11, 2013. ratio after developing the I-6 program and that applicants had 23. Chikwe J, Brewer Z, Goldstone AB, Adams DH. Integrated thoracic residency program applicants: higher USMLE Step 1 and 2 scores, had contributed to more The best and the brightest? Ann Thorac Surg. 2011; publications, and had more advanced degrees compared with 92(5):1586-1591. the traditional group.21 Researchers at Mount Sinai Medical 24. National Resident Matching Program. Main Center in New York, NY, also found that cardiothoracic in- residency match: Match rates by specialty and tegrated applicants had higher USMLE scores but found no state. Available at: http://www.nrmp.org/data/ resultsbystate2012.pdf. Accessed March 11, 2013. difference in research activity. Given that candidates with 25. Guo L, Friend J, Kim E, Lipsitz S, Orgill DP, Pribaz advanced degrees have spent a substantial amount of time J. Comparison of quantitative educational metrics in training already, many are looking for a shorter path to between integrated and independent plastic surgery board certification. residents. Plast Reconstr Surg. 2008;122(3):972-978. It may be that no one paradigm fits every specialty, and by providing multiple pathways, all qualified candidates may enter the field of their choice.T he current shift appears to be back in the direction of allowing early specialization and less general training. 

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

Early surgical subspecialization: A new paradigm?

Part II: Interviews with leaders in surgical education

he practice of general surgery is constantly evolving. Numerous Tfactors such as advances in surgi- Afif N. Kulaylat, MD; cal knowledge, techniques, and tech- Feibi Zheng, MD; nology, as well as patient and physician SreyRam Kuy, MD, MHS; preferences, have driven an increasing | 43 and numbers of surgeons to specialization. James G. Bittner IV, MD More general surgery (GS) graduates are specializing; in fact, more than 80 percent of graduates of general surgery programs are pursuing additional training beyond the five-year surgical residency.1 To accommodate these trends, a number of early-specialization training models have emerged. Models vary with respect to time of entry, board certification process, and length of training. The most well-established approach is the fully integrated model, which is used in plastic, vascular, and car-

Highlights • Describes various pathways to specialization, including the traditional integrated model, the American Board of Surgery- approved Early Specialization Program, the flexibility in surgical training programs, and transition to practice models • Leading surgical educators and training program directors offer their views on issues related to early specialization, including the challenges associated with implementation and the possible effects on the future of surgical training

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

“I see the gulf between skills needed for vascular and general surgery residents widening. Over the last decade, general surgery residents are less well-trained in vascular surgery than they were; often, even those who have had an interest had little experience in the operating room, especially in aortic procedures.” —Dr. Ricotta

diothoracic surgery. In 2004, the American Board What are the practical considerations in of Surgery (ABS) approved the Early Specializa- deciding whether it is prudent or feasible tion Program (ESP), whereby residents interested to begin a new training pathway? in vascular or cardiothoracic surgery would receive one year of fellowship credit for pursuing Integrated programs 12 months of their respective subspecialty train- Dr. Bass: “For our integrated vascular track, which we ing during their fourth and fifth years of general started two years ago, we looked at three main crite- surgery residency.2 For approval, programs must ria. First, it was really the endovascular revolution that demonstrate that residents are able to complete the pushed us over the top. We had already started to see 44 | caseload requirements for general surgery board it as a natural evolution of this surgical subspecialty. certification and must have a fellowship program When certain subspecialties mature into their own in vascular or cardiothoracic surgery, into which unique set of diagnostic and therapeutic tools, they are residents would track. ripe for picking. Second, I think it’s a matter of what Most recently, in 2011, the ABS approved a flex- the needs of your community are. In Houston, and in ibility in surgery training option (or FIST), which probably the vast majority of large cities, what you need allows general surgery residents up to 12 months of are deep and narrow surgeons. If you’re in rural Texas, flexible rotations within postgraduate years (PGY) that’s probably not the case. Third, we had the volume, 3–5 to tailor training to a resident’s future career the faculty expertise, and a track record of teaching by interests.3 Although there has been a strong trend the faculty. In addition, we had a general surgery resi- toward specialization, a countervailing movement dency that was able to lend the foundational aspects has advocated for the strengthening of broad-based of all surgery: wound management, critical care, etc., general surgery. This year, the American College of to the vascular residency.” Surgeons (ACS) began pilot testing the ACS Tran- sition to Practice Fellowship in General Surgery Dr. Ricotta: “I see the gulf between skills needed for for trainees who plan on becoming community or vascular and general surgery residents widening. Over rural surgeons at five sites around the country.4 the last decade, general surgery residents are less well- The authors of this article had the opportunity trained in vascular surgery than they were; often, even to discuss early specialization options and the tran- those who have had an interest had little experience sition to practice program with residency directors in the operating room, especially in aortic procedures. and national leaders in surgical education. (For the Paradoxically, the experience was often the worst full names and titles of the surgeons interviewed, where vascular surgery was the strongest, because of see the sidebar on page 45.) Through the following the vascular fellows.” excerpts from our interviews, we hope to convey some prevailing thoughts on current experiences FIST with early specialization, the challenges encoun- Dr. Delman: “When the opportunity came to join a tered, and the future of early specialization and group of programs [that] will not only jointly pursue general surgery training paradigms. the FIST option within their institutions, but study

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

We have always supported the concept that learners learn better when pursuing an area of interest, and teachers are more enthusiastic when the learners are engaged. —Dr. Delman

it and collect data to see the impact on resident education, we jumped at the chance. The big issues for us were: first, making Interviewees sure that the fellowships at our institution and the specialty divi- • Barbara L. Bass, MD, FACS, is the John F. sions were supportive and willing to work towards this end; sec- and Carolyn Bookout Distinguished and ond, ensuring that we could do this while not compromising the Endowed Chair of Surgery at Methodist resident who wanted the traditional Emory [Atlanta, GA] training Hospital Research Institute, Houston, experience; and finally, the actual scheduling of the residents into TX, and professor of surgery at Weill these flexibility options while still covering all of our services.” Cornell Medical College, New York, NY. • John J. Ricotta, MD, FACS, is ESP the Harold H. Hawfield Chair of | 45 Dr. Awad: “There are a couple of things that are important when Surgery and professor of surgery at you have an ESP. It is important to have a traditional 5+2 or 5+3 Georgetown University, Washington in vascular or CT [cardiothoracic] surgery, respectively. The Hospital Center, Washington, DC. reason for this is in case you do not have residents in a given year that are interested in pursuing vascular and CT surgery • Keith A. Delman, MD, FACS, is the ESP. We have actually had a fairly persistent track of folks [who] general surgery residency program have wanted to pursue those specialties, so it has not been a ter- director and associate professor of ribly big issue, but you do need to have that backup option such surgery at Emory University-Winship Cancer Institute, Atlanta, GA. that in a given year if you do not have a resident [who] wants to pursue that, you can still match a senior trainee through a tra- • Michael A. Awad, MD, FACS, is an ditional fellowship match. assistant professor of surgery, the “In vascular ESP, one pursues four years of general surgery, associate dean for medical student such that in the PGY-5 year, all rotations are in vascular sur- education, program director of gery. It is your chief year, but really your first year of vascular the general surgery residency, and fellowship. So, if you had a year where you did not have anybody director of the Institute for Surgical slotted for that position, then presumably you could still match Education at Washington University somebody through the formal match. Cardiothoracic is split up School of Medicine, St. Louis, MO. differently, with six months as a PGY-4 and six months as a PGY- • Thomas H. Cogbill, MD, FACS, 5, then that together is considered one year of fellowship. Then is the program director for the they do two additional years, PGY-6 and 7, of formal cardiotho- Transition to Practice Fellowship racic fellowship. That does trim it down a year, but their first at Gunderson-Lutheran Hospital year is split up, instead of contiguous like in vascular surgery. in La Crosse, WI, and the chair of “I do think that it does take a certain critical mass of categori- the American Board of Surgery. cal residents, because if you had a smaller program, say five cat- egoricals, and two or three of them went into a cardiothoracic or vascular ESP, then you are down that many chief residents and that can have significant impact on your program.”

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

“One-third of graduating chiefs do not feel comfortable practicing independently. I think there is a clear need for a fellowship program such as ours for the new graduate who wants to perhaps practice in a rural or underserved setting.” —Dr. Cogbill

Transition to practice pendent program. Graduated responsibility is much Dr. Cogbill: “There were four major considerations. more easily achieved than it is in a two-year program. First, protection of our GS residents. We have a small Also, our vascular residents attend our conferenc- program of three chiefs each year and we wanted to es for five years instead of two and the breadth and make sure that the fellows would not be competing depth of their experience should be anticipated to be for the same high-level cases as our senior residents. better than a two-year program. Finally, I also saw a Second, protection of our young faculty. These fac- different source of vascular trainees to tap into. The ulty [members] are also trying to build their prac- number of general surgery residents choosing vascu- tices, so we wanted to make sure that the fellows lar has been static for about a decade. We were not would have enough cases that they wouldn’t start going to train more vascular surgeons if we did not 46 | affecting the young faculty. Third, coordination and tap into a new source of trainees.” buy-in from other specialties. We needed orthopaedics/hand, obstetrics-gynecology (OB-GYN), gas- FIST troenterology (GI), otolaryngology (ENT) on board Dr. Delman: “Next year, we will have flexibility op- to agree to help train a fellow. And fourth, balance tions in endocrine, surgical oncology, plastics, com- autonomy with supervision. prehensive general surgery/global health, minimally “Our intake process for our new fellow would invasive/advanced foregut, and transplant. We have look like this: we would examine his or her current always supported the concept that learners learn bet- level of skill and experience, consider his or her ca- ter when pursuing an area of interest, and teachers are reer goals, and design a one-year curriculum to fit more enthusiastic when the learners are engaged. As those needs. Six months would be spent in the fields a result, I have always supported the idea of electives of orthopaedics/hand, OB-GYN, GI, ENT, and up to and have believed that, within the constraints de- six months would be spent on a rural surgery rota- signed by the ABS, it is nice to allow residents some tion in community hospitals based in towns with opportunities to garner ‘personalized education’ that populations of less than 10,000 people.” will enhance their career.”

Dr. Awad: “The ability to do the flexibility option will What are the advantages to be very attractive and will draw some of the best ap- establishing these new tracks? plicants. Certainly in our own institution we have seen that…some of the really top-notch applicants coming Integrated programs to our program have come in the last few years be- Dr. Ricotta: “Exposure to vascular surgery for a num- cause of the ability to do vascular or cardiothoracic ber of months every year for five years has a num- ESP. Now that the word is out in this coming year ber of advantages. The total exposure to both open when we have a flexibility option and we are really and endovascular cases and the exposure to the out- implementing it across the board, we are curious to patient practice of vascular surgery are much more see, with our applicant pool, whether or not that im- complete with a 36-month experience through the pacts their decision to come to our institution or oth- vascular integrated program than it is in the inde- ers that offer this [option] as well.

