JANUARY 2017 | VOLUME 102 NUMBER 1 | AMERICAN COLLEGE of SURGEONS Bulletin Contents

JANUARY 2017 | VOLUME 102 NUMBER 1 | AMERICAN COLLEGE OF SURGEONS Bulletin Contents

FEATURES COVER STORY: Reimbursement changes in 2017 The 2017 Medicare physician fee schedule: An overview of provisions that will affect surgical practice 11 Lauren Foe, MPH; Jan Nagle, MS, RPh; and Vinita Ollapally, JD

2017 CPT coding changes 16 Albert Bothe, MD, FACS; Megan McNally, MD, FACS; and Jan Nagle, MS, RPh

Profiles in surgical research: Mary T. Hawn, MD, MPH, FACS 26 Juliet A. Emamaullee, MD, PhD, FRCSC, and Kamal M. F. Itani, MD, FACS

The 2016 RAS-ACS annual Communications Committee essay contest: An introduction 33 Erin Garvey, MD | 1

First-place essay: Paying it forward: When the mentee becomes the mentor 34 Kevin Koo, MD, MPH, MPhil

Highlights of Clinical Congress 2016 35

ACS Officers, Regents, and Board of Governors’ Executive Committee 46

JAN 2017 BULLETIN American College of Surgeons Contents continued

COLUMNS A look at The Joint Commission: ASCPA-SurgeonsPAC makes an Annual report provides details impact on 2016 congressional Looking forward 8 on patient safety, quality elections 80 David B. Hoyt, MD, FACS improvements 69 Katie Oehmen ACS NSQIP Best Practices case Carlos A. Pellegrini, MD, Call for nominations for the ACS studies: Impact of SSI reduction FACS, FRCSI(Hon), FRCS(Hon), Board of Regents and ACS strategy after colorectal resection 49 FRCSEd(Hon) Officers-Elect 82 Lisa A. Wilbert, RN NTDB data points: Annual Report Nominations for 2017 Dispatches from rural surgeons: 2016: Almost a 10 71 volunteerism and humanitarian Rural surgery: High pressure Richard J. Fantus, MD, FACS awards due February 28 84 but rewarding 55 Report on ACSPA/ACS activities, Susan Long, MD, FACS NEWS October 2016 86 From residency to retirement: In memoriam: Jay L. Grosfeld, Diana L. Farmer, MD, FACS, FRCS Trust: The keystone of the physician- MD, FACS, champion for pediatric ACS in the news 90 patient relationship 58 surgery patients 73 Carlos A. Pellegrini, MD, FACS, Keith T. Oldham, MD, FACS SCHOLARSHIPS FRCSI(Hon), FRCS(Hon), Coming next month in JACS, 2 | Applications for 2017 Nizar N. FRCSEd (Hon) and online now 74 Oweida, MD, FACS, Scholarship ACS Clinical Research Program: Important changes made in the due March 1 92 Surgery versus monitoring and AJCC Cancer Staging Manual, Apply through February 15 endocrine therapy for low-risk DCIS: Eighth Edition 75 for International ACS NSQIP The COMET Trial 62 David J. Winchester, MD, FACS Scholarships 2017 93 Linda M. Youngwirth, MD; Judy C. ACS Clinical Scholars in Residence 2017 Heller School Executive Boughey, MD, FACS; and E. Shelley benefit from access to outcomes Leadership Program Scholarship Hwang, MD, MPH measures and mentors 77 applications due February 1 94 From the Archives: J. Marion Sims: Karl Y. Bilimoria, MD, MS, FACS, Paving the way 64 and Clifford Y. Ko, MD, MS, MSHS, MEETINGS CALENDAR LaMar S. McGinnis, Jr., MD, FACS FACS Calendar of events 96 ACS Foundation insights: ACS NSQIP honors 60 hospitals New ACS Foundation board for meritorious outcomes in members installed 66 surgical care 79 Sarah B. Klein, MPA

V102 No 1 BULLETIN American College of Surgeons Craig Miller, MD, FACS, researched and wrote The American College of Surgeons is dedicated this engaging account of the impressive life to improving the care of the surgical patient and career of Robert M. Zollinger, MD, FACS. The narrative is a compelling read for anyone and to safeguarding standards of care in an interested in the story behind one of the optimal and ethical practice environment. legends of the surgical profession.

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 Praise for Lynn Kahn daytime telephone The Big Z: The Life of SENIOR EDITOR number via e-mail to Robert M. Zollinger, MD Tony Peregrin dschneidman@facs. org, or via mail to “ …a magnificent piece EDITORIAL & PRODUCTION ASSISTANT Diane S. Schneidman, of prose. This is a Matthew Fox Editor-in-Chief, surgical sequel to The Greatest Generation. Bulletin, American CONTRIBUTING EDITOR A superb effort.” College of Surgeons, Jeannie Glickson 633 N. Saint Clair St., — Hiram C. Polk, Jr., SENIOR GRAPHIC DESIGNER/ Chicago, IL 60611. MD, FACS PRODUCTION MANAGER Letters may be edited Professor Emeritus, University of Louisville Tina Woelke for length or clarity. Permission to publish “ A very easy read about an authoritarian giant in a time of EDITORIAL ADVISORS letters is assumed Charles D. Mabry, MD, FACS giants. The inherent message—complete care of the patient unless the author and the patient’s cares—remains. Leigh A. Neumayer, MD, FACS indicates otherwise. Marshall Z. Schwartz, MD, FACS Dr. Zollinger would like this book; Dr. Dunphy would say he Mark C. Weissler, MD, FACS wasn’t that good! I enjoyed it immensely.”

FRONT COVER DESIGN — Murray Brennan, MD, FACS Benno C. Schmidt Chair in Clinical Oncology, Tina Woelke Memorial Sloan-Kettering Cancer Center

“ Driven, devoted, dedicated, accomplished. Dr. Zollinger was Bulletin of the American College of Surgeons (ISSN 0002-8045) is all of these and much more. Herein learn how greatness was published monthly by the American College of Surgeons, 633 N. forged and how the impact continues. If you like a good tale— Saint Clair St., Chicago, IL 60611. It is distributed without charge to an inspiring, richly told story—you will find it here. This is the Fellows, Associate Fellows, Resident and Medical Student Members, stuff that made American surgery and America what it is.” Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional —LaMar McGinnis, Jr., MD, FACS mailing offices. POSTMASTER: Send address changes to Bulletin of the Senior Medical Advisor and Liaison, American College of Surgeons, 3251 Riverport Lane, Maryland Heights, American Cancer Society MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. Ordering Information The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; To order online, visit facs.org/publications/catalog toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. To order by phone, call 312-202-5474 Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. Price: $14.95, plus sales tax, shipping, and handling Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ Dr. Miller is chief of vascular services and director of vascular imaging personal observations and do not imply endorsement by at Margaret Pardee Memorial Hospital, the University of North Carolina nor official policy of the American College of Surgeons. Health System.

©2017 by the American College of Surgeons, all rights reserved. Contents Published by the American College of Surgeons. 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.

2016_IC_BulletinAd_ZollingerBook_3.75x9.925in_v01.indd 1 11/8/2016 10:44:32 AM Officers and Staff of the American College of Surgeons

Timothy J. Eberlein, MD, FACS James W. Fleshman, Jr., Patrick V. Bailey, MD, FACS Officers St. Louis, MO MD, FACS, FASCRS Medical Director, Advocacy James K. Elsey, MD, FACS Dallas, TX Christian Shalgian Courtney M. Townsend, Atlanta, GA Samual R. Todd, MD, Director Jr., MD, FACS Henri R. Ford, MD, FACS FACS, FCCM Galveston, TX Houston, TX AMERICAN COLLEGE OF PRESIDENT Los Angeles, CA SURGEONS FOUNDATION J. David Richardson, MD, FACS Gerald M. Fried, MD, FACS, FRCSC Shane Hollett Louisville, KY Montreal, QC Advisory Council Executive Director IMMEDIATE PAST-PRESIDENT James W. Gigantelli, MD, FACS ALLIANCE/AMERICAN to the Board COLLEGE OF SURGEONS Hilary A. Sanfey, MB, Omaha, NE CLINICAL RESEARCH PROGRAM BCh, MHPE, FACS B. J. Hancock, MD, FACS, FRCSC of Regents Kelly K. Hunt, MD, FACS Springfield, IL Winnipeg, MB FIRST VICE-PRESIDENT (Past-Presidents) Chair Enrique Hernandez, MD, FACS Kathryn D. Anderson, MD, FACS CONVENTION AND MEETINGS Mary C. McCarthy, MD, FACS Philadelphia, PA Dayton, OH Eastvale, CA Robert Hope Director SECOND VICE-PRESIDENT Lenworth M. Jacobs, Jr., MD, FACS W. Gerald Austen, MD, FACS Edward E. Cornwell III, Hartford, CT Boston, MA DIVISION OF EDUCATION Ajit K. Sachdeva, MD, MD, FACS, FCCM L. Scott Levin, MD, FACS L. D. Britt, MD, MPH, Washington, DC Philadelphia, PA FACS, FRCSC FACS, FCCM Director SECRETARY Mark A. Malangoni, MD, FACS Norfolk, VA William G. Cioffi, Jr., MD, FACS Philadelphia, PA John L. Cameron, MD, FACS EXECUTIVE SERVICES Providence, RI Fabrizio Michelassi, MD, FACS Baltimore, MD Maxine Rogers TREASURER Director, Leadership Operations New York, NY Edward M. Copeland III, MD, FACS David B. Hoyt, MD, FACS FINANCE AND FACILITIES Chicago, IL Leigh A. Neumayer, MD, FACS Gainesville, FL Tucson, AZ Gay L. Vincent, CPA 4 | EXECUTIVE DIRECTOR A. Brent Eastman, MD, FACS Director Gay L. Vincent, CPA Linda G. Phillips, MD, FACS Rancho Santa Fe, CA Galveston, TX HUMAN RESOURCES Chicago, IL Gerald B. Healy, MD, FACS AND OPERATIONS CHIEF FINANCIAL OFFICER Marshall Z. Schwartz, MD, FACS Wellesley, MA Michelle McGovern Philadelphia, PA R. Scott Jones, MD, FACS Director Anton N. Sidawy, MD, FACS Charlottesville, VA INFORMATION TECHNOLOGY Officers-Elect Washington, DC Edward R. Laws, MD, FACS Brian Harper (take office October 2017) Beth H. Sutton, MD, FACS Boston, MA Interim Director Wichita Falls, TX Barbara L. Bass, MD, FACS LaSalle D. Leffall, Jr., MD, FACS DIVISION OF INTEGRATED Houston, TX Courtney M. Townsend, Jr., Washington, DC COMMUNICATIONS PRESIDENT-ELECT MD, FACS LaMar S. McGinnis, Jr., MD, FACS Lynn Kahn Galveston, TX Director Charles D. Mabry, MD, FACS Atlanta, GA Pine Bluff, AR Steven D. Wexner, MD, FACS David G. Murray, MD, FACS JOURNAL OF THE AMERICAN FIRST VICE-PRESIDENT-ELECT Weston, FL COLLEGE OF SURGEONS Syracuse, NY Timothy J. Eberlein, MD, FACS Basil A. Pruitt, Jr., MD, Patricia J. Numann, MD, FACS Editor-in-Chief FACS, FCCM, MCCM Syracuse, NY San Antonio, TX Board of DIVISION OF MEMBER SERVICES SECOND VICE-PRESIDENT-ELECT Carlos A. Pellegrini, MD, FACS Patricia L. Turner, MD, FACS Governors/ Seattle, WA Director Executive Richard R. Sabo, MD, FACS M. Margaret Knudson, MD, FACS Board of Regents Committee Bozeman, MT Medical Director, Military Health Seymour I. Schwartz, MD, FACS Systems Strategic Partnership Michael J. Zinner, MD, FACS Diana L. Farmer, MD, FACS Rochester, NY Boston, MA Girma Tefera, MD, FACS Sacramento, CA Director, Operation Giving Back CHAIR CHAIR Frank C. Spencer, MD, FACS New York, NY Leigh A. Neumayer, MD, FACS, Steven C. Stain, MD, FACS PERFORMANCE IMPROVEMENT Tucson, AZ Albany, NY Andrew L. Warshaw, MD, FACS Will Chapleau, RN, EMT-P VICE-CHAIR VICE-CHAIR Boston, MA Director Anthony Atala, MD, FACS Susan K. Mosier, MD, MBA, FACS, DIVISION OF RESEARCH AND Winston-Salem, NC Lawrence, KS OPTIMAL PATIENT CARE Clifford Y. Ko, MD, MS, FACS John L. D. Atkinson, MD, FACS SECRETARY Executive Staff Director Rochester, MN Daniel L. Dent, MD, FACS EXECUTIVE DIRECTOR James C. Denneny III, MD, FACS San Antonio, TX David B. Hoyt, MD, FACS David P. Winchester, MD, FACS Alexandria, VA Francis D. Ferdinand, MD, FACS DIVISION OF ADVOCACY Medical Director, Cancer Margaret M. Dunn, MD, FACS Wynnewood, PA AND HEALTH POLICY Michael F. Rotondo, MD, FACS Dayton, OH Frank G. Opelka, MD, FACS Medical Director, Trauma Medical Director, Quality and Health Policy

V102 No 1 BULLETIN American College of Surgeons Author bios*

*Titles and locations current at the time articles were submitted for publication.

a b c

d e | 5

f g h

DR. BILIMORIA (a) is an American DR. BOUGHEY (c) is professor of DR. FARMER (f) is a pediatric surgeon, College of Surgeons (ACS) Faculty Scholar; surgery and vice-chair, department of Pearl Stamps Stewart Professor of a surgical oncologist; and director, Surgical surgery, Mayo Clinic, Rochester, MN. surgery, and chair, department of Outcomes and Quality Improvement She is Chair, ACS Clinical Research surgery, University of California, Davis, Center, Feinberg School of Medicine, Program (CRP) Education Committee. Health System, Sacramento. She is Northwestern University, Chicago, IL. Chair, ACS Board of Governors. DR. EMAMAULLEE (d) is a transplant DR. BOTHE (b) is chief quality officer, surgery fellow, University of Alberta, MS. FOE (g) is Regulatory Associate, Geisinger Health System, Danville, PA. He is Edmonton, and member of the ACS ACS Division of Advocacy and a member of the ACS General Surgery Coding Surgical Research Committee. Health Policy, Washington, DC. and Reimbursement Committee (GSCRC) and ACS advisor to the American Medical DR. FANTUS (e) is vice-chairman, DR. GARVEY (h) is a postgraduate year-6 Association (AMA) Current Procedural department of surgery; medical director, pediatric surgery fellow, Phoenix Children’s Terminology (CPT) Editorial Panel. trauma services; and chief, section of Hospital, AZ. She is Immediate Past-Chair surgical critical care, Advocate Illinois of the Communications Committee of the Masonic Medical Center. He is clinical Resident and Associate Society of the ACS. professor of surgery, University of Illinois College of Medicine, Chicago, and Past- continued on next page Chair, ad hoc Trauma Registry Advisory Committee, ACS Committee on Trauma.

JAN 2017 BULLETIN American College of Surgeons Author bios continued

i j k

l m n 6 |

o p q

DR. HWANG (i) is vice-chair of DR. KO (l) is Director, ACS Division of DR. McNALLY (p) is a surgical oncologist, research, department of surgery; Research and Optimal Patient Care, Chicago. St. Luke’s Health System, Kansas City, MO, chief of breast surgery; and professor, and assistant clinical professor, department of Duke University, Durham, NC. DR. KOO (m) is a fourth-year urology surgery, University of Missouri-Kansas City resident, Dartmouth-Hitchcock School of Medicine. She is a member of the DR. ITANI (j) is chief of surgery, Veterans Medical Center, Lebanon, NH. ACS GSCRC and serves as the ACS alternate Affairs Boston Health Care System, MA; advisor to the AMA CPT Editorial Panel. professor of surgery, Boston University; and DR. LONG (n) is chief of surgery, St. Chair, ACS Surgical Research Committee. Joseph’s Hospital, Buckhannon, WV. MS. NAGLE (q) is an independent consultant DR. McGINNIS in Chicago. She assists the ACS with CPT MS. KLEIN (k) is Director, Donor (o) is senior medical coding education and health data analyses. Relations and Communications, consultant and advisor, American Cancer ACS Foundation, Chicago. Society, and adjunct clinical professor continued on next page of surgery, Emory University, Atlanta, GA. He is Past-President of both the ACS and the American Cancer Society.

V102 No 1 BULLETIN American College of Surgeons Author bios continued

r s

t u v | 7

w x

MS. OEHMEN (r) is ACS Professional MS. OLLAPALLY (t) is Regulatory DR. WINCHESTER (w) is the NorthShore Association-SurgeonsPAC Associate, ACS Affairs Manager, ACS Division of Board of Directors/David P. Winchester Division of Advocacy and Health Policy. Advocacy and Health Policy. Chair of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, DR. OLDHAM (s) is vice-chairman, surgery, DR. PELLEGRINI (u) is chief medical and professor of surgery, University of and surgeon-in-chief, Children’s Hospital of officer, UW Medicine, and vice-president for Chicago Pritzker School of Medicine. Wisconsin; and professor, surgery, Medical medical affairs, University of Washington, College of Wisconsin, Milwaukee. He is Seattle. He is a Past-President of the ACS. DR. YOUNGWIRTH (x) is a general Chair, ACS Children’s Surgery Verification surgery resident, department of surgery, Committee, and a member of the ACS MS. WILBERT (v) is assistant director, Duke University Medical Center. Performance Measures Committee. quality measurement and analytics, division of quality management, Stony Brook Medicine, East Setauket, NY.

JAN 2017 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

ndoubtedly, many of you are familiar with the our clinical registries, including the National Surgical phrase “the seven year itch.” It was first used in Quality Improvement Program, the National Cancer Uthe play The Seven Year Itch to describe an incli- Database, the National Trauma Data Bank®, the Meta- nation to evaluate your marriage after seven years bolic and Bariatric Surgery Accreditation and Quality and gained popularity in 1955 with the release of the Improvement Program data bank, and the Surgeon movie version directed by Billy Wilder and starring Specific Registry. This project, which is being imple- Marilyn Monroe and Tom Ewell. It is now used to mented incrementally, will make it easier for surgeons describe any situation in which people feel the need to meet American Board of Surgery (ABS) Maintenance to make a change after being in the same role for sev- of Certification requirements and Medicare payment en or more years. mandates under the Centers for Medicare & Medicaid I recently concluded my seventh year as Executive Services' new Quality Payment Program (QPP). We Director of the American College of Surgeons (ACS) anticipate that within the next three years, by my 10th and admittedly have been feeling a bit of an itch to see year as Executive Director, this database of the future the goals I set when first assuming this position come will be fully integrated and in widespread use. fully to their fruition.

Advocacy 8 | Quality improvement The QPP was created through the Medicare Access and One of my primary goals when I first became Executive CHIP (Children’s Health Insurance Program) Reautho- Director was to improve the stature and capabilities rization Act (MACRA). The QPP replaces the flawed of our Quality Programs. I wanted to ensure that the sustainable growth rate (SGR) methodology that was public better understood the College’s role in qual- used for many years to calculate Medicare physician ity improvement and safeguarding the well-being of reimbursement. Repealing the SGR was a major goal surgical patients. We succeeded in increasing public for all of organized medicine seven years ago. Now that awareness of the impact of quality improvement in we have achieved this objective, the College’s focus has health through our multi-year ACS Inspiring Quality turned to ensuring that surgeons are able to comply Forum tour. Each stop along the tour included presen- with the QPP’s reporting requirements and performance tations and discussions by surgeon leaders, members measures. We have established a resource center for sur- of Congress, and patient advocates. geons who are seeking information about the QPP and Expansion of our accreditation programs was other MACRA provisions moving forward and work- another component of this objective. We have con- ing with health policy experts at Brandeis University, tinued to grow our verification programs, including Waltham, MA, and Brigham and Womens’ Hospital, the accreditation activities in cancer, trauma, breast, Boston, to propose alternative payment models. bariatric, geriatric, and pediatric surgery. Advances in We anticipate that the new presidential adminis- these areas continue, and will expand to other surgi- tration and Republican-controlled Congress will leave cal specialties and subspecialties in the coming years. QPP untouched—at least for a while. However, we The next step will be in setting standards for quality also speculate that they will attempt to either repeal improvement overall based on the ACS quality manual the Affordable Care Act (ACA) or overturn a number that is in development. of its provisions. The College needs to be prepared to Making certain that surgeons have the tools they offer viable health care reforms and to take a stance need to measure and evaluate their performance has on any modifications that may affect access to surgical been a key mission in the last seven years. To this end, care. We will need to offer alternatives that uphold our we have initiated the database integration system, principles of ensuring the provision of quality and safe which will bring together, under a unified platform, care, patient access to surgical care, and reduction of

V102 No 1 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

We anticipate that the new presidential administration and Republican-controlled Congress will leave QPP untouched—at least for a while. However, we also speculate that they will attempt to either repeal the Affordable Care Act (ACA) or overturn a number of its provisions. health care costs. These values served us well when the ACA was being developed and will serve us well as the law is revised and implemented. We also need to continue to push for liability reforms that will ensure patients are justly compensated for any harm they experience while under a surgeon’s care. In addition, we need to address ongoing issues with the electronic health record and with the sustainability of graduate medical education (GME) and the surgical workforce. With the addition of Patrick V. Bailey, MD, FACS, Medical Direc- tor, Advocacy, and Frank G. Opelka, MD, FACS, Medical Director, Quality and Health Policy, in our Washington Office in 2014, we have become better positioned as an authoritative source of information inside the Beltway. I anticipate that this trend will continue and look forward to working with the new administration.

Education Surgical education and training have been at the heart of the Col- lege’s mission since the organization’s inception. We believe the | 9 ACS’ education and training programs are the cornerstones of excellence, transform possibilities into realities, and instill the joy of lifelong learning. Of particular concern in recent years have been reports that a significant percentage of general surgeon residency graduates leave training feeling uncertain about their ability to perform advanced procedures autonomously and to manage a practice. In response, the College launched the Transition to Practice in General Surgery program, which supports the transition to independent practice in general surgery through the following activities:

• Individualized, hands-on learning tailored to individual needs

• Independence and autonomy in clinical decision making

• Practical general surgery experience under the guidance of notable practicing surgeons

• One-year, paid staff appointments at institutions accredited by the ACS

• Exposure to important elements of practice management

This program continues to grow, with 25 institutions in 21 states now participating. In addition, the College has been working with other stakeholders, including the ABS, the Accreditation Council for Graduate Medical

JAN 2017 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their services, it is imperative that the House of Surgery takes responsibility for ensuring that graduates of general surgery training programs have the full range of skills and the confidence necessary to care for these vulnerable patients.

Education, the Association of Program Directors in Sur- responsibility for ensuring that graduates of general gery (APDS), and the Residency Review Committee for surgery training programs have the full range of skills Surgery (RRC), to develop a roadmap to secure the future and the confidence necessary to care for these vulner- of general surgery. Concepts discussed in these meetings able patients. include the following:

• Development of boot camps, which may be added to Member services and communication residency requirements The College has re-energized the internal bodies that serve as the voice of the membership—the Board of • Possible addition of further training after five years of Governors, the Advisory Councils, the Young Fellows core general surgery training Association, the Resident and Associate Society, and the ACS chapters. As a result, the College is a more diverse, • Modifications to duty hour requirements in light of find- dynamic, and nimble organization than ever before. ings from the ongoing Flexibility In duty hour Require- We are offering more opportunities for engage- ments for Surgical Trainees Trial studies ment, including a revitalized Operation Giving Back program with an emphasis on international and domes- 10 | • Development of a Competency-based Education and tic volunteerism. Likewise, the annual Leadership & Skills Assessment, with the ACS claiming responsibil- Advocacy Summit in Washington, DC, provides mem- ity for creating a tool to track progress and compare bers with opportunities to hone their leadership skills residents and programs and working with the APDS to and advocate on their patients’ behalf. Furthermore, develop skills training we strengthened our emphasis on international development and have established a Regental committee to • Provision of opportunities for mentored autonomy provide direction in this regard. The College has continued to make its communica- • Institution of community rotations tions vehicles more interactive and user-friendly. We launched a fully rebuilt website in 2014 along with our • Establishment of guidelines for self-assessment during ACS Communities, which allow members to share their residency concerns and interests in a protected environment. We also are working to have all of our major publications, • Capstone training including the Bulletin and the Journal of the American Col- lege of Surgeons, move to fully digital platforms. • Initiation of an effort to have surgeon reviewers partici- I am proud of the strides the College has made in pate in 10-year reviews of residency programs the last seven years and am itching to see us continue to grow and flourish in the next three. As always, please • Creation of a faculty development requirement, with the let us know your suggestions for the College’s future. ♦ ACS and APDS establishing the curriculum

• Proposal for a model for career-long record keeping starting in medical school

Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their ser- If you have comments or suggestions about this or other issues, please vices, it is imperative that the House of Surgery takes send them to Dr. Hoyt at [email protected].

V102 No 1 BULLETIN American College of Surgeons 2017 MEDICARE PHYSICIAN FEE SCHEDULE

The 2017 Medicare physician fee schedule: | 11 An overview of provisions that will affect surgical practice

by Lauren Foe, MPH; Jan Nagle, MS, RPh; and Vinita Ollapally, JD

JAN 2017 BULLETIN American College of Surgeons 2017 MEDICARE PHYSICIAN FEE SCHEDULE

ew payment policy and coding and reimburse- states are not required to report on all 10- and 90-day ment changes set forth in the 2017 Medicare global codes; rather, CMS will publish on its website a Nphysician fee schedule (MPFS) final rule took list of approximately 260 10- and 90-day global codes effect January 1. The MPFS, updated annually by the that are furnished by more than 100 practitioners and Centers for Medicare & Medicaid Services (CMS), are either furnished more than 10,000 times or have lists payment rates for services furnished under Medi- allowed charges of more than $10 million annually. care Part B and introduces or modifies other policies CMS estimates that these codes will describe approxi- that affect physician reimbursement and quality mea- mately 87 percent of all furnished 10- and 90-day global surement. services and about 77 percent of all Medicare expendi- On September 6, 2016, the American College of Sur- tures for 10- and 90-day global services under the MPFS. geons (ACS) submitted comments to CMS related to the This is a mandatory reporting requirement intended MPFS proposed rule released earlier in the year. These to allow CMS to gather enough data on postoperative comments provided CMS with feedback on a number of visits to revalue global codes starting in 2019. MACRA provisions that are in the final rule, which was released gave CMS the authority to implement a 5 percent with- November 2, 2016. Although the MPFS final rule out- hold in Medicare payments to encourage compliance lines important payment and policy changes that affect with reporting the postoperative data; however, the all physicians, this article focuses on updates that are agency chose not to implement this provision in the particularly relevant to general surgery and its related final rule. 12 | medical specialties. In addition to the claims-based data collection, CMS finalized a policy to conduct a survey of Medicare practitioners to gain information about postoperative Collecting global codes data activities to supplement the claims-based data collec- CMS finalized a policy mandated in the Medicare tion. CMS had not finalized the design of the survey at Access and CHIP (Children’s Health Insurance Pro- press time, but intends to begin surveying in mid-2017. gram) Reauthorization Act (MACRA) of 2015, whereby This survey could affect physicians in all states, not certain physicians who provide 10- and 90-day global just the nine selected for claims-based data reporting. services will be required to report information on the The agency intends to collect global code data from number of postoperative visits they provide. Starting Accountable Care Organizations (ACOs) but has yet July 1, physicians who are part of practices with 10 or to describe how it plans to collect those data or when more practitioners and who live in one of nine spec- ACO data collection will start. ified states—Florida, Kentucky, Louisiana, Nevada, The final rule on global codes data collection is New Jersey, North Dakota, Ohio, Oregon, and Rhode a result of aggressive ACS legislative and regulatory Island—will be required to report Current Procedural advocacy. CMS released a drastically improved policy Terminology (CPT)* code 99024, Postoperative follow-up on collection of data from what was in the proposed visit, normally included in the surgical package, to indicate rule. The proposed rule would have been impractical that an evaluation and management service was performed for surgeons in part because it would have created an during a postoperative period for a reason(s) related to the unreasonable reporting burden that was not aligned original procedure, for each postoperative visit they pro- with clinical workflow. When first proposed, all phy- vide within the global period. sicians who perform 10- and 90-day global codes in all The nine states were selected based on size mea- states would have been required to report, not just those sured by the number of Medicare beneficiaries per state in large practices in a limited number of states. In addi- and Census Bureau region. Physicians in the selected tion, the proposed policy would have required using new Healthcare Common Procedure Coding System *All specific references to CPT codes and descriptions are © 2016 Ameri- can Medical Association. All rights reserved. CPT and CodeManager are (HCPCS) G-codes that would have been reported in registered trademarks of the American Medical Association. 10-minute increments, rather than submitting CPT

V102 No 1 BULLETIN American College of Surgeons 2017 MEDICARE PHYSICIAN FEE SCHEDULE

TABLE 1. SUMMARY OF PROPOSED AND FINAL REQUIREMENTS FOR REPORTING GLOBAL SERVICES

PROVISION PROPOSED FINAL

Start date January 1 July 1

How data G-codes reported in 10-minute Use 99024 to report number of postoperative visits are reported increments Pre-service and postoperative What data Just postoperative visits on only high-volume or high- care on all 10- and 90-day are reported expenditure 10- and 90-day global codes global codes

Physicians who provide 10- and 90-day services who are: All physicians, regardless of • In a practice of 10 or more practitioners Who reports practice size, who provide 10- the data • In one of the identified nine states (Florida, Kentucky, Louisiana, and 90-day services in all states Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island), comprising a representative sample, which was required by MACRA

code 99024 once for each postoperative visit. Further- CMS’ statement of disability disparities and perspective more, the proposed rule would have required reporting on the challenges that individuals with disabilities face on all 10- and 90-day global codes, rather than the in accessing the health care system. However, most also narrow list of high-volume and high-Medicare expen- agreed that the root cause and scope of these issues are diture codes. Finally, the proposed rule would have not well defined and suggested that CMS work with required reporting to begin January 1, rather than July stakeholders to conduct additional studies and gain | 13 1, as finalized. (See Table 1, this page, for revisions to information regarding the underlying reasons for barri- the proposed rule advocated by the ACS.) ers to access to care and lower quality scores on certain ACS legislative and regulatory advocacy efforts measures. included letters to lawmakers on Capitol Hill and CMS did not finalize payment for code G0501 and to CMS staff, in-person meetings with members of instead indicated the agency will engage with inter- Congress, participation in CMS town hall meetings, ested beneficiaries, advocates, and practitioners to strategic meetings of the ACS Health Policy and continue to explore improvements in payment accu- Advocacy Group and General Surgery Coding and racy for care of people with disabilities. In addition, the Reimbursement Committee, and the formation of an agency included the code G0501 in the HCPCS code ACS-led Globals Coalition made up of multiple medi- set and noted that practitioners would be able to report cal associations. the code if they were so inclined.

