October 2013 | Volume 98 NUmber 10 | american college of surgeons Bulletin

Training in OR crisis management Contents

Features SCORE provides residents with Web-based curriculum for developing key competencies 10 Mary E. Klingensmith, MD, FACS, and Mark A. Malangoni, MD, FACS

Chapter lobby days forge ahead in state capitals 16 Charlotte Grill and Jon Sutton

Progress or retrogress? Status of the 113th Congress 19 John Hedstrom, JD

Cover story: Operating room crisis management leadership training: Guidance for surgical team education 24 Kenneth A. Lipshy, MD, FACS, and Anthony LaPorta, MD, FACS

Surgeons lead educational program to improve kidney care in Vietnam 34 | 1 Douglas P. Slakey, MD, and Ingemar Davidson, MD, FACS

Centennial reprint: The College’s ongoing commitment to the quality imperative 41

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

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Columns News Two ACS NSQIP® collaboratives receive AHA Davidson Quality Looking forward 8 ACS joins campaign to encourage Awards 78 use of surgical crisis checklists 64 David B. Hoyt, MD, FACS Register now for 2013 ACS Clinical Coding and practice management T. Forcht Dagi, MD, DmedSc, Trials Methods Course 80 MPH, FACS, FAANS, FRCS(Ed), corner: The complexities of coding Chapter news 81 bilateral procedures 47 and Gerald B. Healy, MD, FACS, FRCS(Eng)(Hon), FRCS(I)(Hon) Donna Tieberg Jenny J. Jackson, MPH, CPC; Commission on Cancer announces Charles D. Mabry, MD, FACS; ACS NSQIP® National Conference: 2013–2014 cancer research paper and Mark Savarise, MD, FACS Speakers promote professionalism, collaboration to achieve quality competition for physicians in Dispatches from rural surgeons: improvement 66 training 87 Rural surgery in “The Great ACS in the news 88 White North”— universal care or Jeannie Glickson universal challenge? 50 New ACS NSQIP® Surgical Risk Scholarships Nadine R. Caron, MD, Calculator offers personalized ACS Scholarship Endowment MPH, FRCS(C); Christine estimates of surgical Fund awards Faculty Research M. Kennedy; and Garth L. complications 72 Fellowships, 2013–2015 91 Warnock, MD, FACS, FRCS(C) Dr. Arden Morris appointed 2 | ACS Board of Regents awards ACS Clinical Research Program: to National Quality Forum Committee 73 six 2013 Resident Research Does altering diet affect progression Scholarships 92 of prostate cancer? The MEAL ACS Convention and Meetings study 57 Director featured in magazine 73 Apply by November 1 for Faculty Research Fellowships 93 J. Kellogg Parsons, MD, MHS, Issues discussed at the AMA House FACS; James R. Marshall, PhD; of Delegates meeting include 2013 Traveling Fellow to Germany and Heidi Nelson, MD, FACS definition of surgery, obesity 75 reports on experiences 95 Anneke T. Schroen, MD, MPH, FACS A look at The Joint Commission: John H. Armstrong, MD, FACS, Finding new solutions to hand and Jon H. Sutton hygiene problems 60 ACS and CoC join Choosing Wisely Meetings Calendar NTDB® data points: London Bridge Campaign to identify overused Calendar of events 100 is falling down 62 procedures 78 Richard J. Fantus, MD, FACS

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

V98 No 10 Bulletin American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

Editor-in-CHIEF Letters to the Editor Diane Schneidman should be sent with the writer’s Director, Division of name, address, Integrated Communications e-mail address, and Lynn Kahn daytime telephone Senior Editor number via e-mail to SurgeonsVoice Tony Peregrin dschneidman@facs. org, or via mail to Educate | Advocate | Motivate Ctontribu ing Editors Diane S. Schneidman, Jeannie Glickson Editor-in-Chief, Katie McCauley Bulletin, American SurgeonsVoice is a complete College of Surgeons, Graphic Designer grassroots advocacy resource 633 N. Saint Clair St., Tina Woelke providing you with the tools Chicago, IL 60611. and training necessary to be Editorial Advisors Letters may be edited Charles D. Mabry, MD, FACS for length or clarity. an effective surgeon advocate. Leigh A. Neumayer, MD, FACS Permission to publish Marshall Z. Schwartz, MD, FACS letters is assumed Educate yourself and colleagues Mark C. Weissler, MD, FACS unless the author on how to get involved indicates otherwise. Foront c ver design Advocate on behalf of your Tina Woelke profession, practice, and patients Motivate policymakers to advance Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, surgical advocacy priorities 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Have your voice heard. Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of www.SurgeonsVoice.org Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800-621-4111; e-mail:[email protected]; website: www.facs.org. Washington, DC, office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701; website: www.tmiva.net/20fstreetcc/home. American College of Surgeons Professional Association Unless specifically stated otherwise, the opinions expressed Political Action Committee and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2013 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. Officers and Staff of the American College of Surgeons

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

V98 No 10 Bulletin American College of Surgeons Author bios

a b

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f g h i

Dr. Armstrong (a) is Surgeon General Dr. Dagi (c) is Distinguished Scholar Ms. Glickson (f) is Communications and Secretary, Florida Department and Professor, The School of Medicine, Associate, ACS Division of Integrated of Health, Tallahassee, FL. He serves Dentistry and Biomedical Sciences, Queen’s Communications, Chicago, IL. on the American College of Surgeons University Belfast, Northern Ireland; (ACS) Board of Governors and the ACS lecturer, department of global health and Ms. Grill (g) is State Affairs Health Policy and Advocacy Group. social medicine, Harvard Medical School, Associate, ACS Division of Advocacy Boston, MA; and member, Council on and Health Policy, Chicago. Dr. Caron (b) is assistant professor, Surgical and Perioperative Safety (CSPS) Dr. Healy University of British Columbia, department Board of Directors. He is Chair of the (h) is Emeritus Gerald B. Healy of surgery and Northern Medical ACS Committee on Perioperative Care. Chair in Otolaryngology, Children’s Hospital, Program, Prince George, BC; associate Boston; professor of otology and laryngology, member, University of British Columbia, Dr. Davidson (c) is professor of Harvard Medical School; and member, CSPS School of Population and Public Health, surgery, department of surgery, University Board of Directors. He is ACS Past-President Vancouver; adjunct faculty, University of Texas Southwestern, Dallas, TX. and Past-Chair of the Board of Regents. of Northern British Columbia, Prince Mr. Hedstrom George; and associate faculty, Johns Dr. Fantus (e) is director, trauma (i) is Deputy Hopkins University Bloomberg School services, and chief, section of surgical critical Director, Legislative Policy and Political of Public Health, Baltimore, MD. care, Advocate Illinois Masonic Medical Affairs, ACS Division of Advocacy and Center, and clinical professor of surgery, Health Policy, Washington, DC. University of Illinois College of Medicine, continued on next page Chicago. He is Past-Chair of the ad hoc Titles and locations were current at the time Trauma Registry Advisory Committee the articles were submitted for publication. of the ACS Committee on Trauma.

OCT 2013 Bulletin American College of Surgeons Author bios continued

j k

l m n 6 |

o p q r

Ms. Jackson (j) is Practice Affairs Dr. Lipshy (n) is a chief surgery D r. Malangoni (p) is an ACS Regent Associate, ACS Division of Advocacy consultant for the U.S. Department of and associate executive director, American and Health Policy, Washington, DC. Veterans Affairs Health Care System Board of Surgery, Philadelphia, PA. and residency educational director, East Ms. Kennedy (k) is a research Virginia Medical Center–Hampton Veterans D r. Marshall (q) is senior vice-president assistant, University of Northern British Affairs Medical Center, Hampton, VA. for cancer prevention and population Columbia Northern Medical Program. sciences and chair, department of cancer Dr. Mabry (o) is associate professor of prevention and population sciences, Roswell Dr. Klingensmith (l) is chair, surgery at the University of Arkansas for Park Cancer Institute, Buffalo, NY. Surgical Council on Resident Education Medical Sciences, Little Rock. He is Chair of and Mary Culver Distinguished Professor the ACS Health Policy Advocacy Council, Dr. Nelson (r) is Fred C. Andersen of Surgery and vice-chair for education, a member of the ACS General Surgery Professor of Surgery and chair, division of Washington University, St. Louis, MO. Coding and Reimbursement Committee, surgery research, Mayo Clinic, Rochester, and is alternate ACS advisor to the American MN, and Program Director of the Alliance/ Dr. LaPorta (m) is a retired U.S. Army Medical Association (AMA) Specialty Society ACS Clinical Research Program. Colonel and professor of surgery, Rocky Vista Relative Value Scale Update Committee. University School of Medicine, Parker, CO. continued on next page

V98 No 10 Bulletin American College of Surgeons Author bios continued

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u v w | 7

x y

Dr. Parsons (s) is associate Dc r. S hroen (u) is associate professor MS. Tieberg (x) is Manager of professor of surgery, department of surgery, division of surgical oncology, Chapter Services, ACS Division of of urology, Moores Cancer Center, University of Virginia, Charlottesville. Member Services, Chicago. University of California-San Diego. Dr. Slakey (v) is professor and Robert Dr. Warnock (y) is Woodward Professor Dr. Savarise (t) is assistant clinical and Viola Lobrano Chair of Surgery, of Surgery, University of British Columbia, professor of surgery at the University of department of surgery, Tulane University department of surgery, Vancouver. Utah, Salt Lake City. He serves on the ACS School of Medicine, New Orleans, LA. General Surgery Coding and Reimbursement Committee and the Advisory Councils for M r. Sutton (w) is Manager of State General Surgery and Rural Surgery and is the Affairs, ACS Division of Advocacy ACS alternate advisor at the AMA Current and Health Policy, Chicago. Procedural Terminology Editorial Panel.

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

Looking forward

by David B. Hoyt, MD, FACS

urgeons work in a physically demanding field, and the risk of injury is considerable. More- Sover, most physicians and surgeons in the U.S. are now 50 years of age or older, and like all aging Americans, need to be prepared for the likelihood that they will develop a debilitating or chronic con- dition that will prohibit them from remaining in practice. Furthermore, surgeons are facing height- ened stress with each passing day due to reimburse- ment, liability, and workforce shortage issues. For some surgeons, the pressures can be extraordinary, leading to burnout, substance abuse, and other mental and physical health care problems. Most of us have little time or inclination to con- template these possibilities and to plan for a future in which we are unable to experience the financial and personal rewards of surgical practice. In fact, When surgeons lose their ability to more than half of 2,365 physicians who responded practice for extended periods of time, to a survey conducted by a subsidiary of the Ameri- 8 | they are vulnerable to losing everything can Medical Association admit they are behind in preparing for retirement and their financial future. they have worked so hard to acquire. Many reported gaps in their knowledge of personal finances and expressed a lack of confidence in their financial decisions related to retirement savings, es- tate planning, and insurance.* As a professional organization, the American Col- lege of Surgeons (ACS) offers its members a range of services designed to help them plan for the years leading up to and beyond retirement, so that they can continue to enjoy the benefits of their many years of dedication to patient care. With the majority of surgeons looking toward retirement in as little as 10 years, protection of future income takes on signifi- cant importance. One form of protection that is par- ticularly relevant to an aging population of surgeons is disability insurance.

Need for disability insurance A disability is defined as any illness or injury that interferes with an individual’s ability to work. Among those individuals who experience a disability, one in

*AMA Insurance. 2013 Report on U.S. Physicians’ Financial Preparedness. Available at: http://www.amainsure.com/resourcecenter/2013-report-on- physicians-financial-preparedness.html. Accessed September 1, 2013.

V98 No 10 Bulletin American College of Surgeons Executive Director’s report

An estimated 81 percent of all physicians have private disability insurance; however, few of them have coverage that is sufficient to protect their income and allow them and their families to enjoy their current lifestyle.

three is out of work for three months or more, one in respondents had not reviewed their disability insur- five is unable to work for a year or longer, and one in ance policy either in the last five years or since they seven cannot work for five years or more.† When sur- purchased it. Furthermore, most of them were uncer- geons lose their ability to practice for extended peri- tain whether they were carrying the right amount of ods of time, they are vulnerable to losing everything protection for their needs, and another 50 percent said they have worked so hard to acquire. they were unsure if the disability benefit they would According to the Council for Disability Awareness, receive was considered taxable income. nearly three in 10 new long-term disability claims in In researching and obtaining disability insurance, 2012 were caused by musculoskeletal system and con- surgeons should seek out opportunities within the tra- nective tissue disorders, such as rheumatoid arthritis; ditional disability insurance markets as well nontradi- the next leading cause was cancer or neoplasms.† As we tional long-term disability insurance plans. The nontra- all know, if a surgeon were to develop severe arthritis ditional marketplace offers coverage with higher limits or end-stage cancer, his or her ability to operate would on benefits as well as novel policy features and liberal be significantly limited for at least some period of time, underwriting with specialty occupation definitions. As if not draw to an end. a result, surgeons may experience an income replace- | 9 Although certain safety nets are in place to assist ment ratio of up to 65 percent of their current income. individuals who are injured, such as Workers’ Com- pensation and Social Security, these programs offer little protection for most Americans, especially those Consider your options of us in professional positions. Most disabilities are not It is important that surgeons take the time to review directly work-related and, therefore, not covered by their current disability benefit amounts.I would Workers’ Compensation. Meanwhile, to qualify for encourage members of the ACS to research the pos- Social Security disability, an individual must be com- sibilities available to them through this organization pletely unable to work for at least a year or have a ter- and their personal financial consultants to obtain a minal, irreversible illness. higher income replacement amount and higher dis- ability benefits. As unpleasant as it is to contemplate, we all need to Surgeons may be underinsured accept the realities of being part of a demanding profes- An estimated 81 percent of all physicians have pri- sion and of the inevitable effects of the aging process. vate disability insurance; however, few of them have Take the necessary steps to protect your family and coverage that is sufficient to protect their income and to maintain the lifestyle you have earned and enjoy. allow them and their families to enjoy their current For more information about ACS-sponsored disabil- lifestyle. For example, if a surgeon earns $600,000 and ity programs, contact our administrator, NEBCO, at has a maximum monthly benefit of $20,000, his or her 1-800-433-1672.  family’s income will drop to 40 percent of its existing level. According to the 2013 study of U.S. physicians’ fi- nancial preparedness cited earlier, 42 percent of the

†The Council for Disability Awareness. The 2013 Council for Disabil- ity Awareness Long-Term Disability Claims Review. Available at: http:// www.disabilitycanhappen.org/research/CDA_LTD_Claims_Sur- If you have comments or suggestions about this or other issues, please vey_2013.asp. Access August 30, 2013. send them to Dr. Hoyt at [email protected].

OCT 2013 Bulletin American College of Surgeons SCORE Web-based curriculum

SCORE provides residents with Web-based curriculum for developing key competencies

by Mary E. Klingensmith, MD, FACS, and Mark A. Malangoni, MD, FACS

stablished in 2004, the Surgical Council on Resident Education (SCORE) is a consortium of seven U.S.-based surgical organizations: Ethe American Board of Surgery (ABS), American College of Surgeons (ACS), American Surgical Association (ASA), Association of Program Di- rectors in Surgery (APDS), Association for Surgical Education (ASE), Ac- creditation Council for Graduate Medical Education (ACGME), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). 10 | In an effort led by the ABS, six founding members of the group initially met in November of that year (with SAGES joining later) and agreed to work toward two goals:

1. Develop a standardized, competency-based curriculum for general surgery residency training that addresses the six competency areas as defined by the Accreditation Council for Graduate Medical Education (ACGME).

Highlights 2. Develop a Web portal to deliver this content to general surgery residents in training. The first official meeting of the entire group convened Nin ovember • Describes the reasons that 2006. Richard Bell, MD, FACS, who was hired by the ABS to oversee the ini- SCORE established a Web- tial development of the curriculum and Web portal, chaired this conference.1 based curriculum for surgical residents seeking to develop Over the next two years, an initial curriculum outline was developed the six core competencies that covering the competency of patient care and operative skills. This cur- the ACGME has identified riculum was developed through an iterative process that involved SCORE • Offers information on purposes council representatives and program directors in surgery. The operative of the SCORE portal and the case experience of surgery residents was examined and classified by pro- structure of the curriculum gram directors in surgery, and input was obtained from other stakehold- • Provides details on the status ers.2 This curriculum outline was the basis for development of the early of the portal and its contents, content that was delivered on the SCORE Web portal, which was piloted to including availability of 33 selected residency programs in 2008.3 This curriculum outline has since modules, textbooks, videos, been expanded to include the competencies of medical knowledge, systems- self-assessment questions, based practice, professionalism, and interpersonal skills and communication. and supplemental resources The curriculum outline is dynamic and is reviewed and updated annually according to recommendations made by various stakeholder groups, as coordinated by the ABS. It is publicly available on the SCORE Web portal (http://www.surgicalcore.org/public/curriculum), as well as in a print version.

V98 No 10 Bulletin American College of Surgeons SCORE Web-based curriculum

In 2009, the Web portal was made available to all residency programs free of charge. In the 2010-2011 academic year, the portal became a subscription-only resource, and by 2012, 96 percent of general surgery residency programs subscribed to the SCORE Web portal to support education.