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

“The biggest challenge is in what we alluded to earlier, the resident complement of each given year. —Dr. Awad

“This [option] will allow more exposure and What concerns do you have more experience earlier, and as the name implies about these new programs? provide you with flexibility. In the past the Resident Review Committee (RRC) and ABS have been very Integrated programs strict about making sure that everyone looks the Dr. Bass: “There has certainly been some angst about same (in fact, you get a citation by your RRC) and whether the final surgeon produced from these new that all your residents should have the same rota- integrated training pathways will be as good as [those tions—that they should have similar case numbers surgeons who trained under] the traditional 5+2 mod- for any given year of residency—whereas now, it el, and it’s too early to tell. But the same concerns ex- allows folks to look different from each other, and isted for plastic surgery when they began integrated that is something fairly new and exciting.” programs, and now most people would agree that the | 47 final surgeon product is equivalent.T here is also angst ESP about whether medical students coming out of resi- Dr. Awad: “The benefits are that the ESPs can shorten dency know what they’re committing to. The aver- a year of your training. In those two specialties [car- age general surgery resident will change their minds diothoracic and vascular] in particular, the residents several times about the type of fellowship they want are still eligible for general surgery boards, but if they to pursue. But again, we had the same concerns about found out that they were not able to or that they did orthopaedics, urology, etc., in the past, and the people not want to sit for their boards, it would not jeopar- who go into urology stay in urology.” dize their careers; they could still pursue a career in vascular surgery or cardiothoracic surgery…. We have really studied our experience with those two What have been the challenges in programs, carefully looking at the in-service train- implementing your new programs? ing exam scores and the board passage rates, as well as their qualifications to sit for the boards, such as their Integrated programs case numbers and so forth. We found that they were Dr. Bass: “In the beginning, our general surgery able to meet all their case numbers even if they did one night float system took vascular call, but it became less year of general surgery, they were still doing well clear that the volume of vascular care required at on the American Board of Surgery In-Service Training night required an extra resident in house, so we Exam, and they were still passing their vascular and split the system and now vascular takes their own cardiothoracic surgery board exams.” calls. We’ve had some lateral moves out of general surgery residency into the vascular residency in the TTP beginning. One drawback is that we have probably Dr. Cogbill: “One-third of graduating chiefs do not feel seen a decline in interest in our own general surgery comfortable practicing independently. I think there is residents in going into vascular surgery, and since we a clear need for a fellowship program such as ours for no longer have a vascular fellowship, we currently have the new graduate who wants to perhaps practice in a no pathway for them here if that’s what they want to rural or underserved setting.” do; they’ll have to go somewhere else.”

AUG 2013 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

“One drawback is that we have probably seen a decline in interest in our own general surgery residents in going into vascular surgery, and since we no longer have a vascular fellowship, we currently have no pathway for them here if that’s what they want to do; they’ll have to go somewhere else.” —Dr. Bass

Dr. Ricotta: “The operative experience in the first three What additional specialties will years and, in particular, on the core surgery rotations be ripe for new tracks? have been lower than anticipated. Part of this [equation] is the desire to “save” cases for general surgery Dr. Ricotta: “I would like to see advanced minimally residents, but part is because junior general surgery invasive surgery, which I see as the basis of general trainees simply do not operate much in most programs. surgery, brought back into the core general surgery It has also been a challenge to have our vascular fac- training, along with enhanced endoscopy and good ulty let junior trainees, even in vascular surgery, do training in bariatric surgery. I think that advanced major parts of vascular reconstructive operations such surgical oncology and hepatopancreaticobiliary should as carotids and distal bypasses or open aortic expo- probably merge.” sures. We are used to not allowing junior residents to Dr. Bass: 48 | do much, and this now has to change. Finally, some “The wish list would be thoracic and perhaps of the core rotations we chose have had to be altered then, further down the line, colorectal. For thoracic, we because they did not give the residents the experience have an existing co-managed fellowship that we would that we thought they would.” have to evolve first. It may be best for that [fellowship] to live in the 3,4,5 tailored modification [flexibility op- ESP tion] for a few years before fully integrating the track. Dr. Awad: “You have to really map out carefully the resi- Again, a lot of this depends on our community and the dent block or resident cohort in any given year for the local resources/expertise over the next couple of years.” next couple of years for people who are going to do the ESP so that you are not going to be short in that given year. We have to pick these folks in their third year of Conclusion residency, and for CT it is fairly early in the third year when that decision is made. We have to march out our Since 1968, surgical specialties such as urology, ENT, grids and look at what our resident complements will be and orthopaedics have reduced or eliminated their time a year from now, two years from now, and make sure in general surgical training to accommodate increased there is not a significant impact there, and if there is, exposure to their subspecialty.1 In similar fashion, there [determine] how we are going to mitigate that. Some- is presently a trend toward the development of alterna- times it works out…we have somebody coming out of tive tracks or pathways to provide earlier or increased the lab earlier and it just happens to march out. But we exposure to subspecialties and disciplines that were have to be very careful and that’s one of the challenges traditionally two- to three-year fellowships after the we identified early.” completion of five years of general surgery training. There is certainly an interest in and place for early TTP specialization in surgery today. Various early special- Dr. Cogbill: “This is the first cohort of five programs -pi ization routes are attracting highly competitive medi- loting transitions to practice. There will be some leeway cal student applicants. Many of these applicants are in the start time, it may not be in the traditional aca- interested in completing their training sooner, paying demic year, but there will be standardization in terms off medical school or undergraduate debt faster, and of total length of the fellowship (1 year).” developing a more focused area of expertise.2,5 This

V98 No 8 Bulletin American College of Surgeons RAS-ACS: Evolving demands of resident training

[option] is particularly relevant in a medical world with rapidly ex- References panding knowledge and advancing technology. Furthermore, an 1. Stain SC, Biester TW, Hanks JB, Ashley increasingly well-informed public frequently seeks advanced and SW, Valentine RJ, Bass BL, Buyske specialized care.5 Moreover, some evidence indicates that complex J. Early tracking would improve the operative experience of general surgery operations performed by specialized, high-volume surgeons have residents. Ann Surg. 2010;252(3):445-449; better outcome.1 discussion 9-51. The enthusiasm for early specialization is tempered with a prag- 2. Klingensmith ME, Valentine RJ. Early matic understanding and mindfulness of the importance and need for experience with alternative training broad-based general surgeons. There is also concern that increased pathways: A view from the trenches. J Surg Educ. 2009;66(2):80-84. focus on early specialization will reduce interest in general surgery. 3. The American Board of Surgery. The fact of the matter is that the need for general surgeons is increas- Flexible rotations during general surgery residency. Available at: ing as community-based general surgeons provide the majority of | 49 surgical care delivered in the U.S.1 Consequently, there is a growing http://www.absurgery.org/default. need for more broadly trained surgeons capable of addressing a diverse jsp?policyflexrotations. Accessed May 1 20, 2013. array of surgical conditions. Concerns have also been raised regard- 4. Hoyt DB. Looking forward. Bull Am Coll ing accountability for the surgical patient as a whole, as one job of Surg. 2013;98(2):7-10. specialists is often to determine whether a problem falls within their 5. Longo WE, Sumpio B, Duffy A, scope of expertise or practice.6 As Dr. C.M. Ferguson, former direc- Seashore J, Udelsman R. Early tor, Massachusetts General Hospital, Boston, cautions, “as a surgeon specialization in surgery: The new frontier. Yale J Biol Med. 2008;81(4):187- concentrates on a single disease and becomes more specialized, he or 191. she becomes less competent in treating other diseases. The specialist 6. Ferguson CM. The arguments becomes disease centered rather than patient centered.6 against fellowship training and early Dr. Awad noted that much of the current training paradigm is specialization in general surgery. Arch based on tradition and history and not necessarily educational theory Surg. 2003;138(8):915-916. or practices. Early specialization is still young, and the outcomes that these new models may yield will certainly have a significant impact on future surgical training. As Walter Longo, MD, professor of surgery at Yale University School of Medicine, New Haven, CT, reaffirmed in stating the principles of surgical training, “It is the goal of general surgery residency training to produce competent surgeons who will be able to meet the challenges of innovation, new technology, difficult pathology, and above all, to be safe, compassionate doctors.”5 The challenge rests in developing training paradigms that satisfy and reconcile surgical history and tradition with educational rationale, as well as with the needs of physicians, patients, and society. 

AUG 2013 Bulletin American College of Surgeons ACS Bulletin: October 1982

Centennial reprint: Course coordinator describes purposes of ATLS® program

o help commemorate the Ameri- 50 | can College of Surgeons’ (ACS) TCentennial, the Bulletin of the Amer- ican College of Surgeons has been reprint- ing articles that exemplify how the organization has responded to the pressing issues in surgery over the last century. This month’s reprint from the October 1982 issue describes the purposes of the Advanced Trauma Life Support (ATLS®) course. This article explains why the ACS Committee on Trauma agreed to spon- sor and contribute to the development of the course. The purposes of the course, the format of the program, and the national and international response to it also are described. For a more complete overview of the ATLS course, see the “Looking forward” column by ACS Executive Director David B. Hoyt, MD, FACS, on page 8. 

V98 No 8 Bulletin American College of Surgeons ACS Bulletin: October 1982

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AUG 2013 Bulletin American College of Surgeons ACS Bulletin: October 1982

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V98 No 8 Bulletin American College of Surgeons What surgeons should know about...

Using S-CAHPS

by Jill Sage, MPH

atient experience-of- with other surgical and anesthesia and promote the assessment of care measures have been organizations, sponsored the consumers’ experiences with Pidentified as critical for development of the S-CAHPS. health care.4 AHRQ is an agency increasing the quality of care The S-CAHPS is a patient of the U.S. Department of Health in the U.S. Expanding patients’ experience-of-care survey and Human Services that seeks involvement in their own care measure specifically tailored for to improve the quality, safety, has shown to improve health surgical patients. The S-CAHPS efficiency, and effectiveness of outcomes.1,2 Access to reliable, survey was developed by working health care services by supporting meaningful, and understandable with patients to report on the research that helps people health care information full experience of surgical care, make informed decisions. empowers patients to determine including their experience with The development of the survey which providers offer high- the surgeon, the anesthesiologist, followed the standardized and value care and to make health and the facility. The data evidence-based methods that are care decisions that are aligned gathered through S-CAHPS used in the creation of all CAHPS with their personal needs. assist consumers in identifying surveys. The S-CAHPS expands The National Quality Strategy a high-quality surgeon and help on the CG-CAHPS Survey, (NQS), part of the Affordable surgeons to better understand and which focuses on primary and | 53 Care Act (ACA), sets priorities to ultimately improve patient care. specialty care, by incorporating guide local, state, and national domains that are relevant to efforts to improve the quality of surgical care, including informed health care in the U.S. The NQS What does S-CAHPS measure? consent, anesthesia care, and aims to provide better, more In 2007, the ACS, in partnership postoperative follow-up. The affordable care, includes person- with other surgical and anesthesia survey assesses surgical patients’ and family-centered care as one organizations, reviewed the experiences before, during, and of its top priorities;3 and gives Clinician and Group CAHPS after surgical procedures and precedence to the inclusion of (CG-CAHPS), which measures focuses on concerns that patients validated patient experience-of- patients’ perceptions of care identified as most important to care survey measures in national in the physician office setting, their experience. Specifically, payment, quality improvement, and concluded that it did not the S-CAHPS survey captures and public reporting programs. adequately capture information data on such issues as how well This column summarizes the that is relevant to patients’ patients were prepared for their benefits and application of assessment of surgical care. operation, how well the surgeon the Consumer Assessment of As a result, the surgical and communicated with them about Healthcare Providers and Systems anesthesia groups and the what to expect when having an Surgical Care Survey (S-CAHPS). Agency for Healthcare Quality operation, and what information and Research’s (AHRQ) CAHPS was provided to aid in recovery. Consortium collaborated to The use of this type of What is the purpose create a CAHPS survey to assess standardized surgical care survey of S-CAHPS? surgical patients’ experiences and is critical in comparing individual To offer surgical patients and thereby identify opportunities practice against benchmarks. surgeons valid and reliable to improve quality of care, To develop the S-CAHPS information on patient experience surgical outcomes, and patient survey, six patient focus of care, the American College of experience. CAHPS is a multi-year groups were formed to identify Surgeons (ACS), in partnership initiative of AHRQ to support important quality issues inherent