Improving payment accuracy for Non-face-to-face prolonged E/M services care of people with disabilities Public commenters have repeatedly recommended that In the 2017 MPFS proposed rule, CMS proposed the CMS establish separate payments for many services creation of a new add-on code (G0501) to describe addi- that are currently bundled under the MPFS, including tional services furnished in conjunction with evaluation non-face-to-face prolonged E/M service codes: 99358, and management (E/M) services to beneficiaries with Prolonged evaluation and management service before disabilities that impair their mobility. CMS indicated and/or after direct patient care; first hour, and 99359, that the proposed add-on code would be reported with Prolonged evaluation and management service before physician office and outpatient E/M codes (99201–99205, and/or after direct patient care; each additional 30 min- 99212–99215), as well as transitional care management utes (List separately in addition to code for prolonged codes (99495, 99496). service). These non-face-to-face prolonged service codes In their comments on the proposed rule, the ACS are broadly described (although they include only and other medical specialty associations agreed with time personally spent by the physician or other billing

JAN 2017 BULLETIN American College of Surgeons 2017 MEDICARE PHYSICIAN FEE SCHEDULE

TABLE 2. CALCULATION OF THE 2017 MPFS CONVERSION FACTOR

Conversion factor in effect in 2016 $35.8043 Update factor 0.50 percent (1.0050) 2017 RVU budget neutrality adjustment -0.013 percent (0.99987) 2017 target recapture amount -0.18 percent (0.9982) 2017 MPPR adjustment -0.07 percent (0.9993) 2017 conversion factor $35.8887

practitioner) and have a relatively high time threshold. The College encouraged CMS to allow physicians (The time counted must be an hour or more beyond more time to select a CDSM and recommended that the usual service time for the primary or “companion” AUC reporting be implemented gradually in the ini- E/M code that also is billed.) They are not reported for tial years of the program, to allow for transparency time spent in care plan oversight services or other non- and input from specialty societies. CMS considered the face-to-face services that have more specific codes and College’s comments and delayed the requirement for no upper time limit in the CPT code set. providers to consult CDSMs from its original January 1, In the final rule, CMS agreed that payment for 99358 2017 deadline. The agency said it will direct qualified and 99359 codes would provide a means to recognize provider-led entities to post AUC—along with the pro- the additional resource costs of physicians and other cess used to develop and modify AUC—online to allow billing practitioners when they spend an extraordinary for stakeholder review. amount of time outside of an E/M visit performing work that is related to that visit and does not involve 14 | direct patient contact (such as extensive medical record Corrections to value-based modifier review, review of diagnostic test results, or other ongo- For 2016, CMS finalized the processes through which ing care management work). physician groups or solo practitioners may request a In addition, CMS indicated its intention to adopt correction of errors related to the value-based payment the CPT code descriptors and prefatory language for modifier (VM) calculation. The 2017 MPFS proposed reporting these services, which requires that time rule solicited comments on how to update these VM counted toward the codes describe services furnished informal review policies and establish how the quality during a single day directly related to a discrete face- and cost composites under the VM would be affected to-face service that may be provided on a different day. if unanticipated issues, such as those involving data One caveat is that the services must be directly related integrity, were to arise. CMS proposed four informal to those furnished in a face-to-face visit. CMS stressed review policies intended to help individual and group that these codes are to be used to report extended non- practitioners reduce uncertainty and better predict the face-to-face time that is spent by the billing physician or outcome of their final VM adjustment. other practitioner (not clinical staff) that is not within The College urged CMS to give groups and individ- the scope of practice of clinical staff, and that is not ual practitioners the opportunity to resubmit data when adequately identified or valued under existing codes errors are discovered, and requested that the agency or the 2017 new codes. clarify how it plans to prevent data integrity issues in the new Quality Payment Program (QPP) outlined in MACRA. CMS finalized its four informal review poli- AUC for advanced diagnostic imaging services cies to modify physicians’ quality and cost composites Beginning January 1, 2018, physicians will be based either on an informal review determination or required to report appropriate use criteria (AUC) widespread quality and cost data issues. The agency through a qualified clinical decision support mech- addressed the College’s comments and indicated that anism (CDSM). The MPFS final rule indicated that quality data issues will be significantly limited moving a list of qualified CDSMs will be published by June forward due to program reporting enhancements. 30, 2017, at which time some providers will be able Starting with the 2017 performance year, the QPP to begin reporting AUC. will combine the existing Medicare meaningful use

V102 No 1 BULLETIN American College of Surgeons 2017 MEDICARE PHYSICIAN FEE SCHEDULE

TABLE 3. 2017 MPFS ESTIMATED EFFECT ON TOTAL ALLOWED CHARGES FOR SURGICAL SPECIALTIES

Impact of work Impact of PE RVU Impact of MP RVU Combined Specialty RVU changes changes changes impact

Total—all providers 0% 0% 0% 0% Cardiac surgery 0 0 0 0 Colon and rectal surgery 0 0 0 0 General surgery 0 0 0 0 Hand surgery 0 0 0 0 Neurosurgery -1 0 0 -1 Obstetrics/gynecology 0 0 0 0 Ophthalmology -1 -2 0 -2 Orthopaedic surgery 0 0 0 0 Otolaryngology 0 0 0 -1 Plastic surgery 0 0 0 0 Thoracic surgery 0 0 0 0 Urology -1 0 0 -2 Vascular surgery 0 0 0 -1

| 15 Physician Quality Reporting System (PQRS) and VM MPFS expenditures resulting from adjustments to rela- programs into the Merit-based Incentive Payment tive values of misvalued CPT codes for 2017–2020. The System (MIPS). MIPS defines four categories of eligible Achieving a Better Life Experience Act of 2014 set a 0.5 clinician performance (quality, advancing care infor- percent target for reduced expenditures for 2017 and mation, clinical practice improvement activities, and 2018. If the estimated net reduction in MPFS expendi- resource use), which contribute to an annual MIPS final tures resulting from adjustments to misvalued CPT score to determine Medicare Part B payment adjust- codes in 2017 is equal to or greater than the 0.5 percent ments. The MIPS data collection system will provide target, the reduced expenditures will be redistributed enhanced real-time support to submitters to identify within the MPFS. The amount by which such reduced VM errors in a more rapid and accurate manner than expenditures exceed the target for 2017 will be treated the stand-alone PQRS and VM programs. as a reduction in expenditures for 2018 to determine whether the annual target has been met. Conversion factor The 2017 MPFS conversion factor (CF) is $35.8887, which Overall effect on surgery is slightly higher than the 2016 CF of $35.8043. The 2017 The 2017 combined impact of changes to relative value CF reflects a budget-neutral adjustment, a 0.5 percent units (RVU) for specific services under the misvalued update adjustment factor specified under section 1848 of code initiative, along with changes to practice expense the Social Security Act, an adjustment due to the non- (PE) and malpractice (MP) RVUs, was 0 percent for gen- budget neutral 5 percent multiple procedure payment eral surgery. Table 3, this page, shows the estimated reduction (MPPR) rule for the professional component impact for all providers and other surgical specialties. ♦ of imaging services, and a -0.18 percent target recapture amount. (See Table 2, page 14, for details.) The target recapture amount was specified in the Protecting Access to Medicare Act of 2014, under which CMS established an annual target for reductions in

JAN 2017 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

16 | 2017 CPT coding changes

by Albert Bothe, MD, FACS; Megan McNally, MD, FACS; and Jan Nagle, MS, RPh

V102 No 1 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

ignificant changes in Current Procedural Termi- Medicaid Services (CMS) determined that moderate nology (CPT)* coding are being implemented in sedation services furnished by the same practitioner S2017. Notably, new codes have been established to reporting a gastrointestinal (GI) endoscopy pro- separately report moderate sedation when provided in cedure was less work than for other procedures. conjunction with a procedure, and Appendix G in the Therefore, CMS created a new Healthcare Common CPT manual—“Summary of CPT Codes that Include Procedure Coding System (HCPCS) code (G0500) Moderate (Conscious) Sedation”—has been elimi- to be reported instead of CPT code 99152. nated. This article provides reporting information The new HCPCS and CPT moderate sedation about the codes that are relevant to general surgery codes include the following (• = new code for 2017, and its related specialties. + = add-on code):

•G0500, Moderate sedation services provided by the same Moderate (conscious) sedation physician or other qualified health care professional In 2014, the CPT Editorial Panel and the American performing a gastrointestinal endoscopic service that Medical Association (AMA)/Specialty Society Rela- sedation supports, requiring the presence of an indepen- tive Value Scale Update Committee (RUC) convened a dent trained observer to assist in the monitoring of the joint workgroup to discuss correct reporting of moder- patient’s level of consciousness and physiological status; ate (conscious) sedation services. This workgroup was initial 15 minutes of intra-service time; patient age 5 years formed after Medicare claims data demonstrated that or older (additional time may be reported with 99153 as | 17 anesthesia services were being reported for codes that appropriate) include moderate sedation as inherent to the work of the physician performing a procedure. After almost •99151, Moderate sedation services provided by the same two years of discussion by the joint workgroup, the physician or other qualified health care professional CPT Editorial Panel approved the following changes performing the diagnostic or therapeutic service that the for the 2017 code set: sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the • Creation of six new codes (99151, 99152, 99153, 99155, patient’s level of consciousness and physiological status; 99156, 99157) to report moderate sedation services in initial 15 minutes of intraservice time, patient younger 15-minute increments than 5 years of age

• Revision of the moderate (conscious) sedation subsec- •99152, Moderate sedation services provided by the same tion guidelines physician or other qualified health care professional performing the diagnostic or therapeutic service that the • Deletion of the moderate sedation symbol () from all sedation supports, requiring the presence of an indepen- codes in the CPT code set that were previously noted to dent trained observer to assist in the monitoring of the inherently include moderate sedation services patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years • Elimination of Appendix G, “Summary of CPT Codes or older That Include Moderate (Conscious) Sedation” +•99153, Moderate sedation services provided by the same Subsequent to the establishment of new CPT codes physician or other qualified health care professional per- for moderate sedation, the Centers for Medicare & forming the diagnostic or therapeutic service that the sedation supports, requiring the presence of an indepen- All specific references to CPT codes and descriptions are © 2016 Ameri- can Medical Association. All rights reserved. CPT and CodeManager are dent trained observer to assist in the monitoring of the registered trademarks of the American Medical Association. patient’s level of consciousness and physiological status;

JAN 2017 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

each additional 15 minutes intraservice time (List separately the physician time, clinical staff time, supply, and in addition to code for primary service) equipment inputs related to moderate sedation. As a result, practice expense RVUs and professional liabil- •99155, Moderate sedation services provided by a physi- ity RVUs will be decreased. However, if a surgeon cian or other qualified health care professional other than performs moderate sedation and reports both the the physician or other qualified health care professional moderate sedation code and the procedure code, the performing the diagnostic or therapeutic service that the net total RVU will not change. sedation supports; initial 15 minutes of intraservice time, It will be important for surgeons to deter- patient younger than 5 years of age mine whether non-Medicare payors recommend using G0500 or 99152 for moderate sedation for GI •99156, Moderate sedation services provided by a physician endoscopy procedures when moderate sedation is or other qualified health care professional other than the phy- performed by the surgeon who also performs the sician or other qualified health care professional performing procedure. Furthermore, for an endoscopy patient the diagnostic or therapeutic service that the sedation sup- younger than five years old, the surgeon furnish- ports; initial 15 minutes of intraservice time, patient age ing moderate sedation should not use HCPCS code 5 years or older G0500, but instead use the appropriate CPT code(s). Table 1 on pages 19–22 identifies the GI endoscopy +•99157, Moderate sedation services provided by a physi- procedures for which HCPCS code G0500 should be 18 | cian or other qualified health care professional other than used to report moderate sedation services for Medi- the physician or other qualified health care professional care patients. As shown in this table, the wRVU has performing the diagnostic or therapeutic service that the been reduced by 0.10 for calendar year 2017. sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) Selecting code(s) to report moderate sedation Intraservice time is used to determine the appropri- Moderate sedation relative ate code to report moderate sedation services. The value unit (RVU) changes intraservice time begins with the administration As of January 1, the physician work relative value units of the sedating agent(s) and ends when the proce- (wRVUs) will have been reduced for all services that dure is completed, the patient is stable for recovery, previously included moderate sedation as an inher- and the physician or other qualified health care ent part of the procedure. GI endoscopy procedures, professional providing the sedation ends personal, with a few exceptions, will have been reduced by 0.10 continuous face-to-face time with the patient. If the wRVUs and the non-GI endoscopy procedures will physician or other qualified health care professional be reduced by 0.25 wRVUs. These wRVU reductions who provides the sedation also performs the pro- match the values for the new HCPCS code G0500 cedure supported by sedation (99151, 99152, 99153, (wRVU = 0.10) and new CPT code 99152 (wRVU = G0500), the physician or other qualified health care 0.25). If a surgeon provides moderate sedation ser- professional will supervise and direct an indepen- vices as described by code G0500 or code 99152, the dent, trained observer who will assist in monitoring surgeon would report both the moderate sedation the patient’s level of consciousness and physiological code and the procedure code. However, if another status throughout the procedure. Table 2 on page provider (for example, an anesthesiologist) performs 23 provides examples to assist users in selection of the moderate sedation service, the surgeon would the appropriate code(s) to report time spent provid- only report the procedure code. ing moderate sedation services. In addition to reduction in wRVUs for all codes affected by this coding change, CMS also has removed continued on page 23

V102 No 1 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

TABLE 1. GI ENDOSCOPY CODES RELATED TO REPORTING CODE G0500 FOR MODERATE SEDATION FOR MEDICARE PATIENTS*

CPT / 2016 2017 HCPCS Descriptor work work code RVU RVU 43200 Esophagoscopy flexible transoral diagnostic 1.52 1.42 43201 Esophagoscopy flexible transoral with submucous injection 1.82 1.72 43202 Esophagoscopy flexible transoral with biopsy 1.82 1.72 43204 Esophagoscopy flex transoral injection varices 2.43 2.33 43205 Esophagoscopy flex with band ligation esophageal varices 2.54 2.44 43206 Esophagoscopy transoral with optical endomicroscopy 2.39 2.29 43211 Esophagoscopy flexible transoral mucosal resection 4.30 4.20 43212 Esophagoscopy transoral stent placement 3.50 3.40 43213 Esophagoscopy retrograde dilate balloon/other 4.73 4.63 43214 Esophagoscopy dilate esophagus balloon 30 mm 3.50 3.40 43215 Esophagoscopy flexible removal foreign body 2.54 2.44 43216 Esophagoscopy flexible lesion removal hot biopsy forceps 2.40 2.30 43217 Esophagoscopy flexible lesion removal tumor snare 2.90 2.80 43220 Esophagoscopy flexible balloon dilation <30 mm diameter 2.10 2.00 43226 Esophagoscopy flexible guide wire dilation 2.34 2.24 43227 Esophagoscopy flexible with bleeding control 2.99 2.89 43229 Esophagoscopy flex transoral lesion ablation 3.59 3.49 | 19 43231 Esophagoscopy flexible transoral ultrasound exam 2.90 2.80 43232 Esophagoscopy intra/transmural needle aspiration/biopsy 3.69 3.59 43233 Esophagogastroduodenoscopy (EGD) esophagus balloon dilation 30 mm or larger 4.17 4.07 43235 EGD transoral diagnostic 2.19 2.09 43236 EGD submucosal injection 2.49 2.39 43237 EGD ultrasound (US) scope with adjacent structures 3.57 3.47 43238 EGD intramural US needle aspirate/biopsy esophagus 4.26 4.16 43239 EGD transoral biopsy single/multiple 2.49 2.39 43240 EGD transoral transmural drainage pseudocyst 7.25 7.15 43241 EGD intraluminal tube/catheter insertion 2.59 2.49 43242 EGD intramural needle aspiration/biopsy altered anatomy 4.83 4.73 43243 EGD injection sclerosis esophageal/gastric varices 4.37 4.27 43244 EGD band ligation esophageal/gastric varices 4.50 4.40 43245 EGD dilation gastric/duodenal stricture 3.18 3.08 43246 EGD percutaneous placement gastrostomy tube 3.66 3.56 43247 EGD flexible foreign body removal 3.21 3.11 43248 EGD insert guide wire dilator passage esophagus 3.01 2.91 43249 EGD balloon dilation esophagus <30 mm diameter 2.77 2.67 *HCPCS code G0500 should be used to report moderate sedation services for Medicare patients when a surgeon performs both the moderate sedation service and the GI endoscopy procedures.

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JAN 2017 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

TABLE 1. GI ENDOSCOPY CODES RELATED TO REPORTING CODE G0500 FOR MODERATE SEDATION FOR MEDICARE PATIENTS* (CONTINUED)

CPT / 2016 2017 HCPCS Descriptor work work code RVU RVU 43250 EGD flex removal lesion(s) by hot biopsy forceps 3.07 2.97 43251 EGD removal tumor polyp/other lesion snare tech 3.57 3.47 43252 EGD flex transoral with optical endomicroscopy 3.06 2.96 43253 EGD US guided transmural injection/fiducial marker 4.83 4.73 43254 EGD transoral endoscopic mucosal resection 4.97 4.87 43255 EGD transoral control bleeding any method 3.66 3.56 43257 EGD deliver thermal energy sphincter/cardia gastroesophageal reflux disease 4.25 4.15 43259 EGD US exam surgical alter stomach duodenum/jejunum 4.14 4.04 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic collection 43260 5.95 5.85 specimen brushing/washing 43261 ERCP with biopsy single/multiple 6.25 6.15 43262 ERCP with sphincterotomy/papillotomy 6.60 6.50 43263 ERCP with pressure measurement sphincter of Oddi 6.60 6.50 43264 ERCP remove calculi/debris biliary/pancreas duct 6.73 6.63 43265 ERCP destruction/lithotripsy calculi any method 8.03 7.93 43274 ERCP stent placement biliary/pancreatic duct 8.58 8.48 43275 ERCP remove foreign body/stent biliary/pancreatic duct 6.96 6.86 20 | 43276 ERCP biliary/pancreatic duct stent exchange with dilation and wire 8.94 8.84 43277 ERCP balloon dilate biliary/pancreatic duct/ampulla each 7.00 6.90 43278 ERCP tumor/polyp/lesion ablation with dilation and wire 8.02 7.92 43450 Dilation esophagus unguided sound/bougie one or more pass 1.38 1.28 43453 Dilation esophagus guide wire 1.51 1.41 44360 Endoscopy upper small intestine 2.59 2.49 44361 Endoscopy upper small intestine with biopsy 2.87 2.77 44363 Enteroscopy > second portion with removal foreign body 3.49 3.39 44364 Enteroscopy > second portion with removal lesion snare 3.73 3.63 44365 Enteroscopy > second portion with removal lesion cautery 3.31 3.21 44366 Enteroscopy > second portion with control bleeding 4.40 4.30 44369 Enteroscopy > second portion ablation lesion 4.51 4.41 44370 Enteroscopy > second portion transendoscopic stent placement 4.79 4.69 44372 Enteroscopy > second portion with placement percutaneous tube 4.40 4.30 44373 Enteroscopy > second portion conversion to jejunostomy tube 3.49 3.39 44376 Enteroscopy > second portion with ileum with or without collection spec 5.25 5.15 44377 Enteroscopy > second portion with ileum with biopsy single/multiple 5.52 5.42 44378 Enteroscopy > second portion ileum control bleeding 7.12 7.02 *HCPCS code G0500 should be used to report moderate sedation services for Medicare patients when a surgeon performs both the moderate sedation service and the GI endoscopy procedures.

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V102 No 1 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

TABLE 1. GI ENDOSCOPY CODES RELATED TO REPORTING CODE G0500 FOR MODERATE SEDATION FOR MEDICARE PATIENTS* (CONTINUED)

CPT / 2016 2017 HCPCS Descriptor work work code RVU RVU 44379 Enteroscopy > second portion with ileum with stent placement 7.46 7.36 44380 Ileoscopy thru stoma diagnostic with collection spec when performed 0.97 0.87 44381 Ileoscopy thru stoma with balloon dilation 1.48 1.38 44382 Ileoscopy thru stoma with biopsy single/multiple 1.27 1.17 44384 Ileoscopy thru stoma with placement of endoscopic stent 2.95 2.85 44385 Endoscopic evaluation intestinal pouch diagnostic with collection spec 1.30 1.20 44386 Endoscopic evaluation intestinal pouch with biopsy single/multiple 1.60 1.50 44388-53 Colonoscopy thru stoma diagnostic including collection spec 1.41 1.36 44388 Colonoscopy thru stoma diagnostic including collection spec 2.82 2.72 44389 Colonoscopy thru stoma with biopsy single/multiple 3.12 3.02 44390 Colonoscopy thru stoma with removal foreign body 3.84 3.74 44391 Colonoscopy thru stoma control bleeding 4.22 4.12 44392 Colonoscopy thru stoma removal lesion by hot biopsy forceps 3.63 3.53 44394 Colonoscopy thru stoma with removal tumor polyp/other lesion by snare 4.13 4.03 44401 Colonoscopy thru stoma ablation lesion 4.44 4.34 44402 Colonoscopy thru stoma with endoscopic stent placement 4.80 4.70

44403 Colonoscopy thru stoma with endoscopic mucosal resection 5.60 5.50 | 21 44404 Colonoscopy thru stoma with submucosal injection 3.12 3.02 44405 Colonoscopy thru stoma with balloon dilation 3.33 3.23 44406 Colonoscopy thru stoma with ultrasound exam 4.20 4.10 44407 Colonoscopy thru stoma with US guided needle aspiration/biopsy 5.06 4.96 44408 Colonoscopy thru stoma with decompression 4.24 4.14 44500 Introduction of long gastrointestinal tube (separate procedure) 0.49 0.39 45303 Proctosigmoidoscopy rigid with dilation 1.50 1.40 45305 Proctosigmoidoscopy rigid with biopsy single/multiple 1.25 1.15 45307 Proctosigmoidoscopy rigid with removal foreign body 1.70 1.60 45308 Proctosigmoidoscopy rigid removal one lesion cautery 1.40 1.30 45309 Proctosigmoidoscopy rigid removal one lesion snare 1.50 1.40 45315 Proctosigmoidoscopy rigid removal multi-tumor by cautery/snare 1.80 1.70 45317 Proctosigmoidoscopy rigid control bleeding 2.00 1.90 45320 Proctosigmoidoscopy rigid ablation lesion 1.78 1.68 45321 Proctosigmoidoscopy rigid decompression volvulus 1.75 1.65 45327 Proctosigmoidoscopy rigid transendoscopic stent placement 2.00 1.90 45332 Sigmoidoscopy flexible with removal foreign body 1.86 1.76 *HCPCS code G0500 should be used to report moderate sedation services for Medicare patients when a surgeon performs both the moderate sedation service and the GI endoscopy procedures.

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JAN 2017 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

TABLE 1. GI ENDOSCOPY CODES RELATED TO REPORTING CODE G0500 FOR MODERATE SEDATION FOR MEDICARE PATIENTS* (CONTINUED)

CPT / 2016 2017 HCPCS Descriptor work work code RVU RVU 45333 Sigmoidoscopy flexible with removal tumor by hot biopsy forceps 1.65 1.55 45334 Sigmoidoscopy flexible control bleeding 2.10 2.00 45335 Sigmoidoscopy flexible directed submucosal injection any substance 1.14 1.04 45337 Sigmoidoscopy flexible with decompression with placement of tube 2.20 2.10 45338 Sigmoidoscopy flexible removal tumor, polyp, or other lesion by snare 2.15 2.05 45340 Sigmoidoscopy flexible transendoscopic balloon dilatation 1.35 1.25 45341 Sigmoidoscopy flexible transendoscopic US exam 2.22 2.12 45342 Sigmoidoscopy flexible transendoscopic US-guided needle aspiration/biopsy 3.08 2.98 45346 Sigmoidoscopy flexible ablation tumor polyp/other les 2.91 2.81 45347 Sigmoidoscopy flexible placement of endoscopic stent 2.82 2.72 45349 Sigmoidoscopy flexible with endoscopic mucosal resection 3.62 3.52 45350 Sigmoidoscopy flexible with band ligation(s) 1.78 1.68 45378-53 Colonoscopy flexible diagnostic with collection spec when performed 1.68 1.63 45378 Colonoscopy flexible diagnostic with collection spec when performed 3.36 3.26 G0105-53 Screening colonoscopy on individual at high risk 1.68 1.63 G0105 Screening colonoscopy on individual at high risk 3.36 3.26

22 | G0121-53 Screening colonoscopy on individual not high risk 1.68 1.63 G0121 Screening colonoscopy on individual not high risk 3.36 3.26 45379 Colonoscopy flexible with removal of foreign body(s) 4.38 4.28 45380 Colonoscopy flexible with biopsy single/multiple 3.66 3.56 45381 Colonoscopy flexible with directed submucosal injection any substance 3.66 3.56 45382 Colonoscopy flexible with control bleeding any method 4.76 4.66 45384 Colonoscopy flexible with removal lesion by hot biopsy forceps 4.17 4.07 45385 Colonoscopy flexible with removal of tumor polyp lesion by snare 4.67 4.57 45386 Colonoscopy flexible with transendoscopic balloon dilatation 3.87 3.77 45388 Colonoscopy flexible ablation tumor polyp/other lesion 4.98 4.88 45389 Colonoscopy flexible with endoscopic stent placement 5.34 5.24 45390 Colonoscopy flexible with endoscopic mucosal resection 6.14 6.04 45391 Colonoscopy flexible with limited endoscopic US exam 4.74 4.64 Colonoscopy flexible with US-guided needle aspiration/biopsy with limited 45392 5.60 5.50 endoscopic US exam 45393 Colonoscopy flexible with decompression 4.78 4.68 45398 Colonoscopy flexible with band ligation(s) 4.30 4.20

*HCPCS code G0500 should be used to report moderate sedation services for Medicare patients when a surgeon performs both the moderate sedation service and the GI endoscopy procedures.

V102 No 1 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

TABLE 2. Moderate sedation (MS) provided MS provided by different MODERATE SEDATION by physician or other qualified physician or other qualified health care professional (SAME health care professional (NOT the CODING GUIDANCE physician or qualified health care physician or qualified health care professional also performing the professional who is performing procedure MS is supporting) the procedure MS is supporting)

Total intraservice time Patient age Code(s) Code(s) for moderate sedation Less than 10 minutes Any age Not separately reported Not separately reported 10–22 minutes <5 years 99151 99155 10–22 minutes 5 years or older 99152* 99156 23–37 minutes <5 years 99151 + 99153 × 1 99155 + 99157 × 1 23–37 minutes 5 years or older 99152* + 99153 × 1 99156 + 99157 × 1 38–52 minutes <5 years 99151 + 99153 × 2 99155 + 99157 × 2 38–52 minutes 5 years or older 99152* + 99153 × 2 99156 + 99157 × 2 53–67 minutes <5 years 99151 + 99153 × 3 99155 + 99157 × 3 53–67 minutes 5 years or older 99152* + 99153 × 3 99156 + 99157 × 3 68–82 minutes <5 years 99151 + 99153 × 4 99155 + 99157 × 4 68–82 minutes 5 years or older 99152* + 99153 × 4 99156 + 99157 × 4 83 minutes or longer <5 years Add 99153 Add 99157 83 minutes or longer 5 years or older Add 99153 Add 99157

*For Medicare patients, report HCPCS code G0500 for GI endoscopy procedures instead of CPT code 99152.

Reprinted with permission, American Medical Association. | 23

CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright of the AMA. No payment schedules, fee schedules, RVUs, scales, conversion factors, or components thereof are included in CPT. The AMA is not recommending that any specific relative values, fees, payment schedules, or related listings be attached to CPT. Any RVUs or relative listings assigned to CPT codes are not those of the AMA, and the AMA is not recommending use of these relative values.