SCORE Web portal grams may provide sufficient experience for competen- In 2009, the Web portal was made available to all resi- cy by their graduates. These classifications are reviewed dency programs free of charge. In the 2010–2011 aca- annually to determine their continuing relevance to demic year, the portal became a subscription-only a given category. We anticipate that the curriculum resource, and by 2012, 96 percent of general surgery will be dynamic and that some topics will change over residency programs subscribed to the SCORE Web time as technology and disease management evolve.5 portal to support education. Participation in the Web portal has expanded to include surgery residencies in Canada and other nations throughout the world, as Organizational structure and outreach well as more than half of all osteopathic surgery train- SCORE, as a consortium, curriculum, and Web portal, ing programs. has a defined and complementary organizational struc- The patient care competency is organized in 28 ture (see boxed item, page 12). The daily operation of categories and presented in individual content areas, the Web portal is overseen by a leadership group, which termed “modules.” These modules are divided into two is also responsible for implementing new features on overarching areas: diseases/conditions and operations/ the portal as well as overseeing overall direction and | 11 procedures. Each area is subdivided according to the business operations of the portal and curriculum. The level of proficiency a residency graduate is expected to SCORE council (composed of representatives from each possess. These designations serve to focus the learning of the seven member organizations) helps set the strat- experience during training. For diseases/conditions, egy and meets at least once a year. An editorial board, modules are defined as either “broad” or “focused.” composed of residency program directors and other A graduate should be able to provide comprehensive surgical educators, oversees the development of all management for all aspects of diseases classified as content for the Web portal, and works to ensure that broad. For focused diseases, a graduate should be able all content is relevant, timely, and up-to-date. Lastly, to make a diagnosis and provide initial management a resident advisory group, populated with residents and stabilization but should not be expected to provide representing a variety of program types, locations, comprehensive care. Operations/procedures topics are and sizes, advises on the delivery and type of content classified into one of three areas: essential-common, that best suits trainees’ learning needs and preferences. essential-uncommon, and complex. This combination of stakeholders, users, and education Essential-common operations are defined as “fre- experts helps to ensure that the SCORE curriculum quently performed operations in general surgery; and Web portal remain relevant, useful, and engaging. specific procedure competence is required by the end Representatives of SCORE have participated in a of training.” 4 Essential-uncommon operations are number of national presentations related to the SCORE “uncommon, often urgent operations seen in general curriculum and Web portal use, including a presenta- surgical practice but not typically done in significant tion describing the best methods to incorporate the numbers by residents; specific procedure competency many features of the portal into the defined curriculum required by end of training (but may not be obtained that drives an individual program’s learning and teach- by case volume alone).” 4 Complex operations are “not ing.6 This topic has been the subject of workshops dur- consistently performed by general surgeons in train- ing Surgical Education Week (the combined meetings ing or not typically performed in general surgery prac- of the APDS and ASE) for the past five years and has tice.”4 It is expected that residents will obtain generic been part of panel discussions during the ACS Clinical experience in complex procedures but not competence Congress on several occasions. These efforts, combined in individual procedures and that some residency pro- continued on page 13

OCT 2013 Bulletin American College of Surgeons SCORE Web-based curriculum

SCORE Organization

SCORE leadership team Mary E. Klingensmith, MD, FACS Mark J. Hickey Chair, SCORE Council Chief operating officer Mary Culver Distinguished Professor of Surgery, vice-chair for education, Kerry B. Barrett Washington University, Saint Louis, MO Content management specialist

Mark A. Malangoni, MD, FACS Associate executive director, American Board of Surgery

SCORE editorial board Cameron Akbari, MD, FACS Douglas S. Smink, MD, MPH, FACS Daniel Vargo, MD, FACS Assistant professor of surgery, Program director, general surgery Program director, general surgery division of vascular surgery, residency; associate medical director, residency; associate professor Georgetown University School of Medicine STRATUS Center for Medical Simulation, of surgery, Washington, DC Brigham and Women’s Hospital; University of Utah School of Medicine assistant professor of surgery, Salt Lake City, UT Michael Awad, MD, PhD, FACS Harvard Medical School, Program director, general surgery; Boston, MA Tina W.F. Yen, MD, MS, FACS director, surgical skills laboratory; Associate professor of surgery, assistant professor of surgery, Eric G. Van Eaton, MD, FACS division of surgical oncology, Washington University Assistant medical director for surgical Medical College of Wisconsin 12 | St. Louis, MO critical care; service director, Milwaukee, WI surgical intensive care unit; Mary E. Klingensmith, MD, FACS assistant professor of surgery, Mary Culver Distinguished Professor Division of Harborview Trauma and Burns; of Surgery, Adjunct assistant professor of biomedical Washington University informatics and medical education, St. Louis, MO division of biomedical and health informatics, Monica E. Lopez, MD, FACS, FAAP University of Washington Assistant professor of surgery and Seattle, WA pediatrics, Baylor College of Medicine Houston, TX

SCORE resident advisory group Jenny Guido, MD Richard Miskimins, MD Lin Riccio, MD University of South Florida University of New Mexico University of Virginia Tampa, FL Santa Fe, NM Charlottesville, VA

Grace Hsiung, MD Danielle Pigneri, MD Anna Royer, MD University of Texas-San Antonio Robert Packer Hospital/Guthrie Clinic University of Tennessee-Chattanooga San Antonio, TX Sayre, PA Chattanooga, TN

Ray King, MD Georgia Health Sciences University Augusta, GA

V98 No 10 Bulletin American College of Surgeons SCORE Web-based curriculum

Textbooks with chapters available on SCORE

ACS Surgery: Principles Greenfield’s Surgery: Surgical Pitfalls: Prevention and Practice, 6th edition Scientific Principles and and Management Editorial Board: Stanley W. Ashley, Practice, 5th edition Editor: Stephen R.T. Evans, MD, FACS MD, FACS, Editorial Vice-Chair; Editors: Michael W. Mullholland, Philip S. Barie, MD, FACS; William MD, FACS; Keith D. Lillemoe, MD, The ASCRS Textbook of G. Cance, MD, FACS; Gregory J. FACS; Gerard M. Doherty, MD, Colon and Rectal Surgery Jurkovich, MD, FACS; Larry R. Kaiser, FACS; Ronald V. Maier, MD, FACS; MD, FACS; William H. Pearce, MD, Editors: Bruce G. Wolff, MD, Diane M. Simeone, MD, FACS; FACS; James W. Fleshman, MD, FACS; John H. Pemberton, MD, FACS; Gilbert R. Upchurch, Jr., MD, FACS and Nathaniel J. Soper, MD, FACS FACS; David E. Beck, MD, FACS; John H. Pemberton,MD, FACS; Surgery: Basic Science and Stephen D. Wexner, MD, FACS Ethical Issues in Clinical Evidence, 2nd edition Clinical Surgery Editors: Jeffrey A. Norton, MD, The SAGES Manual: Editors: Mary H. McGrath, MD, FACS; Phillip S. Barie, MD, FACS; R. Fundamentals of Laparoscopy, MPH, FACS; Donald A. Risucci, Randal Bollinger, MD, FACS; Alfred Thoracoscopy, and GI PhD; Abraham Schwab, PhD E. Chang, MD, FACS; Stephen Lowry, Endoscopy, 2nd edition MD, FACS; Harvey I. Pass, MD, FACS; Fischer’s Mastery of Robert W. Thompson, MD, FACS Editors: Carol E.H. Scott- Surgery, 6th edition Conner, MD, FACS Editors: Josef E. Fischer, MD, Surgical Palliative Care: A Resident’s Guide The Physiologic Basis of FACS; Daniel B. Jones, MD, FACS; Surgery, 4th edition Frank B. Pomposelli, MD, FACS; Editors: Geoffrey P. Dunn, MD, Gilbert R. Upchurch, Jr., MD, FACS FACS; Robert Martensen, MD, Editors: J. Patrick O’Leary, MD, PhD; David Weissman, MD, FACP FACS; Arnold Tabuenca, MD, FACS | 13

with frequent, free webinars, have helped program Currently, approximately 650 modules on patient care, directors and residents better understand the content medical knowledge, and systems-based practice com- available on the SCORE Web portal and how to best petency are posted on the SCORE portal, and approxi- use it to optimize resident teaching and learning. mately 150 additional modules are in production. Once these remaining modules are posted, which is expected to occur by the end of 2013, the current curriculum out- Status of the SCORE portal line will be complete. The content on the SCORE Web portal is categorized into several areas, including modules, textbooks, • Textbooks. With the permission of their publishers, the videos, self-assessment questions, and supplemental Web portal features chapters from a number of major resources. This structure is intended to provide an inte- surgical textbooks to supplement the learning experi- grated, comprehensive site for both program-directed ence. Chapters are linked to specific learning modules. and self-directed learning. The list of available textbooks is shown in the box on this page. Most of the textbooks support the patient care and • Modules. A module defines a specific disease/condition medical knowledge competency areas, but two recent or operation/procedure in the curriculum outline. Each additions, Ethical Issues in Clinical Surgery and Surgical module is an originally authored subject that follows a Palliative Care: A Resident’s Guide, support professional- specific outline, ensuring consistency in the learner expe- ism and interpersonal and communication skills. Addi- rience. Within each module are defined learning objec- tional content is under development for these general tives to focus the residents’ learning and mastery of the competency areas. material, open-ended questions that residents may use to assess their knowledge of the material or that faculty • Videos. As a digital interface for learning, the SCORE may use to facilitate a didactic conference, links to chap- portal is ideal for incorporating multimedia instruc- ters from the major surgical texts, and relevant videos. tional channels. The video library available on SCORE

OCT 2013 Bulletin American College of Surgeons SCORE Web-based curriculum

Currently, approximately 650 modules on patient care, medical knowledge, and systems-based practice competency are posted on the SCORE portal, and approximately 150 additional modules are in production.

covers a broad range of topics, from minimally inva- this additional resource for self-assessment of knowl- sive operations, to operative exposures for trauma, edge, whereas residency program directors use the to endoscopy. SAGES has contributed a number of weekly schedule of topics as a method for developing excellent videos to SCORE, including the SAGES Top an annual outline for their own program-based didac- 21 Videos. The ACS has contributed videos from the tic conference schedule. Advanced Surgical Skills for Exposure in Trauma The American Society of Transplant Surgeons (ASSET) and Advanced Trauma Life Support® (ATLS®) Academic Universe is a collection of information that courses, the University of Texas-Southwestern has provides in-depth exposure to selected topics in sol- contributed a number of trauma operative videos, id organ transplantation. The Academic Universe is and a number of individuals have provided important intended to support the resident learning experience videos of other procedures to round out the catalog. during his or her transplant surgery rotations and for SCORE continues to seek additional videos for use as residents who are interested in learning more about adjuncts to instruction. these transplantations. Journal Club (an evidence-based, critical appraisal • Self-assessment questions. A feature on the Web por- of the literature) is an important part of the resident tal that has been popular with resident users is the learning experience. This resource is supported on 14 | self-assessment area, which features more than 2,000 the SCORE portal via links to the ACS Evidence-Based multiple-choice questions, covering all of the content Reviews in Surgery (EBRS) and the Annals of Surgery Jour- areas on the curriculum outline. These questions nal Club. The EBRS comprises an extensive catalog of allow trainees to assess their knowledge and focus topics, divided by either research methodology or clini- their learning, as each question is accompanied by cal category, that teaches critical appraisal skills in the a detailed explanation of the correct and incorrect context of current articles from the surgical literature. answers. In the future, these questions will be linked Methodological and clinical reviews of the articles are directly to modules for an improved navigation expe- included for each topic and can easily be used to pro- rience. vide residents with the tools to learn important skills essential to lifelong learning. The Annals of Surgery Journal Club is an interactive resource for surgery resi- Supplemental resources dents and surgeons to discuss and critically evaluate The supplemental resources area of the Web portal articles published in the journal. A guest expert selects comprises several important adjuncts to the learning an article for discussion each month, summarizes it, experience. For example, StatDx is an online decision and poses questions to the residents, who may respond support system primarily intended for radiologists. This using an interactive, online forum. extensive resource provides a written overview of a The Comprehensive Online Archived Care Heu- vast range of topics with differential diagnoses as well ristic (COACH) operated by the Columbia University as anatomic drawings and radiologic images, includ- Medical Center, New York, NY, is an online multi- ing plain films, ultrasound, and computed tomogra- media educational resource based on pretraining. It phy scan and magnetic resonance imaging examples provides users with training videos, articles, and sim- representing a broad spectrum of radiologic diagnoses ulations that are intended for resident review prior to and findings. exposure to real-life situations. COACH delivers rich, Educational tools include the ACS Surgery Weekly multimedia content including operative videos, 3-D Curriculum, which is drawn from ACS Surgery: Prin- animations, lectures, illustrations, and text that are ciples & Practice and features a short, multiple-choice ideal for both in-depth study and just-in-time learn- quiz on a selected topic each week that is indexed to ing. Popular items in this extensive learning resource the SCORE curriculum outline. Residents often use include “case cards” that residents may view for the

V98 No 10 Bulletin American College of Surgeons SCORE Web-based curriculum

COACH delivers rich, multimedia content including operative videos, 3-D animations, lectures, illustrations, and text that are ideal for both in-depth study and just-in- time learning.

pragmatic aspects of preparing for an operative case, as well as exten- References sively annotated 3-D animations of surgical anatomy. 1. Bell RH. Surgical council on resident education: A new organization devoted to graduate surgical education. J Am Coll Surg. The future of SCORE 2007;204(3):341-346. The SCORE curriculum outline has become widely accepted as an 2. Bell RH Jr, Biester TW, Tabuenca essential resource for resident education. The ABS has started to use the A, Rhodes RS, Cofer JB, Britt curriculum outline to construct questions for its examinations and to LD, Lewis FR Jr. Operative experience set expectations for evaluation. The SCORE Web portal, in particular, of residents in U.S. general surgery programs. Ann Surg. 2009;249(5):719- has enjoyed early success for delivery of educational content. Perhaps 724. as an acknowledgement of this accomplishment, educators in other 3. Schmidt CC, Risucci D, Plass J, Jones specialty areas including anesthesia, orthopaedics, otolaryngology, A, Darosa DA. Preimplementation and neurosurgery have all made inquiries regarding the feasibility of predictors of website use: Preliminary developing a similar system to support training in these fields. Pedi- findings from the SCORE portal pilot study. Am J Surg. 2011;201(1):7-15. atric surgery, vascular surgery, surgical oncology, and surgical critical 4. Surgical Council on Resident care have all begun efforts to develop and deliver curricular content Education. SCORE curriculum outline. Available at: http:// to support the learning of trainees in these fields using the existing | 15 Web platform. Through partnerships with other specialty boards and surgicalcore.org/public/curriculum. societies, SCORE is working to develop specific curricula for each of Accessed August 12, 2013. 5. Lewis FR, Klingensmith ME. Issues in these disciplines. general surgery training—2012. Ann The Web portal continues to evolve and improve with input from Surg. 2012;256(4):553-557. our organizational structure and from users. New features planned 6. Moalem J, Edhayan E, DaRosa for the portal include improved navigation to self-assessment content, DA, Valentine RJ, Szlabick more robust reporting and tracking features, and expanded content RE, Klingensmith ME, Bell RH Jr. Incorporating the SCORE curriculum to support all six of the competency areas. and web site into your residency. J Surg Controlling financial costs remains a priority for the SCORE coun- Educ. 2011;68(4):294-297. cil. To date the ABS has invested several million dollars in the SCORE curriculum project and Web portal, with the ACS, ASA, and APDS also contributing to their development. SCORE was developed to help provide more equity in curricular resources available to support resi- dency learning, and keeping subscription costs low has been a guid- ing principle. Training programs are charged a $500 enrollment fee in addition to $125 per resident per year. With significant stewardship of resources, it is anticipated that the SCORE Web portal will become self-sustaining within the next two years. The SCORE council will be performing a needs assessment to determine the feasibility of expand- ing subscriptions to the Web portal to other users. The SCORE Web portal has been widely accepted in surgical train- ing programs and has provided a resource that affords the vast majority of residents a rich, multimedia resource to support both their didactic learning as well as patient care activities. This collaborative effort of major surgical organizations, including the College, has resulted in a comprehensive and user-friendly Web portal that has become a valu- able adjunct to resident learning and patient care. 

OCT 2013 Bulletin American College of Surgeons Chapter lobby days

Chapter lobby days forge ahead in state capitals

by Charlotte Grill and Jon Sutton

Alabama Highlights The Alabama Chapter meeting took place February 5 • Describes the purposes of the ACS Chapter in conjunction with a legislative reception sponsored Lobby Day Grant Program and identifies the by the Medical Association of the State of Alabama. chapters that have participated in the program Several members of the medical community attended the “State of the State Address” that Gov. Robert Bent- • Provides details on how chapters ley (R) delivered that day. have used the the grants The Alabama surgeons who attended the event 16 | were able to meet with several legislators, including the chairs of many important committees. During n 2010, the American College of Surgeons (ACS) these meetings they discussed funding for the state began a Chapter Lobby Day Grant Program that trauma system, workforce and professional liability Iprovides funding to chapters that intend to spon- issues, graduate surgical education, Medicaid fund- sor lobby days in their respective state capitals. Over ing, and scope of practice, among other topics. Those the course of the last three years, many chapters have meetings spurred further discussion regarding how taken advantage of the grant program in an effort surgeons could offer expert input on future legisla- to energize and engage their leadership and mem- tive efforts pertaining to health care. bers in grassroots advocacy. As of press time, 19 ACS chapters have participated in this program, includ- ing Alabama, Connecticut, Florida, Georgia, Illinois Florida and Metro Chicago, Indiana, Kansas, Maine, Massa- The Florida Chapter and the Florida Chapter Com- chusetts, Michigan, North Carolina, New York and mittee on Trauma members met in Tallahassee, FL, Brooklyn-Long Island, Northern California, Ohio, February 19–20, for 2013 Legislative Day events. The Oregon, Tennessee, and Virginia. activities began with participants and state represen- By sponsoring lobby days, chapters have laid the tatives convening at a reception. The casual setting groundwork for advancing surgical issues and effecting provided an informal opportunity for chapter leaders health system reforms at the state level through meet- to introduce themselves to legislators before lobby ings with their elected state officials. Chapter member day events at the state capital, which began with pre- visibility with state legislators helps to remind lawmak- sentations from Chris Nuland, Florida Chapter lob- ers that ACS chapters are the voice of surgery in their byist. Mr. Nuland discussed relevant state health care states, and it is anticipated that relationships forged issues and provided talking points for participants today will result in legislative successes tomorrow. to use when meeting with legislators on proposed Most chapters have wrapped up their lobby days for bills. Jon Sutton, co-author of this article, provided 2013, given that most state legislatures meet between an overview of resources that the College provides January and June. This article provides a snapshot of to chapters and of state legislation that the ACS is several 2013 lobby day activities and accomplishments. tracking across the country.

V98 No 10 Bulletin American College of Surgeons Chapter lobby days

Following the presentations, participants met with Indiana their representatives and some health committee mem- The Indiana Chapter held its third lobby day program bers during the final week of meetings before the gen- February 4, earlier in the month than in previous years, eral session began. Having the lobby day before the offering surgeons the opportunity to address a broad session provided an opportunity for the chapter to do array of legislation with lawmakers. Nearly 30 surgeons some legwork on critical legislation, including a mod- participated in the event, as well as a couple of speak- est tort reform bill that the legislature passed, which ers, including Indiana State Sen. Mike Delph (R), who limits expert witness testimony to those health care gave an informal presentation on the legislative pro- professionals in the defendant’s own specialty. A scope- cess. He stressed that surgeon attendance at the event of-practice bill also passed that allows optometrists to was very important and truly a part of their civic duty. prescribe certain pharmaceuticals but prohibits them Other speakers included Mr. Sutton, who addressed from performing surgery. the resources and programs available to Fellows through the state affairs area of the ACS Division of Advocacy and Health Policy; and Mike Rinebold, direc- Georgia tor of governmental relations for the Indiana State Med- The Georgia Society of the ACS hosted two new ical Association, who spoke about health care-related | 17 events during its lobby day program, March 20–21. legislation that is expected to affect all physicians. First, a dinner for the chairs and physician and nurse Two speakers provided updates on the Affordable members of the House and Senate Health Commit- Care Act: Seema Verma, a consultant who developed tees took place, followed the next morning by a leg- the Healthy Indiana Plan, provided an update on state islative breakfast at the state capitol. health insurance exchanges, and Greg Kiray, MD, Indi- The dinner provided an opportunity for a core ana University Health Physicians Service-Line Chief for group of surgeons and legislators to engage in many Primary Care, provided an update on the meaningful productive conversations, and thereby fostered the use provision of the law. Attendees received handouts development of personal relationships between ACS with pertinent information on bills moving through members and legislators. The Board of the Georgia the legislature. After a group discussion and brief lobby Society of the ACS was so pleased with the event training, attendees met with legislators at the Capitol. that they decided to host a dinner each night of next The measure of success was evident as two bills dis- year’s lobby day events: one for the House and one cussed in meetings were enacted. These laws pertain for the Senate. Surgeons who attended the dinner to scope of practice and end-of-life patient care. appreciated the convenience of meeting with leg- islators in the evening so that it did not affect their regular work hours, and legislators said they appre- Kansas ciated the opportunity to focus on issues important The Kansas Chapter collaborated with the Kansas to surgeons without the daily distractions that come Academy of Family Physicians to jointly sponsor a with meeting at the capitol. lobby day program on January 23. This collabora- The breakfast at the capitol the following tion allowed the chapter to capitalize on the lever- morning provided an opportunity for legislators age that the Kansas Academy of Family Physicians and their staff to connect with Georgia surgeons. has built through the presentation of lobby day pro- Especially memorable for some participants was grams over a number of years and to provide speak- the fact that the state House and Senate adopt- ers and legislators with a larger audience. Seven ed resolutions declaring March 21 to be Georgia chapter leaders attended, including the Chapter Surgeons’ Day. President and President-Elect.