AUG 2013 Bulletin American College of Surgeons What surgeons should know about... Figure 1 NQF-endorsed S-CAHPS survey measures S-CAHPS composite measures: Information to help you prepare for surgery (2 items) How well surgeon communicates with patients before surgery (4 items) Surgeon’s attentiveness on day of surgery (2 items) Information to help you recover from surgery (4 items) How well surgeon communicates with patients after surgery (4 items) Helpful, courteous, and respectful staff at surgeon’s office (2 items) S-CAHPS single item: Rating of surgeon (1 item) Source: National Quality Forum, Surgery Endorsement Maintenance 2010: Technical Report, June 2012. Available at: http://www.qualityforum.org/Projects/Surgery_Maintenance.aspx. Accessed June 3, 2013.

in patients’ experiences of surgical includes six composite measures survey items that are specific care. Nine surgical specialties— and one single-item measure (see to their patients and practice. colon-rectal, ophthalmology, Figure 1, this page). Composite However, the core survey must general, orthopaedic, plastic, measures summarize categories be used in its entirety in order otolaryngology, thoracic, of experiences, thereby shortening to be comparable with other urology, and vascular— the report, which makes it easier S-CAHPS data. The S-CAHPS participated in the main field for consumers to understand. survey may be used in both the test. The S-CAHPS Technical (Figure 2 on page 55 provides an inpatient and outpatient setting. Advisory Panel included 21 example of a composite measure 54 | representatives of various included in the S-CAHPS.) surgical specialty societies. Where are CAHPS surveys being used? Why should surgeons The implementation of patient How is S-CAHPS used use S-CAHPS? experience-of-care measurement to measure quality? Surgeons can be confident that is a priority for national payment The S-CAHPS is the only National survey results will accurately and public reporting programs. Quality Forum (NQF)-endorsed assess patients’ surgical care The Centers for Medicare measure designed to assess experiences because S-CAHPS & Medicaid Services (CMS) surgical quality from the patient’s was developed in consultation has included the CG-CAHPS perspective. The NQF endorses with patients using the most survey in the Physician Quality quality measures through sophisticated, valid, and reliable Reporting System (PQRS) as a scientific and evidence-based methodologies available in survey measure that may be applied review and a multi-stakeholder and measurement science. An to the physician value-based consensus development process important distinction when payment modifier (VM) under with the aim of improving quality comparing patient experience the quality-tiering option for of care. Measures that the NQF versus patient satisfaction is that PQRS reporters, and as a measure endorses are rigorously reviewed patient experience measures that may be reported for large to determine whether they meet aspects of care that are actionable group practices on the CMS certain criteria, including the for surgical quality improvement. Physician Compare website. The ability to make significant gains And because the survey American Board of Surgery (ABS) in health care quality, scientific instrument, protocol, analysis, has also elected to participate acceptability, usability, feasibility, and reporting are standardized, in the PQRS Maintenance of and reliability. NQF endorsement surgeons can benchmark and CertificationI ncentive Program. confirms that the survey meets compare their performance In order to be eligible for the the “gold standard” in quality with that of their peers. incentive payment associated measurement. The NQF endorsed Surgeons may customize with that program, a surgeon the S-CAHPS as a measure that the S-CAHPS survey by adding must submit data on patient

V98 No 8 Bulletin American College of Surgeons What surgeons should know about... Figure 2 NQF-endorsed S-CAHPS Composite How well surgeon communicates with patients after surgery 1. After your surgery, did this surgeon listen carefully to you? 2. After your surgery, did this surgeon spend enough time with you? 3. After your surgery, did this surgeon encourage you to ask questions? 4. After your surgery, did this surgeon show respect for what you had to say? Response options: Yes, definitely; Yes, somewhat; No Source: National Quality Forum, Surgery Endorsement Maintenance 2010: Technical Report, June 2012. Available at: http://www.qualityforum.org/Projects/Surgery_Maintenance.aspx. Accessed June 3, 2013. experience-of-care surveys. the unintended consequence of attribute patient care so that Following are descriptions misclassifying a physician’s care patients can select physicians who of how CAHPS surveys have and unfairly affecting payment.5 truly deliver high-value care. been incorporated into quality improvement programs. Where can surgical patients Can I report CAHPS get information on patient as part of MOC? How does my practice use experience of care? Is CAHPS During 2013 and 2014, physicians CAHPS when applying the VM? information reported on who participate in PQRS have The Affordable Care Act (ACA) Physician Compare? the opportunity to earn an requires staged implementation of Physician Compare is a website additional 0.5 percent incentive a VM to physicians enrolled in the that provides information to payment through the PQRS MOC Medicare program. The VM will consumers to help them make Payment Incentive Program. be applied to specific physicians better-informed health care Physicians may participate by (1) | 55 and groups of physicians starting decisions and to encourage satisfactorily submitting data on in 2015 and to all physicians and physicians to maximize quality measures under PQRS for groups of physicians by 2017. performance.6 In support of a 12-month reporting period, and Under this program, physicians consumer choice and value-based (2) reporting “more frequently who report through PQRS have a purchasing, the ACA requires than is required” to qualify for or few reporting options, including CMS to publicly report patient maintain board certification.7 As a quality-tiering option that experience-of-care measures on part of this program, the ABS will calculates the VM based on a Physician Compare. As early as submit information from a patient quality-of-care composite score 2014, CMS will include the names experience-of-care survey. The and a cost composite score. For of physicians who earned a PQRS ABS has applied in 2013 for CMS those who choose the quality- Maintenance of Certification approval of its MOC program for tiering option, PQRS patient (MOC) Payment Incentive on the PQRS MOC Incentive and experience measures are included Physician Compare and will will include S-CAHPS as a patient as one of the domains of the post performance information experience-of-care survey option. quality composite, as illustrated collected through the PQRS For more information on the in Figure 3 on page 56. Currently, Group Practice Reporting Option submission process, contact the CG-CAHPS is the only patient- (GPRO) Web interface, which ABS at http://www.absurgery.org/. experience-of-care measure in applies to groups of 100 or more The CG-CAHPS is the first the PQRS program, and thus providers, and for groups that step in the implementation the only measure of its type participated in the Accountable of patient experience-of-care that can be used to calculate the Care Organization GPRO. For measures across physician-level VM. The ACS has emphasized similar reasons for concerns CMS programs. The Hospital to CMS that it is critical that the regarding the inclusion of CAHPS (H-CAHPS) has been measures included in the quality- measures that could misclassify used nationally since 2008 for tiering composite are valid, a physician’s care and impact facility-level patient experience of reliable, and applicable to all payment, it is critical that CMS care.8 The ACS has recommended health care professionals, to avert select measures that accurately the future inclusion of S-CAHPS

AUG 2013 Bulletin American College of Surgeons What surgeons should know about... Figure 3. Value-based Payment Modifier quality-tiering methodology9

Clinical Care

Patient Experience

Population/Community Health Quality of Care Composite Score Patient Safety

VALUE Care Coordination MODIFER AMOUNT

Efficiency

Total Overall Costs Cost Composite Total Costs for Beneficiaries Score with Special Conditions

Source: Quality-tiering methodology, physician value-based payment modifier under the Medicare physician fee schedule 2013 final rule. Available at: http://www.cms.gov/Outreach-and-Education/ Outreach/NPC/Downloads/Presentation-QRUR-112012.pdf. Accessed June 3, 2013.

for the VM, Physician Compare, References 1. Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care: 56 | and PQRS, stressing that the CG-CAHPS is not equally Effects on patient outcomes. Ann Intern Med. 1985;(102):520-528. meaningful to surgical patients, 2. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;(152):1423-1433. and is an inappropriate patient 3. U.S. Department of Health and Human Services. 2012 Annual Progress Report to experience-of-care survey for Congress: National Strategy for Quality Improvement in Health Care. Available at: surgeons and surgical groups. http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf. Accessed The S-CAHPS assesses care June 3, 2013. by focusing on aspects of surgical 4. Agency for Healthcare Quality and Research. CAHPS. Available at: http:// cahps.ahrq.gov/about.htm. Accessed June 3, 2013. quality that are important to 5. Centers for Medicare & Medicaid Services. Value-based payment modifier. patients and for which patients are Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- the best source of information. Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. As patient experience-of-care Accessed June 3, 2013. measures are increasingly 6. Byers R, Estella C, Adams S. Centers for Medicare & Medicaid Services: Public reporting, Physician Quality Reporting System (PQRS), Group incorporated into public reporting Practice Reporting Option (GPRO), and Consumer Assessment of Healthcare and payment programs, it is Providers and Systems (CAHPS). Presented at: Surgical Quality Alliance especially important that the Meeting, March 2013, Washington, DC. patient-centered instruments 7. Centers for Medicare & Medicaid Services. 2013 Physician Quality Reporting chosen accurately reflect patient System (PQRS) maintenance of certification program incentive. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- experience and are meaningful Instruments/PQRS/Maintenance_of_Certification_Program_Incentive. to both consumers and surgeons. html. Accessed June 3, 2013. For more information and 8. Agency for Healthcare Research and Quality. HCAHPS fact sheet reference. to access the survey, visit the Available at: http://www.hcahpsonline.org/files/HCAHPS%20Fact%20 ACS website at www.facs.org/ Sheet%20May%202012.pdf. Accessed June 3, 2013. 9. Centers for Medicare & Medicaid Services. Quality-tiering methodology, ahp/cahps/index.html.  physician value-based payment modifier under the Medicare physician fee schedule 2013 final rule. Available at: http://www.cms.gov/Outreach-and- Education/Outreach/NPC/Downloads/Presentation-QRUR-112012.pdf. Accessed June 3, 2013.