Amputation of tuft of distal phalanx or interphalangeal joint excision, toe, proximal end of pha- Code 11752, Excision of nail and nail matrix, partial or lanx, each. In addition, procedures related to skin (for complete (for example, ingrown or deformed nail), for per- example, pinch graft) may be separately reported when manent removal; with amputation of tuft of distal phalanx, performed. was deleted from the 2017 CPT code set. It was determined that the work inherent to this procedure was widely variable and appropriate treatment depended Excisional bone biopsy on the patient presentation and diagnosis. For example, In 2014, the RUC identified two codes used to report fingertip amputations are described according to the excisional bone biopsy (20240, 20245) as potentially mis- angle of loss (lateral, dorsal, transverse, palmar), skel- valued in the Medicare physician fee schedule (MPFS) etal loss (soft tissue only, tuft, shaft, base) and zone of because the codes included more than one postopera- injury relating to mechanism of injury (sharp, crush, tive visit within the 010 global period. After review saw blade, thermal knife). Treatment is individual- by the RUC, it was determined that both codes had ized for each patient based on these and other factors. wide variability in postoperative care and, therefore, For correct reporting, see codes 26236, Partial excision both codes should have a 000 global period assignment; (craterization, saucerization, or diaphysectomy) bone (for CMS agreed to this change. For 2017, both codes have example, osteomyelitis); distal phalanx of finger; code 28124, a 000 global assignment and the code descriptors have Partial excision (craterization, saucerization, sequestrec- been revised to include additional examples of bones tomy, or diaphysectomy) bone (for example, osteomyelitis or to differentiate superficial bones from deep bones bossing); phalanx of toe; or code 28160, Hemiphalangectomy ( = revised code for 2017):

JAN 2017 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

20240, Biopsy, bone, open; superficial (for example, the vein intima or for catheter injection of an adhesive, sternum, spinous process, rib, patella, olecranon process, code 37799, Unlisted procedure, vascular surgery, should calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) be reported.

20245, Biopsy, bone, open; deep (for example, humeral shaft, ischium, femoral shaft) Dialysis circuit The Joint CPT/RUC Workgroup on Codes Reported Together Frequently identified codes related to dialy- Mechanochemical ablation therapy sis circuit interventions that are frequently reported of incompetent vein(s) together in various combinations. This required cre- The CPT code set includes a number of codes to report ation of bundled codes for reporting these services. the treatment of venous disease such as varicose veins The arteriovenous (AV) dialysis circuit is designed for and incompetence of truncal veins, including the fol- easy and repetitive access to perform hemodialysis. It lowing: direct puncture sclerotherapy with or without begins at the arterial anastomosis and extends to the local anesthesia (36468, 36470, 36471); stab phlebectomy right atrium. The circuit may be created using either under local anesthesia (37765, 37766); laser or radiofre- an arterial-venous anastomosis, known as an arterio- quency thermal ablation utilizing tumescent anesthesia venous fistula, or a prosthetic graft placed between (36475, 36476, 36478, 36479); and surgical vein ligation an artery and vein, known as an arteriovenous graft. 24 | and/or vein stripping under monitored or general anes- The dialysis circuit comprises two segments: (1) the thesia (37700–37761, 37780–37785). peripheral dialysis segment, and (2) the central dialysis As of January 1, two new codes may be used to segment. For 2017, the CPT Editorial Panel established describe mechanochemical ablation (MOCA) therapy of nine new bundled codes to report angioplasty, stent incompetent lower extremity vein(s). The MOCA pro- placement, thrombectomy, embolization, and radio- cedure can be performed using local anesthesia without logical supervision and interpretation within the the need for tumescent (peri-saphenous) anesthesia and dialysis circuit, including the following: involves concomitant use of an intraluminal device that mechanically disrupts/abrades the venous intima, •36901, Introduction of needle(s) and/or catheter(s), dialysis and infusion of a physician-specified medication in the circuit, with diagnostic angiography of the dialysis circuit, target vein(s). This ablation method does not use ther- including all direct puncture(s) and catheter placement(s), mal energy; therefore, the potential for nerve damage injection(s) of contrast, all necessary imaging from the arte- is minimized. The following two new codes are used rial anastomosis and adjacent artery through entire venous to describe MOCA therapy: outflow, including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation •36473, Endovenous ablation therapy of incompetent vein, and image documentation and report extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated •36902, with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological +•36474, Endovenous ablation therapy of incompetent vein, supervision and interpretation necessary to perform the extremity, inclusive of all imaging guidance and monitoring, angioplasty percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List •36903, with transcatheter placement of intravascular separately in addition to code for primary procedure) stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to Note that for catheter injection of sclerosant without perform the stenting, and all angioplasty within the periph- concomitant endovascular mechanical disruption of eral dialysis segment

V102 No 1 BULLETIN American College of Surgeons 2017 CPT CODING CHANGES

•36904, Percutaneous transluminal mechanical thrombectomy •43284, Laparoscopy, surgical, esophageal sphincter aug- and/or infusion for thrombolysis, dialysis circuit, any method, mentation procedure, placement of sphincter augmentation including all imaging and radiological supervision and inter- device (ie, magnetic band), including cruroplasty when pretation, diagnostic angiography, fluoroscopic guidance, performed catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s) •43285, Removal of esophageal sphincter augmentation device

•36905, with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological super- Abdominal aortic aneurysm screening vision and interpretation necessary to perform the angioplasty A new CPT Category I code (76706) was established to report abdominal aortic aneurysm (AAA) screening. An •36906, with transcatheter placement of intravascular stent(s), AAA is a weakening in the wall of the infrarenal aorta peripheral dialysis segment, including all imaging and radio- that typically results in an increased anteroposterior logical supervision and interpretation necessary to perform diameter of 3 cm or greater in the adult population. the stenting, and all angioplasty within the peripheral dialy- AAAs are often undiagnosed because a large proportion sis circuit of patients are asymptomatic until the development of rupture, which is generally acute and often fatal. +•36907, Transluminal balloon angioplasty, central dialy- Screening is recommended to identify those patients sis segment, performed through dialysis circuit, including who may be at increased risk and to assist in early | 25 all imaging and radiological supervision and interpretation detection. required to perform the angioplasty (List separately in addi- The U.S. Preventive Services Task Force recommends tion to code for primary procedure) one-time screening for AAA with ultrasonography in men ages 65 to 75 years who have smoked, and recom- +•36908, Transcatheter placement of intravascular stent(s), mends screening for AAA be offered selectively to men central dialysis segment, performed through dialysis circuit, ages 65 to 75 who have never smoked. Code 76706 will including all imaging radiological supervision and interpre- replace HCPCS code G0389, Ultrasound B-scan and/or tation required to perform the stenting, and all angioplasty real time with image documentation; for abdominal aortic in the central dialysis segment (List separately in addition to aneurysm (AAA) screening, which is deleted for 2017. code for primary procedure) In addition, it is inappropriate to report code 76770, Ultrasound, retroperitoneal (for example, renal, aorta, +•36909, Dialysis circuit permanent vascular embolization nodes), real time with image documentation; complete, or or occlusion (including main circuit or any accessory veins), code 76775, Ultrasound, retroperitoneal for example, renal, endovascular, including all imaging and radiological supervi- aorta, nodes), real time with image documentation; limited, sion and interpretation necessary to complete the intervention for AAA screening. Rather, use the following code: (List separately in addition to code for primary procedure) •76706, Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneu- Esophageal sphincter augmentation rysm (AAA) ♦ with magnetic band Two new codes (43284, 43285) were established to report laparoscopic implantation and to report removal of Note a magnetic bead sphincter augmentation device for Accurate coding is the responsibility of the provider. This treatment of gastroesophageal reflux disease (GERD). summary is intended to serve only as a resource to assist in With establishment of these codes, the following two the billing process. CPT Category III codes (0392T, 0393T) were deleted:

JAN 2017 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

ary T. Hawn, MD, MPH, FACS, professor of surgery and chair, department of surgery, Stanford University, CA, is the 26 | M fifth interviewee in the “Profiles in Surgical Profiles in surgical research: Research” series. Dr. Hawn specializes in minimally invasive foregut surgery and has been Mary T. Hawn, a prolific health services researcher, focusing on complications and policy in postoperative MD, MPH, FACS patients. She has published more than 100 articles and currently serves on the editorial boards of the Journal of the American College of Surgeons, by Juliet A. Emamaullee, MD, PhD, FRCSC, Annals of Surgery, the Journal of Gastrointestinal and Kamal M. F. Itani, MD, FACS Surgery, and the American Journal of Surgery. Dr. Hawn is director, American Board of Surgery; treasurer, Surgical Society of the Editor’s note: The Bulletin is collabo- Alimentary Tract; Chair, Scientific Forum Com- rating with the American College of mittee for the ACS Clinical Congress; and a Surgeons (ACS) Surgical Research Com- member of the American Surgical Association. mittee to present a series titled “Profiles Dr. Hawn earned her doctor of medicine in surgical research.” These interviews (MD) degree, a master of public health (MPH), are published periodically and highlight and completed her general surgery training at prominent surgeon-scientist members the University of Michigan, Ann Arbor. She of the ACS. completed a fellowship in minimally invasive surgery at the Oregon Health and Science Uni- versity (OHSU), Portland. Dr. Hawn was interviewed in Septem- ber 2016 by Juliet A. Emamaullee, MD, PhD, FRCSC, a transplant surgery fellow at the Uni- versity of Alberta, Edmonton, and a member of the Surgical Research Committee.

V102 No 1 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

It was not until I took my faculty position at UAB that I transitioned to health services research. Before I took that job, there were buzzwords like “outcomes research,” which was reporting outcomes in a more detailed fashion. The field of health services research was introduced to me by a woman, Catarina Kiefe, MD, PhD, who became one of my most significant mentors at UAB.

gender. I don’t think he was explicitly recruiting Are you the first physician in your family? women or minorities, but [simply] the “best athlete.” It was a place where I could see myself being I am the first medical doctor in the family, although successful as a trainee. my father was a dentist. I am the sixth of seven kids, with four older sisters, an older brother, and a younger brother. When I was four years old, I told When did you decide on a career in general sur- one of my sisters that I wanted to be a nurse when gery? I grew up, and she said, “Well, why do you want to be a nurse? Why don’t you want to be a doctor?” My Early in medical school, I thought I wanted to do some- | 27 response was, “Girls can’t be doctors!” I grew up in thing procedurally oriented, and based on advice from a small town. There were no women physicians in other people, I considered otolaryngology because you my town, and there were no women physicians on can do surgery and be a clinician. It was a nice combi- TV at that time. She said, “Yes they can!” I went nation of medicine and surgery. However, when I did and asked my mother if my sister was telling the my third-year general surgery clerkship, I just loved it. I truth. My mom said that she was correct, and at loved that the residents seemed to be totally in charge of that point, I decided that I wanted to become a the hospital. If you were on call overnight as a student, doctor. I don’t know what it was that made the it was clear that the general surgery residents carried career seem appealing to me at such a young age, a lot of responsibility. If there was anything going on, but I had decided very early on that I wanted to they were the ones being called to help. I loved that, and become a doctor. I enjoyed having an immediate impact on the patients and then seeing the outcome of what you had done in the operating room (OR). Why did you make the decision to do much of your training in Michigan? Your husband also is a surgeon (otolaryngology). I was admitted to a combined pre-medical/MD pro- Did you meet in medical school? gram at the University of Michigan right out of high school. After I decided to go into surgery, I inter- I met my husband, Eben L. Rosenthal, MD, FACS, when viewed around the country but ultimately chose to he was a third-year medical student and I was a sec- stay at Michigan for several reasons: One, it’s a great ond-year resident in general surgery. We did not meet training program, and two, we had a lot of women in the hospital; we actually met while ice skating. He faculty and residents in the program. This was 1990, had just finished his third-year surgery clerkship and when many programs had, at best, a “token” woman recognized me from the hospital. When the Zamboni trainee. Our chair, Lazar Greenfield, MD, was com- was out cleaning the ice, he came and sat down and we mitted to training the best residents, regardless of started talking. The rest is history.

JAN 2017 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

months pregnant when I started my fellowship. I think Did you need to coordinate your training and they were a little surprised, but it turned out okay. career goals? People often struggle to coordinate those goals in two-physician families. When you started your first faculty position at Yes, he was applying to otolaryngology residency pro- Michigan, was research a major focus? grams while I was in my third year of general surgery residency. At Michigan, we all took time off for research At that time, my husband was finishing his resi- after our third clinical year. I applied for research fellow- dency, and my mother had been diagnosed with ships locally as well as at the University of Washington, gastric cancer. My father died when I was a child, so Seattle, and Beth Israel Deaconess, Boston, MA. He had my mom was my only remaining parent. I also had applied to those training programs as well as other pro- my first child in August of that year. I was faced with grams. We had a tentative plan in place where I could having a newborn child and a dying parent, which do a research fellowship in the same city as his resi- took a lot of my attention and focus. I took good care 28 | dency program, but luckily he matched at Michigan. of my patients, but I could not do much academically When I finished residency, he was still a resident at beyond that. It was a tough start to a faculty job. The Michigan. I took a faculty position at Michigan for two second year, we were looking for fellowship positions, years as a staff surgeon at the VA (Veterans Affairs) hos- so it was really hard to get anything going. I honestly pital. Then we applied for fellowship together, which did not accomplish much during those first two years. was a different challenge as we looked for fellowships I think it challenged my idea of what I wanted to do in each of our specialties that were the same length with my career, because those first two years were so and available in the same city. We figured out that only tough combined with the other challenges in my life. about three places fulfilled those criteria. Fortunately, we were able to go to OHSU for fellowship. When we were looking for jobs afterward, it At this point in your career, you are a well- required tight coordination for positions, which luckily recognized health services researcher. How did worked out first at University of Alabama at Birming- you become interested in research? ham (UAB) and now at Stanford. We both made many compromises along the way, and the important mes- During my research years in residency at the Univer- sage is that you can still be successful if you have a sity of Michigan, I did bench research in colorectal positive attitude. tumor genetics. My research was outside the department of surgery, and I was funded through a cancer prevention and control grant from the School of Public Did you find when you were applying for these Health. One of the requirements of the grant was that various positions that there were any gender- I complete an MPH program. At that time, I used my specific questions, such as, "Do you plan to start MPH training with my research project, as we were a family soon?" looking at responses to chemotherapy for patients with different tumor types, whether or not they had micro- Looking back, it was so unusual for women to have satellite instability. It was not until I took my faculty children during residency at that time that it did not position at UAB that I transitioned to health services even come up. I had a two-year-old child and was six research. Before I took that job, there were buzzwords

V102 No 1 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

Having my MPH opened doors for me. It allowed me to meet with clinical researchers with well-established funding to talk about how we could do that type of research in surgery. I believe that my MPH was particularly valuable because I had the training and knowledge required to transition to a health services research career.

like “outcomes research,” which was reporting out- meet with different types of researchers. A couple of comes in a more detailed fashion. The field of health people took me under their wing and helped me along. services research was introduced to me by a woman, They were amazing mentors to me and helped me get Catarina Kiefe, MD, PhD, who became one of my most my career going. They were incredibly supportive. significant mentors at UAB. She is a prominent health services researcher and chair of preventative medicine. I had a research idea that she helped me frame so that Did the department offer you a start-up package it was not just an outcomes project; it was more of to help you become an established researcher? Did a health services project. She successfully mentored you have protected research time, for example? me in getting funding and getting my project off the ground. That is when I made the transition from bench Honestly, protected time was not something I had research to health services research, which has been discussed when I accepted the position. When I first the primary focus of my research career ever since. went to UAB, I had a part-time appointment at the VA hospital. On the university side, we were so tight for inpatient beds and OR time that it was difficult to | 29 Like many surgeon-scientists, you have experi- build my clinical practice until our new hospital was enced gaps between your dedicated research completed three years later. My division chief, Selwyn time in training and your first faculty position. M. Vickers, MD, FACS—a Past-Governor of the ACS How did you maintain your research goals and and now the dean of medicine at UAB—was very sup- interests, given the challenges you faced early on portive and encouraging of my scientific endeavors. in your career as faculty? I never felt the pressure to produce more clinically, only academically. Once I received my funding, I was When I arrived at UAB, I was not sure what my aca- able to accommodate my schedule to develop specific demic focus would be other than teaching residents. protected time for research. I received funding from It took me some time and meeting with many dif- the U.S. Department of Veterans Affairs, which pro- ferent people to solidify my goals. Having my MPH vided full support for my research time. It was a good opened doors for me. It allowed me to meet with clini- structure to protect my time during daytime hours. cal researchers with well-established funding to talk Most academic surgeons end up pushing most of their about how we could do that type of research in sur- academic time to nights and weekends. You can have gery. I believe that my MPH was particularly valuable protected time on paper, but it is up to you to ensure because I had the training and knowledge required you use it in that way. Having that grant funding from to transition to a health services research career. Dr. the VA allowed me to focus that time on my research. Kiefe was intrigued by surgery and thought it was an untapped area of health services research. In some ways, I think it was the right time and the After you were established with your research, right place with the right mentor that set me on this did you experience any major setbacks? path. It was not a specific vision that I had for myself when I took that position. I knew I wanted to do some Yes, we had an incident where our research center sort of science. I had that intellectual curiosity; I just had a data breach, and we were shut down for 15 did not have a mentor or a role model for what it looked months, meaning we could not access our data. We like. I had to go outside the department of surgery and technically could not do research during that time, at

JAN 2017 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

Dr. Rosenthal, Dr. Hawn (center), and their children take a break from hiking to the Tiger’s Nest on a family vacation in Bhutan 30 |

least not within the VA system. Until then, things had been moving along very well; I had research residents Where did you get your experience writing grants? working with me, and my project was at the point where we were putting all the data together. We had I received support from the same mentors who helped to be really creative about which data we could use me establish myself as a health services researcher. and which papers we would publish. I thought that Dr. Kiefe helped me with my first letter of intent. She would be a huge blow to my research program. I was helped me respond to the critiques for proposal. It not sure if the center would re-open, if we could ever was literally back and forth—I would make edits and finish those grants, or if the wonderful staff that I send them to her, and she would send it back with had hired would stay with me during that time. The more writing on it than mine. She would carefully thought of having to rebuild it all over was really edit my grant proposals. It was help from her, along daunting. Thankfully, we found work to do during with examples of successful grants that were given to the downtime so when our center reopened, my staff me by other mentors, that helped me to prepare pro- was still with me and we were able to hit the ground posals that eventually were funded. While writing running. this grant, I also reached out to [ACS Regent] Leigh More recently, transitioning to Stanford in 2015 as Neumayer, MD, FACS, who was at the University of chair of surgery has created new challenges. Most of Utah, Salt Lake City, at the time. She was well con- my research team is still at UAB. There are more and nected in the VA for getting access to data. She became more demands on my time, but I still want research a co-investigator on my grant and one of my most to be part of my life. I am trying to find a way to keep influential mentors and is now a wonderful friend. I things moving, and I am trying to set aside time to have also learned a lot as a grant reviewer about how write the next grant. to clearly communicate an idea.

V102 No 1 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

Being an effective leader requires control over your emotions. In the OR, situations can become very tense, and having the ability to control your emotions and respond to events sets the tone of leadership.

attended the Executive Leadership in Academic Medi- You have had wonderful mentorship along the cine course. I have taken advantage of opportunities to way. How has that affected you as you have work on my own leadership skills and to understand become a mentor to others? the theory behind much of what we do—behind con- flict resolution and human resource management, as I don’t think any of us would be where we are without well as how to effectively communicate a vision. the influence of incredibly influential mentors. I reflect on that a lot; thinking of the people who have really affected my career and continue to do so. When I think Do you think the leadership skill set is applicable of my mentees, I feel that same obligation to ensure in the OR? they get the skills and support they need, that they get promoted, and that they are able to take advantage of Yes, being an effective leader requires control over | 31 opportunities as they arise. I have had the benefit of your emotions. In the OR, situations can become very really great mentors, which allows me to be a better tense, and having the ability to control your emotions mentor. and respond to events sets the tone of leadership. If you panic, then everyone else is going to panic. If you can keep your cool, it helps everyone else stay calm and You have developed significant leadership roles effectively solve the problem. through your career. How has that benefited you?

The leadership roles I have held have been critically You have had an active clinical, research, and important to my career. As I have had different oppor- leadership career. How have you balanced that tunities for leadership, I have reflected and wondered with your family life? if it was a good use of my time and in line with my goals. I would also speak to my mentors and appreci- It has not always been easy. When I was offered the ate their perspective. I did not want to sacrifice time chair position at Stanford, my daughter was a rising and effort on other aspects of my career, which were senior in high school. To say the least, it wasn’t ideal important, and on my family. Having the opportunity for her, but it was not the worst timing either. My son to be a leader, and being successful at it, gives you access was between eighth and ninth grade. We had open to more leadership roles. communication as a family about the move. We agreed that we would move to Palo Alto as a family and have that experience together. After Sarah’s first semester Did you do additional training for leadership? in her new school in California, she was unhappy, and we agreed that she could move back to Birmingham to I attended a course through the Association of finish high school. She was back with us in Palo Alto American Medical Colleges for women leaders in medi- for the summer before starting college. In the end, cine. I also attended a mid-career course through the we were able to find a good compromise, and it will Society of University Surgeons, and most recently I always be an experience that will define our family.

JAN 2017 BULLETIN American College of Surgeons PROFILES IN SURGICAL RESEARCH

surgeons; otherwise, the sentiment might be that a Do you think that for younger faculty, the pres- surgeon-scientist cannot be as effective in either role sure to generate clinical revenue compromises as a colleague who only does science or only does sur- their ability to do research? gery. We need to continue to advocate that surgeons can be effective at both of those disciplines, and that it Margins from clinical revenue are smaller and are what is really important to have them do both. we use to offset the cost of research. There is an increasing emphasis on a division’s profitability. It means that you can only support a certain number of people in What do you think the surgical community can do research positions and still have a financially solvent to support surgeon-scientists? division. If everybody was a funded researcher, maintenance of a positive profit margin would be nearly We can advocate for surgeon-scientists, we can impossible, unless it has other significant sources of rev- celebrate their successes, and we can encourage enue, such as endowments. We use the clinical margin surgeon-scientists to be on grant review committees to supplement our researchers, so many of our faculty and NIH study sections to provide their perspective 32 | will generate the margin to support the academic mis- and support during grant competitions. We need to sion. The challenge for leadership is to create a culture value research in our training programs and find dedi- where everyone values each other’s contributions to cated time to support surgeons who want to become the overall academic mission. scientists. However, we have to demonstrate that our scientific training process is as rigorous as that of our colleagues in the basic sciences. What do you think are the greatest challenges fac- ing surgeon-scientists today? You said that you have six siblings, and you are I think the greatest challenge is keeping support for the first physician in your family. You come from surgeon-scientists as a foremost mission in academic a small town in Michigan. What do they think of surgery departments. Surgeons need to be leaders in all of your success, including your appointment the field of scientific discovery and investigation. It is to chair of surgery at Stanford? really important because surgeons bring a different perspective and have different interactions and under- My brothers and sisters might say, “Well, they didn’t ask standing of the diseases we treat. Having that approach us about her!” People in my hometown are really proud and mindset fundamentally changes the way you might of me. I received many nice notes from my former high think about a solution to a problem. The challenges to school teachers after an announcement in the local achieve this are, quite simply, talent, time, and money. paper about my appointment at Stanford. I would not be It is increasingly competitive to do basic science where I am today without the support I have received research. PhD-trained scientists do not have the time from my family. We were competitive as kids, but now commitments of training residents and taking care of we’re each other’s biggest supporters. ♦ patients competing with their research; to compete with them head-to-head for funding is a challenge. The National Institutes of Health (NIH) funding rates have been flat. We need to keep surgeons on study sections that are advocating for grants from

V102 No 1 BULLETIN American College of Surgeons RAS-ACS ESSAY CONTEST

mentor is defined as someone who teaches or The 2016 RAS-ACS annual gives help and advice to a less experienced, A often younger person. We’ve all had mentors Communications Committee throughout the various stages of our lives. I have particularly fond memories of my high school advanced essay contest: placement Spanish teacher, who not only had a true gift for teaching the Spanish language to teenagers, An introduction but also for connecting with and encouraging her stu- | 33 dents to grow into responsible young adults. Mentorship in medicine is a popular topic, with more than 4,500 PubMed articles published on the subject over the last five years. With this in mind, the prompt for this year’s annual Resident and Associate Society of the American College of Surgeons (RAS-ACS) Com- munications Committee essay contest was Paying It Forward: When the Mentee Becomes the Mentor. We received more than 40 submissions detailing residents’ coming of age stories, many of which occurred by Erin Garvey, MD at different stages in medical training, but all of which highlighted the transformation of the student to a position of teaching, guiding, or advising someone with less experience. Our winning essay, written by Kevin Koo, MD, MPH, MPhil, will resonate with many readers who have guided trainees through their first skin closure and should remind us all of what it felt like to be given an opportunity to contribute to an operation for the first time while surrounded by our colleagues impatiently watching the ticking clock. We must remember that no matter how busy or burned out we may be or how inexperienced we may feel, we have so much to offer in the form of teaching, helping, or advising those following in our footsteps. In so doing, we keep the promise of our profession alive. ♦

JAN 2017 BULLETIN American College of Surgeons RAS-ACS ESSAY CONTEST

First-place essay: Paying it forward: When the mentee becomes the mentor

by Kevin Koo, MD, MPH, MPhil

’mon, doc, can we get this show on the The resident paused. “He’s already practiced with road?” the anesthesiologist asks optimisti- me, and he’s done a good job,” he replied. Then to me, “C cally. I couldn’t have planned a longer cys- assuredly, unwaveringly, “It’s your turn to operate.” tectomy if I had tried. The abdominal adhesions were My surgical mask hid a smile that spread unexpect- 34 | a tangled mess. The bulky tumor was more invasive edly across my face. I was overcome by a sudden sense than anticipated. The pelvic lymph nodes bled as if of belonging. Yes, I was the slowest in the room; I might avenging the dissection of their brethren. make a mistake and have to start over; the fastest way Across the table, Andy—my medical student who out was to move on. But what a thrill to have that has looked forward to observing this operation all proverbial hand on my shoulder, to be given a chance week—is nervously preparing to close the midline to try! Readying my hands and sharpening my focus, incision. I felt for the first time what it means to be a surgeon. Tick, tick, tick. The clock taunts us with each pass- My mind clears; my attention returns. I place the ing second. needle driver back in Andy’s hand. Andy fumbles with the needle driver. “Go on, Andy,” I say, echoing the resident who had I hear a chorus of suggestions: Why don’t you close, given me my chance, “It’s your turn to operate.” doc? Yeah, so we can get out before midnight. He can As his needle weaves back and forth, I’m reminded sew next time! of the mentors who stepped aside—or stepped up— Andy sets the instruments down, offering them to so that I could become more skilled, experienced, and me. compassionate. Many of us remember a calling to My mind conjures a sepia-toned memory. I was surgery and its appeal to those steady of hand and cou- standing at the operating table. It had been a long day. rageous of heart. What is not as evident—and what I’ve Everyone else’s eyes were on me, the surgery clerk, come to understand as I grow from student to teacher while my own eyes stared blankly at the instruments and from trainee to surgeon—is that our transforma- in my hands, betraying the hours I had spent practicing. tion is anchored by those who guide our hands to be “We’ll never get out of here tonight if he keeps this steady and inspire us with their courage. up,” the attending surgeon mumbled to the resident As Andy ties the final knot, his mask barely con- opposite me. “I need those clinic notes dictated, and cealing a proud smile, I feel profoundly honored by the you still have to see the consults.” commitment of my mentors and once again humbled I passed the needle driver to the resident. by the promise of our profession. ♦ “You finish this up, and let him practice some other time,” the attending directed.