OCT 2013 Bulletin American College of Surgeons Chapter lobby days

Applications for the 2014 lobby day grants were distributed to chapter presidents and executive directors and were due September 13, 2013. For additional information about the lobby day grant program, visit http://www.facs.org/ahp/chaptergrant.html.

The first portion of the day was reserved for the Ohio’s statewide trauma system. Both surgeons and chapter to meet with the executive director of the Kan- legislators noted that the dinner was a success in that sas State Board of Healing Arts, which is responsible it provided a unique opportunity to exchange ideas on for approving state licensure for appropriately quali- important issues affecting the health care system and fied health care professionals. A key issue discussed the practice of medicine in Ohio. in this meeting was the development of a system that allows out-of-state health care practitioners to have their licenses recognized in Kansas during a declared Oregon state of emergency. The executive director of the board A total of 15 surgeons participated in the Oregon Chap- agreed to initiate conversations with the governor on ter lobby day on March 11. Event speakers included Rep. this topic to ensure his continued support but cautioned Mitch Greenlick (D), chair of the House Healthcare that for the policy to receive consideration, it would Committee; Sean Kolmer, a policy advisor to Gov. John have to include certain essential components, such as a Kitzhaber, MD (D); and Bryan Boehringer, a lobbyist governor-issued declaration identifying the nature and for the Oregon Medical Association. area of the disaster; a specific time when the disaster Surgeons and their legislators discussed a number would be declared over; evidence of current licensure of important pieces of legislation and issues. One bill 18 | in their respective state; professional liability insur- that gained a lot of attention centered on disclosure and ance coverage; and no disciplinary actions on record. offer as a means of tort reform. Although the bill did Following a lunch with presentations by the Kansas not fundamentally address the claims resolution pro- Medical Society and the Kansas Academy of Family cess, it did address certain aspects of tort reform, such Physicians, attendees went to the capitol to meet with as apology and early disclosure, which could remedy their legislators and participated in committee hearings. some problems in the tort system. Community Care Organizations (CCOs)—a net- work created by state policymakers to reduce health New York care expenditures—was another topic covered dur- The New York/Brooklyn-Long Island Chapters and the ing the event. Lobby day attendees discussed how the New York Coalition of Specialty Physicians presented CCOs would actually function versus how they are their annual lobby day program on April 23. The day described in theory, including their potential impact included visits with more than 100 legislative offices on reimbursement rates—an issue on which hospitals and began with a panel discussion on key pieces of leg- and CCOs sometime disagree and which may lead to islation, such as nonphysician scope-of-practice expan- legal disputes. The lobby day ended with members sion, out-of-network reform, and various tort reform meeting with legislators at the state capitol and attend- bills that could dramatically increase liability insurance ing a Health Care Committee hearing. rates if enacted. More success anticipated Ohio As this overview demonstrates, numerous successful More than 16 members of the Ohio Chapter and the models are available for chapters to use in planning and Ohio Committee on Trauma attended a legislative din- conducting lobby days. State chapters are encouraged to ner on February 28 with six state legislators who are participate in the ACS Chapter Lobby Day Grant Pro- experts on health and human services issues. Conver- gram and develop strategic alliances to help advance sations over dinner ranged from pending legislation important state legislation. that would affect breast reconstruction mandates and To learn more about the grant program, contact Jon the use of surgical technology, to the need to reform Sutton, ACS State Affairs Manager, at [email protected]. 

V98 No 10 Bulletin American College of Surgeons St atus of the 113th Congress

Progress or retrogress? Status of the 113th Congress

by John Hedstrom, JD | 19

t press time, U.S. senators and representatives in response to the committee’s request for feedback, had left Washington, DC, for their annual maintaining that any new payment system must be Asummer recess without much to show for the based on the complementary objectives of improving first seven months of the 113th Congress. Locked in outcomes, quality, safety, and efficiency while reduc- inter- and intra-party sniping, Congress had its least ing the growth in health care spending.4 productive year since the World War II era. How- On July 31, the Energy and Commerce Commit- ever, some significant issues were moving forward tee unanimously approved a bill crafted from the and were likely to be part of an enormous end-of- proposal. The Medicare Patient Access and Quality year legislative/fiscal package. Improvement Act (MPAQIA) is bipartisan legislation that would permanently repeal the SGR and develop a new physician payment system based on health care Medicare payment professionals’ proven ability to provide high-quality In February, the Republican majority staffs of the care to patients.5,6 The introduction of this legislation U.S. House Energy and Commerce and the Ways and represents the beginning of what will likely be a long Means Committees jointly released an initial frame- process, as the House Ways and Means Committee— work for repealing the Medicare sustainable growth which has jurisdiction over revenue-related aspects of rate (SGR) formula used to calculate physician pay- Medicare—at press time was expected to take up its ment and reforming the reimbursement system (see own legislation in September, when Congress returns table, page 20).1,2 from its month-long recess. After months of back-and-forth discussions with the On the Senate side, the Finance Committee issued a College and other stakeholders, on May 28, the Energy request for feedback on several questions regarding the and Commerce Committee released its long-awaited Medicare physician payment system.7 In late May, the legislative draft proposal to reform the Medicare physi- ACS responded, with a number of recommendations cian payment system.3 The ACS submitted comments on how to reduce health care spending in the current

OCT 2013 Bulletin American College of Surgeons St atus of the 113th Congress

Framework and progress: Efforts to repeal the SGR2

Senate Finance House Energy and Commerce House Ways and Means

Committee Committee Committee

Does the committee No Yes, and legislative language Yes have a Medicare http://energycommerce.house.gov/ http://waysandmeans.house. physician payment sites/republicans.energycommerce. gov/uploadedfiles/sgr_reform_ reform proposal? house.gov/files/BILLS-113hr-PIH-SGR.pdf short_summary_2013.pdf Has the ACS testified Yes Yes Yes before the committee http://www.facs.org/ http://www.facs.org/ahp/medicare/ http://www.facs.org/ahp/ on Value-Based ahp/testimony/2012/ hoyt.513.html medicare/hoyt.513.html Update plan? opelka071112.pdf

system while improving quality and paving the way disaster are able to do so without facing concerns over for physicians to move into new payment models.8 The potential liability. Finance Committee is also expected to act on this issue The College supports these and other trauma- when the Senate returns from the summer recess. related bills under consideration because rapid medi- Over these last 10 months, Congress has repeatedly cal response in a disaster can greatly decrease loss of life sought to tap the medical community for feedback on and improve outcomes, and when disaster strikes, the numerous issues regarding the physician payment sys- needs of victims often overwhelm the services avail- tem. In written correspondence and congressional tes- able locally. The medical profession has a long history timony, the College has encouraged Congress to imple- of stepping forward to assist disaster victims. Unfor- ment the ACS Value-Based Update, a patient-centered tunately, existing legislation, namely the Volunteer model that is based on the dual goals of improving Protection Act, which was enacted in 1997 specifically quality and reducing growth in health care spending. to encourage such actions, fails to address the issue of 20 | liability protections for health care providers who cross state lines to aid disaster victims. Trauma care On May 20, the College issued a letter of support Several other priority issues for the College have gained for H.R. 984, another trauma-related bill. This legisla- traction, including many bills pertaining to trauma ser- tion would establish a National Task Force to study vices. On May 15, Sen. Roy Blunt (R-MO) introduced S. the impact of Improvised Explosive Devices (IEDs) on 961, the first bill brought before the Senate that seeks returning service personnel’s urogenital organs. Geni- to improve patient access to emergency care services tourinary trauma, or urotrauma, is a class of wounds by providing liability protection to those health care that affects the urinary tract and reproductive organs, professionals working under the Emergency Medical as well as the kidneys. These injuries are among the Treatment and Active Labor Act (EMTALA). EMTALA most common suffered by service personnel injured by mandates that a physician provide care to stabilize a IEDs and have long-lasting physical and psychological patient who presents at a hospital emergency depart- effects. U rotrauma accounts for 1 to 10 percent of all ment.9 Surgeons in emergency settings provide com- war injuries, and, unfortunately, that number is ris- plex, high-risk surgical care for severely injured patients, ing. While many physicians are working on this issue, often late at night and at the expense of their elective the effort lacks coordination and a centralized mecha- surgery schedules the following day. Unfortunately, the nism to share findings. This lack of coordination espe- high liability risk associated with providing such care cially affects victims of urotrauma as they transition is broadly acknowledged as a key factor contributing from receiving services through the U.S. Department to the growing shortage of specialists participating in of Defense to the Veteran Affairs health care system, emergency on-call panels. Rep. Charlie Dent (R-PA) where they will receive most of the treatment for these introduced the House version (H.R. 36) of this legisla- wounds for the duration of their lives. tion in January. The National Task Force created by H.R. 984 In April, Reps. Marsha Blackburn (R-TN) and Jim would better coordinate the care for the victims of Matheson (D-UT) introduced the Good Samaritan urotrauma by examining what is known about the Health Professionals Act, H.R. 1733, which would injuries and their treatment and encouraging the ensure that health professionals who would like to pro- development of a plan to address shortfalls where vide voluntary care in response to a federally declared research and care may be lacking.

V98 No 10 Bulletin American College of Surgeons St atus of the 113th Congress

Scope of practice The legislation would make common-sense reforms, The expanding scope of practice for some nonphy- including: sician clinicians continues to be of great concern to the College. In an effort to control this problem, • Creating a hardship exemption for solo practitioners Reps. Larry Bucshon, MD, FACS (R-IN), a cardio- and physicians near retirement to avoid exacerbating thoracic surgeon, and David Scott (D-GA) intro- workforce shortages duced the Truth in Healthcare Marketing Act.10 The goal of this legislation is to empower patients to • Shortening the gap between the performance period make the best health care choices for themselves and the application of the penalty and their families. This legislation would make it unlawful for any health care professional to make • Expanding options for participation in the incentive pro- deceptive statements or make misleading claims gram and improving quality measures through incor- in advertisements and marketing efforts. Addi- poration of specialty-led registries | 21 tionally, the bill calls for a study on the frequency and consequences of these disingenuous acts and • Increasing participation among rural health care pro- authorizes allocating funds to the Federal Trade viders Commission for enforcement. In introducing the bill, Representative Scott said, • Tailoring requirements to meet the specific needs of “Patients today are confused about the health care certain specialties system, especially when it comes to differentiating among the qualifications of the many types of health • Establishing an appeals process before application of care providers.” That’s why, according to Representa- penalties tive Bucshon, “It is imperative that health care con- sumers have adequate information, including the • Ensuring that those participating successfully in the education and training level of the health care profes- Medicaid incentive program are not inadvertently penal- sionals treating them, so that they are able to make ized in the Medicare program12 wise healthcare choices.”10 The College acknowledges that EHR technology has proven useful in improving patient safety as well EHR as the efficiency of health care. However, the ACS also Many surgeons and other health care professionals, maintains that the existing program should be modi- particularly those in small, community-based prac- fied to ensure its full potential is recognized without tices continue to have concerns about their ability creating an undue burden on physicians. to comply with federal mandates for implementing electronic health records (EHR). Legislation that Rep. Diane Black, RN (R-TN) reintroduced in March, the GME Electronic Health Records Improvement Act, would The ACS has continued to actively lobby on legisla- implement much-needed reforms to the Medicare and tion related to the education of the next generation Medicaid EHR Incentive Program, ensuring that small of surgeons. On March 14, Sens. Bill Nelson (D-FL), practices are better prepared to adopt EHRs.11 Charles Schumer (D-NY), and Harry Reid (D-NV),

OCT 2013 Bulletin American College of Surgeons St atus of the 113th Congress

After months of back-and-forth discussions with the College and other stakeholders, on May 28, the Energy and Commerce Committee released its long-awaited legislative draft proposal to reform the Medicare physician payment system.

the Senate Majority Leader, reintroduced the Resident eign physicians who trained in the U.S. to rural, inner Physician Shortage Reduction Act of 2013 (S. 577). The city, and other medically underserved communities. ACS supports the bill, which would address both short- Under current law, foreign physicians in the U.S. on and long-term workforce demands by increasing the J-1 visas must return to their home countries for two number of Medicare-supported graduate medical educa- years after completing residency. Under the Conrad 30 tion (GME) residency positions by roughly 15,000 over program, these physicians may receive a waiver of that the course of five years. requirement if they commit to providing three years of Reps. Joseph Crowley (D-NY) and Michael Grimm service in an underserved area. The “30” in the name (R-NY) introduced similar legislation for consideration of the program represents the maximum number of in the House, H.R. 1180.12 Under both bills, half of the physicians who can participate in each state every year. new residency slots must be used for shortage specialty Congress has reauthorized the program several times, residency programs as defined by the Health Resources and it is used in every state in the country. and Services Administration. The measure also directs S. 616 would not only remove the sunset provision the National Health Care Workforce Commission to and permanently authorize the program, but also would study the physician workforce and identify physician improve the functioning of the program and allow it specialty shortages.13 to expand to better meet the nation’s physician work- 22 | In addition, Reps. Aaron Schock (R-IL) and Allyson force needs. (The Conrad 30 program was created on Schwartz (D-PA) reintroduced the Training Tomor- a pilot basis to allow Congress to periodically evaluate row’s Doctors Today Act, H.R. 1201, which also calls for the benefit to Americans.) increasing the number of Medicare-supported residen- The bill also makes other improvements to the cy positions by 15,000 over five years. Moreover, H.R. immigration laws affecting foreign physicians outside 1201 will establish Medicare GME accountability and of the Conrad 30 program with the same goal of increas- transparency measures. More specifically, the Training ing access to medical professionals in underserved com- Tomorrow’s Doctors Today Act would direct the Sec- munities. For example, under the current Conrad 30 retary of the U.S. Department of Health and Human law, physicians may receive a National Interest Waiver Services (HHS) to implement a budget-neutral Medicare green card under the EB-2 category if they serve for indirect medical education performance adjustment pro- five years (three of which can be under the Conrad gram and to submit an annual report to Congress on 30 program) in a medically underserved area or Vet- Medicare GME payments. Furthermore, the Govern- eran Affairs facility. Moreover, the legislation would ment Accountability Office would be required to study exempt these physicians from the worldwide cap on and release a report identifying physician shortage spe- employment-based green cards. cialties along with strategies for increasing health pro- fessional workforce diversity. Medical liability The March 2013 Bulletin of the American College of Sur- Workforce issues geons is a special edition of the magazine, featuring ACS-supported legislation designed to address physi- articles drawn from discussions that occurred at the cian shortages has been reintroduced this year. The 2012 Medical Liability Reform Summit, which took Conrad State 30 and Physician Access Act (S. 616), intro- place last October at the College’s Washington Office.13 duced in March by Sens. Amy Klobuchar (D-MN), Hei- The ACS Division of Advocacy and Health Policy and di Heitkamp (D-ND), Jerry Moran (R-KS), and Susan the College’s Legislative Committee assembled expert Collins (R-ME), would expand and permanently reau- researchers, physicians, attorneys, and patient advo- thorize the Conrad 30 program. Since 1994, the Con- cates to examine various solutions to the problems asso- rad 30 program has worked to bring thousands of for- ciated with the medical liability system and how these

V98 No 10 Bulletin American College of Surgeons St atus of the 113th Congress

approaches may affect patient care and clinical References practice. Potential reforms discussed include 1. U.S. House of Representatives. Energy and Commerce Committee. alternative dispute resolution, disclosure and Available at: https://energycommerce.house.gov/press-release/energy- offer programs, health courts, and safe har- and-commerce-ways-and-means-outline-collaborative-medicare- bors. Based on the lessons learned at the sum- physician-payment-reform-effort. Accessed on August 6, 2014. 2. American College of Surgeons. The ACS Advocate. Available at: http:// mit, the ACS plans to offer new liability reform www.facs.org/ahp/news/2013/july.html. Accessed July 16, 2013. resources to the Fellows beginning this fall. 3. U.S. House of Representatives. Energy and Commerce Committee. Reform of the sustainable growth rate and Medicare payment services for physicians. Available at: http://energycommerce.house. Cancer gov/sites/republicans.energycommerce.house.gov/files/BILLS-113hr- PIH-SGR.pdf. Accessed August 16, 2013. And lastly, as a member of One Voice Against 4. American College of Surgeons. Comments to U.S. Energy and Cancer (OVAC), the ACS Commission on Can- Commerce Committee. Available at: http://www.facs.org/ahp/ cer continues to request funding for programs medicare/response-ec-wm0613.pdf. Accessed August 16, 2013. essential to the fight against cancer in the fiscal 5. Medicare Patient Access and Quality Improvement Act. Available year 2014 Labor-HHS-Education appropria- at: http://energycommerce.house.gov/press-release/committee- advances-fair-transparent-bipartisan-bill-reform-medicare-physician- tions bill. If the current cuts to existing cancer payments. Accessed August 6, 2013. research and prevention programs take effect, 6. U.S. House of Representatives. Energy and Commerce Committee | 23 the U.S. risks losing the progress made during Medicare Patient Access and Quality Improvement Act of 2013 and the past few years in cancer care, which could Federal Communications Commission Consolidated Reporting Act. cause lasting harm to cancer patients and their Available at: http://energycommerce.house.gov/markup/markup-hr- 2810-medicare-patient-access-and-quality-improvement-act-2013-and- families. Cancer research and prevention pro- hr-2844-federal. Accessed August 6, 2013. grams were also subject to sequestration— 7. U.S. Senate. Committee on Finance. Baucus, Hatch call on health spending cuts lawmakers believe are necessary care providers to pitch in and provide ideas to improve Medicare to balance the nation’s fiscal budget. Physician Payment System. Available at: http://www.finance.senate. Congress may be enacting laws at a glacial gov/newsroom/ranking/release/?id=d2cd55b2-4ba3-43ae-ab06- 71ecb96aba75. Accessed August 6, 2013. pace, but all of ACS’s priority legislative issues 8. American College of Surgeons. Comments to U.S. Senate Committee have experienced significant movement this on Finance. Available at: http://www.facs.org/ahp/medicare/ year. The College will be ready for the end of medicare-053113.pdf. Accessed August 6, 2013. the year frenzy as Congress seeks to address 9. Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act. Available at: http://www.cms.gov/ several issues at once.  Regulations-and-Guidance/Legislation/EMTALA/index.html. Accessed August 17, 2013. 10. Truth in Healthcare Marketing Act. Available at: https:// bucshon.house.gov/press-release/reps-bucshon-scott-introduce- %E2%80%9Ctruth-healthcare-marketing-act%E2%80%9D. Accessed August 6, 2013. 11. American College of Surgeons. Comments on Electronic Health Records Improvement Act. Available at: http://www.facs.org/ahp/ hit/ehr-0413.pdf. Accessed August 6, 2013. 12. Congressman Joseph Crowley. Crowley, Grimm, Nelson, Schumer, Reid reintroduce legislation to address looming doctor shortage. Available at: http://crowley.house.gov/press-release/crowley-grimm- nelson-schumer-reid-reintroduce-legislation-address-looming-doctor. Accessed August 6, 2013. 13. Bulletin of the American College of Surgeons. New approaches to liability reform: An introduction. Available at: http://bulletin.facs. org/2013/03/approaches-to-liability. Accessed August 6, 2013.