V98 No 8 Bulletin American College of Surgeons Coding and practice management corner

Coding for damage-control surgery

by Linda M. Barney, MD, FACS; Jenny J. Jackson, MPH, CPC; Charles D. Mabry, MD, FACS; Mark T. Savarise, MD, FACS; and Christopher K. Senkowski, MD, FACS

he American College of address definitive management (metabolic acidosis, anemia, Surgeons (ACS) General when the patient is stable and coagulopathy) and volume TSurgery Coding and able to undergo more prolonged replacement, as well as provision Reimbursement Committee procedures. Initially developed of ventilation and vasopressor | 57 (GSCRC) frequently receives by the military and major support. Massive tissue edema questions regarding appropriate trauma centers, the concept and concern for compartment coding for “damage-control of damage-control surgery syndrome may necessitate a laparotomy” or “damage- is now widely accepted and temporary closure strategy. control surgery.” Damage- may be applied to the chest, During the subsequent control surgery typically abdomen, or extremities. phases of damage control, the involves a multistage approach In the initial stage of surgeon completes definitive and is performed with the damage control, hemorrhage operative management in the intention to first avoid or is stopped, contamination is stable patient, reestablishes correct the lethal triad of controlled, and temporary gastrointestinal continuity, hypothermia, acidosis, and wound closure methods may evaluates all areas for viability, coagulopathy before definitive be employed. Vascular control and delineates any missed management of injuries. The may include ligating bleeding injuries. Vascular shunts general concept is the expedient vessels, oversewing mesentery are removed and long-term control of life-threatening or organ injury, packing of the repairs of vascular injuries bleeding and contamination, abdomen or chest, and even are constructed. Orthopaedic, usually terminated as soon placing vascular shunts without plastic, head and neck, or other as possible in order for the definitive repair of blood specialty-specific repairs are also patient to undergo correction of vessels. For gastrointestinal performed in concert with the physiologic abnormalities due contamination, the bowel is abdominal, chest, or vascular to hemorrhagic shock or sepsis. resected or lacerations oversewn. surgery, as necessary. With the Subsequent stages of surgery Restoration of bowel continuity advent of temporary abdominal *All specific references to CPT (Current (anastomosis) or maturation of closure technology, the concept Procedural Terminology) codes and an ostomy is performed at a later of damage control also applies descriptions are © 2012 American Medical stage. The resuscitation phase to the second-look laparotomy Association. All rights reserved. CPT and CodeManager are registered trademarks is characterized by correction approach to ischemic bowel, of the American Medical Association. of physiologic abnormalities severe necrotizing infections

AUG 2013 Bulletin American College of Surgeons Coding and practice management corner

seen in pancreatitis, and a host of other conditions. C PT codes to avoid or to use Temporary closure of abdomen, Because of the complexity An exploratory laparotomy, large extremity wounds and range of injuries treated for whether for trauma or a medical In many cases of damage-control purposes of damage control, condition, may be reported using surgery, the patient’s condition no single Current Procedural CPT code 49000 (exploratory may require that closure of skin, Terminology (CPT)* code can laparotomy, exploratory celiotomy subcutaneous tissue, muscle, or adequately describe all of the with or without biopsy(s) (separate fascia be delayed, resulting in potential combinations and procedure). The term “separate the abdominal wound left open permutations of the procedures procedure” refers to a complete and the abdominal contents that may be required. More procedure that stands alone. protected by application of one of importantly, because the Centers Therefore, CPT code 49000 various mechanical techniques for Medicare & Medicaid refers to a complete procedure to maintain sterility, moisture, Services (CMS) requires that that stands alone and normally is and heat in the abdominal cavity. any value assigned to a CPT not billed with other procedure Temporary closure is code represent the typical codes. Thus, CPT code 49000 typically used during the first 58 | patient, any attempt to arrive describes a laparotomy where operation but may also be at one proper value for a single nothing is repaired, removed, used during subsequent re- damage laparotomy code would or reconstructed, for example, explorations of the abdomen likely devalue the complexity a negative laparotomy. This if abdominal fascia and skin of work performed in many scenario would be unlikely in closure cannot be achieved. For instances. For procedures such the face of a damage-control large contaminated extremity as damage-control surgery, situation in which other wounds, this temporary where many combinations are CPT codes would typically closure technique also may possible, it is always best to use be required, such as bowel be applied. Although there a series of discrete CPT codes repair or splenectomy. is not a specific CPT code to to both describe and value the Typically during a trauma describe a specific temporary services performed rather than laparotomy, multiple extensive closure technique, some codes attempt to lump these myriad of abdominal procedures are may be used if a negative procedures into a single damage- performed. The surgeon should pressure wound dressing is control surgery CPT code. first select a series of CPT codes used as part of the temporary To help Fellows and their staff that appropriately reports wound closure technique. properly code for damage-control the specific repairs, excisions, For example, use CPT 97606 surgery, the ACS GSCRC has anastomoses, or drainage (negative pressure wound therapy carefully reviewed the existing procedures performed. From (eg, vacuum-assisted drainage CPT codes and has determined those procedures, one is then collection), including topical that most variations of damage- selected that represents the application(s), wound assessment, control surgery can be adequately primary or most major surgical and instruction(s) for ongoing reported with existing CPT codes. procedure, and is reported first, care, per session; total wound(s) This column explains how to with the additional procedures surface area greater than 50 square correctly code for damage-control performed being reported centimeters, for application of approaches using the current CPT with the appropriate CPT this type of device as an aid manual, which could prove useful codes and modifiers (typically to close large wounds of the to surgeons and their coding staff. modifier 51 is appended). abdomen, trunk, or extremities.

V98 No 8 Bulletin American College of Surgeons Coding and practice management corner

session as the re-exploration Case 2: A 38-year-old motor-vehicle Reopening of a recent of the laparotomy, such as crash patient with multiple laparotomy CPT code 44120 (enterectomy, injuries initially undergoes a As previously discussed, damage- resection of small intestine; single damage-control laparotomy with control surgery involves a follow- resection and anastomosis), then direct repair of torn mesenteric up phase in which the abdomen re-exploration of the laparotomy blood vessels, small bowel is re-explored and definitive (49002) should not be used, as resection without reconstruction, procedures may be performed, it is considered inherent to the and temporary abdominal for example, bowel anastomosis, more extensive procedure and closure using a vacuum-assisted packing removed, and so on. is not separately reportable. wound drainage device. Final abdominal fascial closure On hospital day three, will likely be part of the final following resuscitation in the procedure in a damage-control Clinical scenarios intensive care unit (ICU), the scenario. For re-exploration that patient undergoes re-exploration involves re-opening, completely Case 1: A 40-year-old gunshot- of the laparotomy, debridement/ exploring, and irrigating the wound patient is taken to resection of the previously the operating room for a abdomen, where no other major stapled ends of the bowel, | 59 procedures (for example, bowel planned reopening of a and anastomosis of the small anastomosis or resections) recent laparotomy to examine intestine, again with temporary are performed, report CPT the progress of healing. abdominal closure. On the fifth code 49002 (reopening of recent The surgeon completes an day, the surgeon completes an laparotomy.) CPT code 49002 abdominal exploration; the small abdominal exploration to confirm describes a procedure that may bowel is examined, revealing anastomotic integrity, irrigates be used in instances of trauma, the site of the anastomosis to the abdomen, and applies a sepsis, or ischemic bowel surgery be completely intact with no vacuum-assisted wound drainage to examine the progress of evidence of a leak or vascular as part of the progression to healing, check on the integrity compromise. The surgeon fascial and skin closure when of an anastomosis, detect missed irrigates the abdomen and the timing is appropriate. The injuries or further ischemia, and then applies vacuum-assisted reportable procedures include: irrigate the abdomen. In the wound drainage before closing case of damage-control surgery, the wound again. Reportable Day 1: the re-exploration falls within procedures include: • 44120-52, Enterectomy, resection of the 90-day global period of the small intestine; single resection and initial procedure. Therefore, it is • 49002-58, Reopening of recent anastomosis important to append modifier 58 laparotomy (staged or related procedure by the • 35221, Repair blood vessel, direct; same physician) if re-explorations • 97606, Negative pressure wound intraabdominal of the abdomen are performed by therapy (eg, vacuum-assisted the same surgeon (or a surgeon in drainage collection), including topical • 97606, Negative pressure wound the same billing group) in order to application(s), wound assessment, therapy (eg, vacuum-assisted capture the correct value of this and instruction(s) for ongoing drainage collection), including topical procedure. Remember, if a more care, per session; total wound(s) application(s), wound assessment, extensive abdominal procedure surface area greater than 50 square and instruction(s) for ongoing is required in the same operative centimeters care, per session; total wound(s)

AUG 2013 Bulletin American College of Surgeons Coding and practice management corner

surface area greater than 50 square the fascia of the abdominal • 97606, Negative pressure wound centimeters cavity remains closed, or therapy (eg, vacuum-assisted the granulation tissue of the drainage collection), including topical Note that modifier 52 (reduced abdominal wall is not entered application(s), wound assessment, services, is applied to the enterectomy to gain access to the abdomen, and instruction(s) for ongoing code because a resection, but not an the appropriate code to report care, per session; total wound(s) anastomosis) was performed. is 97606 plus any applicable surface area greater than 50 square wound debridement codes centimeters Day 3: (CPT 11042–11047). You should • 44120-58, Enterectomy, resection of not report CPT 49002 if the Day 2: small intestine; single resection and abdominal cavity is not entered. • 47362-58, Management of liver anastomosis hemorrhage; re-exploration of hepatic Case 3: A 32-year-old gunshot- wound for removal of packing. Note • 97606, Negative pressure wound wound patient undergoes an that there is a specific code for re- therapy (eg, vacuum-assisted initial laparotomy for repair exploration for liver wound, and drainage collection), including topical of stomach and liver, with 49002 is not appropriate here.) debridement of the liver and 60 | application(s), wound assessment, and instruction(s) for ongoing packing, plus placement of • 97606, Negative pressure wound care, per session; total wound(s) negative pressure dressing therapy (eg, vacuum-assisted surface area greater than 50 square for temporary closure. drainage collection), including topical centimeters The next day, the patient application(s), wound assessment, is re-explored and the liver and instruction(s) for ongoing Day 5: packing is removed with no care, per session; total wound(s) • 49002-58, Reopening of recent other injuries found, but the surface area greater than 50 square laparotomy abdomen still cannot be closed. centimeters Over the next three days the • 97606, Negative pressure wound patient is managed aggressively Day 6: therapy (eg, vacuum-assisted in the ICU, including diuresis, • 49002-58, Reopening of recent drainage collection), including topical and on day six, the patient can laparotomy application(s), wound assessment, be returned to the operating and instruction(s) for ongoing room for final inspection, wash- care, per session; total wound(s) out, debridement, and closure Definitive abdomen closure surface area greater than 50 square of the abdominal fascia. To appropriately report the centimeters delayed definitive closure Day 1: of the open abdomen, the It is important to note that • 47361, Management of liver condition of the abdomen, at some point the abdominal hemorrhage; exploration of hepatic abdominal wall, and soft tissue fascia is closed, leaving only a wound, extensive debridement, around the open defect will superficial abdominal wound. coagulation and/or suture, with or help to determine the best Thus, when the procedure without packing of liver combination of CPT codes involves only a negative to report. Many abdominal pressure wound therapy • 43840-51, Gastrorrhaphy, suture of wounds need some form of device change and “active perforated duodenal or gastric ulcer, debridement prior to, or at wound management” but wound, or injury the time of, definitive closure.