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

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Highlights of Clinical Congress 2016

JAN 2017 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

he American College of Surgeons (ACS) Clini- Also at the Convocation, Honorary Fellowship cal Congress 2016 in Washington, DC, provided was conferred on five international surgeons: Her- Tsurgeons, medical students, surgical residents, nando Abaúnza Orjuela, MD, FACS, MACC(Hon), and other members of the surgical patient care team Bogota, Columbia; Jacques Belghiti, MD, PhD, Paris, with the opportunity to participate in myriad educa- France; S. Adibul Hasan Rizvi, MB, BS, FRCSEng, tional experiences and to interact with their peers. FRCSEd, Karachi, Pakistan; Sachiyo Suita, MD, PhD, Total registration for the meeting was 12,783, includ- Fukuoka, Japan; and John F. Thompson, AO, MD, ing 8,700 physicians and 4,083 exhibitors, guests, FACS, FRACS, FAHMS, Sydney, Australia. spouses, and convention personnel. Named Lectures 36 | Convocation Clinical Congress featured 11 Named Lectures, starting Courtney M. Townsend, Jr., MD, FACS, the with the Martin Memorial Lecture, presented immedi- Robertson-Poth Distinguished Chair in General Sur- ately after the Opening Ceremony on October 17. Delos gery, department of surgery, University of Texas Medical M. Cosgrove III, MD, FACS, chief executive officer, Branch (UTMB), Galveston; professor of surgery, depart- Cleveland Clinic, OH, presented the well-received lec- ment of surgery; professor of physician assistant studies, ture, Doctors in Distress: The Burnout Crisis. School of Allied Health Sciences; and graduate faculty Other Named Lectures presented at Clinical Con- in the cell biology program, UTMB, was installed as gress 2016 were as follows: 97th President of the ACS at Convocation October 16. Dr. Townsend delivered the Presidential Address, Do • Edward D. Verrier, MD, FACS, the K. Alvin and Shirley What’s Right for the Patient: Franklin H. Martin and E. Merendino Endowed Professor and chief of cardiotho- the American College of Surgeons, to the College’s 1,823 racic surgery, University of Washington Medical Center, Initiates, more than 800 of whom were in the audience. Seattle, presented the John H. Gibbon, Jr., Lecture: The Two Vice-Presidents also assumed office at the Con- Elite Athlete...the Master Surgeon. vocation. The First Vice-President is Hilary Sanfey, MB, BCh, MHPE, FACS, FRCSI, FRCS, professor of surgery • Andres M. Lozano, MD, PhD, FRCSC, FRSC, the Dan and vice-president for educational affairs, department of Family Chair in Neurosurgery, the R. R. Tasker Chair surgery, and associate director, Academy for Scholarship in Stereotactic and Functional Neurosurgery, and the and Education, Southern Illinois School of Medicine, Canada Research Chair in Neuroscience at the Univer- Springfield. The Second Vice-President is Mary C. sity of Toronto Health Network, ON, presented the I. S. McCarthy, MD, FACS, the Elizabeth Berry Gray Chair Ravdin Lecture in the Basic and Surgical Sciences: Sur- and Professor, department of surgery, Boonshoft School gery to Adjust the Activity of Misfiring Brain Circuits of Medicine, and adjunct graduate faculty, School of to Improve Movement, Mood, and Memory. Engineering, Wright State University; and acute care surgeon at Miami Valley Hospital, Dayton, OH. • H. Hunt Batjer, MD, FACS, the Lois C. A. and Darwin E. Smith Professor and chair, department of neurologi- Clinical Congress photography by Oscar & Associates. cal surgery, University of Texas Southwestern Medical

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Convocation: Distinguished Service Award Convocation: Mary Edwards Walker Inspiring Convocation: Incoming President recipient Dr. Opelka (right) with Dr. Richardson Women in Surgery Award recipient Dr. Maniscalco- Dr. Townsend delivers his Theberge (right) with Dr. Richardson Presidential Address

Center, Dallas, delivered the Charles G. Drake History d’Ivoire, presented the Distinguished Lecture of the of Surgery Lecture: Athletic Head Trauma: The Inter- International Society of Surgery: Challenges in Open face between Sport, Science, Pseudoscience, Politics, Heart Surgery in Africa: Côte d’Ivoire Experience. and Money. • Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), • Robert D. Fry, MD, FACS, the Emilie and Roland FRCS(Hon), FRCSEd(Hon), ACS Past-President and DeHellebranth emeritus professor of surgery and former professor of surgery and chair, department of surgery, chairman, department of surgery, Pennsylvania Hos- University of Washington, Seattle, delivered the John | 37 pital, Philadelphia, presented the Herand Abcarian J. Conley Ethics and Philosophy Lecture: TRUST: The Lecture: Surgical Mentorship, More Than Just Teaching. Keystone of the Patient-Physician Relationship.

• Lenworth M. Jacobs, Jr., MD, MPH, FACS, direc- • Richard L. Schilsky, MD, FACP, FASCO, senior vice- tor, Trauma Institute at Hartford Hospital, CT, and a president and chief medical officer, American Society member of the ACS Board of Regents, presented the of Clinical Oncology, Alexandria, VA, presented the Excelsior Surgical Society/Edward D. Churchill Lec- Commission on Cancer Oncology Lecture: Finding the ture: Strategies to Increase Survival in Active Shooter Evidence in Real-World Evidence: Moving from Data to and Intentional Mass Casualty Events. Information to Knowledge.

• Susan M. Briggs, MD, MPH, FACS, associate professor of surgery, Harvard Medical School and Massachusetts Notable events General Hospital, Boston, presented the Scudder Oration This year’s Clinical Congress featured three Special on Trauma Lecture: Responding to Crisis: Surgeons As Sessions on hot topics in surgery, including Firearm Leaders in Disaster Response. Injury Prevention, ACS Strong for Surgery, and Global Engagement. The session on Firearm Injury Preven- • Alexa I. Canady, MD, FACS, former chief of neurosur- tion was presented by the ACS Committee on Trauma gery at Children’s Hospital in Michigan, Ann Arbor, (COT) and focused, in part, on results from a survey presented the Olga M. Jonasson Lecture: The Journey: of COT members to determine their views on a range Becoming a Neurosurgeon and Back Again. of related topics. The ACS Strong for Surgery Session introduced this new College initiative, which is aimed • Koffi Herve Yangni-Angate, MD, professor of surgery, at optimizing patients for surgery through smoking and consultant and head, cardiovascular and thoracic cessation, nutrition, medication management, and surgery department, Bouake University Teaching Hos- glucose homeostasis. The Global Engagement session pital, and professor and chairman, cardiovascular and introduced the College’s new strategic direction in thoracic diseases department, Bouake University, Côte international and domestic volunteerism.

JAN 2017 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Convocation: Maya A. Babu, MD, Dr. Cosgrove delivers the Martin Dr. Briggs delivers the Scudder Dr. Canady delivers the Olga MBA, Chair of the ACS Resident Memorial Lecture Oration on Trauma M. Jonasson Lecture and Associate Society, speaks on behalf of incoming Initiates

The Commission on Cancer was honored to have offered throughout the U.S. to the general public. Greg Simon, Executive Director of the White House More information on this program can be found at Cancer Moonshot initiative, serve as the keynote bleedingcontrol.org. speaker at its annual meeting. The Moonshot proj- Member engagement activities initiated at Clini- ect, introduced by President Barack Obama during cal Congress 2015 continued at this year’s meeting. his 2016 State of the Union Address and led by Vice- The ACS Taste of the City offered Fellows, families, President Joe Biden, focuses on cancer prevention, staff, and guests the opportunity to experience the 38 | early detection, and accessible therapies. diverse dining and cultural scene of Washington, DC, The revitalized Excelsior Surgical Society, which and to network with other ACS members and leaders. is composed of military surgeons and dedicated to Clinical Congress attendees were again challenged their unique needs and issues, held its second annual to snap photos of themselves with ACS leaders and meeting October 16. A highlight of the meeting was members at various conference events and to post the presentation of the Second Annual U.S. Army the selfies on Twitter. The second annual Chapter Major John P. Pryor Lecture by retired U.S. Army Speed Networking event was presented to facilitate Colonel Norman M. Rich, MD, FACS, professor of interaction by chapter leaders and ACS Governors. military medicine, Uniformed Services University A Speed Mentoring event also took place this year, of the Health Sciences (USUHS), Bethesda, MD, and allowing residents to seek guidance from young Fel- director, Vietnam Vascular Registry. Dr. Rich’s com- lows of the ACS. ments focused on the history of the Excelsior Surgical New this year for the youngest Clinical Con- Society and the Vietnam Vascular Registry, which gress guest attendees was a Little Medical School he and his colleagues started in 1966 to register the day offered as part of the Clinical Congress Child injuries of American casualties and to provide long- Care Program. Children of Clinical Congress par- term follow-up care for the injured troops. ticipants were able to explore the world of medicine, The ACS COT piloted the Bleeding Control Basic science, and health in an engaging and fun environ- course at Clinical Congress. The new version of the ment. Each child who participated in this optional Bleeding Control course, endorsed by the Hartford program received a disposable white physician’s coat, Consensus™, enables surgeons to teach these life- organ sticker set, surgical kit, and a diploma. saving techniques to nonclinical members of their communities. The course, which was offered to ACS leaders and members of several committees, was Awards and honors developed in conjunction with the President’s “Stop Several surgeons were honored for their contribu- the Bleed” national campaign to bring awareness to tions to the ACS and to surgery. Frank G. Opelka, bleeding control and techniques for saving lives after MD, FACS, a colon and rectal surgeon and Medical hemorrhagic injury. The course ultimately will be Director, Quality and Health Policy, ACS Division of

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Mr. Simon delivers the Commission Dr. Rich delivers the U.S. Army Dr. Jacobs (right) demonstrates on Cancer Keynote Address Major John P. Pryor Lecture bleeding control procedures

Advocacy and Health Policy, Washington, DC, received points to Dr. Kuhls’ “persistent, patient, passionate, the ACS Distinguished Service Award, the College’s and effective leadership of the Injury Prevention and highest honor, at Convocation. The Board of Regents Control programs of the American College of Surgeons presented the award to Dr. Opelka “in appreciation Committee on Trauma.” for his continuous and devoted service as a Fellow of Rebekah Ann Naylor, MD, FACS, a general sur- the American College of Surgeons and the physician geon from Fort Worth, TX, received the Surgical leader of the College’s quality and health policy efforts Humanitarian Award for her work in improving and in the Washington, DC, office over the last 15 years.” expanding the Bangalore Baptist Hospital, Karna- | 39 The ACS presented the inaugural Mary Edwards taka, India. Additionally, four surgeons received the Walker Inspiring Women in Surgery Award ACS/Pfizer Surgical Volunteerism Awards.Sandra “with admiration and appreciation” to Mary E. Lynn Freiwald, MD, FACS, a general surgeon, Kaiser Maniscalco-Theberge, MD, FACS, at Convocation. Permanente Hospital, San Diego, CA, received the Dr. Maniscalo-Theberge, Interim Medical Inspector, Domestic Surgical Volunteerism Award for her work Veterans Health Administration, Washington, DC, with the San Diego County Medical Society Foun- and clinical professor of surgery, USUHS, has been a dation’s Project Access San Diego, which enables champion for the advancement of women in surgery low-income, uninsured individuals to receive spe- and an inspiration to women surgeons in the metro- cialty care services at no charge. J. Nilas Young, MD, politan Washington, DC, area. FACS, a cardiothoracic surgeon from Sacramento, The Fellows Leadership Society (FLS) of the ACS CA, received the International Surgical Volunteerism Foundation presented the 2016 Distinguished Philan- Award for developing, implementing, and sustaining thropist Award to past-Distinguished Service Award children’s heart surgery programs throughout Russia. Recipient Mary H. McGrath, MD, MPH, FACS, pro- James A. O’Neill, Jr., MD, FACS, a pediatric surgeon fessor of surgery, department of surgery, division of from Nashville, TN, received the International Surgi- plastic and reconstructive surgery, University of Cali- cal Volunteerism Award for his work as clinician and fornia, San Francisco. The award was announced at innovator, as well as his decades-long involvement in the 27th annual FLS Donor Recognition Luncheon medical outreach. Barclay T. Stewart, MD, MPH, and acknowledges Dr. McGrath’s commitment as a PhD, a general surgery resident from Beaufort, SC, generous donor to the College, her service to the larger received the Surgical Resident Volunteerism Award philanthropic community, her longstanding record of for his efforts to provide care to underserved domestic ACS volunteerism, and her dedication to the quality and international populations. of surgical patient care. The 2016 Owen H. Wangensteen Scientific Forum Debrah A. Kuhls, MD, FACS, received the National abstract supplement was dedicated to Ori D. Rot- Safety Council Surgeons’ Award for Service to Safety stein, MD, FACS, director, Keenan Research Centre at the annual ACS COT Dinner. The award citation for Biomedical Science; professor and associate chair,

JAN 2017 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Distinguished Philanthropist Award recipient Dr. McGrath National Safety Council Award recipient Dr. Kuhls (center), (left) with Amilu Stewart, MD, FACS, ACS Foundation Chair with Raul Coimbra, MD, PhD, FACS, President, American Association for the Surgery of Trauma, and Past Vice-Chair, COT (left), and Ronald M. Stewart, MD, FACS, Chair, COT

department of surgery at the University of Toronto; presented to Sarah L. M. Greenberg, MD, MPH, a and surgeon-in-chief, St. Michael’s Hospital, Toronto, chief resident in general surgery at Medical College ON. of Wisconsin Affiliated Hospitals, Milwaukee. The Practicing surgeons, residents, and medical stu- award recognizes a chief resident in general surgery dents were recognized for their contributions to who exemplifies the values of compassion, technical advancing the art and science of surgery. Recipients skill, and devotion to science and learning. The ACS honored with the Scientific Forum Excellence in established the award with gifts from the Chassin 40 | Research Awards included the following: Elizabeth family, colleagues, and friends of the late Dr. Chas- J. Lilley, MD, MPH; Mitchell R. Dyer, MD; Alicia E. sin, who was a skilled surgeon, teacher, and scholar Snider, MD; Vanagh C. Nikolian, MD; Marina Ibra- in New York, NY. him, MD, CM, MSc; David L. Colen, MD; Rebecca Members of the ACS Scientific Forum Committee, Scully, MD; and Matthew A. Hornick, MD. including Paula M. Termuhlen, MD, FACS, member; Ankit Bharat, MD, FACS, assistant professor of Dennis P. Orgill, MD, PhD, FACS, Vice-Chair; and thoracic surgery and pulmonary and critical care Mary T. Hawn, MD, FACS, Chair, awarded the Best medicine, Feinberg School of Medicine, Northwest- Scientific Poster of Exceptional Merit to Dani Odette ern University, Chicago, IL, received the 12th Joan L. Gonzalez, MD, for Variability in Surgical Manage- and Julius H. Jacobson II Promising Investigator ment of Benign Ovarian Neoplasms in Children. The Award. The award honors outstanding surgeons coauthors of this poster included the following: Jen- who engage in research, advance the art and sci- nifer N. Cooper, PhD; Jennifer H. Aldrink, MD, ence of surgery, and demonstrate early promise of FACS; Geri D. Hewitt, MD; Peter C. Minneci, MD, making significant contributions to the practice of MHSc; and Katherine J. Deans, MD, MHSc, FACS. surgery. In addition, the following medical students were The 14th annual ACS Resident Award for Exem- honored for their Basic Science Research posters: plary Teaching was presented to Afif N. Kulaylat, MD, MSc, a fourth-year resident in general surgery • First place: Michaela C. Bamdad, Yale University at the Penn State Milton S. Hershey Medical Center, School of Medicine, New Haven, CT: Serotonin Reup- Hershey, PA. The ACS Division of Education sponsors take Inhibitors Protect the Intestinal Mucosa from the the award to recognize excellence in teaching by a Effects of Chemotherapy resident and to highlight the importance of teaching in residents’ daily lives. Dr. Kulaylat was selected by • Second place: Daniel Walden, Medical College of an independent review panel of the Committee on Wisconsin, Milwaukee: Xanthohumol, a Hop Plant Resident Education. Extract, Decreases NOTCH1 and Mediates Cellular The fourth annual Jameson L. Chassin, MD, FACS, Anti-Carcinogenic Pathways in Cholangiocarcinoma Award for Professionalism in General Surgery was Cell Lines

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Volunteerism awards (from left): Francis D. Ferdinand, MD, FACS, ACS Board Surgical Forum dedicatee Dr. Rotstein (center) with of Governors’ Executive Committee; awardees Dr. Barclay Stewart, Dr. Naylor, introducer John C. Marshall, MD, FACS (left), and Dr. Hawn Dr. O'Neill, Dr. Freiwald, and Dr. Young; and Frank W. Sellke, MD, FACS, Chair, ACS Surgical Volunteerism and Humanitarian Awards Workgroup

| 41

Scientific Forum Excellence in Research Award recipients, from left: Drs. Lilley, Dyer, Snider, Nikolian, Ibrahim, Colen, Scully, and Hornick; Dr. Hawn; Drs. Jackson, Cauley, Dolejs, Gonzalez, Pearl, Schwartz, Nevo, and Gallaher

• Third place: Jacob C. Young, University of Chicago, IL: • Third place: Tania Hassanzadeh, University of Arizona, Generation and Characterization of an IL13RA2-Tropic Tucson: Defining Non-Surgical Head Bleeds; When Do Modified Adenovirus for the Personalized Treatment You Need a Neurosurgeon? of Glioblastoma The International Relations Committee (IRC) wel- The following medical students were recognized comed the International Guest Scholars (IGS) for 2016 for their Clinical and Educational Research posters: and other guests, including the following: Adewale Oluseye Adisa, MB, BCh, FACS, International Sur- • First place: Michael C. Bambad, Yale University School gical Education Scholar I; Tanveer Ahmed, MB, BS; of Medicine: Antibiotic Standardization Decreases Wan Mohammed Aldohuky, MB, BCh, FACS, Com- Antibiotic-Associated Costs in Pediatric Patients with munity Surgeons Travel Awardee; Waddah Badir Appendicitis Al-Refaie, MB, BCh, FACS, Chair, Designated Schol- arship Subcommittee; Vivek Bindal, MB, BS, FACS, • Second place: Adam C. Fields, Icahn School of Medi- International Surgical Education Scholar II; Joseph S. cine at Mount Sinai, New York, NY: Risk Factors for Butler, MB, BCh, BOA, Dr. Abdol Islami & Mrs. Joan Unplanned Readmission following Cholecystectomy: Islami Scholar I; Yi Chen, MB, BS, PhD, FRACS, ANZ A NSQIP® Analysis of 27,125 Patients Exchange Fellow; Nai-Chen Cheng, MD, PhD, Elias

JAN 2017 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

Joan L. and Julius H. Jacobson II Promising Resident Award for Exemplary Teaching recipient Investigator Award recipient (left) Ankit Bharat, Dr. Kulaylat (left) with Dr. Townsend MD, FACS, with Kamal M. F. Itani, MD, FACS

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Jameson L. Chassin, MD, FACS, Award recipient Posters of Exceptional Merit recipient Dr. Gonzalez (second from left), Dr. Greenberg (left) with Dr. Townsend with (from left) Dr. Termuhlen, Dr. Orgill, and Dr. Hawn

Hanna Scholar; Marcello Donati, MD, PhD; Hiba PhD, Stavros Niarchos Foundation Scholar; George Ezzeddine, MD, Resident Exchange Fellow; Chris- Velmahos, Chair, IRC; Anubhav Vindal, MB, BS, topher C. K. Ho, MD, MS; Mohammed Kamal, MD, FACS; and Thilo Welsch, MD, MBA, Germany Baxiram S. and Kankuben B. Gelot Community Sur- Exchange Fellow. geons Travel Awardee; Manabu Kawai, MD, PhD; The Commission on Cancer (CoC) presented Omar Khalaf, MD; Gustavo Kohan, MD, Dr. Abdol the State Chair Outstanding Performance Award to Islami & Mrs. Joan Islami Scholar II; Guiseppe R. Ted James, MD, FACS, Vermont; Sharon Lum, MD, Nigri, MD, FACS, Chair, Scholarships Subcommit- FACS, California; and Richard Zera, MD, FACS, tee; Joseph Martin Plummer, MB, BS; Mauricio A. Minnesota. Pontillo, MD, FACS, Murray F. Brennan Scholar; In addition, the CoC held its annual Paper Com- Goran Santak, MD; Anthony Yuen Bun Teoh, MB, petition. The three surgical residents who submitted BCh, FRCSEd, PHKAM, PCSHK, Carlos Pellegrini winning papers are as follows: Kendell Keck, MD, Uni- Traveling Fellow; Takeo Toshima, MD, PhD, Japan versity of Iowa Hospitals and Clinics, Iowa City (first Exchange Fellow; Dimitrios Tsamis, MD, MSc, place); Ahsan Raza, MB, BS, University of Florida,

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

2016 International Guest Scholars and Travelers and other guests of the IRC: Front row, from left: Dr. Ho; Dr. Kawai; Guiseppe R. Nigri, MD, FACS, Chair, Scholarships Subcommittee; George Velmahos, Chair, IRC; Waddah Badir Al-Refaie, MB, BCh, FACS, Chair, Designated Scholarship Subcommittee; Dr. Ezzeddine; and Omar Khalaf, MD, Beirut Middle row: Drs. Tsamis, Adisa, Toshima, Plummer, Bindal, Pontillo, Ahmed, Kohan, Chen, and Aldohuky Back row: Drs. Vindal, Santak, Kamal, Cheng, Donati, Butler, and Teoh

Gainesville (second place); and Justin Wilkes, MD, Uni- Executive Director; and Michael J. Sutherland, MD, | 43 versity of Iowa Carver College of Medicine (third place). FACS, Chair of the ACS Professional Association Chayanin Musikasinthorn, MD, FACS, general, political action committee (ACSPA-SurgeonsPAC) trauma, and critical care surgeon, Gallup Indian Board of Directors. Medical Center, NM, attended Clinical Congress The election of the ACS President-Elect, Vice- as the recipient of the 2015 Nizar N. Oweida, MD, Presidents-Elect, Regents, and Governors also took FACS, Scholarship. place at the Annual Business Meeting. Barbara Lee Lastly, the winners of the 2016 Resident and Asso- Bass, MD, FACS, the John F. and Carolyn Bookout ciate Society (RAS) of the ACS essay contest spoke at Distinguished Endowed Chair and chair, department the RAS Symposium, the theme of which was Explor- of surgery, Houston Methodist Hospital, TX, and ing the Limits of Surgeon Disclosure: Where Are the executive director, Houston Methodist Institute for Boundaries? Christopher F. McNicoll, MD, MPH, Technology, was elected President-Elect of the ACS. MS, a second-year general surgery resident, Univer- Charles D. Mabry, MD, FACS, a general surgeon, sity of Nevada School of Medicine, Las Vegas, was Pine Bluff, AR; associate professor of surgery and the first place winner for his “pro” essay, and Reema practice management advisor to chair, department of Mallick, MD, an Associate in the ACS Transition to surgery, University of Arkansas for Medical Sciences, Practice Program, Geisinger Medical Center, Danville, Little Rock; and medical director of quality, Jefferson PA, wrote the winning “con” essay. Regional Medical Center, Pine Bluff, was elected First Vice-President-Elect. The Second Vice-President-Elect is Basil A. Pruitt, Jr., MD, FACS, FCCM, MCCM, Annual Business Meeting the Dr. Ferdinand P. Herff Chair in Surgery, clinical The ACS Annual Business Meeting of Members con- professor of surgery, department of surgery, trauma vened October 18 with Dr. Townsend presiding. division, University of Texas Health Science Center, The following officials presented reports: Valerie San Antonio, and professor of surgery, USUHS. W. Rusch, MD, FACS, Chair of the Board of Regents; The B/G elected Michael J. Zinner, MD, FACS, a Fabrizio Michelassi, MD, FACS, Chair of the Board general surgeon, Coral Gables, FL, to serve as Chair of Governors (B/G); David B. Hoyt, MD, FACS, ACS of the Board of Regents. Leigh A. Neumayer, MD,

JAN 2017 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

CoC State Chair awardees (from left, with awards) Dr. James, Dr. Lum, and Dr. Zera, with (from far left) Otis Brawley, MD, FACP, Chief Medical Officer, American Cancer Society; Mary Milroy, MD, FACS, Chair, Committee on Cancer Liaison; and Peter Hopewood, MD, FACS, Vice-Chair, Committee on Cancer Liaison

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CoC Papers Competition winners, from left: Drs. Raza, Keck, and Wilkes Oweida Scholar Dr. Musikasinthorn, with Tyler G. Hughes, MD, FACS (left), and Dr. Richardson

Recipients of the ACS Distinguished Service Award. Front row, left to right (all MD, FACS): Dr. McGrath; LaMar S. McGinnis, Jr.; Dr. Amilu Stewart; Murray F. Brennan; and Jack W. McAninch. Back row: F. Dean Griffen; John A. Weigelt; David B. Hoyt; Patricia J. Numann; J. Wayne Meredith; Frank G. Opelka; and Richard B. Reiling. Dr. Michelassi, then-Chair of the ACS Board of Governors, is at the far right

V102 No 1 BULLETIN American College of Surgeons CLNIICAL CONGRESS HIGHLIGHTS

The ACS Division of Education welcomed more than 360 medical students to the 2016 Medical Student Program

FACS, a general surgeon, Tucson, AZ, was elected FOR MORE INFORMATION Vice-Chair of the Board of Regents. This article contains information that is discussed in The B/G also elected two new Regents: greater depth in previous issues of the Bulletin, as follows: Anthony Atala, MD, FACS, a urologist, Winston- Salem, NC, and Fabrizio Michelassi, MD, FACS, September 2016 a general surgeon, New York, NY. • Frank G. Opelka, MD, FACS, chosen as 2016 | 45 The following Regents were reelected: Mar- Distinguished Service Award recipient, page 59 garet M. Dunn, MD, FACS, a general surgeon, • Fellows honored for volunteerism and Dayton, OH (third term); James W. Gigantelli, humanitarianism, page 62 MD, FACS, an ophthalmologist, Omaha, NE (second term); and Dr. Zinner. October 2016 The B/G elected Diana Farmer, MD, FACS, • Mary H. McGrath, MD, MPH, FACS, to be honored a pediatric surgeon, Sacramento, CA, to serve with Distinguished Philanthropist Award, page 71 as Chair, B/G Executive Committee; Steven C. Stain, MD, FACS, a general surgeon, Albany, NY, November 2016 as Vice-Chair; and Susan K. Mosier, MD, FACS, an • RAS-ACS Symposium essays, page 34 ophthalmologist, Topeka, KS, as Secretary. Newly • Courtney M. Townsend, Jr., MD, FACS, installed elected to the B/G Executive Committee are S. Rob as 97th President of the ACS, page 57 Todd, MD, FACS, an acute care surgeon, Houston, • Inaugural Mary Edwards Walker Award presented TX (initial one-year term); and Nicole S. Gibran, to Dr. Maniscalco-Theberge, page 60 MD, FACS, a burn surgeon, Seattle, WA (initial two- year term). • Five outstanding surgeons conferred Honorary Fellowship in the ACS, page 63 December 2016 Clinical Congress 2017 Be sure to attend the Clinical Congress 2017, Octo- • Barbara Lee Bass, MD, FACS, is 2016–2017 ACS President-Elect, page 76 ber 22–26, in San Diego, CA. Details regarding the educational program, registration, housing, and • New Regents and Governors elected, page 80 transportation will be posted at facs.org. ♦ All articles can also be viewed online at bulletin.facs.org.