OCT 2013 Bulletin American College of Surgeons Operating room crisis management

Operating room crisis management leadership training:

24 |

Guidance for surgical team education

by Kenneth A. Lipshy, MD, FACS, and Anthony LaPorta, MD, FACS

V98 No 10 Bulletin American College of Surgeons Operating room crisis management

Highlights • Provides information on strides that the military, EMS, and other first responders have made with respect to training personnel to lead in crisis situations • Explores the myths regarding performance improvement techniques that are frequently embedded in the culture of high-risk professions, often to their detriment • Describes how the military and EMS are using a unique simulation training model to train team members in optimal crisis response

| 25

n 1924, W. Wayne Babcock, MD, FACS, raised a critical ques- tion: “How efficient a lifesaving station have you in your operat- Iing room? Is it safe for me to collapse or have respiratory or car- diac arrest while undergoing an abdominal operation under your care?”1 Nine decades later, the answer to this question still seems elusive. If one queries his or her surgical cohorts regarding their ability to lead a team through an in-operating room crisis (IORC), the typical response is a boastful rendition of exemplary leadership of teams through any crisis. However, surgeons frequently rate their own ability to lead a team higher than their teammates do.2- 4 Recognizing the limits of surgeons’ leadership skills in routine, non-threatening circumstances, it behooves surgeons to compre- hend the skills necessary for effective survival leadership. Formal orientation of surgical teams to human error as it relates to the creation or perpetuation of an IORC, as well as the systematic role in mitigating the effects of those errors, is necessary for teams to be highly functional in all circumstances. Unfortunately, the lack of this formal training is exacerbated by a progressive reduc- tion in resident operative experience combined with a self-reported decline in self-confidence.5-9 Because IORCs are rare, few health care professionals will have gained notable experience in crisis manage- ment during their career.2-4,10-12 In addition, anesthesia studies have revealed the following: past experience does not necessarily pre- vent failure; even senior surgeons make mistakes during IORCs; the signs of developing IORCs are often non-specific, resulting in a

OCT 2013 Bulletin American College of Surgeons Operating room crisis management

delay in the determination of the cause and appropriate corrective action; and during complex life-threatening crises, the team is required to rely upon cognitive task- ing far beyond the information processing capacity of the Photo 1 human brain.10,13-14

a Given that only an estimated 10 to 20 percent of the t

or population has an ability to remain calm in the midst of a P a

y L y crisis, it is important to know how maladaptive responses

h to stress arise, how to develop coping mechanisms to over- t n A ON come maladaptive behavior, and how to effectively lead a team through the risk-management process.15-16 Although past experience may not prevent a crisis from develop- ing, understanding the concepts of human error, panic control, and team leadership, combined with repetitive realistic simulation training, should improve the outcome dramatically. Other high-risk sectors, such as the U.S. military, law enforcement, the aviation industry, and even our anesthe- 26 | sia colleagues, are clearly ahead of surgery with respect to using simulation in disaster preparation. Immersion training, for example, currently in use in the U.S. mili- tary, allows for provider intervention in realistic intense Immersion training allows for the actual intervention environments. (See Photo 1, this page.) Additional infor- at all levels of care. Here an actor is undergoing a mation on immersion training is highlighted later in this cricothyroidotomy by the first responder. article. In spite of these innovations in simulation train- ing, however, orientation to cognitive error, maladaptive responses, and rapid process decision making is actually limited in those fields as well. This article provides information on the major strides that the military, emergency medical services, and other first responders have made in training personnel to lead in crisis situations and overcome maladaptive behavior that may exacerbate these situations. The myths regard- ing performance improvement techniques that are fre- quently embedded in the culture of high-risk profes- sions—often to their detriment—are also explored in this article. And lastly, the authors describe a unique simulation training model that the military is using to prepare team members to respond to a crisis in the best possible way.

ORCM leadership training Before they can effectively respond to crisis situations in the operating room (OR), trainees must understand basic concepts in crisis evolution and perpetuation, including maladaptive behavior, as well as effective leadership.T he

V98 No 10 Bulletin American College of Surgeons Operating room crisis management

Before they can effectively respond to crisis situations in the operating room, trainees must understand basic concepts in crisis evolution and perpetuation, including maladaptive behavior, as well as effective leadership.

U.S. Department of Defense and the Department of experience in unexpected situations, typically leads to Veterans Affairs health systems have used the follow- hesitation or panic. Trained medical team members ing basic principles to educate residents and personnel should seek to minimize these maladaptive responses in OR crisis management (ORCM): to stress and threats.17,26-27 Team members must be capa- ble of rapidly accepting that the situation is no longer • Understand how IORCs evolve. On any given day, a normal, and then adapt and begin an organized risk- seemingly minor error or spontaneous, out-of-the- assessment and planning-execution process. blue event coupled with underlying systemic issues, Once these negative responses are under control, poor coping mechanisms, subsequent mistakes, and effective leadership, precise communication, risk- faulty system safety nets may evolve into an IORC. assessment, planning, and execution create a path- This trajectory exists when the event is unexpected, way to a successful outcome.17,20,28-29 potentially life-threatening, and requires time-critical, A leader who will take command of the situ- rapid decision making. Mitigating the consequences ation should be selected well in advance of a cri- requires movement away from the current trajectory. sis to avoid potential confusion and anarchy. The Effective system design combined with preemptive leader’s first responsibility is to recognize and man- team training should prevent propagation of an IORC age potential cognitive errors, including fixation to a disaster.17-20 errors, oversteering of the situation, and a loss of situational awareness. Become familiar with time-critical, rapid-process deci- • Fixation errors occur when people fail to | 27 sion-making strategies. It is important that trainees under- acknowledge a change in their environment and stand the decision-making processes surgeons use when construct a familiar mental image based on past they encounter time-critical events. Cohen and Pauley experience and fixate on it. Because they are unable have described problem-recognition and problem-solv- to discount that impression, they cannot recognize ing pathways in detail. Following an unexpected event, what is really happening in the situation at hand and according to these researchers, people subconsciously respond inappropriately.17,20 detect that a change has occurred. At this juncture either Oversteering can also complicate matters. This maladaptive or adaptive trained responses will guide indi- behavior commonly occurs when people attempt viduals either to failure or success, respectively. Adaptive to solve a new problem with an excessive amount of individuals will comprehend all is not normal and begin normally acceptable actions. For example, when peo- developing risk-analysis scenarios in their mind to seek ple find themselves lost, they frequently continue to viable alternatives.17,21-22 wander and become more lost, instead of stopping to become oriented. Stress worsens this response. • Understand how maladaptive response, effective team Loss of situational awareness occurs when the team command, and risk management affect outcomes. The is overstressed, distracted, or trapped in confirmation goal at the onset of an IORC is to successfully manage biases and, as a result, lose touch with reality.17,30 maladaptive behavior and to organize, assess, and plan. Fatigue, environmental stressors, and distraction also increase the risk for errors. In multiple studies, The road to successful navigation of a team through surgical mistakes increased significantly with simple a crisis hinges on team recognition of the stages of increases in flow disruptions, such as communication crisis evolution and their ability to rapidly command failures, equipment or technology problems, extraneous the situation. To avoid confusion under stress, many interruptions, and issues in resource accessibility.3,17,31-33 responders use the easy mnemonic STOP—Stop! Just as the leader must be selected before a crisis Think! Observe! and Plan!15,17, 23-25 develops, ground rules regarding team participation The initial stage of this process centers on gaining must be established in advance of a threat. Team par- control of maladaptive responses by stopping all activ- ticipants must understand their individual roles during ity. The fight or flight response, which most people a crisis to avert further tension and confusion.

OCT 2013 Bulletin American College of Surgeons Operating room crisis management

Basic communication processes also must be in that “ultimately, it is the surgeon who is responsible for place. Information passed to the team leader must be ensuring that the entire operative team delivers safe explicit, clear, concise, and focused. care.”36 Salas noted in 2007 that although medical team Effective organizations practice and maintain order- training was in wide use, if physicians did not believe ly processes for risk-assessment, planning, and action. that teamwork was a critical element in the elimina- Principles that can be applied in developing these pro- tion of avoidable medical error, creating effective teams cesses include defining the goal, gathering informa- would be “an uphill battle.”37,39 The attending in charge tion, prognosticating potential scenarios, creating an sets the tone for the entire health care team, and there- action plan, executing the strategy, and reassessing fore, must serve as the champion of IORC team training the results.17,26 and its potential benefits.37 Changing a culture to one After any crisis, debriefing is critical. Team mem- of continued vigilance requires cooperation through- bers should review the positive and negative aspects out an institution, including administrative, medical, of care provided during the IORC and seek to answer and support staff. three important questions: How did this happen? How did we respond? And what other solutions might • I am able to lead any team through any crisis without have been used?17,34 concern. During a post-incident evaluation, a pilot once stated, “We have to anticipate the worst case scenario. We are not just up there to press a button and trust in 28 | Common myths the wonders of modern technology. We have to be ready Unfortunately, many institutions are still misinformed for this eventuality.”38 Until surgeons recognize that about the benefits of crisis training and the establish- preparation for these rare, worst-case events is essen- ment of protocols to guide team behavior. Following tial, continued mishaps and disastrous outcomes will are some of the myths that inhibit the use and adop- occur. There is minimal evidence in the literature that tion of these techniques, many of which are deeply the field of surgery has caught up to other high-risk ingrained in the surgical culture: fields with respect to crisis management. Overconfi- dence and a belief that these events are too rare to be • Team training and OR checklists have never been prov- of concern could have disastrous consequences when en to provide substantial benefit.T hat’s what the “top an IORC arises.2-4 guns” in aviation used to believe in the 1970s, but stud- ies conducted by the aviation industry and the U.S. • We don’t let OR crises affect us. Adverse events cre- Coast Guard have shown otherwise. In fact, several ate distraction and stress for the surgeon and team decades later, aviation and military leaders have not members. A 2008 survey of ACS Fellows showed that only come to accept standardization of cockpit man- 8.9 percent of respondents committed a medical error agement training (CMT), but are at the forefront of within three months of completing the survey; lapses implementing these procedures in their institutions. in judgment, fatigue, lack of concentration, and other Surgical team leaders inevitably will have to accept the distractions contributed to these mistakes; and medi- proven benefits of CMT to the patients and the surgical cal errors and subsequent stress often led to burnout, team.35 As the military has demonstrated, new tech- alcoholism, and suicidal ideation. Errors inevitably nology will change surgical training, and acceptance increase stress and strain, create more distraction, and of OR “cockpit” training will follow suit (see related lead to more mishaps. Persistent stress and strain in story, page 64). an individual who is inadequately equipped to tolerate those forces does affect theO R team and institutions • Training needs to be run and maintained by organi- as a whole—often to the detriment of their function- zational leadership—not by the surgeons. Former ality and reputation.39-41 American College of Surgeons (ACS) Executive Direc- tor Thomas R. Russell, MD, FACS, reminded us in 2006 continued on page 30

V98 No 10 Bulletin American College of Surgeons Operating room crisis management

Photos 2a–2E. Live immersion scenario a t or P a y L y a t on or h P t a n A y L y h t n A ON

A and B show an actor preparing for the scenario A B wearing a cut-suit. a a t t or or P P a a | 29 y L y y L y on on h h t t n n A A

C D C and D show the actor placed in the center of a disaster scenario. The realism of the battle scene is fortified through accurate location replication and visual, auditory, and olfactory input, including gunfire and explosions. a t or P a y L y on h t n A

E shows the actor (now a live “victim”) wearing the suit that includes movie- grade internal organs that are exposed by skin that must be accessed using appropriate skin incisions. E

OCT 2013 Bulletin American College of Surgeons Operating room crisis management a t or P a y L y h t n A ON

Photo 3. Simulation training in operative management commanded by Navy CDR Tuan Hoang MD, FACS, while on board ship.

References The time has come for surgeons to set aside these 1. Babcock W. Resuscitation during anesthesia. Anesth Analg. myths and misconceptions so that the proper proto- 1924;3:208-213. Available at: http://www.anesthesia- cols are in place to handle any problem in the OR— analgesia.org/content/3/6/208.full.pdf. Accessed August no matter how big. 12, 2013. 30 | 2. Arora S, Sevdalis N, Nestel D, Tierney T, Woloshynowych M, Kneebone R. Managing intraoperative stress: What do surgeons want from a crisis training program? Am J Effective ORCM training through simulation Surg. 2009;197:537–543. More than a decade ago, it was discovered that col- 3. Wiegmann DA, ElBardissi AW, Dearani JA, Daly lateral damage caused by military personnel and RC, Sundt TM III. Disruptions in surgical flow and their relationship to surgical errors: An exploratory first responders was sometimes worse than the situ- investigation. Surgery. 2007;142(5):658-665. ation to which they were responding. This inabil- 4. Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, ity to respond appropriately and avoid further harm Millman EA, Rowen L, Pronovost PJ. Operating room was a consequence of training that was frequently teamwork among physicians and nurses: Teamwork in the not life-like and therefore did not simulate the same eye of the beholder. J Am Coll Surg. 2006;202(5):746-752. 5. Sakran J, Kaarfarani H, Mouawad N, Santry H. When epinephrine-surging environment encountered in a things go wrong. Bull Am Coll Surg. 2011;96(8):13-15. real-world event. Poor knowledge of cognitive errors 6. Chung RS, Ahmed N. The impact of minimally invasive led to mishaps attributed to individual ignorance or surgery on residents’ open operative experience: Analysis lack of adherence to known protocols. Soon thereafter of two decades of national data. Ann Surg. 2010;251(2):205- the face of crisis training would change and evolve.42 212. 7. Markelov A, Sakharpe A, Kohli H, Livert D. Local and To understand how to correct the problems with national trends in general surgery residents’ operative ORCM, surgeons must understand the basis of the experience: Do work hour limitations negatively affect case mistakes just after such an event has occurred. Only volume in small community-based programs? Am Surg. recently have live, interactive immersion train- 2011;77(12):1675-1680. ing, team training, and technical training advanced 8. Yeo H, Viola K, Berg D, Lin Z, Nunez-Smith M, Cammann C, Bell RH Jr, Sosa JA, Krumholz HM, Curry enough to be effective. Approximately 20 years ago, LA. Attitudes, training experiences, and professional the groundbreaking work of U.S Navy consultant expectations of U.S. general surgery residents: A national Bruce Siddle helped demonstrate that the immedi- survey. JAMA. 2009;302(12):1301-1308. ate stress response to any crisis includes a loss of fine 9. Pugh CM, DaRosa DA, Bell RH. Residents’ self-reporting motor skills, amnesia, inability to listen effectively, and learning needs for intraoperative knowledge: Are we missing the bar? Am J Surg. 2010;199(4):562-565. tunnel vision. He was able to correlate the immedi- ate effect of the mistakes made during the immediate continued on next page response phase to the eventual outcome of events.42

V98 No 10 Bulletin American College of Surgeons Operating room crisis management

PHOTOS 4A–4B. Physician Immersion training including needle thoracentesis and hemorrhage control on live victims in Cut Suit Trainer® during retraining on location at the Birds of Prey downhill ski course. a a t t or or P P a a y L y y L y h h t t n n A ON A ON

A B References (continued) Replication of a major femoral artery laceration in true Replication of a fatal ski accident requiring needle decompression conditions. In freezing conditions, providers learn to on the ski slope. Simulation scenarios are now preventing what in control potentially fatal hemorrhage. the past would have been fatal events.

Based on Mr. Siddle’s findings, the U.S. Marine References (continued) Corps developed immersion training rooted in the 10. Runciman WB, Merry AF. Crises in clinical care: theory of stress inoculation. Stress inoculation involves An approach to management. Qual Saf Health Care. training that puts the subject’s visual, auditory, olfac- 2005;14(3):156-163. 11. Wiggins-Dohlvik K, Stewart RM, Babbitt RJ, Gelfond J, tory, and tactile sensations in the actual environment Zarzabal LA, Willis RE. Surgeons’ performance during | 31 and under real-world conditions. This training, now critical situations: Competence, confidence, and composure. trademarked as Hyper-Realistic Training, has been Am J Surg. 2009;198(6):817-823. developed by U.S. Marines and the U.S. Navy with 12. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient the assistance of Strategic Operations, Inc., which is Performance in an Age of Uncertainty. San Francisco CA: John Wiley; 2007. a part of Stu Segall Productions, a large independent 13. Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, television and movie studios. Now a mandatory course Barker L. The Australian incident monitoring study: Crisis for medical personnel in both branches of the mili- management—validation of an algorithm by analysis of 2000 tary, more than 1,000 health care practitioners—from incident reports. Anaesth Intensive Care. 1993;21(5):579-592. corpsmen and women to surgeons—have participated 14. Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ, Runciman WB. The Australian incident in Hyper-Realistic Training. monitoring study: An analysis of 2000 incident reports. This training system, developed over the last 10 Anaesth Intensive Care. 1993;21:520-528. years, now includes a unique simulation device to 15. Gonzales L. Deep Survival: Who Lives, Who Dies and Why. train health care professionals in team management New York, NY: WW Norton; 2003. and open surgical management. This instrument, 16. The survival list: 101 skills guaranteed to get you out of trouble fast. Backpacker. 2006;34(244):45-53. known as the “cut suit,” allows trainees to develop 17. Lipshy KA. Crisis Management Leadership in the Operating skills needed for major hemorrhage control and to Room: Have You Prepared Your Team to Handle Any Crisis They perform open laparotomy, open thoracotomy, cri- Might Encounter in the OR, or Are They Destined to Fail? San cothyroidotomy needle decompression, and closed Diego, CA: Creative Team Publishing; 2013. thoracostomy (see Photos 2A–E, page 29). The suit is 18. Seeger MW, Sellnow TL, Ulmer RR. Communication, Organization, and Crisis. Communication Yearbook. Thousand worn by a human actor, thereby accurately simulating Oaks, CA: Sage; 1998. the real-life stress involved in a major crisis. 19. Venette SJ. Risk Communication in a High Reliability This type of training had proven successful in Organization: APHIS PPQ’s Inclusion of Risk in Decision Making operative management and training of the fleet sur- [dissertation]. Fargo, North Dakota: North Dakota State gical team led by U.S. Navy Commander Tuan Hoang, University of Agriculture and Applied Science; 2003. 20. Gaba DM, Fish KJ, Howard SK. Crisis Management in MD, FACS, both on ship and with a Marine ground Anesthesiology. New York, NY: Churchill Livingstone; 1994. force (see Photo 3, page 30).43 CDR Hoang’s crisis man- agement team scenarios initiate in the emergency continued on next page