V98 No 8 Bulletin American College of Surgeons Coding and practice management corner

CP T codes 11042–11047 are In some instances in which parts operation,’’ to achieve debridement codes arranged by a certain amount of time has closure of large fascial defects or depth and size of debridement. passed between the initial surgery ventral hernias is becoming more For some patients with a and definitive closure of the common in these complicated recent open abdomen, the fascial abdomen, a wide gap between cases. The muscle flap code edges, subcutaneous tissue, the opposing fascial edges may 15734 (muscle, myocutaneous, or and skin can all be mobilized develop in the abdominal wall. fasciocutaneous flap; trunk) is the and then closed primarily. In Under these circumstances, the appropriate code to report; it is this instance, the abdominal resultant fascial defect creates reported twice to represent the wall functions as one unit that a potential hernia. If this fascial mobilization of the musculo- can be re-approximated to defect can be closed primarily, fascial flap on both sides and is itself, and there is not a fascial report CPT code 49560 (repair paid at 150 percent of a unilateral defect, per se. Where this type initial incisional or ventral hernia; separation. For a more detailed of closure can be accomplished, reducible) which would include explanation on coding component report CPT code 49900 (suture, any isolation and dissection of separation, go to www.facs.org/ secondary, of abdominal wall for fascia or a hernia sac, reduction of ahp/pubs/tips/tips0911.pdf. evisceration or dehiscence). intraperitoneal contents, fascial For additional information | 61 If the entire abdominal wall repair, and soft tissue closure. on billing critical care services cannot be closed primarily, then Additionally, if the fascia cannot for severely ill or injured coverage of an open abdominal be easily or safely approximated patients, see the June Bulletin wound may be achieved with and mesh is needed to assist with column, “Effectively using E/M autograft skin, tissue cultured skin, closure, the implantation of mesh codes for trauma care” (Bull or skin substitute grafts. If the area or other prosthesis is described Am Coll Surg, 98(6):56-65). to be grafted requires incision or with the use of an add-on CPT The coding for damage-control excisional procedures to properly code 49568 (implantation of mesh or surgery involves many potential prepare the site to accept a graft, other prosthesis for open incisional CPT codes, modifiers, and use the skin preparation CPT or ventral hernia repair or mesh for concurrent coding rules. If you codes 15002–15005 to appropriately closure of debridement for necrotizing have additional coding questions, report those services. Autografts soft tissue infection. [List separately in contact the ACS Coding Hotline are reported with CPT codes addition to code for the incisional or at 800-227-7911 between 7:00 am 15100–15111. Tissue cultured skin ventral hernia repair.]) This add-on and 4:00 pm Mountain time, grafts are reported with CPT code applies to any type of mesh excluding holidays, or go to www. codes 15150–15152. Skin substitute or other prosthesis—whether facs.org/ahp/pubs/tips/index.html.  grafts, regardless of the type synthetic, biologic, or otherwise. (for example, nonautologous Other patients with human skin, nonhuman skin complicated conditions may Editor’s note substitutes, or biological), are have lost part of their abdominal Accurate coding is the responsibility reported with CPT codes 15271– wall or have contractures of of the provider. This summary 15274. The appropriate codes the abdominal musculature is only intended as a resource to for grafting are selected based over time so that more complex assist in the billing process. upon location (body area) of the procedures are needed to graft and size of the defect, thus properly close this fascial gap. it is important to include those Component separation, also details in the operative report. known as the “separation of

AUG 2013 Bulletin American College of Surgeons A CS Clinical Research Program

Improving cancer care through quality measures: Putting evidence to work with the CoC by Christopher M. Pezzi, MD, FACS; Henry M. Kuerer, MD, PhD, FACS; and Heidi Nelson, MD, FACS

he emphasis on quality had access to and were offered Table 1. health care has continued to the evidence-based care they Organizations Tincrease in recent years in deserve, outcomes would involved in defining the U.S. However, defining and improve and fewer patients and measuring breast then measuring quality fairly and would die from cancer without cancer quality care appropriately can be a challenge, any additional breakthrough • ACS CoC and keeping up with the large in treatment. To achieve • ACS National Accreditation number of organizations involved this goal, the development, Program of Breast Centers in this evolving process can be measurement, and reporting daunting. Cancer and specifically of quality measures in cancer • Quality Oncology Practice breast cancer quality measures are care are necessary. Increasingly, Initiative of the American Society of Clinical Oncology 62 | being developed by a host of often insurers, accrediting bodies, the jointly collaborating organizations federal government (the largest • American Society of and subsidiary groups (see Table 1, insurer), and the public expect Breast Surgeons this page), and the types of quality us to find ways to measure • Society of Surgical Oncology measures for breast cancer may be quality, report our outcomes, • American Society for grouped into at least six general and minimize deviations Radiation Oncology categories (see Table 2, page 63). from evidence-based care. • NQF Strong evidence has emerged from prospective, randomized • Physician Quality Reporting trials and other high-quality Raising the bar System of the Centers for clinical research in oncology, The American College of Medicare and Medicaid Services which is useful in determining Surgeons (ACS) Commission • PPS-Exempt Cancer the optimal treatment currently on Cancer (CoC) collects more Hospital Quality Reporting available—not just for each major than 100 individual data points Program mandated under cancer type, but for each stage of regarding the treatment of every the Affordable Care Act each disease site. This evidence cancer patient at more than • American Medical Association serves as the basis for detailed, 1,500 CoC-accredited hospitals. Physician Consortium for accessible national guidelines for Certified cancer registrars Performance Improvement cancer care, such as those that the collect and submit the data. CoC • College of American Pathology National Comprehensive Cancer hospitals treat approximately • National Comprehensive Network (NCCN) has developed. 70 percent of all new patients Cancer Network However, inconsistencies in diagnosed with cancer annually care persist across the country, in the U.S. The data collected • National Consortium of Breast Centers resulting in some patients being resides in the National Cancer unable to receive the proven Data Base (NCDB), which and optimal care that would contains the records of more maximize their outcomes. If all than 30 million cancer patients. patients with a cancer diagnosis Long-term follow-up also allows

V98 No 8 Bulletin American College of Surgeons A CS Clinical Research Program

The American College of Surgeons Commission on Cancer collects more than 100 individual data points regarding the treatment of every cancer patient at more than 1,500 CoC-accredited hospitals.

Table 2. the examination of survival patients to be considered for the Categories of quality rates. In addition to emerging as treatment. Quality improvement measure for breast a powerful tool for research and measures are strongly supported cancer national cancer control efforts, by the literature and are • Breast cancer risk assessment the NCDB enables the CoC to considered optimal care, but measure and report specifics supporting evidence often is less • Appropriateness of care (diagnostic and imaging, of cancer care individually to definitive than for accountability pathologic, surgical, medical, CoC-accredited hospitals. measures. Finally, surveillance radiation, and follow-up) The CoC has adopted a panel measures report patterns of care of clinically proven, specific that the CoC believes hospitals • Timeliness of breast quality measures and provides should monitor, but for which no cancer care this information to participating optimal pattern of care is known, | 63 • Patient-centered hospitals. The CoC also submits and for which patterns of care satisfaction with care appropriate measures to the may vary for legitimate reasons. • Treatment-related National Quality Forum (NQF) The CoC has adopted five breast complication rates for potential endorsement. CoC cancer accountability or quality im- • Breast cancer care outcomes quality measures currently provement measures and the NQF (recurrence and survival) address cancers of the breast, has endorsed four of them. These lung, esophagus, stomach, colon, four NQF-endorsed measures are and rectum. New measures are summarized in Table 3 on page 64. planned, which will address other The fifth breast quality measure disease sites including melanoma, that the CoC has adopted states that sarcoma, gynecologic, and patients undergoing mastectomy urologic. These measures will and having four or more positive be adopted in collaboration with lymph nodes should be offered ra- leaders from premier disease- diation therapy in addition to the site societies in each field. surgical procedure. This measure will be submitted for NQF consid- eration this year. CoC quality measure categories The CoC confidentially reports Three levels of quality measures compliance levels with quality mea- are considered: accountability, sures to all 1,500 accredited hospi- quality improvement, and tals. However, federal law mandates surveillance. Accountability public reporting of compliance with measures are supported by the two of the NQF-endorsed breast highest level of medical evidence cancer quality measures (NQF 0220 (usually prospective randomized and 0559 from Table 3 on page 64) clinical trials), indicating that it for 11 prospective payment system is appropriate to expect nearly all (PPS)-exempt cancer hospitals start-

AUG 2013 Bulletin American College of Surgeons A CS Clinical Research Program

The CoC also submits appropriate measures to the National Quality Forum for potential endorsement. CoC quality measures currently address cancers of the breast, lung, esophagus, stomach, colon, and rectum.

Table 3. ing in 2014. This “report card” of Four NQF-endorsed CoC breast cancer quality measure compliance for measures (as of October 2012)* the 11 PPS-exempt hospitals will • Post-breast conservation surgery irradiation: be available for public review on Percentage of female patients, age 18 to 69, who have their first diagnosis the Medicare Hospital Compare of breast cancer (epithelial malignancy), at American Joint Committee on website at www.medicare.gov/hospi- Cancer (AJCC) stage I, II, or III, receiving breast conserving surgery, who talcompare. receive radiation therapy within one year of diagnosis (NQF 0219) Through collaboration with so- • Adjuvant hormonal therapy: cieties devoted to breast surgery, Percentage of female patients, age 18 and older at diagnosis, who have their radiation oncology, and medical first diagnosis of breast cancer (epithelial malignancy), at AJCC stage I, II, oncology, additional breast cancer or III, whose primary tumor is progesterone or estrogen receptor-positive 64 | measures will be adopted. Lastly, recommended for tamoxifen or third-generation aromatase inhibitor collaboration with the Alliance for (considered or administered) within one year of diagnosis (NQF 0220) Clinical Trials in Oncology will en- • Combination chemotherapy is considered or administered within four sure the more rapid incorporation months (120 days) of diagnosis for women under age 70 with AJCC T1c, of new knowledge and development or stage II or III hormone receptor-negative breast cancer: of important quality measures to Percentage of female patients, age 18 and older at diagnosis, who have facilitate timely practice implemen- their first diagnosis of breast cancer (epithelial malignancy), at AJCC stage tation.  T1c, or stage II or III, whose primary tumor is progesterone and estrogen receptor-negative recommended for multi-agent chemotherapy (considered or administered) within four months (120 days) of diagnosis (NQF 0559) • Needle biopsy to establish the diagnosis of cancer precedes surgical excision/resection: Percentage of patients presenting with AJCC stage group 0, I, II, or III disease, who undergo surgical excision/resection of a primary breast tumor, who undergo a needle biopsy to establish diagnosis of cancer preceding surgical excision/resection (NQF 0221)

*National Quality Forum. Endorsement summaries. Available at: http:// www.qualityforum.org/News_And_Resources/Endorsement_Summaries/ Endorsement_Summaries.aspx. Accessed June 13, 2013.