JAN 2017 BULLETIN American College of Surgeons ACS OFFICERS, REGENTS, AND BOARD OF GOVERNORS’ EXECUTIVE COMMITTEE

Officers/Officers-Elect

Courtney M. Hilary Sanfey Mary C. McCarthy Townsend, Jr. First Vice-President Second Vice-President President General surgery General surgery General surgery Professor of surgery and Elizabeth Berry Gray Chair Robertson-Poth vice-chair for educational and Professor, department Distinguished Chair affairs, department of of surgery, Boonshoft in General Surgery, surgery; and associate School of Medicine, and department of surgery, director, Academy for adjunct graduate faculty, University of Texas Medical Scholarship and Education, School of Engineering, Branch Southern Illinois School of Wright State University; Galveston, TX Medicine, Springfield acute care surgeon, Miami Springfield, IL Valley Hospital Dayton, OH

J. David Richardson William G. Cioffi, Jr. Edward E. Cornwell III Immediate Past- Treasurer Secretary President General surgery General surgery General, thoracic, and J. Murray Beardsley The LaSalle D. Leffall, Jr., trauma surgery Professor and chairman, Professor and Chairman of Professor of surgery Alpert Medical School of Surgery, Howard University and vice-chairman, Brown University; and College of Medicine; and department of surgery, surgeon-in-chief, Rhode surgeon-in-chief, Howard University of Louisville Island Hospital and The University Hospital School of Medicine Miriam Hospital Washington, DC Louisville, KY Providence, RI

Barbara L. Bass Charles D. Mabry Basil A. Pruitt, Jr. 46 | President-Elect First Vice-President- Second Vice-President- General surgery Elect Elect John F. and Carolyn General surgery General surgery Bookout Distinguished Associate professor of Dr. Ferdinand P. Herff Chair in Endowed Chair and chair, surgery and practice Surgery, clinical professor of department of surgery, management advisor surgery, department of surgery, Houston Methodist Hospital to chair, department of trauma division, University of Houston, TX surgery, University of Texas Health Science Center; Arkansas for Medical and professor of surgery at Sciences; and medical Uniformed Services University director of quality, of Health Sciences Jefferson Regional Medical San Antonio, TX Center Pine Bluff, AR

Michael J. Zinner Leigh A. Neumayer Chair Vice-Chair General surgery General surgery CEO and Executive Medical Professor and chair, Board of Director, Miami Cancer department of surgery; Institute Margaret and Fenton Coral Gables, FL Maynard Endowed Chair in Breast Cancer Research, Regents University of Arizona College of Medicine Tucson, AZ

Anthony Atala John L. D. Atkinson Urology Neurological surgery Director of the Wake Forest Professor of Institute for Regenerative neurosurgery, Medicine, W. Boyce department of Professor and Chair, neurological surgery, department of urology, Mayo Clinic Wake Forest University Rochester, MN School of Medicine Winston-Salem, NC

V102 No 1 BULLETIN American College of Surgeons ACS OFFICERS, REGENTS, AND BOARD OF GOVERNORS’ EXECUTIVE COMMITTEE

Board of Regents

James C. Denneny III Margaret M. Dunn Timothy J. Eberlein Otorlaryngology–head and General surgery General surgery neck surgery Professor of surgery and Bixby Professor of Surgery Adjunct professor, clinical executive associate dean, and chair of surgery; otolaryngology, department Wright State University Spencer T. and Ann W. Olin of otolaryngology–head and Boonshoft School of Distinguished Professor neck surgery, University of Medicine; and chief and director, The Alvin J. Missouri School of Medicine; executive officer, Wright Siteman Cancer Center; adjunct professor, department State Physicians, Inc. and surgeon-in-chief, of otolaryngology–head and Fairborn, OH Barnes-Jewish Hospital, neck surgery, Johns Hopkins Washington University School of Medicine School of Medicine Alexandria, VA St. Louis, MO

James K. Elsey Henri R. Ford General and vascular Pediatric surgery surgery Vice-president and Private practice; surgeon-in-chief, Children’s visiting professor of Hospital of Los Angeles; surgery, Emory University vice-chairman and School of Medicine vice-dean for medical Atlanta, GA education, Keck School of Medicine, University of Southern California Los Angeles, CA

| 47 Gerald M. Fried James W. Gigantelli B. J. Hancock General surgery Ophthalmology Pediatric surgery Adair Family Professor and Professor of Associate professor, chairman, department of ophthalmology and departments of surgery surgery and surgeon-in- assistant dean of and pediatrics and child chief, McGill University government relations at health, University of Health Centre Hospitals the University of Nebraska Manitoba; and pediatric Montreal, QC Medical Center surgeon and pediatric Omaha, NE intensivist, Children’s Hospital of Winnipeg Winnipeg, MB

Enrique Hernandez Lenworth M. Jacobs, Jr. Gynecology (oncology) General surgery The Abraham Roth Professor of surgery and Professor and Chair, chairman, department department of obstetrics, of traumatology and gynecology, and emergency medicine, reproductive science; University of Connecticut; director, division of and director, Trauma gynecologic oncology; Institute at Hartford and professor of Hospital pathology, Temple Hartford, CT University Philadelphia, PA

L. Scott Levin Mark A. Malangoni Fabrizio Michelassi Orthopaedic surgery General surgery General surgery Paul B. Magnuson Chair of Associate executive Lewis Atterbury Stimson Orthopaedic Surgery; chair, director, American Board Professor and Chair, Weill department of orthopaedics; of Surgery Cornell Medical College and professor of surgery, Philadelphia, PA department of surgery; University of Pennsylvania and surgeon-in-chief, New School of Medicine; and York-Presbyterian/Weill plastic and reconstructive Cornell Medical Center surgeon, University of New York, NY Pennsylvania Health System Philadelphia, PA

JAN 2017 BULLETIN American College of Surgeons ACS OFFICERS, REGENTS, AND BOARD OF GOVERNORS’ EXECUTIVE COMMITTEE

Board of Regents

Linda G. Phillips Valerie W. Rusch Marshall Z. Schwartz Plastic and reconstructive Thoracic surgery Pediatric surgery surgery Vice-chair, clinical Professor of surgery Truman G. Blocker, research, department of and pediatrics and vice Jr., MD, Distinguished surgery; Miner Family Chair chairman, department of Professor and chief, in Intrathoracic Cancers; surgery, Drexel University department of surgery, attending surgeon, thoracic College of Medicine division of plastic surgery; service, department of Bryn Mawr, PA and professor, School of surgery, Memorial Sloan Medicine, University of Kettering Cancer Center; Texas Medical Branch and professor of surgery, Galveston, TX Weill Cornell Medical College New York, NY

Anton N. Sidawy Beth H. Sutton Steven D. Wexner Vascular surgery General surgery Colorectal surgery Professor & Lewis B. Private practice, Wichita Director, Digestive Disease Saltz Chair, department Falls; and clinical Center; chair, department of of surgery, George assistant professor, colorectal surgery, Cleveland Washington University University of Texas Clinic Florida; affiliate Washington, DC Southwestern Medical professor, Florida Atlantic School, Dallas University College of Medicine; Wichita Falls, TX and clinical professor, Florida International University College of Medicine Weston, FL

48 | Diana L. Farmer Chair Pediatric surgery Pearl Stamps Stewart Professor of Surgery, and chair, department of surgery, University of California-Davis Health System Sacramento, CA

Steven C. Stain Board of Vice-Chair General surgery Henry & Sally Schaffer Chair & Professor, Governors’ department of surgery, Albany Medical Center Executive Albany, NY Committee

Susan K. Mosier Secretary Ophthalmic surgery Secretary, Kansas Department of Health and Environment, and State Health Officer for Kansas Topeka, KS

V102 No 1 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

Impact of SSI reduction strategy after colorectal resection

by Lisa A. Wilbert, RN

Editor’s note: Hospitals that his case study was conducted management, medicine, nursing, participate in the American at Stony Brook Medicine, and social welfare) and myriad College of Surgeons National TLong Island, NY, and focused centers, institutes, programs, Surgical Quality Improvement on surgical site infection (SSI). and clinics. With 603 beds, the Program (ACS NSQIP®) use the SSI is a common complication University Hospital serves as program’s data and reports of colorectal surgery, adding to Suffolk County’s only tertiary to improve performance and increased morbidity, readmission care center and regional trauma surgical outcomes. Sites are rates, and overall costs.1,2 In fact, center. With 106 beds, Stony invited to share their experiences SSIs are responsible for more than Brook Children’s offers the most at the ACS NSQIP Annual $3.5 billion in annual U.S. health advanced pediatric specialty Conference through abstract care expenditures.3,4 Colorectal care in the region. We also are submissions for poster and panel surgery is consistently associated home to a Cancer Center, Heart presentations. Hospitals also are with SSI rates that are between Institute, and Neurosciences encouraged to share their quality 5 percent and 45 percent higher Institute. A Medical and improvement initiatives, so other than other forms of surgery. Research Translation (MART) institutions can learn from their Stony Brook’s ACS NSQIP building, dedicated to imaging, | 49 experience and develop their own data from 2006 to 2009 indicated neurosciences, and cancer quality improvement programs. that colorectal surgery was a care and research, and a new high outlier for SSI. With the Hospital Pavilion and Children’s ACS NSQIP Best Practices Case first publication of decile ranks Hospital will open in 2017. Studies will be an ongoing series in 2009, our hospital ranked in Stony Brook administrators in the Bulletin starting with this the 10th (worst) tier. In response have a vision for quality and issue. These case studies have to the prevalence of SSIs in patient safety and are working been edited to comply with colorectal patients, our team to achieve top decile in all Bulletin style and provide a designed a multidisciplinary clinical outcomes. Reducing description of the clinical problem approach to standardize the SSI in colorectal surgery ties being addressed, the context care and methods involved in in with the institution’s goals of the quality improvement managing colorectal patients to of providing world-class project, the planning and determine the impact on SSI rates health care to its patients. development process, a following colorectal resection. In the development process, description of the activity, the ACS NSQIP data from 2006 resources needed, the results, to 2014 were supplemented and tips for other case studies. How was the quality with an institutional review improvement (QI) board-approved chart review. activity put in place? Patients were divided into three Stony Brook Medicine is an groups: a pre-SSI reduction academic medical center that strategy group (January 1, 2006– encompasses Stony Brook June 30, 2009), an SSI reduction University Hospital, Stony Brook strategy group (July 1, 2009– Children’s Hospital, five health December 30, 2012), and a third sciences schools (dental medicine, group testing the durability health care technology and of the implemented measures

JAN 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

ACS NSQIP Best Practices Case Studies will be an ongoing series in the Bulletin starting with this issue.

(January 1, 2012–September 30, stating that the surgical team was implement our own possible 2014). The SSI reduction strategy responsible for the initial dressing solutions to the known SSI risks was prospectively implemented change, with contact information inherent to colorectal resection. in a single institution and and instructions in the event that compared with historical questions arose regarding the controls (pre-SSI strategy arm). integrity or contamination of the What resources and dressing (see Figure 5, page 54). skills were needed? ACS NSQIP data used in the Before patients arrived at the What strategies were study aided in standardizing our hospital for their operation, they used to reduce SSI? own patient data and the outcome underwent a standard bowel The SSI reduction strategy against that of other institutions preparation and took a prescribed included preoperative, through their formatted enema two hours before leaving intraoperative, and postoperative evaluation system. This approach home. Patients were instructed to components (see Figure 1, was beneficial in comparing the shower from the neck down with page 51). Patients were given post-SSI strategy outcome with chlorhexidine after completion of 50 | instructions and materials the pre-SSI value and aided in the the bowel prep and after noting for preoperative procedures, study’s external validity because clear bowel movements. An including a chlorhexidine ACS NSQIP’s standardized antimicrobial scrub brush and gluconate (CHG) shower. definitions of evaluated solution were provided for the Mechanical bowel preparation variables allow for accurate patients’ use. On the morning of without oral antibiotics was comparison among institutions. surgery, the patient underwent used before and after the SSI In selecting the processes that a chlorhexidine antimicrobial reduction strategy protocol. were anticipated to reduce the scrub of the abdomen. At Upon arrival at the hospital, SSI rate, we used a combination preoperative admission on the patient was taken to a of guiding principles, including the day of surgery, the patient preoperative holding area where best practice recommendations was asked a series of questions a member of the colorectal team and evidence-based medicine. We by trained nursing staff to met the patient and completed a began developing our strategy determine readiness for transfer preoperative checklist to evaluate by first strengthening the SSI to the operating room (OR). compliance (see Figure 2, page 52). reducing protocols already in Blood glucose was closely Intraoperative procedures were place while researching the monitored, with a preoperative standardized and included all literature for evidence-based goal of <200 mg/dl. A delay members of the operative team. practices that have proven in the OR was considered if The surgical staff implemented beneficial in colorectal patients. In the patient had a preoperative wound closure guidelines with addition, we adapted and modified glucose of 200–349 mg/dl, and well-defined parameters for fascial select practices that other cancellation of the operation and skin closure (see Figure 3, surgical services had previously was considered if the glucose page 53) and delayed wound implemented in our institution level was >350 mg/dl. While closure (see Figures 4A and 4B, and that had demonstrated the patient was in preoperative page 54). Upon completion of the beneficial results. In addition, admission, hair removal by operation, a sticker was placed we extrapolated possibilities for over the surgical dressings, improvement by attempting to continued on page 52

V102 No 1 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 1. SSI REDUCTION STRATEGIES BY PHASE OF CARE

PREHOSPITAL • Use of chlorhexidine skin • Wound closure guidelines to be prep unless contraindicated followed (see Figure 3, page 53) • Bowel preparation (stoma/allergy) • Normothermia (SCIP • Over-the-counter enema ȖȖSubstitute Betadine when contra- ≥36.0° C); discuss/address patient two hours before leaving indicated: Allow to air dry temperature at debriefing prior to surgeon leaving OR home for hospital • Skin prep area extended from nipple line to knees: side to side • Sticker with dressing • Neck-down shower with change instructions placed chlorhexidine at completion ȖȖ Area inclusive of posterior axil- on dressed wound of prep and after clear lary line bowel movement (BM) • Attending will be present in POSTOPERATIVE OR during skin prep to observe • Do not leave OR in scrubs except • Chlorhexidine antimicrobial staff performing skin prep as when directly walking to and from scrub of abdomen per established guidelines office to change to street clothes morning of operation ȖȖStaff will be reeducated at point of • Discontinuation of antibiotic care by attending if prep does not within 24 hours (SCIP) PREOPERATIVE meet standard expected • Foley catheter removal • Improved licensed independent • OR team operating within the by POD #2 (SCIP) practitioner (LIP) questions to sterile field will prepare for the determine patient readiness for OR case using chlorhexidine scrub • Glucose control (SCIP cardiac brush for more than two minutes surgery measure) ȖȖPercent bowel prep consumed (this includes the scrub nurse) • Appropriate hand hygiene/ gloves on floor ȖȖColor of last stool ȖȖChlorhexidine/alcohol-based preoperative hand antiseptics will not • Dressing changes using | 51 ȖȖEnema two hours before leaving be considered an acceptable sub- sterile technique home stitute for traditional brush hand • Prior to patient discharge; scrubbing attending review of wound Ȗ ȖNeck-down shower with chlorhexi- • Clean scrubs must be worn at dine at completion of prep and af- the start of every colorectal case ter clear BM (staff within the sterile field) ȖȖChlorhexidine neck-down shower • Scrubs worn during a case with additional antimicrobial scrub will not be worn outside of abdomen morning of operation of the OR (surgeon) Ȗ • Blood glucose—preoperative ȖSurgeons will change into clean holding area check (goal <200) scrubs before entering or leaving OR • Prophylactic antibiotic will be ȖConsider delay of case: ≥200 – 349 Ȗ administered within 60 minutes of incision time for optimal results ȖȖConsider cancellation of case: ≥350 • Place iodine-impregnated • Hair removal complete in incision drape over abdomen preoperative holding area before going to OR • Put Alexis wound retractor in place • Before closing the abdominal INTRAOPERATIVE wall, the OR team operating • Staff will wear surgical masks within the sterile field will: at all times in the OR ȖȖ(1) Re-glove • Staff will minimize traffic and ȖȖ(2) Re-prep time OR door is left open ȖȖ(3) Re-towel incision area ȖȖ(4) Use reserved clean instrument tray for closing

JAN 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 2. PREOPERATIVE CHECKLIST

52 |

clipping was completed before the knees and between bilateral was mandated; alternative presenting to the OR. posterior axillary lines. The hand sterilization methods In the OR, staff was instructed attending surgeon was present were deemed an unacceptable to minimize traffic and the time in the OR at this time to observe substitute in colorectal the OR door was left open to and confirm proper application of abdominal surgery cases. minimize contamination risks. skin preparation. All staff working All patients were given a Chlorhexidine skin prep was within the sterile field was prophylactic antibiotic within used unless contraindicated required to wear clean scrubs at 60 minutes of incision time to (for example, because of stoma the start of every colorectal case, ensure optimal compliance or known allergy). The skin and all surgeons were to change with Joint Commission Surgical preparation area extended from into clean scrubs before entering Care Improvement Project the patient’s nipple line down to or leaving OR. Hand washing (SCIP) measures. An iodine-

V102 No 1 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 3. WOUND CLOSURE GUIDELINES WOUND CLOSURE GUIDELINES Delayed primary closure Open/packed • All emergency cases (regardless of infection) • Insulin-dependent diabetic • All stoma closure sites • Case >6 hours • Reoperation within the same hospital stay • Malnutrition (pre-albumin <15 or albumin <2 • BMI ≥35 WOUND CLOSURE STANDARDIZATION Closing fascia Closing skin • Titanium skin staples • Single-strand PDS for laparoscopic port sites • Interrupted monofilament suture when • Single or double-strand PDS for laparatomy case clinically necessary (example: risk of ascites)

impregnated incision drape undertaken prudently due to reviews evaluated and guided was placed on the patient’s the associated discomfort and our strategy. Successful abdomen, and the surgeon used aesthetic impact on the patient. implementation of the goals an Alexis wound retractor to Postoperatively, SCIP rested not only on changing minimize infection risks.5 Before guidelines were followed with the patient care, but also on changing closing the abdominal wall, discontinuation of prophylactic the culture of all involved parties. the team operating within the antibiotics within 24 hours of Mandating certain standards of sterile field would re-glove, reoperation end time and removal practice in the OR minimized prepare the field, and place new of the urethral catheter by the variability between the sterile towels over the incision postoperative day two. Tight surgeons and resident physicians. area. A new clean instrument glucose control was maintained | 53 tray was used for closing. for further minimization of The surgical team followed SSI. Appropriate hand hygiene What were the results? the specific wound closure and sterile gloves were used The strategy used in this guidelines outlined in Figure 4. on the ward for sterile dressing study resulted in a 41 percent Surgeons worked with the changes. The attending surgeon decrease in SSI rates following anesthesia team to maintain evaluated the wound personally colorectal resection over normothermia (>36.0° C) before the patient’s discharge. a six-year period, and its per SCIP guidelines,6 which Essential to the successful durability was demonstrated have shown to minimize implementation of the SSI by continuing improvement SSI risk associated with reduction strategy was the over an additional two years. mild hypothermia.7 After appropriate education and Evaluation of follow-up data was complete wound closure, an support of all staff involved in correlated with independent adhesive sterile dressing was the patient’s care. Educational review by the New York State placed over the site, with the meetings were organized Department of Health, which overlying sticker identifying formally to train all OR and ward demonstrated parallel evidence clear instructions for dressing staff in the rationale and goals of continual improvement.8 changes. Delayed wound closure of these changes. Perioperative Although the most recent ACS was used in patients meeting strategies for SSI reduction that NSQIP data have demonstrated predetermined parameters. were initially developed by the increased SSI rates for colorectal Delayed wound closure was colorectal surgery department surgery, they remain 50 percent reserved for insulin-dependent were then presented to physician lower than when the project diabetic patients requiring and nursing leadership for review. began. A multidisciplinary more than six hours of surgery Discussion and input from all team has been reinvigorated and patients with significant levels were encouraged for the and meets biweekly. Work malnutrition. The decision to development of this strategy. is being done to hardwire use delayed wound closure was Frequent multidisciplinary processes through the use of

JAN 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 4A AND 4B. FIGURE 5. DELAYED WOUND CLOSURE DRESSING STICKER

our electronic health record. The focus has turned REFERENCES to preoperative preparation of in-house surgical 1. Tang R, Chen HH, Wang YL, et al. Risk factors patients and comprehensive wound care instructions for surgical site infection after elective resection of for patients and caregivers upon discharge. the colon and rectum: A single center prospective 54 | Using the NSQIP return on investment study of 2809 consecutive patients. Ann Surg. 2001;234(2):181-189. calculator, Stony Brook has had an average of 2. Wick EC, Shore AD, Hirose K, et al. Readmission 22 fewer infections annually, saving the hospital rates and cost following colorectal surgery. Dis Colon $616,000 dollars per year or a total of $4,928,000 Rectum. 2011;54(12):1475-1479. since the inception of our SSI reduction strategy. 3. Mahmoud NN, Turpin RS, Yang G, Saunders WB. Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect (Larchmt). 2009;10(6):539-544. Suggestions for other institutions 4. Thompson KM, Oldenburg WA, Deschamps C, Some guidelines for other institutions considering et al. Chasing zero: The drive to eliminate surgical site the implementation of an SSI reduction system as infections. Ann Surg. 2011;254(3):430-436. described in this column include the following: 5. Cheng KP, Roslani AC, Sehha N, et al. ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections • Convene a monthly SSI committee in colorectal resections. Colorectal Dis. 2012;14(6):e346- 351. • Implement data tracking for process measures and bundle 6. Bratzler DW, Hunt DR. The surgical infection compliance, power plan use prevention and surgical care improvement projects: National initiatives to improve outcomes for patients having surgery. Clin Infect Dis, 1. 2006;43(3):322-330. • Institute a root-cause analysis tool with a brief case 7. Kurz A, Sessler DI, Lenhardt R. Perioperative summary and bundle compliance normothermia to reduce the incidence of surgical- wound infection and shorten hospitalization. N Engl J • Create a surgical service preoperative power plan and Med. 1996;334:1209-1215. 8. New York State Department of Health. Hospital- comprehensive wound care discharge order set Acquired Infections, New York State 2013. Available at: www.health.ny.gov/statistics/facilities/hospital/ • Review real-time data whenever possible, including both hospital_acquired_infections/. Accessed November Centers for Disease Control and Prevention National 28, 2016. Healthcare Safety Network and ACS NSQIP events as discovered ♦

V102 No 1 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Rural surgery: High pressure but rewarding

by Susan Long, MD, FACS

hat is it like to be a ever see them again, compared truly lives in a fishbowl. Your surgeon in rural America? to my practice now where I every move is under scrutiny. WMany laypeople and even never rotate off the service.” As one surgeon noted on some of our colleagues may have At the same time, the rural surgery listserv: the notion that is idyllic—perhaps rural practice can be | 55 “Doc Hollywood”-like. They incredibly fulfilling. Can How about returning to your rural may imagine lazy days spent this paradox be explained? hometown that you grew up in fishing and tending to occasional to practice general surgery? Over patient in the hospital—a simple, 20 years of operating on count- maybe even boring, life. Your patients are less friends, classmates, teachers, However, those of us who your neighbors and so on—making them better, have chosen to practice in rural Some surgeons would consider giving them bad news, and deal- areas will tell you that the life many aspects of rural surgery ing with bad outcomes. I have a of a rural surgeon can be one of to be disadvantages. Rural guy coming in tomorrow who high pressure and professional surgeons know almost all of tried to pick a fight with me in isolation. As one rural surgeon their patients. A small town high school. I’ve also had people commented on the American affords no anonymity, no ability avoid me because of something I College of Surgeons (ACS) rural to leave work at work. The did 35 years ago. Forget trying to surgery listserv, “Non-rural rural surgeon may operate on go out and having a beer. Every- clinicians get only a fraction of their grocery clerk or someone one knows you and watches [your] this pressure. After 20 years in my else that they see in town every every move. community, almost every case week. In the big city, referrals now is someone I’ve known or may depend on insurance Of course, knowing everyone previously treated. No question networks, one’s professional in town can have its advantages that this causes us to question colleagues, or whoever shows as well. One rural surgeon every decision we make, and it’s up at the emergency room. In a made the following comment just not the same as when I was a small town everyone’s mother, on the listerv: “Just when you big city doctor. If I could just get a brother, and cousin knows you. think the pressure is too much, patient over their hospitalization This can be a good thing or a someone tells you how much they [when I practiced] in the city, bad thing. In contrast to life in appreciate you. I had a lady tell it was very unlikely I would a bigger city, the rural surgeon me this week that she prays for

JAN 2017 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

Those of us who have chosen to practice in rural areas will tell you that the life of a rural surgeon can be one of high pressure and professional isolation.

me every night because I saved like to wander away from their her life several years ago. She homes, farms, or businesses. "You know you’re a rural wants to buy an autographed Rural surgeons are pressured to surgeon when you can’t picture of me. There are so many treat patients in their hospitals, highs and lows it’s hard to figure to keep them close to home so get through the produce out which end wins.” Another their families can avoid traveling section at the grocery surgeon noted the following: to visit and care for them. But the fact is, rural patients are without doing a consult or “(1) You know you’re a rural sur- more likely than urban patients inspecting a wound...." geon when the family of the kid to be elderly and poor and to whose spleen you removed for have chronic illnesses, which trauma pays you in cash and means they may need more blueberry pies (really, really good resources than are available blueberry pies); (2) You know at the community hospital.* 56 | you’re a rural surgeon when you Although rural areas can’t get through the produce sec- often are resource poor, that tion at the grocery without doing doesn’t limit the cases that a consult or inspecting a wound; come through the doors. (3) You know you’re a rural sur- Rural surgeons constantly geon when, before you ask about need to be able to figure out medications, you ask ‘parlor or if they can solve a problem stanchion?’ (which, for those of with the resources they have you who didn’t know, are methods or if it would be better for a of milking cattle); and (4) Lastly, patient to go elsewhere. The you know you’re a rural surgeon perception at some of the larger when you go to a garage sale and referral centers is that rural end up crying with a family over surgeons ship people out so their relative you operated on, but they can go play golf. Quite to who is gone now. There’s just no the contrary—rural surgeons greater calling. I am grateful.” do everything they can to keep their patients close to home, but they have to think Providing myriad services each problem through to its with limited resources conclusion and decide whether Another thing about small towns they have the equipment, that can make rural practice skilled nursing staff, anesthesia challenging is that people don’t services, diagnostics, and so on, to complete the job successfully. Many times, the *Nakayama DK, Hughes TG. Issues that face rural surgery in the United States. surgeon may have the skills J Am Coll Surg. 2014;219(4):814-818. necessary to treat the problem,

V102 No 1 BULLETIN American College of Surgeons DISPATCHES FROM RURAL SURGEONS

but the facility is not equipped go to a movie or a graduation Because the training to provide high-level recovery ceremony and not be able to paradigm for general surgeons and follow-up care. In these turn off your phone. In bigger is becoming narrower and cases, it is in the patient’s best cities, where call is one in three narrower, rural surgeons often interests to be transferred to or four days, the call day may be have to develop some of these a better-equipped facility. busy, but the other three days skills on their own. Graduate the phone can be silenced. medical education programs are configured in such a way as to 24-hour availability encourage subspecialization and Most rural surgeons are on Professional isolation do not prepare young surgeons call every other night or every Despite their vital role in treating adequately for rural practice. third night, and some are on patients, rural surgeons may This challenge, in addition to call every night. People may feel that their peers overlook work hour restrictions, has think that we are not called very or don’t appreciate them. A made it more difficult to train often. However, the potential subtle bias runs through the surgeons who are prepared to | 57 for interrupted sleep every night profession against a surgeon practice in rural areas. Gone can be very stressful. Never who would choose this life are the days when general being able to turn off the phone of relative isolation, apparent surgery residents came out of or travel more than 30 minutes non-specialized surgery, and residency with a broad set of away from the hospital requires a overwork in communities surgical skills. Mentorship and tremendous commitment on the with fewer cultural activities rural surgery fellowships will part of the surgeon, as well as and fewer employment become increasingly important his or her family. Furthermore, options for spouses. Yet rural as the supply of adequately our institutions sometimes work surgeons are essential to trained rural surgeons from the perception that the maintaining the health of dwindles in the next decade. more you do, the more you can millions of rural Americans. do. In other words, if you can take call every other night, why It’s the life we love can’t you take call every night? A breadth of skills Those of us who have chosen Administrators and practitioners Another source of pressure is the rural surgery wouldn’t trade it who have never taken every- need for a broad range of skills. for any other type of practice. night call don’t understand how In rural hospitals, surgeons must We are deeply invested in our stressful it is to always be on. be able to perform a wide variety communities and find our Even if the phone rarely rings, of procedures and to do them practices very rewarding. Is the rural surgeon always has to in times of need. A urologist the life of a rural surgeon an be available. And inevitably, if may not be available to provide easy one? Maybe not. Is it a you go on vacation, someone care if a patient has a bladder or fulfilling one? Absolutely. ♦ you know will get appendicitis, ureter problem. A gynecologist and when you return they will may not be available if a come to you saying, “I was sick suspected appendicitis turns and you weren’t here.” Try to out to be an ovarian problem.