OCT 2013 Bulletin American College of Surgeons Operating room crisis management

References (continued) department and flow to and through theO R. Par- ticipants in these simulated events showed rising 21. Pauley K, Flin R, Yule S, Youngson G. Surgeons’ 44 intraoperative decision making and risk management. Am and sustained adaptation to stress. J Surg. 2011;202(4):375-381. A second training scenario used the device to 22. Cohen I. Improving time-critical decision making in life- retrain U.S. ski team senior physicians (see Photos threatening situations: Observations and insights. Decision 4A-B, page 31), They “operated” in the cold with Analysis. 2008;5:100-110. snow and 40-mile-an-hour winds on the actual 23. Jenkins M. Panic: There’s a backcountry killer on the 45 loose. Backpacker. 2007;35(254):60-119. Birds of Prey ski course in Vail, CO. Participants 24. Survive! What to do when the you-know-what hits the were surveyed before and after the course. Pre- fan. Backpacker. 2010;38(280):71-90. training surveys revealed providers were alarm- 25. Stevenson J. Survive anywhere. Backpacker. ingly overconfident in their skill levels and under- 2006;34(244):39-43. estimated the degree of anxiety they expected to 26. Dörner D. The Logic of Failure: Recognizing and Avoiding Error in Complex Situations. Reading, MA: Perseus Books; face in similar emergent traumatic experiences. 1996. During post-training, participants acknowledged 27. Ripley A. The Unthinkable: Who Survives When Disaster that they faced more anxiety than they originally Strikes and Why. New York, NY: Three Rivers Press; 2000. 32 | anticipated, but also said they realized that in the 28. U.S. Department of Transportation. United States Coast simulation environment they could make mistakes Guard. Operational risk management. Available at: http:// www.uscg.mil/directives/ci/3000-3999/CI_3500_3.pdf. that they could not afford to make in real-life sce- Accessed August 12, 2013. narios. 29. Helmreich RL, Merritt AC. Culture at Work in Aviation and This immersion concept has been integrated into a Medicine. Aldershot, UK: Ashgate Press; 1998. four-day training course for sophomore medical stu- 30. Endsley MR, Garland DJ. Situation Awareness Analysis and dents at Rocky Vista University School of Medicine, Measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 2000. Parker, CO. This course comprises scenario simu- 31. Balch CM, Shanafelt TD, Dyrbye L, Sloan J, Russell T, lation for the emergency department and the OR. Bechamps GJ, Freischlag. Surgeon distress as calibrated Scenarios involve various surgical illnesses requiring by hours worked, and nights on call. J Am Coll Surg. students to triage patient care and perform operative 2010;211(5):609-619. procedures. This training significantly reduces stu- 32. Moorthy K, Munz Y, Dosis A, Bann S, Darzi A. The effect of stress-inducing conditions on the performance of a dents’ stress levels and boosts their self-confidence 43,46-47 laparoscopic task. Surg Endosc. 2003;17(9):1481-1484. and patient care management capabilities. 33. Feuerbacher RL, Funk K, Spight D, Diggs B, Hunter Historically, simulation training involved stable J. Realistic distractions and interruptions that impair scenarios. Although the environment itself may have simulated surgical performance by novice surgeons. Arch been harsh (as in the Birds of Prey course described Surg. 2012;147(11):1026-1030. 34. McGreevy JM, Otten TD. Briefing and debriefing in earlier in this article), the injured parties were the operating room using fighter pilot crew resource known parameters. In these situations, it is rather management. J Am Coll Surg. 2007;205(1):169-176. difficult to portray an actual unexpected, threat- 35. Diehl A. Does cockpit management training reduce ening event requiring well-timed critical decision aircrew error. ISASI forum. 1992. Available at: http:// making. Recently, Vail Valley Medical Center, CO, www.crm-devel.org/resources/paper/diehl.htm. Accessed February 10, 2013. under the direction of Barry Hamaker, MD, FACS, 36. Russell T, Jones RS. American College of Surgeons performed a simulated episode involving point-of- remains committed to patient safety. Am Surg. injury through the recovery room crisis manage- 2006;72(11):1005-1009. ment. This scenario involved a major disaster in continued on next page the OR—during this training episode a critical care patient ended up in the OR with a visiting surgeon

V98 No 10 Bulletin American College of Surgeons Operating room crisis management

only known to the medical director and who hap- References (continued) pened to be in Vail when the disaster occurred. Dur- 37. Salas E, Wilson KA, Murphy CE, King H, Baker D. What ing the emergency laparotomy, a need arose to also crew resource management training will not do for patient open the chest, posing a crisis as the team was not safety: Unless…? J Patient Saf. 2007;3(2):1-3. set up for any of these emergent procedures. The OR 38. Reason J. Managing the Risks of Organizational Accidents. staff had no prior knowledge that this event would Burlington, VT: Ashgate; 1997. happen. The simulated event evaluated team man- 39. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt agement and maladaptive behavior during an IORC. TD. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174. 40 Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Just the beginning Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J. The simulated events described in this article are just Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. the beginning for this type of immersion training 41. Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell in medicine. An actual 3-D simulated OR environ- T, Satele D, Rummans T, Swartz K, Novotny PJ, Sloan ment and software are being developed to record J, Oreskovich MR. Suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62. and replay every movement the surgeon and team | 33 makes. The growth in immersion training highlights 42. Siddle B. Sharpening the Warrior Edge. The Psychology of Science and Training. Millstadt, IL: PPCT Management Systems; 1995. the fact that intense military techniques are cur- 43. Mueller GR, Moloff AL, WedmoreI S, Schoeff JE, LaPorta AJ. rently being integrated into civilian medical training High-intensity scenario training of military medical students and are not merely a distant thought. to increase learning capacity and management of stress It behooves surgeon leaders to move this issue response. J Spec Oper Med. 2012;12(2):71-76. toward the front burner. Although IORCs are rare, 44. Hoang TN, Kang J, LaPorta AJ, Makler VI, Chalut C. Filling in the gaps of pre-deployment fleet surgical team training they are inevitable in any surgical facility, and failure using a team-centered approach. J Spec Oper Med. In press. to properly prepare the OR teams may have disas- 45. Hunt B, Wall V, LaPorta AJ, Rush R, Moloff A, Schoeff trous consequences for the patient, the surgeon, JE,Tieman M, Lea M. New methods of early surgical training the team, and the institution. With current mili- using the human worn partial task surgical simulator in tary training expertise available, it is up to surgeons scenario based stress immersion training. MEdSim Magazine. 2012;4(3):25-28. Available at: http://issuu.com/halldale/docs/ to develop this training at all major U.S. medical medsim_3_2012. Accessed August 16, 2013. centers. Ignoring the problem or anticipating these 46. Mueller G, Hunt B, Wall V, Rush R Jr, Molof A, Schoeff situations are manageable should they arise should J, Wedmore I, Schmid J, Laporta A. Intensive skills week for no longer be acceptable alternatives.  military medical students increases technical proficiency, confidence, and skills to minimize negative stress. J Spec Oper Med. 2012;12(4):45-53. 47. Chalut C, Martin A, Bostwick K, Hansen D, Low N, Editor’s note Leafblad K, LaPorta A, Moloff A. See one, do one, teach Portions of this manuscript have been excerpted from one using hyper-realistic simulation and testing in medical Crisis Management Leadership in The Operating Room: Have students. MEdSim Magazine. In press. You Prepared Your Team to Handle Any Crisis They Might Encounter In The OR, or Are They Destined to Fail? written by Kenneth A. Lipshy, co-author of this article.17 None of the opinions noted in this manuscript rep- resent the formal opinions of the U.S. Military and are expressly those of the authors.

OCT 2013 Bulletin American College of Surgeons Improving kidney care in Vietnam

Surgeons lead educational program

34 | to improve kidney care in Vietnam

by Douglas P. Slakey, MD, and Ingemar Davidson, MD, FACS

VV9898 NNoo 10 Bulletin American College of Surgeons Improving kidney care in Vietnam

This course was designed to provide local physicians and allied health care providers with the knowledge and skills necessary to improve the delivery of care to ESRD patients using a multidisciplinary approach.

Highlights he need for surgeons to help improve the availability and quality of care provided to underserved populations, es- • Describes how the authors used a pecially in developing countries, is ever-growing. When scholarship from the VEF to develop and T most surgeons think of volunteering, a surgical mission trip provide an educational course designed focused on performing a series of operations over some period to improve the care and outcomes of patients with kidney disease of time is usually what comes to mind. These surgical missions can be very important to the patients served and especially re- • Explains why this training was necessary warding to the surgeons and surgical team. The Bulletin has in Vietnam and the program’s purposes published many reports of such experiences over the years.1-5 • Presents details on how a combination Another venue for Fellows of the American College of Sur- of live lectures and interactive geons (ACS) to contribute to improving global health care is webinars, along with simulation, through education. In 2012, one of the authors, Dr. Slakey, were used to train health care received a scholarship from the Vietnam Education Foun- professionals in effective kidney care dation (VEF) to develop and provide an educational course • Considers the future of this type designed to improve the care and outcomes of patients with of training program and its kidney disease. The title of the educational project was Multi- role in global health care disciplinary Approach to Optimize the Care of Renal Patients and was designed to provide evidence-based knowledge. The | 35 course objectives were reinforced using simulation training and strategies for systems development to improve patient safety, outcomes, and cost-effectiveness of care. Human factors, com- munication, and team training were emphasized in all aspects of the course. The entire project lasted six months, from Sep- tember 2012 to March 2013. The positive reception of the course material and enthusiasm of participants exceeded expectations. This article provides details on the course design and its evo- lution, the practical applications of this approach to surgical volunteerism, its impact, and future plans.

Program development Funding for the entire project was through the VEF, an inde- pendent federal agency created by the U.S. Congress in 2000.6 The mission of the VEF is to strengthen the U.S.-Vietnam rela- tionship through educational exchanges. A board of directors composed of cabinet members, senators and representatives, Photos, opposite, left to right: and presidential appointees governs the VEF. Top row: Sunrise in Da Nang, Vietnam; teaching The individuals involved in the development of the pro- during an operation at Hue Central Hospital. gram viewed it as an opportunity to create and deliver an Middle row: Surgical intensive care unit, Hue educational program that would be durable and reproduc- University of Medicine and Pharmacy; Dr. Slakey ible. The proposal was based on the belief that surgical lead- demonstrates ultrasound guided central venous catheter placement during simulation course. ership provides a vital role in many aspects of the care of the Bottom row: Dr. Davidson demonstrates ultrasound end-stage renal disease (ESRD) patient including the obvious mapping for dialysis access surgery planning; Hue surgical considerations such as dialysis access (fistula, graft, University of Medicine and Pharmacy. peritoneal catheter) and transplantation.

OCT 2013 Bulletin American College of Surgeons Improving kidney care in Vietnam

Left to right: Professor Khanh; Prof. Tran Van Huy, MD, PhD, head of the office of science, technology, and international relations; Prof. Tran Huu Dang, MD, PhD, vice-rector of Hue University of Medicine and Pharmacy; Dr. Davidson; and Dr. Slakey.

The underlying objective of the Multidisciplinary Table 1. On-site lectures Approach to Optimize the Care of Renal Patients • ESRD treatment time line course was to provide an educational foundation to • Why a multidisciplinary team? help physicians improve the care of patients with kid- ney disease. In Vietnam the actual incidence of ESRD • Simulation for medical education is unknown but is reportedly as high as 680 per million, • Dialysis (renal replacement) for the nearly twice the rate of the U.S. Because the provision newly diagnosed ESRD patient: Patient of health care to ESRD patients often is complex and considerations, timing, measuring costly, many patients in Vietnam are unable to receive outcomes, cost, and effectiveness the treatment necessary to keep them alive. • Using human factors to improve outcomes This course was designed to provide local physi- • Checklists and patient data registries— cians and allied health care providers with the knowl- ensuring optimal patient care edge and skills necessary to improve the delivery of care to ESRD patients using a multidisciplinary 36 | • Managing the complex ESRD patient—special techniques for surgery and medicine approach. The course provided evidence-based infor- mation to enhance the understanding of methods • Simulation education—a way to improve used to treat ESRD patients and emphasized a coor- team function and patient safety dinated approach to optimizing the timing of the • Ultrasound evaluation for central various therapies and managing the surgical, phar- venous catheters and dialysis access macological, and other complications that may occur. • Best practice for placement of central Importantly, this course included information and catheters—catheter last or fistula first? training in the role of human factors in the delivery • The OR cockpit: Standardization, of care—a concept that emphasizes the importance of checklists, and communication skills the entire health care team in optimizing patient care. • Improving communication The course included both lectures and simulation when caring for patients training so that students could practice the methods and techniques discussed. Using the knowledge and • Surgery techniques: Best practices for skills taught during the course, the students should using expanded polytetrafluoroethylene be better able to provide safer, more effective health (ePTFE) grafts for dialysis care and thereby reduce medical errors and costs. As • Complex decisions in vascular a consequence, more patients will have access to the access: Interesting cases care they need. • Safety and outcomes—the OR cockpit and communication • Checklists and data—the next Course design steps in measuring outcomes Fortunately, the administration and faculty at the • Simulation sessions—what to expect Hue University of Medicine and Pharmacy, Hue, Viet- nam, were quite supportive of the program. Prof. Lee Dinh Khanh, MD, and Nguyen Vu Quoc Huy, MD, were particularly helpful in organizing the course and providing local support.

V98 No 10 Bulletin American College of Surgeons Improving kidney care in Vietnam

In addition to voice and video feed via the webcam, it was possible to have interactive educational sessions with uploaded course content that included PowerPoint slides and documents. Video could be delivered as part of the real-time lectures by sharing the host computer screen, and students could ask questions by voice or by typing their queries, allowing the presenter to respond to questions as they arose.

As previously stated, the course was divided into two basic formats—lectures and simulation sessions. Table 2. Real-time Internet lectures Lectures were conducted both on-site at Hue (17 lec- • Central access and ultrasound tures) and in real-time via the Internet (12 lectures). • Peritoneal dialysis Tables 1 and 2 (page 36 and this page) feature the titles ȖȖ How it works for all lectures offered in the course. For the on-site ȖȖ Patient evaluation lectures, the lead author, Dr. Slakey, made two trips ȖȖ Surgical considerations to Vietnam—the first was September 17–27, 2012, and • Hemodialysis (HD) the second trip was March 8–16, 2013. Co-author Dr. Davidson accompanied Dr. Slakey on the second trip. ȖȖ How does HD work? ȖȖ HD outcomes Initially, 35 students—a mix of surgeons and ȖȖ Catheter, fistula, or graft? nephrologists—were enrolled in the course. Over time, the number of physicians, medical students, and • Surgery for dialysis access ȖȖ Surgical planning, patient evaluation health care workers who took advantage of the course | 37 increased substantially. By the time the March final full- ȖȖ OR check lists ȖȖ OR cockpit concepts day course was convened more than 100 physicians and ȖȖ Consent health care workers were in attendance. The real-time Internet lectures were presented • AV fistula surgery between October 2012 and March 2013 using Adobe ȖȖ Anatomy Connect Software. Multiple users from different sites ȖȖ Techniques Ȗ Optimizing outcomes could log on simultaneously, and connection speeds Ȗ were set so that wireless connections would work well. • Managing complications of dialysis access In addition to voice and video feed via the webcam, it • Kidney transplantation was possible to have interactive educational sessions ȖȖ History with uploaded course content that included PowerPoint ȖȖ Outcomes slides and documents. Video could be delivered as part ȖȖ Creating a transplant team of the real-time lectures by sharing the host computer ȖȖ Deceased donor evaluation screen, and students could ask questions by voice or by • Kidney transplantation typing their queries, allowing the presenter to respond ȖȖ Evaluating the patient to questions as they arose. ȖȖ Evaluating a living donor It also was possible to record lectures and then post • Donor operation the file online where students could access the record- ed sessions. This Web-based access afforded students ȖȖ Deceased ȖȖ Living the opportunity to review presentations at their own pace. Also, because many of the students were physi- • Kidney transplant operation cians who sometimes had clinical duties that interfered • Immunosuppression with their ability to view the lecture live, the record- • Team training—simulation education ing feature allowed students to access lectures at any ȖȖ Communication point after they were presented. ȖȖ Leadership As part of the scholarship funding, educators at the ȖȖ Including the team Hue University of Medicine and Pharmacy were able

OCT 2013 Bulletin American College of Surgeons Improving kidney care in Vietnam

This project was a valuable educational experience for Tulane’s surgical residents and aided in peer-to-peer interaction with the medical students, residents, and physicians taking the course in Vietnam.

to upgrade the facility’s lecture room with an advanced Table 3. Simulation session topics Internet conferencing system that included a computer, • Ultrasound evaluation for central video projection capability, and wireless microphones. venous catheters and dialysis access This system allowed more than 50 Hue University of • Best practice for placement of central catheters Medicine and Pharmacy students to simultaneously view the live Internet lectures projected onto a screen • The OR cockpit: Standardization, checklists, and communication skills in the lecture room, and to ask questions using wire- less microphones. • Improving communication In accordance with the mission of the VEF, surgi- when caring for patients cal residents at Tulane University School of Medicine, • Surgery techniques: Best practices New Orleans, LA, were involved in the preparation and for using ePTFE grafts presentation of the live Internet lectures. The Tulane surgical residents acted as teaching assistants. They 38 | prepared a 20–30 minute grand rounds-style presenta- tion for each Internet lecture topic, and they also pre- sented with Dr. Slakey during the live Internet lecture. This project was a valuable educational experience for Tulane’s surgical residents and aided in peer-to-peer interaction with the medical students, residents, and physicians taking the course in Vietnam. The Tulane residents were very positive about their experience and enthusiastic about participating in future inter- national education exchange programs. Certainly, it can be anticipated that this degree of participation will encourage cooperation and educational exchanges in the years to come. Each student received one textbook titled Peritoneal Dialysis: Surgical Technique and Medical Management.8 This textbook, along with the companion DVD that illustrated surgical technique, was a valuable resource for the students.