V98 No 8 Bulletin American College of Surgeons A look at T13Ahe UGJointBULL Commission

Preventing surgical fires

ires rarely occur during an create a fire triangle. Many operation, but the estimated flammable materials, or fuels, F650 surgical fires that do are present in the operating break out every year can inflict room (OR), including gowns, serious damage in a matter hoods, towels, blankets, masks, of seconds, according to the ointments, and dressings. Fortunately, most surgical ECRI Institute, a not-for-profit The most common fires can be avoided scientific research firm, Plymouth heat sources in the OR are Meeting, PA.* The most common electrosurgical equipment, such when OR team members surgical fire locations are the as electrosurgical units (ESUs) thoroughly understand the patient airway (34 percent), or electrocautery units, fiber- face or head (28 percent), and optic light sources and cables, causes and dangers, follow elsewhere inside or on the and lasers. Lasers, ESUs, and Joint Commission standards † patient (38 percent). In addition high-speed drills can create and recommendations, to the human toll, surgical fires incandescent sparks that can pose a hazard to the capabilities jump off the tissue target and practice preventive and long-term reputation of and ignite specific fuels. measures. hospitals and ambulatory Oxygen, room air, and nitrous surgery centers (ASCs). oxide are examples of oxidizers. | 65 Surgical fires are among the Many surgical fires erupt in ECRI’s top 10 technology hazards oxygen-enriched environments for 2013.‡ In addition, surgical fire (OEEs), where the percentage of risks have been an issue frequently oxygen is higher than in typical noted during Joint Commission room air. An example of an accreditation surveys, OEE would be environments prompting the commission to in which patients are receiving clarify standards expectations supplemental oxygen, particularly and offer strategies for this via a mask or nasal cannula challenging compliance issue. rather than a laryngeal mask. In an OEE, materials that may not otherwise combust in room “Fire triangle” air can ignite and burn. In 74 Surgical fires occur when three percent of all surgical fire cases, primary elements—fire, heat, OEE was a contributing factor. and an oxidizer—combine to

*ECRI Institute. Surgical fire protection. Preventing surgical fires Available at: https://www.ecri.org/ Fortunately, most surgical fires surgical_fires. Accessed June 25, 2013. †The Joint Commission. Sentinel can be avoided when OR team Event Alert. Preventing surgical fires. members thoroughly understand 2003. Available at: http://www. the causes and dangers, follow jointcommission.org/assets/1/18/ sea_29.pdf. Accessed June 25, 2013. Joint Commission standards ‡ECRI Institute. The top 10 health and recommendations, and technology hazards for 2013. Available practice preventive measures. at: https://www.ecri.org/Documents/ Secure/Health_Devices_Top_10_ Several key Joint Commission Hazards_2013.pdf. Accessed June 25, 2013. Environment of Care (EC)

AUG 2013 Bulletin American College of Surgeons A look at T13Ahe UGJointBULL Commission

A health care facility must critique its fire drills to assess and document fire safety equipment, building features, and staff response.

standards and associated elements • EPs 1, 2, 3 of EC.03.01.01 mandate managing fuels by allowing of performance (EPs) address staff and licensed independent adequate time for patient prep, fire safety. Hospitals and ASCs practitioners to be familiar with and establishing guidelines for should review and follow these their responsibilities and roles reducing oxygen concentration requirements to eliminate related related to the EC. They should be beneath drapes. hazards and minimize liabilities. able to demonstrate or describe Among the accreditation methods for eradicating and • Develop, implement, and test standards are the following: reducing physical risks in the EC, procedures to ensure that all actions to take in the event of an members of the OR teams are • Standard EC.02.03.01 requires that EC incident, and how to report EC able to respond appropriately to organizations manage fire risks. risks. In addition, organizations OR fires. (This list includes full EPs 9 and 10 of this standard are should pay particular attention to participation in the fire drills.) particularly valuable, requiring EC.04.01.01, which stipulates that 66 | an organization to have a written practitioners collect information • Report to The Joint Commission, fire response plan that describes to monitor conditions in the ECRI Institute, and the U.S. Food the specific roles of staff and environment. EP 1 requires that a and Drug Administration any licensed independent practitioners process or processes be established surgical fires in order to increase at and away from a fire’s point of for sustained monitoring, internal awareness and, most importantly, origin—including when and how reporting, and examination prevent fires. to sound fire alarms, contain fire of several types of conditions, and smoke, use a fire extinguisher, including injuries to facility For more information about and evacuate to safe areas. occupants; property damage; fire preventing surgical fires, go safety management problems, to www.jointcommission.org/ • Standard EC.02.03.03 mandates failures, and deficiencies; and sentinel_event_alert_issue_29_ fire drills. EPs 1, 3, and 5 state problems, failures, and user preventing_surgical_fires/ to that organizations should errors related to management of access Sentinel Event Alert Issue conduct these drills once medical/laboratory equipment or 29: Preventing surgical fires.  per shift per quarter in each utility systems. building defined by the Life Safety Code as a health care occupancy; each building Tips to prevent surgical fires defined by the Life Safety Code The Joint Commission as an ambulatory health care recommends that hospitals and occupancy should conduct these ASCs take the following actions drills quarterly (with half of to prevent surgical fires: these quarterly drills classified as “unannounced”). A health • Inform staff members, such as care facility must critique its fire surgeons and anesthesiologists, drills to assess and document of the importance of controlling fire safety equipment, building heat sources by adhering to laser features, and staff response. and ESU safety practices, properly

V98 No 8 Bulletin American College of Surgeons NTDB13A® DUGATBAULLPointS

Geronimo

by Richard J. Fantus, MD, FACS

arachutes have been in use for hundreds of years and Improving record Pdate back to China in the According to the United States 1100s. The pyramid-shaped Parachute Association (USPA), wooden frame from which a the sport of skydiving continues man is suspended in Leonardo da to be associated with an Vinci’s 1495 sketch was actually improved safety record. In the The NTDB Annual Report built and tested centuries later 1960s, close to 8,000 individuals 2012 is available on the ACS by Adrian Nicholas in the late were members of the USPA, with website as a PDF file and as 20th century. The modern a fatality rate of 3.65 per 1,000 a PowerPoint presentation sport of skydiving began as members.† Over the last five at www.ntdb.org. jumping out of hot air balloons decades, the activity’s popularity In addition, information in France near the end of the has grown, and the USPA’s regarding how to obtain 18th century. Women started membership has increased to NTDB data for more to appear on the scene later in close to 34,000 in 2012; members the 19th century. Today, women performed more than 3 million detailed study is available on the website. account for between 15 percent jumps with a fatality rate of 0.64 | 67 and 20 percent of skydivers.* per 1,000 members. In 2012, Parachutes were used in there were 19 skydiving fatalities World War I to rescue occupants and another 915 skydiving of observation balloons that had injuries.† Skydiving involves emergencies, while pilots were inherent risk with most injuries still instructed to land in these resulting from human error. situations. It was not until 1925 Through the efforts of the USPA that the first emergency bailout and an adherence to strict safety from an airplane took place. The standards, training policies, first troop insertion by parachute and programs, skydiving took place in World War II and is is a relatively safe sport. credited with turning the tide of To examine the occurrence the war against the Axis powers. of skydiving injuries in the After World War II, there was a National Trauma Data Bank® surplus of military parachutes (NTDB®) research dataset and former soldiers with the for 2012, admissions medical courage to jump. By 1957, the records were searched using first commercial skydiving the International Classification schools began to appear and the of Diseases, Ninth Revision, term “skydiver” was coined.* Clinical Modification (ICD-9- CM). Specifically searched was * Poynter D, Turoff M. Parachuting: the external cause of injury code The Skydiver’s Handbook. 10th ed. Santa Barbara, CA: Para Publishing; 2007. (E-code) E844.7 (other specified †United Stated Parachute Association. air transport accidents injuring Skydiving safety. Available at: http:// parachutist in voluntary descent). www.uspa.org/AboutSkydiving/ SkydivingSafety/tabid/526/Default. A total of 133 records were aspx. Accessed June 13, 2013. found; 128 contained a hospital

AUG 2013 Bulletin American College of Surgeons NTDB13A® DUGATBAULLPointS

Emergency department disposition

68 |

discharge status including 96 of the jump may look to history available on the website. If you patients discharged to home, for inspiration. In 1940, before a are interested in submitting your 18 to acute care/rehab, and 12 planned mass military training trauma center’s data, contact to skilled nursing facilities; two jump, several soldiers were Melanie L. Neal, Manager, died. These patients were 75 scared due to the potential for NTDB, at [email protected].  percent male, on average 38.2 mishap with so many departing years of age, had an average the aircraft at once. In an effort hospital length of stay of 6.6 to encourage their trepidatious Acknowledgement days, an intensive care unit comrades, a number of soldiers Statistical support for this article length of stay of 4.2 days, an shouted out the name of the has been provided by Chrystal average injury severity score of movie that was shown on Caden-Price, data analyst, NTDB. 11.2, and were on the ventilator base the night before as they for an average of 5.4 days. A exited the plane: Geronimo. total of 22 percent went directly Throughout the year, we will to the operating room, and be highlighting data through another 20 percent went to the brief reports in the Bulletin. The intensive care unit directly from NTDB Annual Report 2012 is the emergency department available on the ACS website as (see figure, this page). a PDF file and as a PowerPoint While jumping out of a presentation at www.ntdb. perfectly good airplane is not org. In addition, information everyone’s idea of fun, those regarding how to obtain NTDB who are apprehensive or fearful data for more detailed study is

V98 No 8 Bulletin American College of Surgeons News

Susan E. Mackinnon, MD, FACS, FRCSC, receives 2013 Jacobson Innovation Award

Dr. Mackinnon (right) receives the Jacobson Innovation Award from Dr. Eastman.

| 69 Susan E. Mackinnon, MD, FACS, work in the development of the injury with microsutures and FRCSC, the Sydney M. Shoenberg, microsurgery. Unfortunately, Dr. expendable sensory nerves from Jr., and Robert H. Shoenberg and Mrs. Jacobson were unable elsewhere in the body to bridge Endowed Chair and professor to attend the dinner this year, a gap. However, this method had and chief, division of plastic but President A. Brent Eastman, significant limitations, resulting and reconstructive surgery MD, FACS, and Dr. Mackinnon in slow nerve regeneration and at Washington University commented on Dr. Jacobson’s poor return of muscle function. School of Medicine, St. many innovative contributions Rather than concentrating Louis, MO, received the 2013 to surgery and expressed on the anatomical area of Jacobson Innovation Award gratitude for the Jacobsons’ nerve injury, Dr. Mackinnon’s of the American College of generosity to the College. approach focuses on the motor Surgeons (ACS). The award endplates of the denervated was presented at a dinner muscle. This surgical held in Dr. Mackinnon’s Pioneer in nerve technique involves working honor June 7 at the The J.B. transfer procedures with expendable branches Murphy Memorial Auditorium Dr. Mackinnon was selected within major nerves near the Building in Chicago, IL. to receive this year’s award compromised muscle. The nerve The prestigious Jacobson because of her leadership in the transfer procedure changes a Innovation Award, made possible innovative use of nerve transfer high-level proximal injury (such through a gift from Julius H. procedures for patients with as at the neck) to a more distal Jacobson II, MD, FACS, and devastating peripheral nerve injury (such as at the axilla, his wife Joan, New York, NY, injuries. Before Dr. Mackinnon’s arm, forearm, or hand) and honors living surgeons who have pioneering work, which began avoids the detrimental impact of developed original and significant in 1991, peripheral nerve prolonged muscle denervation. surgical techniques. Dr. Jacobson injuries were generally treated Previously, Dr. Mackinnon is a general vascular surgeon with a procedure that involved performed the first nerve known for his pioneering repairing the nerve at the site of transplant in 1988, using nerves

AUG 2013 Bulletin American College of Surgeons News

Dr. Mackinnon’s groundbreaking work has produced a paradigm shift in the treatment of peripheral nerve injuries. Today surgeons use new nerve transfers to help patients around the globe.