JAN 2017 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

Trust: The keystone of the physician-patient relationship

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

Editor's note: Dr. Pellegrini achieve that goal, I recognized In medicine, our patients presented the John J. Conley Ethics the impact that those enhanced expect that we, as physicians, and Philosophy Lecture at Clinical relationships had on me as a will behave in a certain way. In Congress 2016 in Washington, person and on my colleagues. this relationship, the patient is DC. Dr. Pellegrini was invited to the trusting party and must have submit the following column, confidence that we will act for which highlights the key points he Trust: The keystone of the their benefit.2 This intrinsic trust made in that lecture. The address physician-patient relationship in the physician is expressed in 58 | was published online in October I envision the patient-physician the discretionary latitude that 2016 in the Journal of the American relationship, and by extension patients give their physicians to College of Surgeons, available the relationship that surgeons do what is necessary to, hopefully, at www.journalacs.org/article/ develop with other members of benefit their well-being. S1072-7515(16)31566-6/fulltext. the team and with themselves, In the world of medicine, as an arch; the surgeon trust results from a number of ohn J. Conley, MD, FACS, represents one pillar, and the interactions and the patient’s an otolaryngologist, felt other party represents the perception of the physician’s Jthat in order to provide other pillar. Trust is that stone technical competency, the best care to patients, at the top of the arch—the interpersonal attributes, and surgeons should be trained in so-called keystone on which values, as well as the patient’s skills that extend beyond the the stability and the integrity impression of how the system technical aspects of surgery. of the arch is dependent. works, including the reputation With this objective in mind, Indeed, I am convinced that of the institution. In addition, he established the Ethics trust is to a relationship like medicine emphasizes the and Philosophy Lecture at a keystone is to an arch— affective nature of trust, the Clinical Congress of the essential for its integrity. identifying patient trust as American College of Surgeons, Trust is defined as “assured reliance on the physician and the which now bears his name. reliance on the character, physician’s intent.3 In surgery, During my years as a ability, strength, or truth of our power to heal extends far surgeon, I realized that my someone or something.”1 Trust beyond our technical prowess ability to heal and provide does not usually result from a and is directly influenced by comfort to my patients was single interaction, but instead it the relationship we establish substantially enhanced when I is built over time, with repeated with our patients. Indeed, developed a bond of trust and a interactions through which studies show that patient trust strong relationship with them. expectations about a person’s in a physician increases the As I started working on ways to trustworthiness can be tested. likelihood of adherence to

V102 No 1 BULLETIN American College of Surgeons AFROM LOOK RESIDENCY AT THE JOINT TO RETIREMENTCOMMISSION

Just as the patient must be able to trust the physician, the physician needs to have trust in the patient. Mutual trust is an important aspect of the patient-physician relationship with potential benefits for each party. Trust improves cooperation and reduces the need for monitoring.

treatment recommendations with potential benefits for and behaviors to enhance both and satisfaction with each party. Trust improves social and interpersonal trust. the physician’s care. cooperation and reduces Trust is the keystone of a It is important to consider the need for monitoring.4 A patient-physician relationship. our patients’ vulnerability in physician’s trust in the patient It is an indispensable virtue the relationship. For physicians enhances the relationship and of a good physician. Without to fulfill their commitment contributes significantly to the this virtue, the relationship to trust, they must protect, physician’s sense of well-being disintegrates, just as happens rather than exploit, this and professional satisfaction. to an arch when the keystone vulnerability. To do so, the Another form of trust plays is removed. With it, we physician must place the an important role in medicine— enhance our ability to heal | 59 medical good in the context of the “social trust,” which has the body and the soul of the the patient’s assessment of what to do with the patient’s trust patient, the physician, and is good. More specifically, the in the institutions where they the patient care team. physician must recognize that receive care. Every individual although he or she has expert enters a consultation with a knowledge of the medical certain element of trust in the Communication: A means facts, the patient is the expert institution or site of practice. of developing trust when it comes to determining The patient’s interaction If trust is a defining element in what is best for him or her with the system as well as any interpersonal relationship, given his or her values, beliefs, the physician will reinforce then communication is the and aspirations.2 Hence, or undermine both social most effective and efficient the physician is obligated to and interpersonal trust. For means of engendering trust. present clinical data as free example, when physicians I am of course talking about as possible of personal or make positive comments about communication in a much professional bias and to assist staff and other members of broader sense than the patients in understanding the medical profession, social traditional concept. Most of the rationale, effectiveness, and interpersonal trust are the communication I refer benefits, and potential risks enhanced. On the other hand, to is, in fact, nonverbal. To of a treatment plan without if a patient perceives a lack of create rich relationships with manipulation or coercion. continuity in the system, it our patients, team members, Just as the patient must be likely will undermine social and, indeed, ourselves, we able to trust the physician, the and interpersonal trust. It is must use all communication physician needs to have trust my advice to you that in your tools available to us. in the patient. Mutual trust interactions with patients, Human beings use a wealth is an important aspect of the always keep in mind the power of methods to communicate patient-physician relationship that you have with your words with one another, and the

JAN 2017 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

Although there is substantial evidence in the literature regarding the effects that a positive physician-patient relationship has on patients, very little has been written on the great influence that this bond has on physician well-being.

process is remarkably complex. psychological context; reaches that have examined physician Communication is a science and a shared understanding of well-being have concluded an art that requires substantial the patient’s problem and that approximately 30 percent skill. It is not just about what treatment; and empowers of all practicing physicians we say, but rather far more the patient by offering in this country are suffering about how we say it, and then meaningful involvement in from burnout.6,7 To avoid this how it is interpreted. It is how choices about their care.5 emotional rollercoaster, some we behave, the way we listen, One of the greatest have suggested that physicians the manner in which we deliver challenges of this era in should remain personally and on what we say, how we treat health care is to preserve the emotionally detached from 60 | others, and how others perceive interpersonal relationship with their patients. On the contrary, our treatment. It is the way we our patients in an environment I would argue that establishing perceive the patient’s feelings that is driven by business, a meaningful connection with beyond their words and the standardization, and large patients and colleagues in the way we ask questions based systems of care that focus on organization is one of the most on that perception. It is the population health rather than powerful deterrents to physician way we relate to the patient’s individual patients. To uphold burnout, and the satisfaction family, clinic staff, and the the human connection with our derived from these relationships organization in which we work. patients, surgeons must improve provides context, meaning, All the ways we communicate their communication skills. and purpose to our lives. have a tremendous impact Although there is substantial Similarly, these improved on developing, building, evidence in the literature relationships will have a positive and reinforcing trust. regarding the effects that a impact across the organization. And let us never forget that positive physician-patient The members of our teams are for every message we intend relationship has on patients, always watching our actions. to give, the values, beliefs, very little has been written When they see someone who and previous experiences of on the great influence that leads by example—delivering those on the receiving end this bond has on physician on promises, caring for will play a key role in how the well-being. Those of us who patients, being approachable, message is interpreted. Effective chose to become health care listening—they develop a communication, the kind that professionals are exposed to sense of inner peace and enhances the relationship, emotional turmoil repeatedly satisfaction and a desire to should be based on a patient- throughout our careers. Patient contribute to the excellent work centered approach that elicits, tragedies of all kinds—due to of the group. This facilitates understands, and validates the violence, trauma, cancer, and so the development of high patient’s experience within on—can affect the most resilient performing teams—teams his or her own cultural and among us. Indeed, studies that share a common purpose

V102 No 1 BULLETIN American College of Surgeons AFROM LOOK RESIDENCY AT THECOLUMN JOINT TO RETIREMENTCOMMISSION

Most of us don’t view surgical practice as a job. We view it as a calling. The passion and sense of purpose that drives physicians connects us with our patients in a way that reassures and inspires them.

and that pursue lofty goals in feel better or to improve the REFERENCES the care of their patients. image of our workplace—and 1. Trust. 2016. Merriam-Webster.com. Most of us don’t view surgical allow us to build trust, no Available at: www.merriam-webster. com/dictionary/trust. Accessed practice as a job. We view it matter how small or how big November 23, 2016. as a calling. The passion and the opportunity or the result 2. Pellegrino ED, Thomasma DC. sense of purpose that drives may be. I invite you to reflect Fidelity of Trust. The Virtues in physicians connects us with on this simple statement, and Medical Practice. Oxford, U.K. Oxford our patients in a way that if you believe it, if you see University Press, 1993. 65-83. 3. Caterinicchio RP. Testing plausible reassures and inspires them. At yourself using each encounter path models of interpersonal trust the same time, it is important to affix that keystone that in patient-physician treatment to emphasize that clinician ensures the integrity of the arch relationships. Soc Sci Med. | 61 well-being and self-awareness described earlier, then I say to 1979;13A(1):81-99. have a powerful effect on our you: do it. Be present. Seize 4. Thom DH, Wong ST, Guzman D, et al. Physician trust in the patient: ability to communicate better, each opportunity to do what Development and validation of a new which in turn will improve the your heart tells you is the right measure. Ann Fam Med. 2011;9(2):148- interpersonal relationships that thing to do at every turn of that 154. drive patient satisfaction and long, winding road that we call 5. Epstein RM, Franks P, Fiscella K, behavior. A clinician’s mental life. That way when you reach et al. Measuring patient-centered communication in patient-physician well-being is a precondition for the sunset of your career, you consultations: Theoretical and being effective in the delivery will feel as if you lived and as practical issues. Soc Sci Med. of care and in recognizing and if your life mattered—to you, 2015;61(7):1516-1528. valuing the patient’s perspective to your patients, to your team, 6. Shanafelt TD, Balch CM, Bechamps as distinct from one’s own.8 and to humanity at large. ♦ GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471. 7. Shanafelt TD, Balch CM, Bechamps Keeping the arch stable G, et al. Burnout and medical errors for a rewarding career among American surgeons. Ann I have described the importance Surg. 2010;251(6):995-1000. 8. Chochinov HM, McClement SE, of building trust through Hack TF, et al. Healthcare provider communications, primarily in communication: An empirical model the context of the practice of of optimal therapeutic effectiveness. medicine. In every encounter Cancer. 2013;119:1706-1713. with our patients, our teams, or for that matter, with ourselves, our own souls, we have a unique opportunity to do good—to make someone

JAN 2017 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Surgery versus monitoring and endocrine therapy for low-risk DCIS: The COMET Trial

by Linda M. Youngwirth, MD; Judy C. Boughey, MD, FACS; and E. Shelley Hwang, MD, MPH

t is estimated that more than of this estimate.6-10 The general halt the likely progression to 50,000 women in the U.S. consensus, however, is that much invasion. Given the long lead Iwill be diagnosed with ductal of the overdiagnosis burden time between the development carcinoma in situ (DCIS, or derives from the treatment of of DCIS and progression to preinvasive breast cancer) in DCIS. For those women who invasive disease, a case can be 2017, and most of the women have DCIS that may never made for tailoring intervention who receive this diagnosis will have progressed even without by age and the presence of be completely asymptomatic.1 treatment, medical intervention competing comorbidities, as In DCIS, the neoplastic cells are can only have harmful effects. is done for prostate cancer. confined to the breast ducts;2 thus, And overdiagnosis comes at 62 | in the absence of progression to a financial as well as personal invasive disease, DCIS has little cost—the annual national COMET study potential of spreading to distant expenditure incurred by DCIS In a recent Cancer and Leukemia organs and causing symptoms overtreatment has been estimated Group B (CALGB) 40903 clinical or death. At present, guidelines to be more than $240 million.11 trial, postmenopausal patients recommend that all DCIS be Advances in epidemiology with DCIS were treated with treated with a combination of and cancer biology have clearly neoadjuvant letrozole to evaluate surgery, radiation, and endocrine established that within the group the magnetic resonance imaging therapy—treatments similar of diseases categorized as cancer (MRI) and pathologic response to those recommended for are many conditions that vary to endocrine therapy. Results patients with invasive cancer. enormously in biologic behavior. from this trial are anticipated However, it is estimated that However, the medical treatment in the next six months. The without treatment only 20 to of DCIS has not kept pace with COMET (Comparing Operative 30 percent of DCIS patients will scientific discovery. Surgical and to Monitoring and Endocrine progress to invasive cancer.3,4 medical oncologists must work Therapy for low risk DCIS) The term “overdiagnosis” to develop a treatment strategy Trial builds upon this previous has been applied in reference to based on biologic risk of clinically work, to assess outcomes with cancerous conditions that are significant disease, rather than a less aggressive approach to unlikely to cause symptoms or treating all DCIS as one disease. the management of DCIS, death in a patient’s lifetime.5 An For DCIS at low risk of and to continue to advance estimated one in four patients is progression to invasive cancer, the knowledge regarding the overdiagnosed with breast cancer such as low-grade, small, biologic behavior of DCIS. as a result of mammographic nonpalpable lesions, surgery COMET is a prospective screening, although the and radiation may offer no randomized trial that will absence of standard definitions benefit, whereas large, palpable, assess the risks and benefits of overdiagnosis has led to high-grade DCIS may require associated with active questions about the accuracy more aggressive approaches to surveillance (AS) versus

V102 No 1 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

FIGURE 1. COMET TRIAL SCHEMA

guideline concordant care (GCC) for patients with low-risk REFERENCES DCIS (see Figure 1, this page). The overarching hypothesis of 1. American Cancer Society. Cancer Facts & the study is that management of low-risk DCIS using an AS Figures 2016. Atlanta, GA: American Cancer approach does not yield inferior oncologic or quality of life Society; 2016. 2. Lakhani SR, Ellis IO, Schnitt SJ, Tan PH, outcomes when compared with guideline concordant care. van de Vijver MJ (eds). WHO Classification of Patient education and close monitoring will be essential Tumours of the Breast, Fourth Edition. Geneva: components of the study. Endocrine therapy will be encouraged, World Health Organization Press; 2012. but not required, in the active surveillance group, and patients 3. Erbas B, Provenzano E, Armes J, et al. The will be followed with mammography every six months to assess natural history of ductal carcinoma in situ of the breast: A review. Breast Cancer Res for invasive progression. The guideline concordant care group Treat. 2006;97(2):135-144. | 63 will be treated with surgery, radiation, endocrine therapy, or a 4. Ozanne EM, Shieh Y, Barnes J, Bouzan C, combination according to usual care guidelines and followed Hwang ES, Esserman LJ. Characterizing with mammography every 12 months to assess for recurrent the impact of 25 years of DCIS treatment. disease. Both groups will be monitored for 10 years. The primary Breast Cancer Res Treat. 2011;129(1):165-173. 5. Welch HG, Black WC. Overdiagnosis in outcome will be the proportion of new diagnoses of ipsilateral cancer. J Natl Cancer Inst. 2010;102(9):605-613. invasive cancer in the GCC group and the AS group. Secondary 6. Bleyer A, Welch HG. Effect of screening outcomes will include assessment of quality of life between the mammography on breast cancer incidence. two arms of the study, as well as long-term survival endpoints. N Engl J Med. 2013;368:679. Inclusion in the COMET Trial will be limited to women 7. Gotzsche PC, Nielsen M. Screening for breast cancer with mammography. ages 40 and older who present with a new diagnosis of DCIS Cochrane Database Syst Rev. Copenhagen: grades I/II. DCIS must be estrogen receptor (ER)-positive and/ The Nordic Cochrane Centre; 2006. or progesterone receptor (PR)-positive. If human epidermal 8. Welch HG. Overdiagnosis and growth factor receptor 2 (HER2) testing is performed, the mammography screening. BMJ. DCIS must be HER2 0, 1+, or 2+ by immunohistochemistry 2009;339:b1425. 9. Zahl PH, Strand BH, Maehlen J. Incidence (IHC). Male patients, patients with bloody nipple discharge, of breast cancer in Norway and Sweden pregnant patients, or patients with documented history of during introduction of nationwide prior tamoxifen, aromatase inhibitor, or raloxifene use will screening: Prospective cohort study. BMJ. be excluded. Results from this study will help to determine 2004;328(7445):921-924. whether de-escalation of treatment for low-risk DCIS is a 10. Etzioni R, Gulati R, Mallinger L, Mandelblatt J. Influence of study features feasible approach, and how clinical outcomes and quality of and methods on overdiagnosis estimates in life compare between treatment and surveillance groups. breast and prostate cancer screening. Ann This trial will recruit 1,200 patients at 100 sites through Intern Med. 2013;158(11):831-838. the Alliance for Clinical Trials in Oncology, with plans to 11. Ong MS, Mandl KD. National expenditure include sites from other national adult cooperative groups. for false-positive mammograms and breast cancer overdiagnoses estimated The trial will open for enrollment in February 2017. For at $4 billion a year. Health Aff (Millwood). more information on the COMET Trial, contact E. Shelley 2015;34(4):576-583. Hwang, MD, MPH, at [email protected]. ♦

JAN 2017 BULLETIN American College of Surgeons FROM COLUMNTHE ARCHIVES

J. Marion Sims: Paving the way

FRANKLIN MARTIN, MD, FACS, by LaMar S. McGinnis, Jr., MD, FACS FOUNDER OF THE AMERICAN COLLEGE OF SURGEONS

Marion Sims, MD, is the most decorated surgeon in American history and the only American surgeon with a J.life-sized statue in a purely public place. He is considered the father of the surgical specialty of gynecology. Many surgeons are familiar with the Sims position, the Sims speculum, and other innovations in gynecologic surgery that bear his name.

Early influences and contributions Born in Lancaster, SC, in 1813, Dr. Sims studied for two years at the University of South Carolina, Charleston. Against his parents’ wishes, he chose medicine as a career and apprenticed in the office of a local doctor. At age 20, he attended a three- 64 | month course of lectures at the new South Carolina Medical College, now the Medical University of South Carolina, Charleston. In 1833, following a one-week stagecoach ride, he enrolled at the new Jefferson Medical College, Philadelphia, PA, where he received his medical degree and where he was strongly influenced by mentors George McClellan, MD, and Granville Pattison, MD, leading to his focus on surgery. He returned to Lancaster to practice, but was so dismayed by the deaths of two patients that he physically walked to a new beginning near Montgomery, AL, where he began his practice anew. It was at this new location that Dr. Sims started Dr. Sims to bloom with a flourishing practice focused primarily on surgery. A number of slave women were brought to him with the devastating problem of vesico-vaginal fistula caused by prolonged, unattended labor. He attempted to treat the condition with a variety of unsuccessful techniques until a jeweler fashioned silver into wire, at Dr. Sims' direction, for use in repair for a woman named Anarcha. Thus began his road to fame through a focus on gynecologic surgery. Gynecology was not a recognized specialty at the time, and the use of anesthesia was just evolving.

Pioneering efforts in cancer treatment In 1853, suffering from unrelenting dysentery and in an attempt to improve the state of his health, he relocated to New York, NY. There, his health improved, his abilities were recognized, and his focus on gynecology flourished.

V102 No 1 BULLETIN American College of Surgeons FROM COLUMNTHE ARCHIVES JOE HENDERSON JOE

Woman's Hospital of New York, 1855 (from New York Illustrated. J. Marion Sims monument in Central Park Rotogravure Edition. New York: Success Postal Card Co. 1914)

He established the Woman’s as much or perhaps more than BIBLIOGRAPHY Hospital of New York, the any other U.S. surgeon who American College of Surgeons Archives. first of its kind, which became lived in the 19th century. Available at: facs.org/about-acs/ an incubator for progressive Today, there are some health archives. Accessed November 19, 2016. concepts in surgery. Years later— care scholars who may discredit Cutter IS. Landmarks in surgical noting that cancer patients could parts of our heritage, largely progress. International abstract of | 65 surgery. 1928. Available at: catalog. not be admitted to hospitals based on a lack of information. nyam.org/cgi-bin/koha/opac-detail. due to the misconception that Therefore, when remembering pl?biblionumber=228180. Accessed cancer was a communicable historical pioneers and their November 19, 2016. disease—Dr. Sims opened the achievements, it is important Massachusetts Medical Society. Marion New York Cancer Hospital, to note the circumstances of Sims and his silver sutures. N Engl J Med. 1945;233:631-633. which evolved over time into the that particular period of history. Marr JP. James Marion Sims: The Founder of Memorial Hospital for Cancer Some have written that because the Woman’s Hospital in the State of New and Allied Diseases (now known Dr. Sims operated on slave York. New York City, New York: The as Memorial Sloan Kettering). women without anesthesia or Woman’s Hospital; 1949. His reputation continued proper informed consent, he Shingleton HM. The lesser known Dr. Sims. ACOG Clin Rev. to grow both nationally and should be disclaimed rather 2009;14(2):13-16. internationally. He operated in than applauded. However, that Sparkman RS. J. Marion Sims: Women’s the U.S. and in Europe. He was view misses the point of what surgeon and more. Bull Am Coll Surg. widely decorated and acclaimed, Dr. Sims accomplished in the 1975;60(3):11-17. serving as president of the mid-19th century. Anarcha and Ward GG. Marion Sims and the origin of modern gynecology. Bull N Y Acad American Medical Association others should be celebrated Med. 1936;12(3):93-104. in 1875 and the American for their contributions just as Abell I. J. Marion Sims: An appreciation. Gynecological Society in 1879. Henrietta Lacks—an African- SMJ. 1933;26(12). He has been recognized as American woman whose cells the father of the specialties of were unwittingly used to create gynecology and infertility. the first human immortal cell Dr. Sims, who died in 1883, line in the 1950s—has been was an inquisitive innovator, acknowledged for her role in an able and talented surgeon, the evolution of medicine. ♦ and a humanitarian. It has been said that he advanced surgery

JAN 2017 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

New ACS Foundation board members installed

by Sarah B. Klein, MPA

Editor's note: The Mayne Heritage bring individual philanthropic After graduating from Society column is replaced by interests, are Mary O. Aaland, medical school at the University "ACS Foundation Insights," a MD, FACS, who advocates for of North Dakota (UND), Grand vehicle for updates on all ACS rural surgeons and patients; Forks, Dr. Aaland completed Foundation contributions including, E. Christopher Ellison, MD, her general surgery residency but not limited to, planned gift FACS, who urges the continued rotations at Yale Affiliates donations. The ACS Foundation’s mentorship and education of Regional Surgical Residency mission is to obtain financial young surgeons; and Colonel Programs, University of South 66 | support for the charitable and Kirby Gross, MD, FACS, who Dakota, Vermillion, and at the educational work of the College, endorses the partnership University of Illinois College of and it receives donations from between the ACS and the Medicine, Peoria. She eventually Fellows, corporations, foundations U.S. Department of Defense returned to North Dakota for and other friends through a wide Military Health System. her surgical practice, where range of gifts. The column will she is an advocate for meeting also update readers on the impact the increasing need for rural of giving, with reports on the Returning to rural roots surgeons and systems, serving as beneficiaries of donors’ generosity. Dr. Aaland, a general and associate professor and director trauma surgeon, knew from of rural surgery, UND School of he American College of childhood that trauma care is Medicine and Health Sciences, Surgeons (ACS) Board of critical to life in rural America. department of surgery. In her role TRegents approved three “Farming is one of the most as director of the rural surgery new members of the ACS dangerous occupations, which I support program, Dr. Aaland Foundation Board of Directors experienced firsthand as a farm is working to address rural for three-year terms beginning girl in North Dakota. During my hospital challenges with surgical in October 2016 at its Annual surgical rotation as a third-year coverage recruitment support and Business Meeting of Members medical student in an inner- continuing education offerings on October 19, 2016. The new city trauma center, I realized in surgery and trauma.* She also board members, all of whom that rural Americans were not practices surgery in critical access receiving appropriate trauma hospitals across the state of North *Sticca R, Aaland MO. The North Dakota care. It was at that moment Dakota, including the cities of Rural Surgery Support Program: Providing surgical services to communities in need. I decided that I wanted to Devils Lake and Jamestown. Bull Am Coll Surg. Available at: bulletin. become a trauma surgeon and When asked what she enjoys facs.org/2015/07/the-north-dakota-rural- help develop trauma systems most about being a rural surgeon, surgery-support-program-providing- surgical-services-to-communities-in- outside major metropolitan she emphasizes the thanks she need/. Accessed November 23, 2016. areas,” Dr. Aaland said. receives from her patients, who

V102 No 1 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

Dr. Aaland Dr. Ellison Dr. Gross

appreciate the surgical care and seeing them mature and to learn new surgical techniques they receive without needing develop into independent and evolving treatment to travel far from home. surgeons is meaningful. paradigms for many surgical An ACS Fellow since 1995, Teaching spreads my individual diseases. With the joy of Dr. Aaland serves on the ACS contribution to health care teaching such a priority for Board of Governors representing onto future providers, and Dr. Ellison, he is the ideal choice North Dakota and has held the impact is manifold over to lead the ACS Transition to leadership roles in ACS chapters. what I could accomplish as Practice Program at Wexner She also supports the College as an individual surgeon.” Medical Center. This position | 67 an ACS Foundation donor, giving Dr. Ellison, a general allows him to further expand back for all she has received from surgeon, is the Robert M. his reach in optimal patient the organization. “Membership Zollinger Professor of Surgery, care by helping other surgeons in the ACS has been the mainstay chief executive officer of faculty develop their peak potential. of my professional life, even as group practice, and senior An ACS Fellow for 30 years, a nonacademic surgeon. It has associate vice-president for Dr. Ellison has found the given me the opportunity to health sciences and vice-dean for College beneficial in developing have access to other members clinical affairs, Wexner Medical his network of colleagues and across the world and to have Center, Ohio State University for offering access to a variety personal contact with key players (OSU), Columbus. Dr. Ellison of educational offerings. in the world of surgery.” received his medical degree He takes pride in the FACS from the Medical College of designation. “FACS means Wisconsin, Milwaukee, and something special. It is like Mentoring the next generation completed a general surgery the Good Housekeeping Seal When asked what brings the residency at OSU. He has served of Approval. My patients most satisfaction to his work as ACS Ohio Chapter president, appreciate the fact the FACS day, Dr. Ellison is quick to ACS Governor-at-Large, and as stands for quality and integrity, respond that it is teaching and the Chair of the ACS Advisory and it gives them an added sense mentoring the next generation Council for General Surgery. of confidence in the care they of surgeons. “Day to day, I am As a medical student, receive,” Dr. Ellison noted. happiest when I teach a new Dr. Ellison chose a career in Giving back as a donor to the concept to students and see the general surgery because it ACS Foundation also reinforces light go on in their eyes and afforded him the breadth of Dr. Ellison’s values: “As a not- they ‘get it,’” he said. “Likewise, patient exposure that he wanted for-profit organization, the ACS the joy of working with as a young surgeon. Since then, supports many meaningful residents over years of training he has valued the opportunity projects in education leadership

JAN 2017 BULLETIN American College of Surgeons ACS FOUNDATION INSIGHTS

development, global health in early 2017. He has deployed A regular and generous initiatives, transition to practice seven times to Afghanistan and donor to the ACS Foundation programs, and quality and Iraq, most recently returning for nearly 25 years, Colonel safety program development. to the U.S. in August 2014. Gross is a strong supporter of the All those who are privileged He has been assigned to Fort Military Health System Strategic to have FACS after their name Campbell, Kentucky; Williams Partnership ACS. This initiative, should be proud to contribute Beaumont Army Medical Center, established in collaboration to these causes through El Paso, TX; Walter Reed Army between the ACS and the 68 | the ACS Foundation.” Medical Center, Washington, DC; Department of Defense military Walter Reed National Military health system, will use battlefield Medical Center, Bethesda, MD; experiences to provide better Answering the call to serve and the Joint Trauma System care for soldiers and civilians. Dr. Gross answered the call at Joint Base San Antonio, TX. Part of the partnership's to serve in the U.S. military After two tours of duty in Iraq, funding will come from ACS mid-career in 2002. His initial he completed a trauma fellowship Foundation contributions. choice of the surgical profession at Vanderbilt University Medical “The ACS Foundation serves was significantly affected by Center, Nashville, TN. as a way for Fellows to support the faculty, specifically his A Fellow since 1989, Colonel their organization, which has mentors the late Jay L. Grosfeld, Gross has embraced his FACS consistently and fervently MD, FACS, and James A. status with gratitude and pride. advanced surgical care,” Colonel Madura, MD, FACS, at Indiana “I viewed recognition as a Gross said. “Even more than University School of Medicine, Fellow of the ACS as a career the personal benefits from Indianapolis. But the events of milestone to confirm to myself Fellowship, such as educational September 11, 2001, changed and to surgical colleagues an offerings and career mentorship, his professional direction, and attainment of professional the College effectively he decided to use his surgical achievement and ethics,” he said. focuses resources to facilitate skills to care for members “Mid-career, the educational improvements in surgical care.” of the U.S. Armed Forces. benefits of Fellowship were For more information on Colonel Gross now serves of great value. Now, as a the ACS Foundation, contact as an officer in the U.S. Army senior surgeon, Fellowship Shane Hollett, ACS Foundation Medical Corps. He will be has provided ready access to Executive Director, at 312-202- assuming the role as director colleagues who are subject 5506 or [email protected]. ♦ of the Army Trauma Training matter experts and thought Center at the Ryder Trauma leaders on effecting change to Center, University of Miami, positively impact outcomes.”

V102 No 1 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Annual report provides details on patient safety, quality improvements

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

ospitals in the U.S. • Children’s asthma management and 97.4 in 2015—a difference continue to make strides (one measure) of 2.9 percentage points. Hin improving patient Any improvements, no safety and quality for common • Inpatient psychiatric services matter how large or small, are conditions, according to (seven measures) important because they all America’s Hospitals: Improving contribute to better care for Quality and Safety: The Joint • Venous thromboembolism (VTE) patients. As a result of continued Commission’s Annual Report 2016. care (five measures) excellent performance, three The report, released November of four individual VTE care 7, 2016, presents information • Stroke care (eight measures) accountability measures on how more than 3,300 Joint were retired effective | 69 Commission-accredited hospitals • Perinatal care (five measures) December 31, 2015. performed on individual, Meanwhile, strong reporting chart-abstracted measures of • Immunization (one measure) performance led to the patient care during 2015 in retirement of all Surgical Care comparison to previous years. • Tobacco use treatment (three Improvement Project (SCIP) Reporting data on these measures) chart-abstracted measures in measures is a requirement of 2015. This decision was based Joint Commission-accredited • Substance use care (three largely on the fact that the hospitals. A total of 33 measures measures) composite scores were so high, were described in the report, 29 ranging in 2014 from 94.2 percent of which were accountability Some measures, such as on the low end (appropriate measures, focused on evidence- those comprising perinatal prophylactic antibiotics for based care processes that are care, show significant gains. colon surgery) to 99.9 percent closely linked to positive patient In 2015, the perinatal care on the high end (patients with outcomes. The measures are result was 97.6 percent—up appropriate hair removal). relevant for accreditation, from 53.2 percent in 2011, public reporting, and pay-for- which is an improvement performance programs that hold of 44.4 percentage points. Pioneers in Quality recognized providers accountable to external Another is the VTE This year’s annual report also oversight entities and the public. care result, which came in recognizes 39 Pioneers in Quality at 95.2 percent in 2015—up hospitals that are at the forefront from 89.9 percent in 2011—an of a new era in health care Measures in the report improvement of 5.3 percentage quality reporting—one in which The chart-abstracted measures points. VTE medicine and/or hospitals collect information on covered in the report treatment in an intensive care the quality of patient care through pertain to the following: unit was 94.5 percent in 2011 electronic health records (EHRs)

JAN 2017 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

and report the data to The Joint the database and share your Report are important because Commission and the Centers for institution’s success stories, go they show that accredited Medicare & Medicaid Services to www.jointcommission.org/core_ hospitals have continued to (CMS). To be recognized as a 2016 measure_solution_exchange/. improve the quality of the care Pioneers in Quality organization, they provide, and the data that a hospital had to meet criteria • Data contributor: Voluntarily hospitals collect help them 70 | in at least one of three of The transmitting 2015 eCQM data in identify opportunities for further Joint Commission's categories of 2016. improvement,” said Mark R. participation. These categories Chassin, MD, MPP, MPH, FACP, of participation are as follows: In 2016, hospitals also will president and chief executive have available to them new officer, The Joint Commission. • Expert contributor: Advancing the eCQMs on surgical care and “The results also show it’s evolution and use of electronic emergency department measures important to note that where clinical quality measures (eCQMs) to report. These electronic (e) a patient receives care makes through contributions such as SCIP measures are as follows: a difference. Some hospitals presenting at a Pioneers in Quality perform better than others in webinar or participating in eCQM • Antibiotics within one hour treating particular conditions.”* development in 2016. before the first surgical incision To read the complete (eSCIP-INF-1a) America’s Hospitals: Improving • Solution contributor: Quality and Safety: The Joint Submitting an eCQM solution • Urinary catheter removed (eSCIP- Commission’s Annual Report 2016, or implementation story to The INF-9) go to www.jointcommission. Joint Commission’s Core Measure org/annualreport.aspx. ♦ Solution Exchange, a quality • Median time from ED arrival to improvement tool that promotes ED departure for admitted ED the sharing of performance patients (eED-1a) Disclaimer measurement successes among The thoughts and opinions accredited hospitals. To access • Admit decision time to ED expressed in this column are *The Joint Commission. Joint Commission departure time for admitted solely those of Dr. Pellegrini and report shows America’s hospitals continue to patients (eED-2a) do not necessarily represent those improve patient care. Press release. November of The Joint Commission or the 7, 2016. Available at: www.new-media-release. com/jointcommission/2016_annual_report_ “The results featured in The American College of Surgeons. release/. Accessed November 30, 2016. Joint Commission’s 2016 Annual

V102 No 1 BULLETIN American College of Surgeons NTDB DATA POINTS

Annual Report 2016: Almost a 10

by Richard J. Fantus, MD, FACS

he Annual Report 2016 of the National Trauma Data TABLE 1. ® ® TBank (NTDB ) is an DIFFERENCES BETWEEN ICD-9-CM updated analysis of the largest AND ICD-10-CM CODE SETS aggregation of U.S trauma registry data ever assembled. ICD-9-CM ICD-10-CM The NTDB now contains close to 7.5 million records. The 3 to 5 characters in length 3 to 7 characters in length Annual Report 2016 is based Approximately 68,000 current on 861,888 records with valid Approximately 13,000 codes codes trauma diagnoses from the single admission year of 2015 First character may be alpha Character 1 is alpha; characters | 71 from 747 facilities, including (E or V) or numeric; characters 2–5 2 and 3 are numeric; characters 239 Level I trauma centers, are numeric 4–7 are alpha or numeric 263 Level II trauma centers, and 196 Level III or IV trauma Limited space for new codes New codes can be added centers; 36 are Level I or Level II pediatric centers. Limited code detail Specific code detail

No laterality Includes laterality Use of ICD-10 in report development The International Classification of Diseases (ICD), owned and published by the World Health Organization, is the world-standard diagnostic tool for health management, epidemiology, and clinical purposes. The ICD is used to monitor incidence and prevalence of diseases and other health care problems.* In 2009, the U.S. Department of Health and Human Services published a regulation requiring

*World Health Organization. Classifications. Available at: www.who.int/classifications/ icd/en/. Accessed November 18, 2016.