Using simulation for training The conclusion of the course consisted of one week in Hue, March 8–16, 2013. At this point in time, the authors participated in patient clinics, in-patient rounds, and operations. This clinical activity provided an excellent opportunity to experience and discuss the realities of caring for patients with ESRD in Vietnam, and to reinforce the application of the evidence-based

V98 No 10 Bulletin American College of Surgeons Improving kidney care in Vietnam

From left: Professor Huy; Hong Van Le, MD; Dr. Slakey; Professor Dang; Professor Khanh; and Mrs. Pham Thi Hop Khanh, international program coordinator. material presented during the course. Throughout the that students were quick to apply the knowledge and course, special attention was paid to the societal, eco- skills they gained. Students were able to appreciate the nomic, and cultural factors that affect the delivery of positive influence of clear, concise, and accurate com- care to the ESRD patient in Vietnam. Incorporating on- munication on health care. The simulation sessions site clinical and educational activities into the course included practicing communication between physi- was critical to its success. cians and other health care workers as well as between March 14 was the last full day of the conference and physicians and patients. included simulation training. Table 3, page 38, lists the One of the more interesting communication prac- simulation session topics. Two device-manufacturing tice sessions involved learning how to talk to patients corporations with an interest in the ESRD patient popu- about bad news or adverse outcomes. During the sim- lation helped support the conference. SonoSite (FujiF- ulations the entire audience of students interacted ilm) professional education personnel participated and with each other and offered their opinions on the supplied a portable ultrasound machine for use dur- appropriateness of their colleagues’ communication, ing the simulation sessions. Covidien’s Vietnam busi- body language, and overall approach to the scenario. | 39 ness development manager brought peritoneal dialysis Post-simulation debriefing sessions helped to rein- devices and central venous catheters as well as instruc- force the knowledge and skills that the students had tional information and videos. Having access to these learned. devices ensured that the simulation sessions allowed The students who completed the entire course were for hands-on interactive training. given course evaluation forms. Feedback regarding the Grant funds allowed for the purchase of a central usefulness of the material presented in the course was vascular catheter-training simulator that Dr. Slakey uniformly positive. All participants stated that they brought from the U.S. and donated to the Hue Uni- would directly incorporate the knowledge and skills versity of Medicine and Pharmacy. Included with the learned into daily patient care. Notably, each student simulator were many spare parts and central venous committed to a continuing education program in which catheters to allow for continued use of the simulator they will serve as a resource to other health care pro- after the completion of the course. Simulation training fessionals. for ultrasound-guided central line placement included a checklist of steps that should be completed prior to use. This training was very popular with the physicians, Looking ahead and the facility should be able to use this simulator for Many exciting opportunities for continuing the edu- years to come. In addition to ultrasound central line cational objectives of the course are available. First, placement, the simulation sessions included practice the students were taught information and skills that with ultrasound mapping of veins for dialysis access, can be used to teach other health care professionals something most of the surgeons had only read about throughout Vietnam. At the end of the course, all of and discussed during lectures. the students expressed optimism that they would be During the simulation sessions, the students had able to train other clinicians in the techniques that can an opportunity to practice communication and health be applied to improve the care of patients with ESRD. care team training—subjects that had been presented This is a classic example of training new trainers, which and discussed in the lectures. Course participants were was a goal of the course. enthusiastic about the communication skills and team At the end of the course we discussed the potential training. Despite potential language barriers, we found for establishing a system for clinical data collection

OCT 2013 Bulletin American College of Surgeons Improving kidney care in Vietnam

All participants stated that they would directly incorporate the knowledge and skills learned into daily patient care.

and analysis to monitor outcomes of ESRD patient References treatment. This is a significant need within Viet- 1. Babakhani A, Guy SR, Falta EM, Elster EA, Jindal TR, nam, which presently lacks a centralized or consis- Jindal RM. Surgeons bring RRT to patients in Guyana. tent method for monitoring the clinical outcomes for Bull Am Coll Surg. 2013;98(6):17-27. ESRD patients. In addition, we discussed implement- 2. Savarise M, Como JJ. ACS Fellows provide surgical leadership and service in India. Bull Am Coll Surg. ing health care checklists, which would be developed 2013;98(4):30-35. using evidence-based knowledge and function as a 3. American College of Surgeons. Cruise to South America: protocol to guide the physicians and other health The College’s first international outreach effort. 1923. Bull care practitioners in providing optimal patient care. Am Coll Surg. 2012;97(11):36-48. These initiatives could be formulated into a second 4. Kim GJ, Wedderburn RV, Ibanga I. Short-term surgical missions make a difference: A life-changing case inI bi, (follow-up) VEF course. The second course would be Nigeria. Bull Am Coll Surg. 2012;97(11):31-35. designed to provide the students with the knowledge 5. Chu QD, Zibari G, Ho HS. Surgical volunteerism in and skills necessary to implement the ESRD check- Vietnam: Surgeons and educators strengthen the U.S.- list, to establish a clinical study to determine if the Vietnam relationship. Bull Am Coll Surg. 2011;96(11):12-8. checklist is effective, and to publish the results in a 6. Vietnam Education Foundation. Welcome message from the VEF executive director. Available at: http://home.vef. peer-reviewed international journal. gov/aboutus.php?mid=5. Accessed August 12, 2013. 40 | In summary, the objectives of the Multidisci- 7. Van Bui P. Dialysis in Vietnam. Perit Dial Int. plinary Approach to Optimize the Care of Renal 2007;27(4):400-404. Patients course were met and actually exceeded the 8. Davidson I, Gallieni M, Saxena R. Peritoneal Dialysis: authors’ expectations. The students were enthusias- Surgical Technique and Medical Management. Dallas, TX: DIVADI, LLC; 2012. tic about both the Internet and on-site lectures. The simulation session at the end of the course was very well-attended and provided an unparalleled oppor- tunity for the students to actively practice the most important skills they learned during the course. This opportunity has improved our understanding of health care in Vietnam and also of the global inter- est in improving health care outcomes and clinical effi- ciency. The course has provided the students with an improved understanding of how to optimize the treat- ment of patients with ESRD and how to build and train health care teams. This course will certainly have a lasting effect on the lives of many patients. Finally, the experience of developing and delivering this course has reinforced the belief that surgeons as educators have a significant impact on improving patient safety and health care outcomes. 

V98 No 10 Bulletin American College of Surgeons ACS Bulletin: March 2003

March 2003 Volume 88, Number 3

What price commitment? | 41

Centennial reprint: The College’s ongoing commitment to the quality imperative

s part of the American College of Surgeons’ treatments for trauma and cancer. They also describe yearlong Centennial celebration, the Bulletin the drivers of the public’s more recent demands for Ahas been reprinting articles centered on the is- quality improvement and public reporting of out- sues and developments that have defined the char- comes data and describes the College’s initial efforts acter and integrity of the organization for the last to bring the National Surgical Quality Improvement 100 years. To close out this series, this month’s re- Program into the private sector through what is now print from March 2003 provides details on the Col- known as ACS NSQIP®. lege’s ongoing efforts to improve quality and patient Given the ground this article covers, its publica- safety. tion here seems a fitting way to end the College’s The authors look back at the College’s earliest con- reflections on the past 100 years and to explore the tributions to quality improvement and its develop- issues and College programs that will define the ment of registries to monitor and identify effective future of surgical care. 

OCT 2013 Bulletin American College of Surgeons ACS Bulletin: MaRCH 2003

t’s difficult for many of us in practice to com- prehend the speed and intensity of the health care quality measurement and public report- The quality Iing movements. The combined pressures of in- creased expenditures, soaring medical liability pre- miums, and patients’ perceived threats of harm imperative: have created an overarching imperative to im- prove quality, control costs, and help patients be- come better health care “consumers.” Payors and New tools and expanded consumer activists are insisting that physicians and other providers become more accountable for responsibilities the quality of medical care they deliver. In response to these demands, policymakers are for surgeons seeking ways to show that access to high-quality, affordable care is possible. This year they hope to make it easier for consumers to access public qual- ity reports for nursing homes and home health care. These reports allow patients to compare per- formance measures of facilities and make educated decisions about where to seek care. However, the challenge lies in defining what works over time and when there are fewer financial resources and 42 | higher patient expectations.

A surgical tradition The College has been at the forefront of the qual- ity improvement movement since 1913, when it was founded to set patient care standards and up- hold the enduring ethical principle of “first do no harm.” Ernest A. Codman, MD, FACS, though shunned in his day for his insistence on tracking outcomes, proved that surgery could measure and police itself. Surgeons were the first clinicians to talk directly to patients about cancer treatment by options in a consumer publication, such as Ladies’ Home Journal. In 1915, the College hosted forums LaMar S. McGinnis, Jr., MD, FACS, throughout the U.S. to talk about early detection Atlanta, GA, and to identify cancer treatments that helped in- crease survival rates. Then in the late 1920s sur- and geons once again became patient advocates, insist- ing that hospitals and surgical suites meet accept- Barbara Cebuhar, able standards of care. This effort set the founda- Division of Advocacy and Health Policy tion for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Since the early 1940s Fellows have developed systems to improve our ability to monitor and identify effective treatments for cancer. Then in the late 1960s, as it became clear that early in- tervention for trauma patients within “the golden hour” meant a higher survival rate, the

28 quality

VOLUME 88, NUMBER 3, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

V98 No 10 Bulletin American College of Surgeons ACS Bulletin: March 2003

College worked to certify and train members of New expectations state networks. Ever since, the College has been Today, payors are asking the medical professions committed to tracking what worked best for care to be more forthcoming with data, measuring their and survival of the trauma patient. Fueled with performance and ultimately being held account- the data, the College has helped develop respon- able for the quality of care provided to their ben- sive, statewide networks to secure the best qual- eficiaries. Accountability means something differ- ity of trauma care for our patients at every step ent to each stakeholder. Many physicians have of the emergency response process. Our vision been surprised by the tacit challenge to their com- for the future includes further analysis and ex- mitment to providing the highest quality care. It pansion of two benchmarking tools—the Na- has become increasingly clear that few tional Cancer Data Base and the National policymakers and consumers understand the rig- Trauma Data Bank™—so that patients and cli- orous requirements for board certification or nicians can identify areas for improvement, as membership in many professional organizations. well as set best practices. Fewer still understand the rigor required and the ongoing education efforts provided by Fellowship Drivers of the movement in the College, or the scrutiny peers offer on our In the last decade, a convergence of factors has caseload and experiences during surgical services driven health care policy. In 1999, the Institute of reviews and in morbidity and mortality confer- Medicine (IOM) report, To Err Is Human: Build- ences. ing a Safer Health System, challenged the entire Instead, purchasers are reacting to the steady American health system to develop a better way climb in health care costs. Once again, they are to protect lives. Subsequent reports from the IOM looking at ways to “buy better.” Their position: and purchasers have caused a ripple effect, increas- set standards for care, remove wasted efforts and | 43 ing the cry for a more transparent quality im- cost from the system, direct patients to the known provement and public reporting system. The con- high-quality providers, and apply volume-based tinued drumbeat about “risks” that exist within purchasing theories. The expected result: better the system, coupled with increased consumer ex- quality for patients and lower costs for purchas- pectations about good outcomes, has stunned ers. While some of these principles have worked medicine and may have undermined the confi- well to improve efficiencies on the assembly line, dence that our patients have in our judgment. patient care doesn’t always lend itself to follow- What caused this shift in the patient care land- ing specific standards. Patients’ needs, conditions, scape, and what is the College doing about it? and circumstances are too varied. At the end of the last decade it became increas- The idea of measuring and reporting quality ingly clear to policymakers that previous attempts makes good sense. But defining and implement- at reform had failed. Managed care was unable, ing the “ideal” quality principles have become in- over time, to both control costs and assure qual- creasingly difficult. Medical standards and prac- ity. The statewide health plan implemented in Or- tice have become more sophisticated in less time. egon suggested that health care services and fund- The half-life or turnover of medical information ing could and should be prioritized, but that sys- and technology has compressed to four years. More tem, too, failed to control costs. patients survive longer, and in the end require These and other health care reform efforts of more expensive care. The complexity of care, the the early 1990s were frustrated by the inability to proliferation of lifesaving technology, and the scar- retrieve useful outcomes data from health care in- city of our resources come together in what seems formation technology systems designed to account to be a “value” collision course. Yet, purchasers for claims. Effective use of resources, we found, have not been forthcoming in offering to pay for depended on a more well-informed and engaged the additional data collection and analysis. Hos- patient, as well as the ability to stay current with pitals burdened with providing more than 30 per- fast-paced innovation, develop thoughtful treat- formance measures want surgery to define three ment plans, effectively manage a practice, and so or four comprehensive (and timeless) measures of on. quality to track over time. It becomes even more 29

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OCT 2013 Bulletin American College of Surgeons ACS Bulletin: MaRCH 2003

important for all the stakeholders to sit down and from the Agency for Healthcare Research and determine what will provide the highest value for Quality (AHRQ) to further validate the Depart- our society and, ultimately, what it is worth to each ment of Veterans Affairs (VA) National Surgical of us. Quality Improvement Program (NSQIP) in 14 pri- vate sector hospitals. Culling the pearls NSQIP is an exciting, risk-adjusted, surgical out- To achieve some consensus on what constitutes comes “registry” and benchmarking effort that is quality, the country’s largest purchaser of health credited with improving mortality rates by 27 per- care services, the Centers for Medicare & Medic- cent and the morbidity of cases by 47 percent in aid Services (CMS) is encouraging an informed 122 VA hospitals. This system has been at work in discussion among all the stakeholders—consum- the VA since 1996 and provides pre-, peri-, and ers, payors, health service researchers, physicians, postoperative observations of all surgical patients and other providers. and conditions for up to 30 days after a procedure.1 The National Quality Forum (NQF), a private Shukri Khuri, MD, FACS, and the many surgeons sector offshoot of the national health care reform who designed the system realized that it needed to efforts, was established to encourage that discus- provide risk- and complexity-adjusted outcomes sion of the overarching quality standards in health that could be compared to national averages. Spe- care with all perspectives at the table. NQF’s mis- cially trained registered nurses, biostatisticians, sion is to develop consensus on what medical in- and surgeons collect and analyze the data, which siders understand to be quality care and to trans- are entered into a Web-based collection and late that information to the public. The difficulty benchmarking system. The resulting sets are risk- has been in defining quality and determining what adjusted and compared with information in a da- 2 44 | sort of comparative information is useful to pa- tabase of more than 900,000 patients. tients as they select providers of elective care. Per- Once the information is processed, the surgeon haps one of the fundamental sticking points in this and the surgical service are able to compare their quality discussion has been the process of collect- observed versus actual outcomes experience (o/e) ing meaningful data, without burdening the health with the national average and comparable hospi- system any further. To some activists, bad data are tals. Additional research on the NSQIP system sug- better than no data. Based on our 90-year history gests that the national database offers us the in- of assuring quality, the College is of the contrary formation necessary to identify outliers. It also opinion that only decisions based on sound data suggests that when volume without risk adjust- are in the best interests of the patient. ment is used as an indicator of quality of care, in Many clinicians, however, have been frustrated 60 percent of the cases the patient could have been by the pressing urgency to report data that aren’t sent to a lower performing facility.3 In addition, reliable. It is not that they are unwilling to come comparison with national data sets serves to high- forward with that information, but their training light costly practices and may be used to predict and commitment, aimed at ensuring that patients the likelihood of difficulties for particular patient have accurate and meaningful data, means a dedi- profiles and procedures. cation to fully validating any procedures that will The challenge for the College and the VA was to affect their patient. So, while each of us knows show that the system worked with a non-static there is a relationship between quality, safety, and population. The three initial test sites—Virginia, cost, it has been difficult to retool the delivery sys- Kentucky, and Emory University in Atlanta, GA, tem and to get the data that will help us uncover showed that the system worked with populations wasted resources and to identify obstacles to pro- not represented in the VA.3 As part of the grant, viding the most effective therapies and systems. the College has engaged 11 additional private sec- It doesn’t have to be such a conundrum. Surgery tor centers in Michigan, Missouri (St. Louis Uni- has never lost sight of our fundamental responsi- versity and Washington Universities), Utah, bility to be the patient’s quality care advocate. In Florida, California (University of California, San addition to ongoing work in cancer and trauma, Francisco), Maryland, New York (Columbia and 30 last year the College received a $5.2 million grant Cornell Universities) and Massachusetts (Massa-

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V98 No 10 Bulletin American College of Surgeons ACS Bulletin: March 2003

chusetts General Hospital) to put NSQIP to the ate and purchase health care. CMS has been test. After one year, the investigators are pleased charged with finding meaningful standards that with the tests of the program’s risk adjustment, can be implemented within the calendar year. data collection, and benchmarking capabilities AHRQ will be releasing the National Quality in hospitals that serve a broader population than Healthcare Report this fall. The subcommittee will typically reflected in the VA systems. While pre- continue to assess, monitor, and advocate on be- liminary results will be reported this spring, half of surgeons in this arena. In the months to principal investigator Dr. Khuri and the site in- come, we hope to continue our role by convening vestigators believe that this model could provide several work groups to address the issue of what a data collection system for the entire surgical information is meaningful for surgeons to report profession. This kind of system has the prospect and for their patients to use in evaluating quality of serving, in very much the same way as the of surgical care. tumor registry program that the Commission on Despite the upheaval in health care, the College Cancer of the College coordinates with the is prepared to maintain its historical role as the American Cancer Society, as a comparative qual- patient’s quality advocate. We look forward to the ity-improvement database. The investigators, results of the NSQIP trials in these health systems. while concentrating on providing meaningful We also hope that in the months ahead, more sur- data to surgeons, understand the need to explore geons will help legislators and regulators under- how the public might use the information to stand what it will take to bridge that gap between assess the strengths of a surgical service. Na- what we know is clinically valuable and what our tional leaders in the health care measurement patients want to know about the quality of the care and public reporting arenas, as well as large they receive. health plans, are very interested in NSQIP, and For more information about the College’s con- | 45 we are currently pursuing opportunities to vali- tinuing efforts to measure quality of patient care date it further. and application of standards, please go to http:// www.facs.org/oebs/otherendeavors.html. For more A long-term situation information about the College’s work translating In the meantime, it is essential that surgeons quality measurement to policymakers, contact understand that the public reporting movement [email protected] or bcebuhar@facs. will not go away. Purchasers are demanding org. If you would like to learn more about NSQIP greater transparency of what is meaningful and and other quality of care initiatives, contact the why in health care. They want to understand the Division of Research and Optimal Patient Care or data that medical insiders consider when evaluat- Karen Richards in the Office of Evidence-Based ing care. The College’s Division of Research and Surgery, [email protected]. ⍀ Optimal patient care is committed to developing continued on page 64 promising improvement systems and expanding the use of current College data sets. Dr. McGinnis is To set a well-informed course for the measure- clinical professor of ment and reporting of quality surgical care, the surgery at Emory University Medical College will be hosting a meeting of the leadership Center in Atlanta, GA, of the Surgical Specialty Societies in March. The and is chair of the group will hear from all the stakeholders involved College’s Health Policy in this national effort and hopes to develop prin- Steering Committee ciples that will guide surgery’s efforts in the legis- Subcommittee on lative and regulatory arenas. While no bills are Quality and Patient pending in Congress, the College’s Health Policy Safety. Steering Committee’s workgroup on quality and patient safety is mindful of the intense pressure to develop report cards, as well as workable and mean- ingful standards that the public may use to evalu- 31

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OCT 2013 Bulletin American College of Surgeons ACS Bulletin: MaRCH 2003

THE QUALITY IMPERATIVE, from page 31

validated, outcome-based, risk adjusted, and peer References controlled program for the measurement and en- hancement of the quality of surgical care. Ann Surg, 1. Khuri SF: Quality, advocacy, healthcare policy, and 228:491-507, 1998. the surgeon: The Ferguson Lecture at the Thirty- 3. Fink A, Campbell D, Mentzer R, et al: Identifying eighth meeting of the Society of Thoracic Surgeons, patient preoperative risk factors and postoperative Ft. Lauderdale, FL, Jan. 28-30, 2002. Ann Thor adverse events in administrative databases: Results Surg, 74:641-694, 2002. from the Department of Veterans Affairs National 2. Khuri SF, Daley J, Henderson W, et al: The Depart- Surgical Quality Improvement Program. Ann Surg, ment of Veterans Affairs’ NSQIP: The first national, 236:344-354, 2002.

ext month in JACS 46 | NThe April issue of the Journal of the American College of Surgeons will feature:

Original Scientific Articles: •Predicting Outcomes of Hepatic Transplantation •Vapreotide and Complications after Pancreatectomy •Outcomes for Breast Conservation Therapy

Education: CME and ABS Examination Performance

Palliative Care: Symposium: Medical Futility and Withdrawal of Care

64

VOLUME 88, NUMBER 3, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

V98 No 10 Bulletin American College of Surgeons Coding and practice management corner

The complexities of coding by Jenny J. Jackson, MPH, CPC; bilateral procedures Charles D. Mabry, MD, FACS; and Mark Savarise, MD, FACS

ncorrect use of modifiers is otherwise identified in the Humana, and Cigna, require a widely recognized billing listing, bilateral procedures that the code be billed on one Ierror on Medicare claims. that are performed at the same line, the unit be listed as 1, and The plethora of guidelines session should be identified modifier 50 be appended: used by various coding rule- by adding modifier 50 to the | 47 makers, such as the Centers for appropriate five digit code.”† The Example: Medicare & Medicaid Services Healthcare Common Procedure XXXXX–50, Units = 1 (CMS), the American Medical Coding System (HCPCS) uses Association (AMA), and various modifiers TL (left) and RT As discussed previously, insurers, increases the complexity (right) instead of modifier 50. the various third-party payors of use. Furthermore, coding In addition, some CPT and have different coverage for bilateral procedures is HCPCS codes are inherently guidelines for reporting bilateral particularly challenging because bilateral by their description, procedures. For example, the it is defined in various ways. such as CPT code 50300, donor Blue Cross Blue Shield (BCBS) CMS defines a bilateral nephrectomy (including cold Association is composed of service as one in which the same preservation); from cadaver donor, multiple companies, and many procedure is performed on both unilateral or bilateral. Regardless of them have different local sides of the body during the of an individual payor’s approach coding and coverage guidelines same operative session or on to coding bilateral procedures, for bilateral procedures. For a the same day.* AMA Current such codes should never be list of local BCBS Association Procedural Terminology reported with the bilateral companies, go to www.bcbs. (CPT) indicates that “unless modifier 50 or modifiersT L and com/about-the-companies/; RT because they are inclusive bilateral procedure rules will *Centers for Medicare & Medicaid Services of the bilateral procedure. be listed under “Provider” and (CMS). Physician/nonphysician practitioners. Medicare Claims Processing Manual. Available “Guidelines and Policies.” at: http://www.cms.gov/Regulations-and- Another variation for Guidance/Guidance/Manuals/downloads/ Reporting codes that can be reporting bilateral procedures clm104c12.pdf. Accessed August 21, 2013. †All specific references to CPT (Current performed bilaterally and with modifier 50: Procedural Terminology) codes and are not otherwise identified descriptions are © 2012 American Medical Medicare and payors that follow The code is billed on two Association. All rights reserved. CPT and CodeManager are registered trademarks Medicare rules, including lines, each with 1 unit, and of the American Medical Association. United Healthcare, Aetna, one line has modifier 50:

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

Example: be listed as 1, and the RT and to identify a payor’s bilateral XXXXX, Units = 1 the LT modifiers be appended: procedures claim form policy. It XXXXX–50, Units = 1 is important to verify a payor’s Example: reporting preference to avoid XXXXX–RT, LT, Units = 1 payment denials because some Reporting codes with bilateral payors may require one- or two- in their intent or with bilateral Another variation that may line entry or the use of HCPCS written in their description be preferred by payors not listed Level II RT and LT modifiers. The code is billed on one above is billing the code on two In an age of electronic health line, the units are 1, and lines, each line with 1 unit and records, it may be unwise for modifier 50 is inappropriate one line with RT and one line providers to rely solely on and should not be appended: with LT modifiers appended: software to accurately apply modifiers by payor preference. Example: Example: As a best practice, run regular XXXXX, Units = 1 XXXXX–RT, Units = 1 payment audits to detect whether XXXXX–LT, Units = 1 bilateral procedures are being 48 | paid correctly or denied. When to apply modifiers When reporting bilateral LT and RT procedures on a single line (for In some instances, procedure example, XXXXX–50 XXXXX Important steps to take when codes do not indicate on which RT, LT), the American College all services are not performed side of the body a procedure is of Surgeons (ACS) recommends If a unilateral procedure has not performed. In those instances, doubling the fee because payors been defined by CPT or HCPCS the modifier TL or RT is used to will reimburse on the lesser of the guidelines and only a bilateral indicate the side of the body on fee submitted or payor allowable. description of a procedure exists, which a service or procedure is Additionally, for billing purposes for example, CPT code 27158, performed. Specifically, modifiers it is important to understand the osteotomy, pelvis, bilateral (eg, LT and RT should be used to payor’s rules regarding multiple congenital malformation), report identify procedures that can procedure payment reductions. the code per the descriptor be performed on contralateral We suggest watching your and with modifier 52 (reduced anatomic sites (such as bones, reimbursement closely to ensure services) when the procedure joints), paired organs (such as ears, the insurer pays 100 percent for is performed unilaterally. For eyes, nasal passages, kidneys, lungs, the first procedure and according additional information on ovaries), or extremities (such as to the payor’s multiple procedure HCPCS guidelines, visit www. arms or legs). Modifiers TL and payment formula for the second cms.gov/Medicare/Coding/ RT should be used to indicate procedure (often 50 percent). MedHCPCSGenInfo/index. that the procedure is performed Third-party payors have html?redirect=/medhcpcsgeninfo/. on only one side of the body. different policies for reporting When a procedure with Medicare and other payors bilateral procedures on the claim “unilateral or bilateral” written that follow Medicare rules as form. It may be difficult to know in the description is performed identified in the portion of this how payors expect bilateral unilaterally, then the CPT or article centered on the use of procedures to be represented HCPCS procedure code need modifier 50 require that the code on the claim form. Providers not be reported with modifier 52 be billed on one line, the unit should not wait for denials since the procedure description

V98 No 10 Bulletin American College of Surgeons Coding and practice management corner

Medicare bilateral payment indicators and rules CMS has defined certain codes as subject to the bilateral payment rule and has assigned the codes a payment indicator in the Medicare physician fee schedule. • 0-indicator: 150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because of physiology or anatomy or because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

• 1-indicator: 150 percent payment adjustment for bilateral procedures applies. If a code is billed with the bilateral modifier (for example, with RT and LT modifiers or one line, one unit, and modifier 50 appended), payment is based on 150 percent of the fee schedule amount for a single code.

• 2-indicator: 150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because these procedure codes are already bilateral.

• 3-indicator: 150 percent payment adjustment for bilateral procedures does not apply. Payment will be based on the lower of 100 percent of the fee schedule for each side or actual charges for each side. Services in this category are generally radiology procedures or other diagnostic tests that are not subject to the special payment rules for other bilateral procedures.

• 9-indicator: 150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because the concept does not apply.

already indicates that the 19303 with modifier 50 (bilateral 24D). Also enter 1 in the “Days service may be performed either procedure) in the “Procedures, or Units” field (Box 24G). In this unilaterally or bilaterally. Services, or Supplies” field (Box scenario there is no need to double 24D). In addition, double the the charge. Bill 100 percent on | 49 charge in the “Charges” field (Box each line. Clinical scenario 24F). Also enter 1 in the “Days or A 68-year-old female undergoes Units” field (Box 24G). If you have additional stereotactic needle biopsy coding questions, contact the of an area of suspicious Non-Medicare reporting variation American College of Surgeons microcalcifications in the left and The code is billed on two Coding Hotline at 800-227- right breasts that reveals ductal lines, each with 1 unit, and 7911 between 7:00 am and 4:00 carcinoma in situ. Review of the one line has modifier 50: pm Mountain time, excluding mammogram shows the areas holidays, or go to www.facs.org/ biopsied are part of an extensive • 19303, Mastectomy, simple, complete, ahp/pubs/tips/index.html.  area of suspicious calcifications Units = 1 extending over a 7-centimeter area along a ductal distribution • 19303–50, Mastectomy, simple, Editor’s note in each breast. Following review complete, Units = 1 Accurate coding is the responsibility of surgical alternatives with the of the provider. This summary is patient, and considering especially • Health Insurance Claim Form intended only to serve as a resource the patient’s breast size relative to 1500 Line 1: Enter CPT code to assist in the billing process. the extent of the calcifications, a 19303 with no modifier in the bilateral mastectomy is planned. “Procedures, Services, or Supplies” How is this scenario reported? field (Box 24D). Enter 1 in the “Days or Units” field (Box 24G). Medicare reporting • 19303–50, Mastectomy, simple, • Health Insurance Claim Form complete, Units = 1 1500 Line 2: Enter CPT code 19303 with modifier 50 (bilateral • Health Insurance Claim Form procedure) in the “Procedures, 1500 Line 1: Enter CPT code Services, or Supplies” field (Box

OCT 2013 Bulletin American College of Surgeons Dispatches from rural surgeons

Rural surgery in “The Great White North”— universal care or universal challenge? by Nadine R. Caron, MD, MPH, FRCS(C); Christine M. Kennedy; and Garth L. Warnock, MD, FACS, FRCS(C)

ealth care in Canada, for this situation further. Several the 80 percent documented by the most part, is under factors affect provision of rural the American Board of Surgery.6,7 Hprovincial rather than surgical services in Canada, Whereas some surgical federal jurisdiction. Although the including: (1) surgeon training; educators would argue that Canada Health Act has flagship (2) certification, licensing, fellowships tailor skills in a criteria and conditions, such as privileges, and credentialing; manner paralleling trends “universality” and “portability,” (3) recruitment and retention; in clinical practice and job 50 | it rests these definitions on what (4) rural surgical care delivery postings, others maintain Canadians perceive as a citizen’s models; and (5) recognition of that they have created a shift right: Health care access for all.1 a rural surgery subspecialty in perception of skills and This definition includes access within general surgery. expertise. Subspecialization to surgical services. Details of will preferentially benefit the traveling a certain distance to 80 percent of Canadians in receive this care and the specifics Training general surgeons urban centers where most, if of what that care encompasses To optimize Canadian rural not all, subspecialty-trained at each hospital never made surgery services, training surgeons will practice. Career it into the act’s fine print. programs must account goals of subspecialization may Access to timely, affordable, for certain trends that are have heightened the demand and quality surgical care is an increasingly problematic. for fellowships at the expense ongoing challenge for Canadians General surgery residency of undermining training for and this challenge is magnified curriculum has been trending future rural surgeons with a in rural communities, which toward subspecialization different set of exit competencies. are defined as locations with with subsequent pursuit of Indeed, even large urban populations of less than 10,000 postresidency fellowship hospitals demand well-rounded and/or fewer than 150 people training categorized by generalist surgeons who apply per kilometer.2 An estimated 95 anatomic association (such as this particular expertise for the percent of the Canadian land mass hepatobiliary), clinical etiology bulwark of surgical emergencies. is considered rural or remote (such as surgical oncology), a A pervasive concern is that (see Figure 1, page 51).2-5 The 20 technical approach (such as many general surgery residents percent of Canadians who call minimally invasive surgery), no longer obtain the skill set rural communities home live with or patient demographics (such that rural, “generalist” general the environmental challenges this as pediatric). More than 70 surgeons require.8-10 This situation landscape presents, in addition to percent of Canadian general is illustrated by challenges for the socioeconomic, cultural, and surgery residents pursue residents to acquire particular political factors that complicate fellowship training, similar to skill sets. For example, in Canada,

V98 No 10 Bulletin American College of Surgeons Dispatches from rural surgeons

F igure 1. Geography and population demographics of Canada

Sources: 2006 Census of Canada. Produced by the Geography Division, Statistics Canada 2007.

| 51 nonsurgeon gastroenterologists While such “off-service,” awareness and likelihood to perform a large volume of nongeneral surgery electives may tackle the unfamiliar path. The endoscopy in teaching centers, be requested, such flexibility is RCPSC has recently established which may limit surgery usually limited to junior residency a task force known as the Future residents’ access to endoscopy years when training focuses on of General Surgery in the 21st training.11 Yet, data from the core surgical principles rather Century to address gaps in Canadian Association of General than procedural competency.6 generalist surgeon training. Surgeons (CAGS) shows that This training occurs years the majority of colonoscopies before residents establish clinical in Canada, especially in rural practice, limiting transition into Certification, licensing, settings, are completed by general their rural surgery career. privileges, credentialing surgeons, necessitating advocacy/ Although graduating Although the RCPSC oversees position statements to support surgery residents have been certification of graduates from acquisition of these skills in deemed competent to perform Canada’s residency programs, surgical residency.6 Similarly, complex subspecialty procedures licensing is overseen by each although the generalist skill within a tertiary care team individual province’s College set overlaps with other surgical environment, these skills may of Physicians and Surgeons.13,14 specialties, the Royal College not transfer to a case-mix with Licensing guarantees neither of Physicians and Surgeons which they are unfamiliar, an privileges nor clinical positions. of Canada’s (RCPSC) general isolating environment with Clinical privileges are acquired surgery training requirements are no peer support, or a lifestyle at a local/regional level, and specific to general surgery and its not previously experienced.6 variations in requirements for subspecialties.12 Residents usually Exposure to the spectrum of a licenses and privileges may limit have little to no formal training rural surgeon’s skill set during portability of a rural surgeon’s in other surgical specialties. training may increase residents’ diverse skill set. Given the

OCT 2013 Bulletin American College of Surgeons Dispatches from rural surgeons

A pervasive concern is that many general surgery residents no longer obtain the skill set that rural, “generalist” general surgeons require.

shortage of surgeons willing procedures from other specialties and able to work in rural— is anticipated, the scope of general Recruitment and retention and particularly remote— surgery is at risk. With the The number of general surgeons locations, this jurisdictional subspecialization trend, turf wars in Canada and the province of barrier can wreak havoc on diversify as general surgeons with British Columbia (BC) (5.0 and issues such as locum programs fellowship training expect referral 4.0 per 100,000, respectively) or rural surgeons moving patterns to shift accordingly. If is lower than health care from province to province. this movement occurs, procedures experts estimate is necessary Fellows of the Royal College specific to the generalist general to provide adequate services of Surgeons of Canada (FRCS[C]) surgeon will shrink further, as (9.4–9.8/100,000).18-20 Health may apply for clinical privileges has historically been observed care facilities in rural Canada anywhere in Canada and with the establishment of other struggle more to both recruit subsequently establish surgical surgical specialties (personal and retain specialists. Growing practice where they are needed communication with co-author evidence demonstrates that and resources are available. In Dr. Warnock and Kenneth where residents complete their contrast, international medical A. Harris, MD, FRCS(C), medical education and surgical graduates (IMGs) undergo a more director of education for the training and where they were complex process.13 Depending RCPSC, May 13th, 2013). raised strongly predict where they 10,19,21,22 52 | on the country in which their The scope of rural surgery will choose to practice. training was conducted and may be further constrained The University of BC’s previous professional experience, by hospital and operative distributed medical school in IMGs may practice in Canada teams’ lack of capacity to deal northern BC, the Northern by repeating none, part, or with anesthetic or technology Medical Program (NMP), was all of their surgical training demands.10,17 Operative volume developed in response to this before qualifying to take the of a rural surgeon is already knowledge gained from medical Canadian examinations. If limited by the catchment education research.23 Since its they completed training at a area they serve, but these inception in 2004, the program FRCS(C)-accredited foreign additional pressures must be has graduated 160 students, 10 residency program, they may considered given the ongoing of whom chose general surgery practice before completing the volume-outcome debate and training. One aim of the NMP requisite examinations and other credentialing bodies proposing is to expose trainees to life and requirements for full provincial “numbers” of procedures rather medicine in rural and northern license, but such opportunities than competency outcomes.17 communities so as to enhance are almost exclusively in rural, Rural surgeons struggle to their interest in these professional northern, and underserviced validate the services they environments. The first class of communities. Rural Canadians provide while the push for surgical trainees with NMP roots initially benefit from these IMGs, regionalization attached to graduated in June 2013, and the but unfortunately, relatively low this complex volume-outcome potential impact on rural surgical retention rates are the typical debate looms.10 This issue is services of these and future NMP result, and once these individuals not simply about hospital and graduates is anxiously awaited. pass their examinations, the surgeon volume, but training Canadian rural surgical rest of Canada opens their and case-mix of the entire services—which is often doors fully to them.15,16 surgical health care team, associated with northern and/ The scope of rural surgery in including anesthesiologists, or remote geography—have Canada has more breadth than nurses, and other allied lifestyle implications, including depth. While a range of emergent health care professionals. environmental, social, and

V98 No 10 Bulletin American College of Surgeons Dispatches from rural surgeons

Programs for recruitment and retention of surgeons to British Columbia’s rural communities Program name* Program description Funding available† Rural Retention Program An incentive program to enhance the supply $0–$31,365/position/year and stability of physician services in rural communities Rural Continuing Medical Education Provides funding for CME to support the $0 –$7,800/year (RCME) maintenance of skills and credentials required for rural practice Recruitment Incentive Fund Provides an incentive to physicians recruited to $5,000–$20,000/position fill vacancies in rural communities Recruitment Contingency Fund Provides financial assistance to rural communities $0–$15,000/position to help with recruitment expenses when filling a vacancy is, or is expected to be, difficult Isolation Allowance Fund Assists physicians who provide services in $8,121–$104,571/community/year eligible rural communities with fewer than four physicians Northern and Isolation Travel Provides compensation to physicians traveling to Travel and lodging expenses Assistance Outreach Program rural communities to provide services “closer to reimbursed home” Travel time honorarium: $500– $1,500/physician Rural Specialist Locum Program Assists with facilitating locum coverage for rural $1,200/day specialists (regarding CME, vacation time, and so Travel honorarium (MSP): $1,000 on) Rural Education Action Plan (REAP)‡ Assists third- and fourth-year medical students $250/week Undergraduate Rural Participation pursuing rural training opportunities $800 for travel Program REAP Provides compensation for physicians training $450/week (maximum eight weeks) Undergraduate Teacher’s Stipend medical students in rural communities | 53 REAP Assists residents in training intending to practice $25,000/year bursary (maximum Specialty Training Bursary Program in rural communities two years)

*Funded by British Columbia Provincial Ministry of Health. †Funds based on degree of isolation, expected difficulty of recruitment, and number of years practicing in a rural community. Specific details are not described. ‡Funded by the British Columbia Ministry of Health and the University of British Columbia.

cultural, to name a few. such as pediatric, transplant, BC’s Northern Health Government and university and so on, with the vital balance Authority (NHA) exemplifies programs attempt to address of a supportive network for rural Canada in its vast the chronic issue of recruitment rural surgeons to maximize the geography (600,000 km2) with and retention. The table on spectrum and volume of care its population density less than this page demonstrates a list of they can provide. This support 0.5 persons/km2 (see Figure programs created over the years historically was limited to patient 1) The NHA implemented for recruitment and retention transfer requiring costly land, telehealth for consultations, of specialists in northern BC.24 water, or air transport; delayed operative preparation, and care; risks of transport; and the follow-up for patients who emotional and physical effects require a broad spectrum of Rural surgical care on patients that occur when specialty care available only in delivery models they are transferred away from regionalized and tertiary care An intuitive model that addresses their community and support centers. Telehealth ensures mounting concerns regarding the systems. A responsive delivery patients can receive care closer need for rural surgical services model requires use of innovative to home.25 Hospital and clinical is regionalization of resource- resources in telehealth and care costs in Canada are covered intense subspecialty services, electronic health records (EHRs). under the public insurance

OCT 2013 Bulletin American College of Surgeons Dispatches from rural surgeons

F igure 2. Growth and evolution of Telehealth in British Columbia’s Northern Health Authority

Figure 2a. Increase in number of video conferences and clinical applications

Education Clinical Administrative 34% 16% 40% 54% Figure 2b. Increase 34% in capacity of 14% 26% 50% 32% video conferencing 4000 + 2004 2008 2012 n = 771 n = 1578 n = 2771 n = # of video conferences per year With addition of Desktop/Laptop computers onto the Video Conferencing 186 network there will 156 be a significant 118 133 increase in 109 connection 66 70 40 42 44 opportunities 16 16 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Growth of video conferencing stations (total)

Source: Northern Health. 54 |

plan, but unless the situation support vehicles, archived Historical terminology of is classified as urgent or radiologic images, and reports. “general practice surgeon” emergent, travel costs are the Now estimated to support (GPS) is morphing into patient’s responsibility.1 The most NWT residents, these “Family Physician with telehealth network decreases EHRs and associated telehealth Enhanced Surgical Skills” travel requirements. Figure partners permit rapid access (FP-ESS), with a proposed 2 on this page demonstrates to consultative expertise from formal curriculum submitted the evolution of telehealth surgeons in referral centers to the Canadian College of in BC’s NHA with surgical and facilitate surgical decision Family Practice in September care in the development making in locations without on- 2012. Novel engagement with stage of use (personal site surgical care.26 Cost savings CAGS includes plans for a communication and Figure are significant because a $10,000 collaborative position paper 2 production: Frank Flood, (one-way) MedEvac flight for on FP-ESS, a concept often BC NHA regional manager, consultation may be supplanted skirted due to professional Telehealth, August 15, 2013). with a $150 video consultation, politics. With multiple studies Canada’s remote North often permitting patients to stay on outcomes and quality of West Territories (NWT) also safely within their community. care of GPS supporting the present vast distances across Rural surgical care in limited but important role which health professionals Canada is provided by a our FP colleagues provide must communicate. Physicians heterogeneous, passionate for rural communities, the there have enhanced on- group of physicians, including general surgery profession site and telehealth care via general surgeons and family is overdue for discussions digitized networked EHRs, physicians who perform specific with these colleagues.27-34 In which house patient databases, procedures, including, but not Canada, if general surgeons do laboratory results, decision limited to, caesarian sections.17 not play an active role in the