Joacobs n Innovation Award recipients from a cadaver to restore 1994 professor Francois Dubois, Paris, France: Laparoscopic cholecystectomy feeling and movement to a 1995 Thomas Starzl, MD, FACS, Pittsburgh, PA: Liver transplantation boy’s injured leg. This landmark 1996 Joel D. Cooper, MD, FACS, St. Louis, MO: Lung transplantation and lung operation began a quarter- volume reduction surgery century of novel work in nerve 1998 Juan Carlos Parodi, MD, Buenos Aires, Argentina: Treatment of arterial transplantation and led to aneurysms, occlusive disease, and vascular injuries by using endovascular many other surgical firsts. She stent grafts has transplanted branches of 1999 John F. Burke, MD, FACS, Boston, MA: Development and implementation the median nerve at the wrist of a number of innovative techniques in burn care, including the codevel- TM to the ulnar nerve and from opment of an artificial skin (Integra ) the median nerve to the radial 2000 Paul L. Tessier, MD, FACS(Hon), Boulogne, France: Development and nerve—the latter for patients establishment of the surgical specialty of craniofacial surgery with difficult high radial injuries 2001 Thomas J. Fogarty, MD, FACS, Portola Valley, CA: Design and develop- associated with fractures ment of industry standard minimally invasive surgical instrumentation, especially for cardiovascular surgery of the humerus. Similarly, 2002 Michael R. Harrison, MD, FACS, San Francisco, CA: Creator of the special- patients with previously ty of fetal surgery and developing techniques of fetoscopy for minimally disastrous brachial plexus invasive fetal technology injuries at the shoulder can 70 | 2003 Robert H. Bartlett, MD, FACS, Ann Arbor, MI: Pioneer in the develop- now be treated with transfers ment and establishment of the first extracorporeal membrane oxygen- of a nerve branch to the motor ation (ECMO) program components of the median 2004 Harry J. Buncke, MD, FACS, San Francisco, CA: Pioneer in the field of nerve for finger flexion and microsurgery and replantation pronation and the ulnar nerve 2005 Stanley J. Dudrick, MD, FACS, Waterbury, CT: Innovator of specialized for intrinsic hand function. nutrition support and a pioneer in the field of clinical nutrition In 2012, Dr. Mackinnon and 2006 Judah Folkman, MD, FACS, Boston, MA: Pioneer in the field of angiogen- her surgical team at Barnes- esis Jewish Hospital, St. Louis, 2007 William S. Pierce, MD, FACS, Hershey, PA: Pioneer in the conception and received worldwide attention development of mechanical circulatory support and the total artificial for a nerve transfer procedure mechanical heart that successfully enabled a 2008 Donald L. Morton, MD, FACS, Santa Monica, CA: Pioneer in research ef- quadriplegic patient to regain forts toward the development and clinical application of sentinel lymph node biopsy some use of one of his hands. This procedure was the first 2009 Bernard Fisher, MD, FACS, Pittsburgh, PA: Development and implementation of a new course for the treatment of breast cancer by proposing report of using nerve transfer that it is a systemic disease that metastasizes unpredictably and would to restore the ability to flex best be treated with lumpectomy combined with adjuvant chemotherapy the thumb and index finger 2010 lazar J. Greenfield, MD, FACS, Ann Arbor, MI: Development of the Green- after a spinal cord injury. field filter, a vena cava filter implanted under fluoroscopic guidance to Dr. Mackinnon’s prevent pulmonary embolism in susceptible surgical patients groundbreaking work has 2011 George Berci, MD, FACS, FRCS(Ed)(Hon), Los Angeles, CA: Pioneering produced a paradigm shift in contributor to the art and science of endoscopy and laparoscopy, result- the treatment of peripheral ing in the high level of technology used to perform many endoscopic and nerve injuries. Today surgeons laparoscopic surgical procedures use new nerve transfers to 2012 W. Hardy Hendren III, MD, FACS, FRCS(Ire, Eng, Glas[Hon]), Boston, MA, Developed novel reconstruction procedures for children with severe help patients around the globe. urogenital abnormalities The practice has significantly improved care of patients

V98 No 8 Bulletin American College of Surgeons News

Dr. Mackinnon with her former department chairs (from left) Samuel A. Wells, Jr., Dr. Mackinnon and her husband, MD, FACS; Timothy Eberlein, MD, FACS; and Bernard Langer, MD, FACS, FRCS(C). Alec Patterson, MD, FACS, FRCS(C).

| 71 with previously devastating research funding support from honor of being elected a fellow of peripheral nerve injuries the Medical Research Council the Institute of Medicine of the who now experience a return in Canada and the National National Academy of Sciences. of function only dreamed Institutes of Health in the U.S. Born in Campbellton, New of in earlier generations. In recent years, she has worked Brunswick, Dr. Mackinnon Legions of patients who have on a military-funded website earned her medical degree at experienced returned function that shares surgical procedures Queen’s University, Kingston, to their injured arms and in step-by-step detail—“surgical ON, where she performed her legs have benefitted from recipes,” Dr. Mackinnon says, residency training in general Dr. Mackinnon’s insightful for disseminating information to surgery for three years. She approach to developing a greater number of surgeons. completed her training in nerve transfer operations. Dr. Mackinnon has been a prolific plastic surgery and a fellowship contributor to the medical in neurosurgery research at literature, with more than 450 the University of Toronto. She Renowned educator peer-reviewed manuscripts served as associate professor in and researcher and 140 book chapters. She has the division of plastic surgery Dr. Mackinnon is a renowned received numerous awards, at the University of Toronto teacher who has assumed including the Royal College and served one fellowship the interdisciplinary training Medal Award in Surgery from year at Raymond Curtis Hand of an entire generation of the Royal College of Physicians Center in Baltimore, MD. Dr. specialists interested in the and Surgeons of Canada in 1988. Mackinnon moved to the U.S. surgical treatment of peripheral She has served in leadership in 1991 and served as professor, nerve injuries, including positions for several surgical division of plastic surgery, at neurosurgeons, orthopaedists, societies, most recently in 2012, Washington University School and plastic surgeons. She as president of the American of Medicine, St. Louis, and credits her remarkable success Association of Plastic Surgeons, has since held several medical in the field to three decades of and in 2007, she received the high leadership positions. 

AUG 2013 Bulletin American College of Surgeons News CoC general session focuses on updates, lessons learned in care for cancer patients

Approximately 200 individuals basic equation, Dr. Sprandio National Committee for Quality attended a general session said, is that the value of care Assurance’s patient-centered during the annual meeting of the equals quality divided by cost. medical home model, Dr. Commission on Cancer (CoC), Quality of care improves when Sprandio and other clinicians May 16–17, at the American the reliability of health care at his institution reengineered College of Surgeons (ACS) services increases, and therefore, the model to address issues of headquarters in Chicago, IL. this equation turns the focus quality and cost and matters of Daniel P. McKellar, MD, FACS, to consistent and reliable care, practice accountability for all CoC Chair, clinical professor with costs controlled by reducing cancer care, standardized patient of surgery at Wright State waste. Waste in health care occurs evaluations, multidisciplinary University, Dayton, OH, and when physicians fail to deliver and care plans, the support of director of the cancer program at coordinate patient care, which, patient navigators, and ongoing Wayne HealthCare, Greenville, in turn, leads to fragmentation performance reviews. OH, presided over the session, and overtreatment, he noted. “The process of improving which focused on advances in In 2012, U.S. health care the delivery of cancer care and 72 | care for oncology patients. came at a cost of $2.8 trillion, reducing unnecessary use are which, taken alone, would intertwined. They are one and represent the world’s fifth largest the same,” he said. “If improving Patient-centered medical home economy, Dr. Sprandio said. care is the plan, then physicians In a keynote address, John D. The U.S. pays a high price for own the plan,” he said. Sprandio, MD, described the health care and outspends the “Government can’t do it. Payors oncology patient-centered rest of the industrial world by can’t do it. Regulations can’t do medical home (OPCMH) model 141 percent.* Ultimately, the it. Only the people who give the that he pioneered at Oncology high cost of health care is driven care can improve the care.” Management Services, Drexel, by deficiencies in delivery of Dr. Sprandio asserted that PA. Dr. Sprandio is the chief of services, coordination of care, the patient-centered medical medical oncology and hematology overuse of resources, pricing, home model defines the and chief physician at the administrative burden, and measurement of care and institution, and told the gathering fraud. Physicians, he noted, have ultimately responds to patients’ that the OPCMH has enhanced control only over the first three needs, and noted improvements quality of care and reduced costs. factors: delivery, coordination of in clinical measures that the Each year, Dr. Sprandio said, care, and overuse of resources. OPCMH model has produced: some 1.6 million Americans These shortcomings, which receive a cancer diagnosis, lead to duplication of services, • Emergency department visits and they enter a health care are attributable in part to low by chemotherapy patients per environment that is expensive adherence to clinical guidelines year declined by 65 percent and fragmented. Health care’s and cause the patient population not only to face unnecessary • The number of patients admitted *Thompson D. OECD: U.S. Outspends Average Developed Country 141% in Health delays in treatment, but to the hospital dropped by 45 Care, Atlantic Monthly. April 12, 2011. also to assume a secondary percent over a five-year period Available at http://www.theatlantic.com/ role in their own care. business/archive/2011/04/oecd-us-outspends- average-developed-country-141-in-health- Using evidence-based • Length of stay for patients care/237171/. Accessed May 22, 2013. platforms, including the admitted declined by 21 percent

V98 No 8 Bulletin American College of Surgeons News

“If improving care is the plan, then physicians own the plan. Government can’t do it. Payors can’t do it. Regulations can’t do it. Only the people who give the care can improve the care.” —Dr. Sprandio

The model, he said, transforms Reporting on the work of the the delivery of cancer care within Quality Integration Committee, the practice without the need Chair Christopher M. Pezzi, MD, for a costly third-party vendor. FACS, senior surgeon, director of surgical oncology, and associate program director for general Updates on CoC activities surgery residence at Abington The general session also featured (PA) Memorial Hospital, and updates on current CoC-related clinical associate professor, activities and programs. Drexel University College Heidi Nelson, MD, FACS, of Medicine, Philadelphia, Rochester, MN, Program described the expansion of Director of the ACS Clinical quality measures that define | 73 Research Program within the cancer care. Part of the Alliance for Clinical Trials in committee’s work is to promote Oncology, noted the group’s the quality, breadth, and ongoing work to seek out timeliness of the data provided new ways to connect diverse for entry into the National Dr. Ferris types of research efforts. Cancer Data Base (NCDB). “Our work is to take basic Speaking on behalf of the science and turn it into cancer CoC-member Organization treatment,” Dr. Nelson said. Steering Committee, Chair The CoC Accreditation Virginia Vaitones, MSE, Committee, represented by OSW-C, Rockport, ME, noted Chair Linda W. Ferris, PhD, efforts to raise awareness of vice-president, oncology system the CoC mission, including service line, Centura Health, use of the Commission’s Denver, CO, continues to create logo, and to support the new accreditation products work of the Advocacy and enhance the best practices Subcommittee. Ms. Vaitones repository. The Accreditation spoke of One Voice Against Committee also has identified Cancer Lobby Day, which potential new surveyors and took place this year in July. begun to revamp the orientation Ms. Vaitones also presented these individuals receive. A the results of a 2013 survey patient Web portal for cancer that was sent to the executive survivors to collect information directors of all member Dr. Roland on the survivorship experience organizations. Among other was discussed and approved findings, the study showed for further evaluation. that the most prevalent reason

AUG 2013 Bulletin American College of Surgeons News

The enemy of quality cancer care, Dr. McKellar concluded, includes the 2 percent sequestration cuts, which the U.S. Congress imposed on March 1, and the out-of-pocket expenses required for cancer patients.