JAN 2017 BULLETIN American College of Surgeons NTDB DATA POINTS

The 2016 Annual Report is based on 861,888 records with valid trauma diagnoses from the single admission year of 2015 from 747 facilities, including 239 Level I trauma centers, 263 Level II trauma centers, and 196 Level III or IV trauma centers; 36 are Level I or Level II pediatric centers.

U.S. providers to transition useful interhospital comparisons. from the ninth edition of the Purpose of report These efforts will be reflected classification system (ICD-9) The mission of the American in future NTDB reports to to ICD-10, which is what the College of Surgeons (ACS) participating hospitals, as well rest of the world was using. Committee on Trauma (COT) as in the annual reports. ICD-10 has several is to develop and implement Throughout the year, we 72 | advantages over its predecessor. meaningful programs for will be highlighting these Some trauma-related highlights trauma care. In keeping with data through brief reports that include expanded injury codes, this objective, the NTDB is are published monthly in the a combination of diagnosis/ committed to being the principal Bulletin. The NTDB Annual symptom codes to reduce the national repository for trauma Report 2016 is available on the number of codes necessary to center data. The purpose of this ACS website as a PDF file at facs. describe a condition, and two report is to inform the medical org/quality-programs/trauma/ additional characters added community, the public, and ntdb. In addition, information is along with subclassifications decision makers about a range available on the website about allowing laterality and of issues that characterize the how to obtain NTDB data for greater specificity in code current state of care for injured more detailed study. If you are assignment. This transition persons. It has implications interested in submitting your required a significant change for many areas, including trauma center’s data contact in institutional infrastructure epidemiology, injury control, Melanie L. Neal, Manager, throughout the U.S. research, education, acute NTDB, at [email protected]. ♦ Consequently, the final date of care, and resource allocation. implementation was delayed Many dedicated individuals until October 1, 2016.† As a on the ACS COT, as well as transitional year, this annual at trauma centers around the report allows the inclusion country, have contributed to of both ICD-9 and ICD-10 the early development of the codes (see Figure 1, page 71). NTDB and its rapid growth in recent years. Building on these †World Health Organization. International achievements, the goals in the Classification of Diseases, Tenth Revision, Clinical Modification. Available at: coming years include improving www.cdc.gov/nchs/icd/icd10cm. data quality, updating analytic htm. Accessed November 18, 2016. methods, and enabling more

V102 No 1 BULLETIN American College of Surgeons NEWS

In memoriam: Jay L. Grosfeld, MD, FACS, champion for pediatric surgery patients

by Keith T. Oldham, MD, FACS

The American College of at Indiana University School of addition to his role as First Vice- Surgeons (ACS), and indeed all of Medicine, Indianapolis, in 1972. President. He was a member of surgery, lost one of its champions He was the first surgeon-in-chief the ACS Advisory Council for October 19, 2016, with the passing at the Riley Children’s Hospital Pediatric Surgery (1996–2001) and of Jay L. Grosfeld, MD, FACS. His and remained in Indianapolis the Advisory Councils for Surgical contributions to surgery and in for the rest of his career. Specialties (1989–1994). As an ACS particular to his beloved specialty, Dr. Grosfeld was a pioneer Governor (1985–1991) he served pediatric surgery, for more than in pediatric surgery as it was on the Governors' Committee 50 years were extraordinary. He emerging as a discipline, and on Chapter Relations (1989–1992) served the ACS in many roles he established the specialty of and the Committee on Physician over the years, most recently as pediatric surgery in Indianapolis Competency (1987–1992). He also First Vice-President (2014−2015). and, indeed, in the state of served as a senior member on Dr. Grosfeld was born in New Indiana. He established the the Committee on Continuing | 73 York, NY, May 30, 1935. He grew pediatric surgery training Education (1981–1991) and on up in New York, graduating program in Indianapolis, and in the Nominating Committee from Midwood High School 1985 he was appointed chairman of the Fellows (1991–1992). in Brooklyn and New York of the department of surgery He held leadership positions University (NYU) subsequently. at Indiana University School in virtually all of the professional He attended medical school at of Medicine. He was the first organizations in which he NYU and completed his general pediatric surgeon in the U.S. to was active. He was secretary surgery training at NYU and chair a department of surgery. and chairman of the Section Bellevue Hospitals (1961−1966). Dr. Grosfeld stepped down on Surgery of the American from his leadership positions at Academy of Pediatrics, president Indiana University in 2003 but of the American Pediatric Surgical Pioneering pediatric surgeon remained actively engaged at Association, president of the He served two years as a Captain the institution and in surgery in Halsted Society, chairman of in the U.S. Army Medical Corps many important roles. He was the American Board of Surgery, and then trained in pediatric the Lafayette F. Page Professor and president of the American surgery at Nationwide Children’s and Chairman Emeritus of Surgical Association. He also Hospital at the Ohio State Pediatric Surgery, department served as president of the Central University, Columbus, under of surgery, at the Indiana Surgical Association and the the mentorship of William University School of Medicine Western Surgical Association, Clatworthy, MD, FACS. After at the time of his death. as well as president of the World completing his pediatric surgery Federation of Associations training in 1970, he returned to of Pediatric Surgeons. New York as an assistant professor Recognized leadership In 1998 he was awarded the of surgery at NYU, but was A Fellow of the ACS since 1973, Denis Browne Gold Medal by the promptly appointed professor Dr. Grosfeld served in a number British Association of Paediatric and chief of pediatric surgery of other leadership capacities in Surgeons, in 2002 he received

JAN 2017 BULLETIN American College of Surgeons NEWS

Dr. Grosfeld was a pioneer in pediatric surgery as it was emerging as a discipline, and he established the specialty of pediatric surgery in Indianapolis and, indeed, in the state of Indiana.

the William E. Ladd Medal Seminars in Pediatric Surgery, a wonderful and loving family. He from the American Academy and the most widely used is survived by his wife Margie, to of Pediatrics, and in 2011 he pediatric surgery textbook, whom he was happily married for was awarded the Fritz Rehbein Pediatric Surgery. He remained 54 years and with whom he shared Medal from the European active as chairman of the board his professional and personal Pediatric Surgical Association. of directors of the American journeys; his sister Claire Zucker; Each of these represents the Pediatric Surgical Foundation children Alicia Thorn, Dalia highest honor these associations and as vice-president of the Maheu, Janice Kaefer, Jeffrey bestow on an individual. American Surgical Association Grosfeld, and Mark Grosfeld; Dr. Grosfeld lectured Foundation until his death. as well as 17 grandchildren. worldwide and was an honorary Dr. Grosfeld’s service to Dr. Grosfeld was an influential member of 15 international essentially all of the major leader, a role model, a mentor, surgical societies, including the organizations in American an important investigator, and a Royal College of Surgeons of surgery, including the ACS, masterful surgeon beloved by his England and Ireland, as well as is evident. Less apparent, but patients, their families, and his 74 | the Royal College of Physicians perhaps more noteworthy, is the colleagues. He made a difference and Surgeons, Glasgow. He fact that he used each opportunity for all of us who knew him and received the Solomon A. Berson to change and improve individual for all the pediatric surgeons Medical Alumni Achievement programs and organizations. who have followed in his path. Award in 2008 from NYU. In addition to his many He will be greatly missed. ♦ He was editor-in-chief of professional accomplishments, the Journal of Pediatric Surgery, Dr. Grosfeld was the patriarch of

Coming next month in JACS, and online now

Latest results from the “FIRST” Trial

Anthony D. Yang, MD, MS, FACS; Jeanette W. Chung, PhD; Allison R. Dahlke, MPH; and colleagues present the latest results from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial in the February issue of the Journal of the American College of Surgeons (JACS). As postgraduate year level increased, residents had increasing concerns about patient care and resident education/training under standard duty hour policies, but had decreasing concerns about well-being under flexible policies. When given the choice between training under standard or flexible duty hour policies, only 14 percent of surgical residents expressed a preference for standard policies. This article and all other JACS content is available at www.journalacs.org. ♦

V102 No 1 BULLETIN American College of Surgeons NEWS

Important changes made in the AJCC Cancer Staging Manual, Eighth Edition

by David J. Winchester, MD, FACS

The American Joint Committee January 1, 2018. The decision to on Cancer (AJCC) recently delay implementation resulted released the eighth edition of the from discussions between the AJCC Cancer Staging Manual. This AJCC Executive Committee, edition incorporates significant the National Cancer Institute, changes in a manual that is Centers for Disease Control now approximately 1,000 pages and Prevention, the College in length. The AJCC member of American Pathologists, organizations worked together to the National Comprehensive devise a comprehensive format Cancer Network, the National revision to provide consistency Cancer Database, and the throughout an expanded list Commission on Cancer. | 75 of chapters, and new organ The time extension will allow sites have been added to the all partners to develop and update text, as well. Several chapters protocols and guidelines and for introduce additional non- software vendors to develop, anatomic prognostic variables test, and deploy their products in into staging schemes to increase time for the data collection and the relevancy of the stage implementation of the eighth with regard to prognosis and edition. Clinicians will continue defining optimal therapy. to use the most recent information for patient care, including scientific content in the latest manual. New implementation postponed Coordinating the implementation for a new staging system is Rationale for changes critically important to ensure that in the manual all partners in patient care and The eighth edition attempts cancer data collection are working to more fully synthesize stage in synchrony. Implementation was groupings with relevant variables originally scheduled for January 1, identified from multiple data sets 2017. However, to ensure that the based on registries and clinical cancer care community has the trials. For example, after reviewing necessary infrastructure in place hundreds of publications, the to successfully implement the Breast Expert Panel decided to new standards, compliance with include estrogen receptor and the eighth edition cancer staging progesterone receptor status, system has been delayed until HER-2 status, and grade into the

JAN 2017 BULLETIN American College of Surgeons NEWS

The eighth edition attempts to more fully synthesize stage groupings with relevant variables identified from multiple data sets based on registries and clinical trials.

creation of a prognostic stage, according to seventh edition aforementioned variables. In combined with traditional tumor, criteria. These stage changes this case, anatomic stage will node, and metastases (TNM) reflect the significant impact continue to be used in the absence variables as defined in Anatomic of prognostic variables that of biomarkers. In contrast, in Stage. Information from multi- clinicians have long recognized developed countries where gene panels was incorporated as important in determining biomarkers are routinely used for patients with T1-2N0M0, prognosis and therapy. Although and available, it will be expected ER-positive, HER2-negative this model provides a much more that physicians and registrars tumors. With these eight variables robust categorization of stage, alike will be committed to using (T, N, M, grade, ER, PR, HER-2, it is essential to recognize that prognostic stage with complete and multi-gene panel score), the the derivation of these survival entry of all prognostic variables as 76 | complexity of staging increased, figures and stage assignments stipulated in respective chapters. creating several hundred possible assumes that patients and As the complexity of staging combinations. Other noteworthy clinicians follow treatment increases beyond the traditional changes included the elimination guidelines. As an example, a TNM work laid out in the of lobular carcinoma in situ patient with a T2N1M0, Grade 3, previous editions of the AJCC as a breast cancer diagnosis. ER-positive, PR-positive, HER2- Cancer Staging Manual, staging As a consequence of including positive breast cancer is assigned calculators and electronic health biomarkers in the staging of to Stage IB, as the survival record software will be necessary breast cancer, more than 40 with proper treatment for such to achieve accurate and consistent percent of patients with stage a patient is similar to that of implementation of stage into I–III disease were reclassified smaller and node-negative the patient’s care. In addition, into a different stage than if cancers. However, without careful and complete entry of seventh edition criteria had been appropriate treatment, including staging variables will help provide applied, with a nearly equal split chemotherapy, pertuzumab, critical information to develop between those patients who trastuzumab, endocrine therapy, future staging algorithms, likely were up-staged (20.0 percent) surgery, and radiation therapy, to consist of rolling updates; to and down-staged (20.6 percent). this patient would be at high risk reflect advancing knowledge Maintaining consistent of cancer-related mortality. and improvements in patient definitions of in situ and distant care; and to show progress and metastatic disease with other establish priorities in cancer organ sites, stage reassignment Accommodating control and prevention. ♦ was excluded for patients with diverse resources stage 0 and stage IV disease. The AJCC remains committed Within the remaining stage to serving cancer patients groupings, 9.8 percent of patients throughout the world. Many were reassigned more than geographic regions lack the one stage higher or lower than resources needed to define the

V102 No 1 BULLETIN American College of Surgeons NEWS

ACS Clinical Scholars in Residence benefit from access to outcomes measures and mentors

by Karl Y. Bilimoria, MD, MS, FACS, and Clifford Y. Ko, MD, MS, MSHS, FACS

The American College of policy, and patient safety, with The primary objective of Surgeons (ACS) is now accepting the goal of helping the ACS the fellowship is to address applications for the 2018–2020 Clinical Scholar in Residence issues in health care quality, Clinical Scholar in Residence prepare for a research career positions. Applications in academic surgery. The ACS health policy, and patient are due April 3, 2017. Clinical Scholars in Residence | 77 safety, with the goal of have worked on projects and research involving the ACS helping the ACS Clinical About the program National Surgical Quality Scholar in Residence prepare The ACS Clinical Scholars in Improvement Program (ACS Residence Program is a two- NSQIP®), the National Cancer for a research career in year fellowship in surgical Database, the National Trauma academic surgery. outcomes research, health Data Bank®, the Surgeon Specific services research, and health Registry, and the Metabolic and care policy performed on- Bariatric Surgery Accreditation site at ACS headquarters in and Quality Improvement Chicago, IL. It was initiated Program. They have assisted in 2005 for the purpose of in the development of practice advancing the College’s quality guidelines and accreditation improvement initiatives standards. Scholars are assigned and to offer opportunities to the appropriate group within for residents to work on the ACS based on their interests ACS quality improvement and the College’s needs. programs. More specifically, In addition, participants ACS Clinical Scholars in earn a master’s degree in Residence perform research health services and outcomes relevant to ongoing projects in research or health care quality the ACS Division of Research and patient safety from and Optimal Patient Care. Northwestern University, The primary objective of the Chicago. This aspect of the fellowship is to address issues program prepares clinicians to in health care quality, health become effective health services

JAN 2017 BULLETIN American College of Surgeons NEWS

The ACS Clinical Scholars in Residence have presented their findings at national meetings and in high- impact, peer-reviewed publications, in addition to having contributed a great deal to the ACS quality improvement programs. Furthermore, scholars have gone on to gain prestigious fellowships in several fields, including surgical oncology and pediatric surgery.

and outcomes researchers. The and project analysts serve as having contributed a great deal health services and outcomes invaluable resources to the ACS to the ACS quality improvement research curriculum focuses on Clinical Scholars in Residence. programs. Furthermore, these issues within institutional scholars have gone on to gain and health care delivery systems, prestigious fellowships in 78 | as well as in the external Past successes several fields, including surgical environment that shapes health Surgical residents from oncology and pediatric surgery. policy centered on quality and throughout the U.S., including safety issues. The program California, Colorado, takes approximately two years Connecticut, Illinois, Kansas, Apply now to complete. The ACS also Louisiana, Michigan, and Ohio, The 2018–2020 scholars will offers a variety of educational have participated in the ACS begin their work on July 1, 2018. programs from which scholars Clinical Scholars in Residence Applicants are required to have may benefit, including the Program since its inception. funding through their institution Outcomes Research Course These individuals report or other grant mechanism. For and the Clinical Trials Course. excellent, productive experiences more information about the ACS mentors meet regularly that have been useful in program and the application with each ACS Clinical Scholar launching their careers in the requirements, go to facs.org/ in Residence. Scholars also field of academic surgery. In clinicalscholars, or send an e-mail have opportunities to interact all, 12 scholars have completed to [email protected]. ♦ with various surgeons who the program, and four scholars are affiliated with the ACS are currently participating. and the Division of Research The ACS Clinical Scholars in and Optimal Patient Care. Residence have demonstrated Exposure to mentors is a key great dedication to outcomes component of this fellowship, research and the improvement as guidance and interaction of the quality of surgical care. with multiple individuals The ACS Clinical Scholars in from diverse backgrounds Residence have presented their provide the best opportunity findings at national meetings and for success. In addition, a core in high-impact, peer-reviewed group of ACS staff statisticians publications, in addition to

V102 No 1 BULLETIN American College of Surgeons NEWS

ACS NSQIP honors 60 hospitals for meritorious outcomes in surgical care

The American College of Surgeons National • Mortality Surgical Quality Improvement Program • Cardiac: Cardiac arrest and myocardial infarction (ACS NSQIP®) recognized 60 of 603 hospitals • Pneumonia participating in the adult program for meritorious • Unplanned intubation outcomes in surgical patient care in 2015. • Ventilator less than 48 hours Participating hospitals track the outcomes • Renal failure of in- and outpatient surgical procedures • Surgical site infection (SSI): superficial incisional and analyze the results. The hospitals were SSI, deep incisional SSI, and organ/space SSI notified of this recognition through a poster • Urinary tract infection announcement at the ACS Clinical Congress 2016. A list of the 60 hospitals is available at Risk-adjusted data from the July 2016 facs.org/~/media/files/quality%20programs/ ACS NSQIP Semiannual Report, which nsqip/meritoriousoutcomes2016.ashx. presents data from the 2015 calendar year, The hospitals achieved this distinction based on were used to determine the hospitals their composite quality score, which is determined with meritorious outcomes. ♦ through a weighted formula combining outcome performances related to patient management in the following eight clinical areas:

| 79

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

ACS Education and Training are the Cornerstones of Excellence

ACS Education and Training Transform Possibilities into Realities

ACS Education and Training Instill the Joy of Lifelong Learning

JAN 2017 BULLETIN American College of Surgeons NEWS

ASCPA-SurgeonsPAC makes an impact on 2016 congressional elections

by Katie Oehmen

The number of close races in the committees. In line with Dr. Dunn, a urologist, won last election cycle illustrates the congressional party ratios, 58 his election, capturing more importance of a strong political percent of the funds were given than 67 percent of the vote. action committee (PAC) focused to Republicans and 42 percent to on the concerns of surgical Democrats. To learn more about • Rep. Roger Marshall, MD (R-KS-01): patients and professionals. Every SurgeonsPAC disbursements, visit ACSPA-SurgeonsPAC partnered campaign contribution, fundraiser, surgeonspac.org/disbursements. with other physician organizations or independent expenditure In addition, ACSPA- to support Dr. Marshall, who could represent the difference SurgeonsPAC staff and the unseated incumbent Rep. Tim between a win and a loss. As the federal legislative team Huelskamp (R-KS), in the American College of Surgeons attended or hosted more than Republican primary. Dr. Marshall, (ACS) Washington, DC, office 350 fundraisers, candidate an obstetrician-gynecologist, went 80 | reprioritizes its legislative efforts, meetings, and health care on to win the general election prepares for the transition to a new industry events to help leverage with 66 percent of the vote. presidential administration, and relationships with key physician welcomes the 115th Congress, it is champions in Congress. critical that the ACS Professional ACSPA-SurgeonsPAC Association political action candidate successes committee (ACSPA-SurgeonsPAC), New physician members • Dr. Dunn (R-FL-02) strengthen relationships with of Congress returning members of Congress Although there are relatively • Drew Ferguson, DMD (R-GA-03) and educate new legislators about few physician members of the issues that could affect the Congress, ACSPA-SurgeonsPAC • Raja Krishnamoorthi (D-IL-08) delivery of quality surgical care. plays a key role in engaging interested physician candidates • Dr. Marshall (R-KS-01) around the country, particularly Supporting Fellows, physicians, Fellows and surgeons. Two and surgical champions key races that SurgeonsPAC ACSPA-SurgeonsPAC- During the 2015–2016 election supported in the last election supported physician and cycle, the ACSPA-SurgeonsPAC cycle include the following: dentist candidates disbursed more than $1.2 million • Scott Angelle (R-LA-03, lost to more than 150 congressional • Rep. Neal Dunn, MD, FACS (R-FL- December 10 runoff) candidates and incumbents, 02): To raise awareness about including two ACS Fellows and Dr. Dunn’s candidacy, the ACS • Dr. Dunn (R-FL-02) 14 other physicians members Washington office organized of Congress, several physician a physician community • Dr. Ferguson (R-GA-03) and dentist candidates, and briefing with more than 25 congressional leadership health professional groups in • Pam Galloway, MD, FACS (R-IN- PACs and political campaign attendance. On November 8, 03, lost May 3 Republican primary)

V102 No 1 BULLETIN American College of Surgeons NEWS

During the 2015–2016 election cycle, the ACSPA-SurgeonsPAC disbursed more than $1.2 million to more than 150 congressional candidates and incumbents, including two ACS Fellows and 14 other physicians members of Congress, several physician and dentist candidates, and congressional leadership PACs and political campaign committees.

• Matt Heinz, MD (D-AZ-02, lost • Rep. Andy Harris, MD (R-MD-01), on Health, Education, Labor, general election to incumbent member, Committee on and Pensions; and Committee Rep. Martha McSally) Energy and Commerce and the on Veterans Affairs Committee on Appropriations • Dr. Marshall (R-KS-01) • Rep. Charles Boustany, Jr., MD, • Rep. Jim McDermott, MD FACS (R-LA), candidate for U.S. • Dena Minning, MD, PhD (D-WA-07), member, Committee Senate, member of the House (D-FL-09, lost August 30 on the Budget and Committee Committee on Ways and Means Democratic primary) on Ways and Means • Rep. Joe Heck, Jr., DO (R-NV), • Rep. Tom Price, MD, FACS candidate for U.S. Senate, member Physicians in the 114th (R-GA-06), Chairman, of the House Committee on Congress supported Committee on the Budget, Education and the Workforce | 81 by SurgeonsPAC and member, Committee on Ways and Means, nominated In early October, the U.S. House of Representatives in December by President- ACSPA-SurgeonsPAC launched Elect Donald Trump to serve as independent expenditures • Rep. Dan Benishek, MD, secretary of the U.S. Department in support of the elections of FACS (R-MI-01), member, of Health and Human Services Congressman Bera and Dr. Heck’s Committee on Veterans Affairs Senate race, both staunch • Rep. Phil Roe, MD (R-TN-01), supporters of the physician • Rep. Ami Bera, MD (D-CA-07), member, Committee community. Although Dr. Heck liability reform champion on Education and the lost his race, strong ACSPA- Workforce and Committee SurgeonsPAC support assisted • Rep. Michael Burgess, MD on Veterans Affairs in re-electing Dr. Bera, a top (R-TX-26), member of the Democratic liability champion Committee on Energy • Rep. Raul Ruiz, MD (D-CA-36), on Capitol Hill. Dr. Bera’s victory and Commerce; founder, member, Committee is one example of how PACs can Congressional Health Caucus; on Veterans Affairs affect tight races for candidates and strong ally in the repeal of the who support the needs of sustainable growth rate formula • Rep. Brad Wenstrup, MD surgeons and surgical patients. (R-OH-02), member, Committee For more information about • Rep. Larry Bucshon, MD, FACS on Veterans Affairs ACSPA-SurgeonsPAC fundraising (R-IN-08), member, Committee and disbursement activities, on Energy and Commerce U.S. Senate visit surgeonspac.org. ♦

• Rep. John Fleming, Jr., • Sen. Bill Cassidy, MD (R-LA), MD (R-LA-04), vice-chair, member, Committee on GOP Doctors Caucus Appropriations; Committee

JAN 2017 BULLETIN American College of Surgeons NEWS

Call for nominations for the ACS Board of Regents and ACS Officers-Elect

The 2017 Nominating Committee All nominations must include: be filled at Clinical Congress of the Fellows (NCF) and the 2017. The deadline for Nominating Committee of the • A letter of nomination submitting nominations is Board of Governors (NCBG) will Friday, February 24, 2017. select nominees for leadership • A personal statement detailing positions in the College as follows. the candidate’s ACS service Criteria and interest in the position (for Candidates must meet the President-Elect position only) following NCBG guidelines to Call for nominations be considered for nomination for Officers-Elect • A current curriculum vitae to the Board of Regents: The 2017 Nominating Committee of the Fellows (NCF) will select • The name of one individual • Nominees must be loyal nominees for the three Officer- who can serve as a reference members of the College Elect positions of the American who have demonstrated College of Surgeons (ACS): Further details outstanding integrity along President-Elect, First Vice- Entities such as surgical specialty with an unquestioned devotion President-Elect, and Second Vice- societies, ACS Advisory Councils, to the highest principles 82 | President-Elect. The deadline and ACS chapters that want of surgical practice. for submitting nominations is to make a nomination must Friday, February 24, 2017. provide a description of their • Nominees must have selection process and the total demonstrated leadership Criteria for consideration list of applicants reviewed. qualities, such as service For candidates to receive full Any attempt to contact and active participation on consideration from the NCF, they members of the NCF by a ACS committees or in other must meet the following criteria: candidate or on behalf of a components of the College. candidate will be viewed in • Nominees must be loyal a negative manner and may • The ACS encourages members of the College result in disqualification. consideration of women and who have demonstrated Applications submitted without underrepresented minorities outstanding integrity along the requested information for all leadership positions. with an unquestioned devotion will not be considered. to the highest principles Nominations may be submitted • The NCBG recognizes the of surgical practice to officerandbrnominations@ importance of the Board facs.org. If you have any questions, of Regents representing • Nominees must have demonstrated contact Betty Sanders, staff liaison all who practice surgery, leadership qualities, such as for the NCF, at 312-202-5360 or including surgeons in service and active participation [email protected]. academic and community on ACS committees or in other practice, regardless of practice components of the College location or configuration. Call for nominations for • The ACS encourages ACS Board of Regents • Individuals of all surgical consideration of women and The 2017 NCBG will select specialties will be considered, underrepresented minorities nominees for pending vacancies although special consideration for all leadership positions on the Board of Regents to will be given to those from

V102 No 1 BULLETIN American College of Surgeons NEWS

general surgery and its specialties • A current curriculum vitae a negative manner and may and cardiothoracic surgery. result in disqualification. • The name of one individual Applications submitted without • Only individuals who are in who can serve as a reference the requested information and expected to remain in will not be considered. active surgical practice for their In addition, entities such as Nominations may be submitted entire term may be nominated surgical specialty societies, ACS to officerandbrnominations@ for election or reelection Advisory Councils, and ACS facs.org. If you have any questions, to the Board of Regents. Chapters that intend to make please contact Betty Sanders, Staff a nomination must propose at Liaison for the NCBG, at 312- All nominations must include: least two nominees and provide 202-5360 or [email protected]. a description of their selection For information only, the • A letter of nomination process, along with the complete current members of the Board of list of applicants reviewed. Regents who will be considered • A personal statement from Any attempt to contact for re-election are (all MD, the candidate detailing members of the NCBG by a FACS) James K. Elsey, Gerald his or her ACS service and candidate or on behalf of a M. Fried, B. J. Hancock, and interest in the position candidate will be viewed in Lenworth M. Jacobs, Jr. ♦ | 83

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JAN 2017 BULLETIN American College of Surgeons NEWS

Nominations for 2017 volunteerism and humanitarian awards due February 28

The American College of which one’s time or talents are based on the extent of the Surgeons (ACS), in association donated for charitable clinical, professional obligation. with Pfizer, Inc., is accepting educational, or other worthwhile nominations for the 2017 activities related to surgery. Surgical Volunteerism Award(s) Volunteerism in this case does Nominations and Surgical Humanitarian not refer to uncompensated care Nominations will be evaluated Award. All nominations must be provided as a matter of necessity by the ACS Board of Governors’ received by February 28, 2017. in most clinical practices. Surgical Volunteerism and Instead, volunteerism should be Humanitarian Awards characterized by prospective, Workgroup and their selections Volunteerism Awards planned surgical care to will be forwarded to the The ACS/Pfizer Surgical underserved patients with no Board of Governors Executive Volunteerism Award—offered anticipation of reimbursement Committee for final approval. in four potential categories or economic gain. The following conditions apply annually—recognizes surgeons to the nominations process: who are committed to giving 84 | back to society by making Humanitarian Award • Self-nominations are permissible significant contributions to The ACS/Pfizer Surgical but require at least one surgical care through organized Humanitarian Award recognizes outside letter of support volunteer activities. The awards an ACS Fellow whose career for domestic, international, has been dedicated to ensuring • Re-nomination of previous and military outreach are the provision of surgical care to nominees is acceptable intended for ACS Fellows underserved populations without but requires completion in active surgical practice expectation of commensurate of a new application whose volunteer activities go reimbursement. This award is above and beyond the usual intended for surgeons who have The ACS recommends that professional commitment or dedicated a significant portion of nominators plan a minimum retired Fellows who have been their surgical careers to full-time of 30 minutes to complete involved in volunteerism in or near full-time humanitarian the application form. For the the course of active practice efforts rather than routine nominee to have a fair review, and into retirement. Resident surgical practice. Examples detailed information is required, Members and Associate Fellows include a career committed including the following: of the ACS who have been to missionary surgery, the involved in significant surgical founding and ongoing operations • Demographic information about volunteer activities during of a charitable organization the nominee and nominator. their postgraduate surgical dedicated to providing surgical training are eligible for the care to the underserved, or a • Details about the nominator’s Resident award. Surgeons retirement characterized by relationship to the nominee, along of all specialties are eligible surgical volunteer outreach. with background information on for each of these awards. Having received compensation the nominee’s surgical career. For the purposes of these for this work does not preclude awards, “volunteerism” is a nominee from consideration • Completion of narrative sections defined as professional work in and, in fact, may be expected requesting detailed information

V102 No 1 BULLETIN American College of Surgeons NEWS

about the nominee’s volunteerism • The information provided will detailed information you have or humanitarian work, including be shared with your nominee obtained about the nominee. the type of service they provide, during our verification the sustainability of the programs process. It may be worthwhile The nomination website in which they are involved, any to obtain input from the will open January 3, 2017, for advocacy efforts in which they may nominee in advance. electronic submission and can be have been involved, along with accessed through the Operation additional roles they have played. • The nomination form does Giving Back (OGB) section of not need to be completed in the ACS website at facs.org/ogb. • It helps to tell a story with your one sitting. You may start an For more information, contact nomination. Specific examples application and then come back OGB at [email protected]. ♦ and anecdotes are encouraged. to enhance it with additional

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JAN 2017 BULLETIN American College of Surgeons NEWS

Report on ACSPA/ACS activities, October 2016

by Diana L. Farmer, MD, FACS, FRCS

The Board of Directors Courses, 14 Skills Courses, 45 of the American College Division of Advocacy Meet-the-Expert Luncheons, and of Surgeons Professional and Health Policy 18 Town Hall Meetings. Three Association (ACSPA) and The Division of Advocacy and Special Sessions were offered the Board of Regents (B/R) Health Policy has established a on Firearm Injury Prevention, of the American College of Quality Payment Program (QPP) ACS Strong for Surgery, Surgeons (ACS) met October Resource Center, which contains and Global Engagement. 15 at the Marriott Marquis several tools that are available In addition, the Division of Hotel in Washington, DC. to help surgeons understand Education collaborated with The following is a summary of the new payment system being the Division of Integrated their discussions and actions. implemented under the Medicare Communication on a targeted Access and CHIP (Children’s e-mail campaign to surgeons in Health Insurance Program) 14 states, recommending courses ACSPA Reauthorization Act (MACRA). that might help them fulfill their As of October 15, 2016, the Videos are available on the respective states’ maintenance ACS Professional Association’s ACS website to explain the of licensure requirements. 86 | political action committee, four components of the QPP’s ACSPA-SurgeonsPAC, raised a Merit-based Incentive Payment total of $1,081,165 from more System (MIPS)—Quality, Division of Integrated than 2,100 College members Resource Use, Advancing Care Communications and staff. In addition, the PAC Information, and Clinical The Division of Integrated also had disbursed more than Practice Improvement Activities. Communications played a $1,044,000 to more than 160 The ACS also is working major role in the creation of congressional candidates, with colleagues at Brandeis Bleedingcontrol.org, a new website leadership PACs, and party University, Waltham, MA, and that highlights the Stop the Bleed committees. In line with Brigham & Women’s Hospital, program developed through a congressional party ratios, 58 Boston, to develop alternative collaboration between the ACS percent of the disbursements payment models for use in Committee on Trauma, the White went to Republicans and 42 the QPP. A redesigned ACS House, the U.S. Department percent to Democrats. The Surgeon Specific Registry (SSR) of Homeland Security, and ACSPA does not contribute will be available this month. other federal agencies. to presidential campaigns. The SSR is a useful means After 100 years as a print for surgeons to report their publication, the Bulletin is outcomes data to the Physician transitioning to an online- ACS Quality Reporting System and only publication beginning In addition to reviewing will be useful in responding to January 1. The member magazine reports from the ACS division the MIPS Quality mandates. is available in the following directors, the Board of Regents three digital formats: a website, reviewed and approved bulletin.facs.org; an interactive new policy approval and Division of Education version that replicates the dissemination principles and The 2016 Clinical Congress print edition; and an app. a white paper on the ACS program comprised 24 Tracks, The Division of Integrated database integration project. 128 Panel Sessions, 18 Didactic Communications was responsible

V102 No 1 BULLETIN American College of Surgeons NEWS

for the development of two this year with young surgeon 1910–1951; minutes of the Annual video series, which are posted networking events in Sacramento, Meeting of the Fellows 1912– on the ACS website. One CA; Seattle, WA; and New York, 1984; extensive Commission on video series centers on the NY. Non-member surgeons were Cancer (CoC) American Joint value of ACS Fellowship and invited to these events to meet Committee on Cancer (AJCC) the other on the value of ACS ACS leaders and learn about the records; and trauma publications. educational programs. benefits of College membership. Improvements have been made to The ACS Communities are Four new videos were released the new Archives online database, now in their third year as a forum this past year highlighting key including the addition of a module to discuss topics of interest to areas of member involvement— to support College publications ACS Fellows. At present, there Advocacy, Leadership, Influence, and a search by subject feature. are 106 active ACS Communities. and Engagement. These videos The College also hired are displayed on the ACS website a new full-time Archivist, and were distributed through Meghan Kennedy. Division of Member Services various College e-newsletters The College had a record and social media outlets. Board of Governors number of Initiates in 2016, a In addition to member The following three specialty | 87 total of 1,823, with 1,256 from recruitment and retention, the societies have been approved the U.S. and its territories, 21 Division of Member Services has for representation on the from Canada, and 546 from purview over the ACS Advisory ACS Board of Governors: 69 other countries. The B/R Councils, Archives, Board of accepted resignations from four Governors, and Chapter Services. • American Society of Fellows: two cardiothoracic Maxillofacial Surgeons surgeons, one general surgeon, Advisory Councils and one ophthalmic surgeon. The Advisory Councils have • The International Society The B/R also approved a been restructured to include for Minimally Invasive change in status from Active Advisory Council pillars aligned Cardiothoracic Surgery (dues paying) to Retired for with the values of the College— 49 Fellows, and from Senior Membership, Communications, • The Society of Black (non-dues paying) to Retired Advocacy, Quality, and Education. Academic Surgeons for 28 Fellows, for a total of The Advisory Council pillars 77 Fellows. In all, the College now meet at the Leadership & Chapters had more than 80,000 members Advocacy Summit and again Chapter Services continues to at the end of October 2016. at the Clinical Congress. provide guidance and assistance The Initiate classes of 1966 to the College’s 109 Chapters, and 1991 received special Archives 67 of which are Domestic and recognition at the Convocation More than 32 new accessions were 42 of which are International. Ceremony at Clinical Congress accepted into the Archives this The Trinidad & Tobago Chapter 2016. Special invitations and past year, including the records of received approval from the Board a recognition website were Past-Executive Director Thomas of Regents earlier this year, and created to support this event. R. Russell, MD, FACS; minutes a surgeon in Kuwait petitioned The Realize the Potential of Your of the Annual Meetings of the the College for a Governor with Profession campaign continued Fellows at the Clinical Congress the intention of forming a new

JAN 2017 BULLETIN American College of Surgeons NEWS

chapter soon. Other Chapter take place May 6–9, 2017, and Quality Improvement Services updates are as follows: at the Renaissance Hotel, Program (MBSAQIP)—725 of Washington, DC. which are fully accredited, • The ACS President and other and 51 of which are initial Officers have attended 22 applicants. The remaining domestic and international Division of Research and 37 are data collection centers chapter meetings as keynote Optimal Patient Care that were originally American speakers, providing updates The Division of Research Society for Metabolic and on College activities or and Optimal Patient Care Bariatric Surgery (ASMBS) presentations on leadership (DROPC) encompasses the provisional centers that chose or clinical topics of interest. area of Continuous Quality to continue with data entry but Improvement and ACS research did not complete the process to • The first Chapter Officer and accreditation programs. meet full accreditation status. Leadership Program will take place in March 2017. This ACS NSQIP Educational course program is designed exclusively A total of 754 hospitals The Health Services Research 88 | for domestic chapter officers and participate in the ACS National Methods Course (HSRM), will provide participants with Surgical Quality Improvement previously the Outcomes the skills they need to help their Program (ACS NSQIP®), 662 Research Course, took place chapters build sustainable success. of which participate in the December 8–10, 2016, at ACS adult option. Following is the headquarters in Chicago, IL. The • A new Chapter Administrator breakdown of participating three-day course, led by Arden Learning Event will take place sites by ACS NSQIP category: M. Morris, MD, MPH, FACS, and in conjunction with the 2017 Caprice C. Greenberg, MD, MPH, Leadership & Advocacy Summit. • Small and rural: 64 FACS, was redesigned in 2016 for clinical and health services • The Chapter Guidebook has • Procedure targeted: 280 researchers with varying degrees been completely revamped and of experience. The program was distributed to all Chapters • Essentials: 318 included didactic lectures and following the Clinical Congress. skills-based labs, and participants A new Chapter Meeting Toolkit • Pediatric: 92 were able to select modules has been developed and will be appropriate to their skill levels integrated into the Guidebook. The 2016 ACS NSQIP and interests. The methods Annual Conference took place focus was on quantitative, • A total of 15 webinars have been in San Diego, CA. Nearly qualitative, and mixed method, held this year to provide chapter 1,500 individuals attended, and implementation science. leaders with strategies and tools representing 690 medical to run a successful chapter. institutions and 14 countries. ACS Clinical Scholars in Residence The ACS Clinical Scholars 2017 Leadership & MBSAQIP in Residence program is a Advocacy Summit A total of 813 surgery centers two-year on-site fellowship The 2017 Leadership & participate in the Metabolic and in applied surgical outcomes Advocacy Summit will Bariatric Surgery Accreditation research, health services

V102 No 1 BULLETIN American College of Surgeons NEWS

research, and health policy. first year as a Clinical Scholar Verification. Since its launch in This program offers surgery and as an ACS-JAHF James C. January 2016, more than 650 residents a unique opportunity Thompson Geriatric Surgery participants have completed to work with College leaders Research Fellow. Her research the online TQIP course. and Quality Programs (see focuses on outcomes in acute care related story, page 77). surgery and trauma, specifically Scholars and their major among geriatric patients. ACS Foundation projects are as follows: The ACS Foundation had a • Ryan Ellis, MD, will be joining the strong year, obtaining financial • Julia Berian, MD, is a general ACS Clinical Scholars in Residence support for the educational surgery resident at the University program in July 2017. Dr. Ellis and outreach programs of of Chicago Medical Center and is a general surgery resident at the College. Examples of is in her third year as a Clinical Northwestern University McGaw support in 2016 include: Scholar and her second year as the Medical Center. In the coming ACS-John A. Hartford Foundation years, Dr. Ellis hopes to further • More than 50 international guest (JAHF) James C. Thompson his career as a practicing surgical scholarships, research fellowships, Geriatric Surgery Research Fellow. oncologist and a health services and other traveling scholarships | 89 Dr. Berian has continued her work and outcomes researcher, with for young surgeons. The ACS on the JAHF-funded Coalition his time evenly split between Foundation is tracking the career for Quality in Geriatric Surgery. research and clinical practice. progress of its past scholarship recipients to show the long-term • Kristen Ban, MD, is a resident Cancer Programs impact that funding can have on in the department of surgery, At present, the Commission on surgical careers and patient care. Loyola University Medical Cancer (CoC) accredits 1,519 Center, Maywood, IL, and cancer programs. • Funding to provide Advanced a second-year ACS Clinical The resource booklet, National Trauma Life Support training Scholar in Residence. Her Cancer Database Tools, Reports, and in Mongolia and Kenya. interests include health Resources, was recently revised services and quality and will be shared with the • Support to Operation Giving improvement research. Cancer Liaison Physicians, staff Back in its strategic planning at accredited programs, attendees for greater outreach. ♦ • Jason Liu, MD, is a general at CoC education programs, and surgery resident at the CoC surveyors. The booklet University of Chicago Medical also will be distributed at the Center. His research focuses meetings where the CoC and on outcomes within general National Cancer Database exhibit. surgical oncology, particularly hepatopancreatobiliary operations. Committee on Trauma As of September 20, 2016, a total • Melissa Hornor, MD, is a general of 530 hospitals participate in the surgery resident at The Ohio Trauma Quality Improvement State University Wexner Medical Program (TQIP); a total of Center, Columbus. She is in her 442 trauma centers have ACS

JAN 2017 BULLETIN American College of Surgeons NEWS

ACS in the

Editor’s note: Media around the MPH, from the University world, including social media, Weight-loss surgery may lower of Wisconsin, Madison.” frequently report on American risk of pregnancy complications College of Surgeons (ACS) activities. U.S. News & World Report, Following are brief excerpts from October 28, 2016 Tweet of the week: news stories covering research and “According to study co-author Surgeons look like activities reported from the ACS Brittanie Young, a medical student MedPage Today, October 23, 2016 Clinical Congress 2016, October at the Philadelphia School of “Surgeons spun 16−20, in Washington, DC. To access Osteopathic Medicine, ‘If the child #WhatADoctorLooksLike from the news items in their entirety, is less at risk of being very large last week into an opportunity 90 | visit the online ACS Newsroom at for its gestational age, the woman to highlight gender disparities facs.org/media/acs-in-the-news. is less likely to have a C-section.’ among surgeons during the The findings were presented annual gatherings of the recently at the Clinical Congress Association of Women Surgeons Trauma: A neglected US of the American College of (#AWS2016) and [the] American public health emergency Surgeons, in Washington College of Surgeons (#ACSCC16).” The Lancet, October 29, 2016 DC. Research presented at “In the USA, the leading cause meetings should be viewed as of death in those younger than preliminary until published Trauma patients not to blame 45 years is trauma, accounting in a peer-reviewed journal.” for opioid epidemic: Study for over half of deaths in that HealthDay, October 19, 2016 age group. Trauma costs the “Almost 75 percent of major USA up to $600 billion [U.S.] Follow-up imaging trauma patients who were each year, and yet despite these lacking for many after prescribed narcotic painkillers sobering figures, this epidemic breast cancer surgery such as OxyContin and goes largely unrecogni[z]ed. Medscape, October 27, 2016 Percocet had stopped using Last week, at their 2016 Clinical “About one third of US them a month after leaving the Congress, the American College women who receive surgical hospital. And only 1 percent of Surgeons (ACS) announced a treatment for breast cancer are were still taking the drugs commitment to achieving zero not receiving appropriate follow- on a prescription basis a year preventable deaths from trauma. up, new research suggests. later, researchers found. If reali[z]ed, this goal would Findings from the National ‘We were really surprised save one in five civilians and a Cancer Database were by how low the numbers were quarter of military personnel presented here at the American for long-term opiate use,’ study currently killed by trauma, College of Surgeons Clinical senior investigator Dr. Andrew an estimated 30,000 lives per Congress 2016 by surgery Schoenfeld said in an American year in the USA alone.” resident Taiwo Adesoye, MD, College of Surgeons news release.”

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techniques were about half with patients’ reported Why don’t more women of those of patients who had postoperative complications.” color have reconstruction conventional surgeries, after breast cancer? according to an analysis by Philadelphia Inquirer, Dr. Lucas Thornblade, a UW Rates of preventive October 25, 2016 Medicine general-surgery mastectomy doubled in a “[Paris Butler, MD, MPH,] resident, and colleagues. decade, and fear is a factor who specializes in plastic and ‘We are encouraged by United Press International, reconstructive surgery, has the results,’ said Thornblade, October 18, 2016 documented the problem lead author of the study “Fear of cancer recurrence nationally and investigated the presented Monday at the 2016 seems to be a primary reason | 91 role of private vs. public insurance Congress of the American why breast cancer patients in determining which patients College of Surgeons.” choose to have their cancer-free receive reconstructive surgery. breast removed at the same time While his work has found that as their affected breast, a new insurance status and geographic Wearable fitness tracker study finds…The study is to be availability to plastic surgeons monitors patients’ presented Tuesday at a meeting of likely play a role in the disparities, postoperative functional the American College of Surgeons ‘we strongly believe it’s something recovery at home (ACS) in Washington, D.C.” about patients’ race and ethnicity Surgical Products, October 21, 2016 that goes beyond insurance status “A new way for surgeons and access to care.’ Recently, we to know how well their asked him a few questions about patients are regaining his work, which he presented to physical function after a the American College of Surgeons major abdominal operation in DC on October 20th.” could be as simple as patients wearing a fitness wristband to count their steps. Results Minimally invasive surgery of a new study, presented at a safe option for major liver the 2016 Clinical Congress cases, UW study finds of the American College of Seattle Times, October 17, 2016 Surgeons, show that monitoring “The odds of serious patients’ postoperative complications or death in functional recovery using patients who had surgeries a commercially available, known as major hepatectomies wireless activity tracker is using minimally invasive feasible, and strongly correlates

JAN 2017 BULLETIN American College of Surgeons SCHOLARSHIPS

Applications for 2017 Nizar N. Oweida, MD, FACS, Scholarship due March 1

The Board of Governors of the • Execute a well-defined proposal • A copy of the applicant’s American College of Surgeons for travel or research to improve current curriculum vitae, no (ACS) has announced the a rural surgeon’s performance more than 10 pages in length availability of the Nizar N. Oweida, MD, FACS, Scholarship Scholars and alternates will for surgeons who serve small Financial support be selected and all applicants will communities. The Oweida Successful applicants will receive be notified of the outcome of the Scholarship provides up to the sum of $5,000, to be used to selection process by May 1, 2017. three awards of $5,000 each to defray expenses for attendance at The Oweida Scholars subsidize the participation of the ACS Clinical Congress or for must attend the meeting or a Fellow or Associate Fellow the approved training or research pursue their project in the serving a small community at opportunity. Cost categories year for which the scholarship the ACS Clinical Congress 2017 include travel expenses, lodging is designated; the award in San Diego, CA; alternatively, and per diem, registration, and may not be postponed. 92 | applicants may propose a plan for course fees. Scholars will make Oweida Scholars will provide additional training or research their own travel arrangements. a narrative and financial report appropriate to a rural surgeon. The Executive Committee of their experiences at the Applications are due to the of the Board of Governors will conclusion of their awarded ACS Scholarship Administrator select awardees following review activity. These final reports no later than March 1, 2017. and evaluation of the applications are due by March 1, 2018. received. Applicants must submit Submit applications for a single PDF document with the this scholarship via e-mail to Requirements following items, in this order: [email protected]. Direct The Oweida Scholarship is questions to the ACS Scholarships available to an ACS member in • A one- to two-page essay Administrator at scholarships@ any surgical specialty who meets discussing the following facs.org or 312-202-5281, or the following requirements: specific topics: visit facs.org/member-services/ scholarships/special/oweida. ♦ • Is a Fellow or Associate ȖȖThe opportunity for which the Fellow under age 55 on the applicant is applying (Clinical date the application is filed Congress, or a personal training or research project) • Is serving a small town or rural community in the U.S. or Canada ȖȖThe applicant’s reasons for submitting an application

Activities ȖȖThe applicant’s qualifications Awardees may use their award for the scholarship stipend to do one of following: ȖȖThe applicant’s current practice • Attend the ACS Clinical Congress in a rural or small community.

V102 No 1 BULLETIN American College of Surgeons SCHOLARSHIPS

Apply through February 15 for International ACS NSQIP Scholarships 2017

The American College of • Applications will be accepted from the chair of the department Surgeons National Surgical for processing only when the of their hospital or an institution Quality Improvement applicants have been in surgical in which they hold academic Program (ACS NSQIP®) and practice, teaching, or research appointment, or a Fellow of the the International Relations for a minimum of one year American College of Surgeons Committee offer International at their intended permanent residing in their country. The ACS NSQIP Scholarships for location, following completion chair’s or the Fellow’s letter two surgeons from countries of all formal training (including must include a specific statement other than the U.S. or Canada fellowships and scholarships). detailing the nature and extent who demonstrate a strong of the applicant’s involvement interest in surgical quality • Applicants must be under 55 years with quality improvement. improvement. Applications of age at the time of application. The individuals making the for the 2017 scholarships are recommendations must submit due February 15, 2017. • Applicants must have the letters of recommendation. The scholarships, in the demonstrated a commitment to | 93 amount of $10,000 each, provide surgical quality improvement. • Applicants are required to the scholars with an opportunity submit a curriculum vitae of to attend the 2017 ACS NSQIP • Applicants must submit a fully no more than 10 pages. Annual Conference, July 21–24 completed online application form in New York, NY, and meet available on the ACS website. • The International ACS NSQIP with program leadership and Applicants must prepare the Scholarships must be used in the surgeon champions from ACS application and accompanying year for which they are designated. NSQIP participating hospitals. materials in English. They may not be postponed. Following the ACS NSQIP Submission of a curriculum conference, the scholars are vitae only is not acceptable. • Applicants who are awarded encouraged to visit one or two scholarships will submit a hospitals with strong quality • Applicants must provide full written report of the programs that reflect the information regarding their work experiences provided through the candidate’s clinical interests. setting, including their hospital scholarships upon completion. and the patients they see, as well as their participation in quality • An unsuccessful applicant may Criteria improvement activities in this reapply only twice and only by The International ACS NSQIP setting. They also must indicate completing and submitting a Scholarship requirements their career goals, specifying current application form provided are as follows: how they plan to transfer by the College, together with • Applicants must be medical their newly acquired learning new supporting documentation. school graduates. to their current situation. The scholarships provide successful applicants with • Applicants must submit their • Applicants must submit letters the privilege of participating applications from their intended of recommendation from three in the ACS NSQIP Annual permanent institution. colleagues. One letter must be Conference. The ACS will

JAN 2017 BULLETIN American College of Surgeons SCHOLARSHIPS

The scholarships, in the amount of $10,000 each, provide the scholars with an opportunity to attend the 2017 ACS NSQIP Annual Conference, July 21–24 in New York, NY, and meet with program leadership and surgeon champions from ACS NSQIP participating hospitals.

assist the scholar in arranging the International ACS NSQIP Section by the February 15 hotel accommodations in Scholarship requirements and deadline. All applicants will the conference city. application form at facs.org/ be notified of the Selection memberservices/scholarships/ Committee’s decision in May 2017. Additional information international/isnsqip. All applications and any regarding ACS NSQIP is Completed applications for questions regarding this available at facs.org/nsqip. the International ACS NSQIP scholarship should be directed All of the requirements Scholarships for the year 2017 to International Liaison must be fulfilled to qualify for and all of the supporting at [email protected]. ♦ consideration by the Selection documentation must be received Committee. There is a link to by the International Liaison

94 | 2017 Heller School Executive Leadership Program Scholarship applications due February 1 The American College of Surgeons (ACS) is Surgical Society, the American Society of Breast offering scholarships to subsidize attendance Surgeons, the American Society of Colon and and participation in the Executive Leadership Rectal Surgeons, the American Society of Plastic Program in Health Policy and Management Surgeons, the American Surgical Association, the at the Heller School for Social Policy and American Urogynecologic Society, the American Management at Brandeis University. Applications Urological Society (via its Gallagher Scholarship are due February 1, 2017. The 2017 course program), the Americas Hepato-Pancreato- will take place June 4−10. The $8,000 award Biliary Association, the Eastern Association for may be used toward the cost of tuition, travel, the Surgery of Trauma Foundation, the New housing, and subsistence during the period of the England Surgical Society, the Society for Surgery course and the post-course follow-up period. of the Alimentary Tract, the Society of Thoracic The ACS, which fully funds two scholarships Surgeons, and the Society for Vascular Surgery. reserved for general surgeons, welcomes the many All applicants will be notified of the outcome surgical specialty societies that are cosponsoring of the selection process by March 31. a scholarship for a member in good standing Direct questions to the ACS Scholarships of both the College and the specialty society Administrator at [email protected] or 312- to attend this intensive program. Participating 202-5281. Requirements for these scholarships societies supporting scholarships include the are posted on the ACS website at facs.org/ American Association of Neurological Surgeons, member-services/scholarships/health-policy. More the American Academy of Otolaryngology-Head information on the program can be found at and Neck Surgery, the American Association for heller.brandeis.edu/academic/execed/index.html. ♦ the Surgery of Trauma, the American Pediatric

V102 No 1 BULLETIN American College of Surgeons AMERICAN COLLEGE OF SURGEONS TRANSITION TO PRACTICE FROM RESIDENT TO GENERAL SURGEON

Congratulations to the Associates who successfully completed the Transition to Practice (TTP) Program in General Surgery in 2016

Samar F. Alami, MD Phillip A. Letourneau, MD Anne Arundel Medical Center Oregon Health & Science University Emily Ament, MD Catherine L. Loflin, MD University of Texas Health Science Center Wake Forest University School of Medicine at San Antonio, University of Texas Priscilla G. Thomas, MD School of Medicine Mercer University School of Medicine Ritha M. Belizaire, MD Tanveer Zamani, MBBS Montefiore Medical Center Geisinger Health System Anne Kuritzky, MD Alpert Medical School of Brown University

Welcome to the following TTP Associates participating in 2016–2017

Larissa Chiulli, MD Juliette Moore, MD Alpert Medical School of Brown University Oregon Health & Science University Elisha M. Collins, MD Cindy-Marie O’Neal, MD University of Florida/St. Vincent’s Mercer University School of Medicine Health Center Joshua S. Rickey, MD Travis L. Holloway, MD Wake Forest University School of Medicine University of Texas Health Science Center Nathan J. Roberts, MD at San Antonio, University of Texas Loyola University Medical Center School of Medicine Rachael Springer, MD Naveen Kumar, MD Wake Forest University School of Medicine Surgery South Michael Tran, MD Reema Mallick, MD Anne Arundel Medical Center Geisinger Health System Lauren I. Wikholm, MD Mandy R. Maness, MD Oregon Health & Science University Wake Forest University School of Medicine

facs.org/ttp [email protected] 312-202-5653

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

2017_ED_BulletinAd_TransitionPractice_7.5x10.25_v02.indd 1 11/16/2016 8:58:53 AM MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit facs.org/events or web2.facs.org/ChapterMeetings.cfm.

North & South Texas Chapters JANUARY February 23–25 MAY Austin, TX Southern California Chapter Contact: Janna Pecquet, Australia and New January 20–22 [email protected], Zealand Chapter Santa Barbara, CA www.ntexas.org/ and May 1 Contact: James Dowden, www.southtexasacs.org/ East Melbourne, Australia [email protected], Contact: Monique Whear, www.socalsurgeons.org/ [email protected]

2017 ACS Surgical APRIL West Virginia Chapter Coding Workshop Minnesota Surgical Society: May 11–13 January 26–27 A Chapter of the ACS White Sulphur Springs, WV Las Vegas, NV April 7–8 Contact: Sharon Bartholomew, Contact: Jan Nagle, Minneapolis, MN wvacs.labs.net [email protected] Contact: Janna Pecquet, [email protected], Ohio Chapter Montana-Wyoming Chapter mnsurgicalsociety.org May 12–13 96 | and Idaho Chapter Cleveland, OH January 27–29 Indiana Chapter Contact: Emily Maurer, Teton, WY April 21–22 [email protected], www.ohiofacs.org Contact: Cyan Sportsman, French Lick, Indiana [email protected], Contact: Tom Dixon, Metropolitan squ.re/2dK13CI [email protected], Philadelphia Chapter www.infacs.org May 22 Philadelphia, PA Northern California Chapter Contact: Robbi-Ann M. Cook, FEBRUARY April 28–29 [email protected], Berkeley, CA www.metrophilasurgeons.org South Florida Chapter Contact: Christina McDevitt, February 1 [email protected], Fort Lauderdale, FL www.nccacs.org FUTURE CLINICAL Contact: Bill Bouck, [email protected], North Dakota and South CONGRESSES www.sfc-acs.org Dakota Chapters 2017 April 28–29, October 22–26 Puerto Rico Chapter West Fargo, ND San Diego, CA February 18–20 Contact: Leann Benson, San Juan, PR [email protected] 2018 Contact: Aixa Velez-Silva, October 21–25 [email protected], Florida Chapter Boston, MA www.acspuertoricochapter.org/ April 28–29 Orlando, FL 2019 Contact: Stacy Manthos, October 27–31 [email protected] San Francisco, CA

V102 No 1 BULLETIN American College of Surgeons