that members stay involved has evolved, he said, from in the CoC is the benefits of participation in performance Need for advocacy participation in CoC programs monitoring to improving the The enemy of quality cancer and initiatives. Executive quality of cancer care and care, Dr. McKellar concluded, directors who responded to shaping cancer leaders. The includes the 2 percent the survey indicated that the state chairs, he noted, also sequestration cuts, which the CoC’s most vital responsibility collaborate with the American U.S. Congress imposed on March is to work collaboratively with Cancer Society and use NCDB 1, and the out-of-pocket expenses other member organizations, data to monitor quality of required for cancer patients. to promote the organization care. In a recent survey, the “We are in a nasty transition to CoC members, and to committee learned that 87 period,” Dr. McKellar said. provide the membership percent of CLPs use NCDB “Hospitals under the most 74 | with regular CoC updates. data to monitor the quality duress may have to stop Howard Kaufman, MD, of care and that 41 percent accepting Medicare patients.” FACS, Rush University Medical of the CLPs are involved in Does the CoC have the ability Center, Chicago, and Chair of advocating for state legislation. to respond to external events the CoC Education Committee, Former CoC Chair Stephen such as these? asked a member of noted that a number of webinars Edge, MD, FACS, the Alfieri the audience. “No, we do not,” are available for educating Family Charitable Foundation responded Dr. McKellar. “That’s CoC members on the newly Endowed Chair in Breast why the CoC needs to increase launched ACS Cancer Programs Oncology and medical director its advocacy efforts nationally.”  Online Education Portal (at of the Breast Center at Roswell http://eo2.commpartners.com/ Park Cancer Institute in users/acsnew/). The new portal Buffalo, NY, and Chair of the allows CoC-accredited cancer CoC Nominating Committee, program staff complimentary described a new process for access to CoC webinars. The nominating members to the committee is actively seeking CoC as ACS representatives. nominations for the 2014 Clinical The CoC, he said, increasingly Congress Oncology Lecturer requires specific expertise and among other activities. experience, and the current Committee on Cancer Liaison system does not identify all Chair Phillip Y. Roland, MD, of the individuals who might FACS, gynecologic oncologist, contribute significantly to the St. Francis Hospital and work of the Commission. Medical Center, Hartford, CT, “It’s very exciting to see the presented a report on activities work of the Commission,” Dr. of the volunteer State and Edge said. “It’s easy to forget that Regional Chairs. The Cancer this is a volunteer organization.” Liaison Physician’s (CLP) role

V98 No 8 Bulletin American College of Surgeons 2013 Webcast Sessions MAKE THE MOST OF YOUR CLINICAL CONGRESS EXPERIENCE Don’t miss out on the sessions you want to attend—even if they’re scheduled at the same time. Webcasts sessions are available on your computer, tablet, or mobile device anytime, anywhere. Maximize your learning opportunities and earn CME credit and self-assessment credit when it’s convenient for you.

PRE-REGISTER FOR CLINICAL CONGRESS AND SAVE. 2013 COMPLETE BEST VALUE PACKAGE Webcast packages are available at a reduced (Webcasts and selected MP3 audio recordings) price until October 5, 2013. All 35 2013 Clinical Congress webcasts AND 45 MP3s of Named Lectures and Selected Panel Sessions

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Pre-Congress Price: $395 ACS Member $460 Nonmember 2013 WEBCAST PACKAGE All 35 2013 Clinical Congress webcast sessions

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WEBCAST PICK 12 OF 2013 Visit facs.org/clincon2013/registration or contact Olivier Petinaux at 800-475-4696 Choose 12 of the 35 2013 Clinical Congress webcast sessions or [email protected].

Pre-Congress Price: $195 ACS Member NOTE: 2013 Webcasts will be available for viewing from $250 Nonmember December 15, 2013; access expires December 31, 2014.

AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION Blended Surgical Education and Training for Life News

Plan to attend these RAS-ACS events during 2013 Clinical Congress Residents and Associates Fellows who will be attending the 2013 American College of Surgeons (ACS) Clinical Congress, October 6–10, in Washington, DC, at the Walter E. Washington Convention Center, are invited to attend sessions designed to respond to their special interests. These programs, sponsored by the Resident and Associate Society (RAS-ACS) and the ACS Division of Education, include the following: are encouraged to participate in a program Sunday, October 6 covering essential nonclinical issues surgical residents face during training and in the • Free Networking Lunch, 11:30 am–12:30 pm transition to their post-training career

• Meet with RAS-ACS leadership Tuesday, October 8 • Focus on RAS-ACS—Resident Leadership Session, 12:30–3:00 pm • Spectacular Cases, 8:00–11:15 am ACS President A. Brent Eastman, MD, FACS Spectacular surgical cases that pose challenging Keynote Address: Learn How to management issues to expert panel members Become Involved in RAS-ACS

• RAS Symposium, 3:00–5:30 pm Wednesday, October 9 Patient Rankings: Should Patient Feedback Affect Surgical Jeopardy, 76 | Our Pay and Delivery of Care? A debate among • 8:00–11:15 am leaders in surgery on the timely topic of patient Based on the popular TV game show, with surgical rankings and their use in day-to-day practice questions and teams of residents competing to showcase their surgical knowledge

Monday, October 7 For more information on these sessions, contact [email protected] and look for updates in • Starting Surgical Practice: Essentials for Success, the weekly electronic ACS NewsScope and on 10:00 am–5:45 pm Facebook at https://www.facebook.com/RASACS.  Surgical residents from all postgraduate levels

Connect with the College via social media!

Facebook.com/AmCollSurgeons Twitter.com/AmCollSurgeons Facebook.com/ACSTrauma Twitter.com/ACSTrauma Facebook.com/RASACS

Event Hashtag: #ACS100 identifies tweets related to the College's centennial celebration, as well as highlights people and events from our 100-year history. Social media questions? For more assistance or if you have questions or com- YouTube.com/AmCollegeofSurgeons ments about the American College of Surgeons' social media sites, send an e-mail to [email protected].

Social Media post-CC half-page ad.indd 1 10/16/2012 10:34:21 AM V98 No 8 Bulletin American College of Surgeons News

College seeks Medical Director for Washington, DC, Office The American College of Surgeons (ACS) has initiated a search process for a full-time staff position: Medical Director, Division of Advocacy and Health Policy (DAHP). The individual T he ACS Washington Office at 20 F Street, NW selected for this position will be based in the Washington, DC, Office and will work with the staff of the DAHP and other areas throughout the College. Responsibilities of this position will include but not be limited to: attending quality, coalition, congressional, administration, and other meetings related to health care issues; supporting policy and network development; contributing to publications and committee work assignments; and serving as a staffing and budgeting resource. Only Fellows of the College will be considered for this position. View the complete job description at http://www.facs.org/ahp/employ/index.html. Interested Fellows should send a curriculum vitae and a statement of interest by e-mail to [email protected]. Applications will be accepted through August 31, 2013. (The American College of Surgeons is an Equal Opportunity/Affirmative Action Employer, AA/EEO/M/F/D/V.) 

| 77 MOC Review: Essentials for Surgical Specialties to be offered at Clinical Congress The American College of Surgeons (ACS) 2013 Clinical Congress will offer a first-time course titled Maintenance of Certification (MOC) Review: Essentials for Surgical Specialties. The course, which will take place Tuesday, October 8, 12:30–4:45 pm, will address surgical fundamentals common across the specialties, such as emergency airway management; deep vein thrombosis prophylaxis; postoperative management, including myocardial infarction recognition; pain management; and patient safety. Course Chair Robert R. Lorenz, MD, FACS—an otolaryngologist and attending surgeon, Cleveland (OH) Clinic—and Co-Chair Robert Bahnson, MD, FACS—a urological surgeon at the Arthur G. James Cancer Hospital and Solove Research Institute and Ohio State University Medical Center, Columbus, and Chair of the American College of Surgeons Professional Association’s political action committee (ACSPA-SurgeonsPAC)—have developed a course that is designed to help prepare participants for recertification examinations and support lifelong learning and practice improvement. Sponsored by the ACS Division of Education and approved by the Program Committee, the MOC course will include continuing medical education credit that may be used for self-assessment purposes. The College has arranged a special fee structure for this premiere course, charging nonmembers the same enrollment fee as ACS Fellows. This reduced fee applies to this course only and not to the Clinical Congress registration fee. To register for the course, go to the 2013 Clinical Congress Web page at h t t p :// www.facs.org/clincon2013/index.html. For details on this course, contact Dr. Bahnson at [email protected], or Dr. Lorenz at [email protected] more information on the scientific sessions at the ACS 2013 Clinical Congress and to register, go to the ACS Clinical Congress Web page at http://www.facs.org/clincon2013/scientific/ postgraduate.html. 

AUG 2013 Bulletin American College of Surgeons News

Procedure-Specific Consents available online

Web-based standardized informed consent NAPBC announces documents with pre- and postoperative instructions for more than 2,300 surgical milestone: Accreditation procedures help ensure compliance with accreditation and regulatory requirements. of 500 breast centers The documents are embedded in a template that the American College of The National Accreditation Program for Surgeons (ACS) has reviewed and can be Breast Centers (NAPBC) announced recently individualized to specific surgical routines. that it has accredited more than 500 breast The consents can be automatically centers, and the program has widespread stored in electronic health records or saved distribution in 48 states, including Alaska to the document management system. and Hawaii, as well as Puerto Rico. This Preprocedure and discharge instructions achievement comes after surpassing the along with patient education resources may 100-accredited-centers mark in 2009, a little be printed or e-mailed to patients to assist more than one year after the NAPBC began with meaningful use compliance. A free 30- the formal process of surveying breast centers day evaluation period of the ACS-reviewed for accreditation in September 2008. iMedConsent™ application is available. Read more about the NAPBC achievement View more information at http://www.facs. at http://www.newswise.com/articles/national- org/patienteducation/consent.html, e-mail  78 | accreditation-program-for-breast-centers- [email protected], or call 312-202-5263. surpasses-the-500-accredited-centers-mark.  Rural Surgery Rural VOLUME 38, NO. 1, 2012 SRGS Rural Surgery Single Issue

IO n Nonsubscribers can earn CME credit for this special issue. t This issue of Selected Readings in General Surgery immerses itself in topics of interest to rural CA surgeons. These include the characteristics of rural practice, challenges in recruitment and

VOL. 38

D u retention, and a selective review of common NO. 1 clinical problems encountered in rural practice: 2012 trauma care, cutaneous surgery, endoscopy Rural f E gynecology, laparoscopic surgery, and urology. Surgery

O To order: Purchase online at www.facs.org/srgs/subscribe/ individuals.html. Scroll to the bottom and select

“SRGS Rural Surgery Single Issue with CME.” AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION If you are an ACS member or have an ACS username, please log in to the e-store using your existing username

ISIO n and password BEFORE you place your order.

American College of Surgeons An order form is availableDivision of Education at www.facs.org/srgs/rural.html 633 N. Saint Clair St. NEXT ISSUE: Chicago, IL 60611-3211 Spleen 800-631-0033 Order by phone at 800-631-0033www.facs.org/srgs/ D I v

V98 No 8 Bulletin American College of Surgeons Good Medicine Has Its Rewards: $287 Million

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