V98 No 10 Bulletin American College of Surgeons Dispatches from rural surgeons

Rural surgery demands a unique skill set. This reality must be addressed to ensure surgeons’ skills match their home addresses.

development, teaching, and References evaluation of the ESS field, they 1. Parliament of Canada. Canada Health 8. Puls MW. College leaders answer the will have minimized influence Act: Overview and options. Available question, “Why is rural surgery an and limited grounds on which at: http://www.parl.gc.ca/content/ important issue now?” Bull Am Coll to criticize its outcome or lop/researchpublications/944-e.htm. Surg. 2013;98(1):54-57. celebrate its success. Rural Accessed August 27, 2013. 9. Fischer JE. The impending surgeons can contribute a 2. Bollman RD, Clemenson HA. disappearance of the general surgeon. Structure and change in Canada’s JAMA. 2007;298(18):2191-2193. gold mine of knowledge that rural demography: An update to 2006. 10. Rinker CF II. Meeting the needs of textbooks seldom capture. Rural and Small Town Canada Analysis rural general surgeons: The ACS Bulletin. 2008;7(7):1-29. Subcommittee on Rural Surgery. Bull 3. How healthy are rural Canadians? Am Coll Surg. 2005;90(8):13-18. The subspecialty of An assessment of their health status 11. Reid S, George R, Warnock GL, and health determinants. Canadian Jamieson CG, Olson D, Buie D, rural surgery Institute for Health Information. Bohnen J, Lidington J. Canadian It might seem odd that “rural” 2006. Available at: https://secure. Association of General Surgeons is an accepted adjective for a cihi.ca/free_products/rural_ statement on endoscopy. Can J Surg. surgeon but is not accompanied canadians_2006_report_e.pdf. 2011;54(5):295. by the kind of fellowship Accessed August 31, 2013. 12. Royal College of Physicians and 4. Government of Canada. Statistics Surgeons. Information by Discipline. training that characterizes other Canada. 2006 Census of population. Specialty training requirements in subspecialties. Rural surgery Geography Thematic Maps. Canada general surgery. 2010. Version 1.0. | 55 demands a unique skill set. This Population Density, 2006 by Available at: http://www.royalcollege. reality must be addressed to Dissemination Area (DA). Available ca/portal/page/portal/rc/public. ensure surgeons’ skills match at: //geodepot.statcan.gc.a/2006/130 Accessed August 17, 2013. 11619/200805130120090313011619/140 13. Royal College of Physicians and their home addresses. Core 1200915140112_13011619/0405141909 Surgeons of Canada. Credentials and surgical principles are mastered 2025_2006_1401200915140112152205 routes to certification. Available at: in residency, but the specific 1822090523.pdf. Accessed September http://www.royalcollege.ca/portal/ skill set is based on the case- 1, 2013. page/portal/rc/credentials/start/ mix for which residents train, 5. Northern Health. Community routes. Accessed August 17, 2013. Health Information Portal. Northern 14. College of Physicians and Surgeons including the environment in BC Communities Map. Prepared of British Columbia. Registration and which they gain these skills by BC Stats and Northern Health, licensing. Available at: https://www. and who teaches them. March 2011. Available at: http:// cpsbc.ca/for-physicians/registration- One solution is flexible chip.northernhealth.ca/Portals/2/ licensing. Accessed August 17, 2013. general surgery residency Document%20Repository/2012%20 15. Dove N. Can international medical Updates/Northern%20Map/2011%20 graduates help solve Canada’s programs that provide trainees -%20Northern%20Map%20FAQ.pdf. shortage of rural physicians? Can J with rotations targeting Accessed September 1, 2013. Rural Med. 2009;14(3):120-123. procedural competencies within 6. Caron NR, Pinney SJ. Surgery in 16. Audas R, Ryan A, Vardy D. Where did the scope of other specialties rural Canada: Challenges and possible the doctors go? A study of retention in their senior residency years solutions. In: Wichmann MW, Caron and migration of provincially licensed NR, Borgstrom DC, Maddern G. Rural international medical graduates rather than limiting them Surgery: Challenges and Solutions for the practicing in Newfoundland and to, or targeting, subspecialty Rural Surgeon. New York: Springer- Labrador between 1995–2006. Can J rotations. Another option is to Verlag Berlin Heidelberg; 2011:7-14. Rural Med. 2009;14(1):21-24. create rural surgery fellowships, 7. Borman KR, Vick LR, Biester TW, continued on next page which would provide an Mitchell ME. Changing demographics of residents choosing fellowships: additional year of training to Long-term data from the American give surgeons exposure to the Board of Surgery. J Am Coll Surg. skills and lifestyle associated 2008;206(5):782-788. with rural practice. The

OCT 2013 Bulletin American College of Surgeons Dispatches from rural surgeons

RCPSC is giving consideration References (continued) to both options, which were 17. Centre for Rural Health Research, 26. Affleck E. The little project that discussed at a summit meeting eds. Proceedings from the Invitational grew—EMRS in the NWT. In: Future in May 2013. Rotations in rural Meeting on Rural Surgical Services. Practice. Canadian Medical Assoc. locations may also increase June 22-27, 2007. Hyatt Regency June 2010. Available at: http://www. understanding among future Hotel, Vancouver, BC. Vancouver, cma.ca/multimedia/CMA/Content_ surgeons in tertiary care BC: Centre for Rural Health Research; Images/Inside_cma/Future_ 2007. Available at: http://www.srpc. Practice/June2010/FP-June2010.pdf. centers of their rural colleagues’ ca/PDF/GPSSympProceeA.pdf. Accessed August 31, 2013. requests for patient transfer, and Accessed August 31, 2013. 27. Deutchman M, Conner P, Gobbo of the challenges facing rural, 18. Hwang H, Karimuddin AA. R, FitzSimmons R. Outcomes of remote, and northern Canada. Dividing the pie into smaller slices: A cesarean sections performed by qualitative and quantitative analysis family physicians and the training of the general surgery workforce in they received: A 15 year retrospective British Columbia, 1992–2012. BCMJ. study. J Am Board Fam Pract. Conclusion 2013;55(1):26-32. 1995;8(2):81-90. General surgery is evolving 19. Deveney K, Deatherage M, Oehling 28. Iglesias S, Bott N, Ellehoj E, Yee J, in Canada. Although the D, Hunter J. Association between Jennissen B, Bunnah T, Schopflocher established subspecialty trend dedicated rural training year and D. Outcomes of maternity care the likelihood of becoming a general services in Alberta, 1999 and 2000: is accepted, rural surgical surgeon in a small town. JAMA Surg. A population-based analysis. J Obstet 56 | care is acknowledged as a 2013; Jul 3. doi. [Epub ahead of print]. Gynaecol Can. 2005;27(9):855-863. discipline to be optimized and 20. Powell AC, McAneny D, Hirsch EF. 29. Lynch N, Thomassen H, Anderson N, preserved so that Canada’s Trends in general surgery workforce Grzybowski S. Does having cesarean surgical delivery matches data. Am J Surg. 2004;188(1):1-8. section capability make a difference to 21. Rourke JT, Incitti F, Rourke LL, a small rural maternity care service? the country’s demographics Kennard M. Keeping family Can Fam Phys. 2005;51(9):1238-1239. and geography: Yet another physicians in rural practice. Solutions 30. Kirby E. Colonoscopy procedures at a canary in the coal mine of a favoured by rural physicians and small rural hospital. Can J Rural Med. universal health care system.  family medicine residents. Can Fam 2004;9(2):89-93. Phys. 2003;49:1142-1149. 31. Edwards JK, Thomas EN. 22. Woloschuk W, Tarrant M. Do Colonoscopy in rural communities: students from rural backgrounds Can family physicians perform the Acknowledgements engage in rural family practice more procedure with safe and efficacious The authors would like to than their urban-raised peers? Med results? J Am Board Fam Pract. acknowledge F. Flood, BC Northern Educ. 2004;38(3):259-261. 2004;17(5):353-358. Health Authority Regional 23. Snadden D, Casiro O. Maldistribution 32. Iglesias S, Saunders LD, Tracy of physicians in BC: What we S, Thangisalam N, Jones L. Manager, Telehealth, for sharing are trying to do about it. BCMJ. Appendectomies in rural hospitals: his expertise in the evolving 2008;50(7):371-372. Safe whether performed by specialist Telehealth services of the NHA. 24. Rural programs: A guide to the or GP surgeons. Can Fam Physician. rural physician programs in British 2003;49(3):328-333. Columbia. Government of British 33. Iglesias S, Tepper J, Ellehoj E, Barrett Columbia. Ministry of Health. B, Hutten-Czapski P, Luong K, Pollett Available at: http://www.health.gov. W. Rural surgical services in two bc.ca/library/publications/year/2013/ Canadian provinces. Can J Rural Med. rural-guide-mar2013.pdf. Accessed 2006;11(3):207-217. July 10, 2013. 34. Caron NR, Lewis Watts DA, 25. British Columbia Ministry of Health. Webber EM. The provision of eHealth-Telehealth. Available at: emergency medical services in http://www.health.gov.bc.ca/ isolated communities. Can J Surg. ehealth/telehealth.html. Accessed 1998;41(suppl):8. August 17, 2013.

V98 No 10 Bulletin American College of Surgeons CodingA C Sa ndClinic praactl Ricees emaarnchage Promentgra cornerm

Does altering diet affect progression of prostate cancer? The MEAL study

by J. Kellogg Parsons, MD, MHS, FACS; James R. Marshall, PhD; and Heidi Nelson, MD, FACS

an modifications in dietary models of prostate cancer therapy more definitive studies, testing intake affect survival in and refocus their efforts on feasible yet robust diet-based Cmen with prostate cancer? developing viable interventions interventions capable of being Despite robust data indicating based on broad patterns of dietary implemented and sustained on that dietary constituents may practice. Epidemiological studies a larger scale, are needed.11 be substantially associated with suggest that altering nutritional the natural history of prostate intake—specifically, switching to cancer, there remains a paucity a diet that emphasizes vegetable Active surveillance for of Level I evidence on which to intake and de-emphasizes meat prostate cancer and base clinical recommendations.1 and fat intake—may inhibit dietary interventions Randomized clinical trials of prostate cancer initiation Nearly 50 percent of newly | 57 dietary supplements have failed and clinical progression.4-6 diagnosed prostate cancer to yield demonstrable benefits. Experimental studies in prostate patients in the U.S. present For example, the Selenium and cell line and animal models with localized, early stage, Vitamin E Cancer Prevention demonstrate that components of relatively indolent disease.13 A Trial (SELECT)—a randomized, cruciferous vegetables (such as substantial proportion of these placebo-controlled study of more kale, broccoli, and turnips) and patients receive unnecessarily than 34,000 men randomized to carotenoids (such as tomatoes aggressive treatment with once daily vitamin E (400 IU), and carrots) induce apoptosis surgery, radiation, or hormone- selenium (200 mcg/day), both, of prostate cancer cells, inhibit based treatments.13,14 These or placebo—showed that neither carcinogenesis, and promote therapies produce considerable vitamin E nor selenium had any the expression of cytoprotective urinary, bowel, and sexual observable benefit in preventing enzymes in prostate tissue.7-9 morbidities, and their impact incident prostate cancer. In fact, Clinical evidence supporting on prostate cancer-specific the study showed a nonsignificant these observational and or overall mortality in increased risk of prostate cancer preclinical data, however, is patients with less aggressive and diabetes for patients taking limited. Three small studies cancers is not clear.15-17 those amounts of vitamin E have evaluated diet change as a Active surveillance, which (p=0.06) and selenium (p=0.06), therapy for prostate cancer, one entails careful monitoring of respectively.2 Other studies have of which suggested a beneficial selected patients with early stage yielded similar results for selenium, effect for a vegetable-intense diet prostate cancer, may provide vitamin E, and vitamin C.2,3 in a small number of patients with a viable and safe alternative to low-stage, low-grade disease.10-12 more aggressive treatments.18,19 However, whereas this intensive Approximately 35 percent of A new approach lifestyle intervention also patients on active surveillance These disappointing observations included dietary supplements, will progress within five years, have prompted researchers to exercise, stress management, while many others will opt for reassess the prior micronutrient and support group participation, intervention even though they

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

MEAL flowchart

References do not meet the objective criteria this page, and table, page 59). 18 1. Silberstein J, Parsons JK. Current for progression. Reducing the It is the first national trial concepts in diet and prostate cancer. number of active surveillance of a nonsupplement dietary Aging Health. 2008;4(5):495-505. patients who progress or intervention for prostate cancer 2. Silberstein JL, Parsons JK. Prostate choose treatment represents and one of the first major studies cancer prevention: Concepts and clinical recommendations. Prostate an important opportunity to of an intervention targeted for Cancer Prostatic Dis. 2010;13(4):300-306. minimize treatment-associated active surveillance patients. 3. Marshall JR, Tangen CM, Sakr WA, morbidity, improve quality A total of 464 patients will be Wood DP Jr, Berry DL, Klein EA, of life, and contain health enrolled and monitored, each Lippman SM, Parnes HL, Alberts care costs among appropriate for up to two years. MEAL DS, Jarrard DF, Lee WR, Gaziano JM, Crawford ED, Ely B, Ray M, prostate cancer patients. uses the same telephone- 58 | Davis W, Minasian LM, Thompson Dietary interventions based counseling intervention IM Jr. Phase III trial of selenium to represent an opportunity to validated in the pilot study.20 prevent prostate cancer in men with potentially reduce the number Patients will be randomized to high-grade prostatic intraepithelial of prostate cancer patients who a telephone counseling program neoplasia: SWOG S9917. Cancer Prev Res (Phila). 2011;4(11):1761-1769. progress on active surveillance. to assist with their dietary 4. Sonn GA, Aronson W, Litwin MS. We have designed and change (Group A) or to receive Impact of diet on prostate cancer: A successfully pilot-tested a dietary printed materials based on U.S. review. Prostate Cancer Prostatic Dis. intervention for prostate cancer Department of Agriculture 2005;8(4):304-310. patients based on well-established recommendations (Group B). 5. Stevens VL, Rodriguez C, Pavluck 20 AL, McCullough ML, Thun MJ, Calle sociological principles. This The target daily intake for EE. Folate nutrition and prostate intervention, which involves Group A is: seven servings of cancer incidence in a large cohort of telephone-based counseling, vegetables (three cruciferous, US men. Am J Epidemiol. 2006;163:989- produced robust diet changes two tomatoes/tomato products, 996. and led to increased plasma two other vegetables); two 6. Richman EL, Carroll PR, Chan JM. Vegetable and fruit intake carotenoid levels—biomarkers servings of whole grains; two after diagnosis and risk of prostate for vegetable intake—in patients servings of fruit; and one serving cancer progression. Int J Cancer. with localized prostate cancer of beans or other legumes. 2012;131(1):201-210. on active surveillance. The primary goal of MEAL 7. Barber NJ, Zhang X, Zhu G, will be to measure disease Pramanik R, Barber JA, Martin FL, Morris JD, Muir GH. Lycopene progression defined by total inhibits DNA synthesis in primary CALGB 70807: The Men’s Eating prostate-specific antigen prostate epithelial cells in vitro and Living (MEAL) Study (PSA), PSA doubling time, and and its administration is associated The MEAL Study is a pathology on repeat prostate with a reduced prostate-specific randomized clinical trial testing biopsy. Secondary measures antigen velocity in a phase II clinical study. Prostate Cancer Prostatic Dis. the effect of a high-vegetable will include treatment 2006;9(4):407-413. diet on disease progression seeking, patient anxiety, in prostate cancer patients on health-related quality of life, continued on next page active surveillance (see figure, and tissue biomarkers.

V98 No 10 Bulletin American College of Surgeons A CS Clinical Research Program

Snclelected i usion criteria for CALGB 70807 • Biopsy-proven adenocarcinoma of the prostate, clinical stage ≤ T2a diagnosed within 24 months • < 25% of biopsy tissue cores positive for cancer • ≤ 50% of any one biopsy tissue core positive for cancer • PSA <10 ng/mL • Aged 50 to 80 years • For men ≤ 70 years, biopsy Gleason score must be ≤ 6; for men > 70 years, biopsy Gleason score must be ≤ (3 + 4) = 7 • Patients who have had prior treatment for prostate cancer by surgery, irradiation, local ablative, or androgen deprivation therapy are not eligible

Therapeutic dietary References (continued) modification would potentially 8. Brooks JD, Paton VG, Vidanes 14. Carroll PR. Early stage prostate promulgate a novel paradigm G. Potent induction of phase 2 cancer—Do we have a problem with for lower-risk prostate cancer enzymes in human prostate cells over-detection, overtreatment or by sulforaphane. Cancer Epidemiol both? J Urol. 2005;173(4):1061-1062. akin to diet alterations for Biomarkers Prev. 2001;10(9):949-954. 15. Miller DC, Sanda MG, Dunn RL, non–insulin-dependent 9. Singh AV, Xiao D, Lew KL, Dhir Montie JE, Pimentel H, Sandler HM, diabetes: medical management, R, Singh SV. Sulforaphane induces McLaughlin WP, Wei JT. Long-term without curative intent, of a caspase-mediated apoptosis in outcomes among localized prostate chronic disease state. There is cultured PC-3 human prostate cancer cancer survivors: Health-related cells and retards growth of PC-3 quality-of-life changes after radical widespread interest in diet as xenografts in vivo. Carcinogenesis. prostatectomy, external radiation, a possible factor in disease risk January 2004;25(1):83-90. and brachytherapy. J Clin Oncol. | 59 and progression. The limited 10. Spentzos D, Mantzoros C, Regan 2005;23(12):2772-2780. data available suggest that a MM, Morrissey ME, Duggan S, 16. Potosky AL, Davis WW, Hoffman diet emphasizing plant products Flickner-Garvey S, McCormick RM, Stanford JL, Stephenson RA, H, DeWolf W, Balk S, Bubley GJ. Penson DF, Harlan LC. Five-year and de-emphasizing animal Minimal effect of a low-fat/high soy outcomes after prostatectomy or products protects against diet for asymptomatic, hormonally radiotherapy for prostate cancer: The carcinogenesis and cancer naive prostate cancer patients. Clin prostate cancer outcomes study. J Natl progression. Experimental Cancer Res. 2003;9(9):3282-3287. Cancer Inst. 2004;96(18):1358-1367. consideration confirming or 11. Ornish D, Weidner G, Fair WR, 17. Albertsen PC, Hanley JA, Fine Marlin R, Pettengill EB, Raisin J. 20-year outcomes following refuting the impact of diet, CJ, Dunn-Emke S, Crutchfield L, conservative management of however, is needed. The Jacobs FN, Barnard RJ, Aronson WJ, clinically localized prostate cancer. MEAL study, which will follow McCormac P, McKnight DJ, Fein JD, JAMA. 2005;293(17):2095-2101. prostate cancer patients under Dnistrian AM, Weinstein J, Ngo TH, 18. Klotz L. Active surveillance for expectant management, will Mendell NR, Carroll PR. Intensive prostate cancer: For whom? J Clin lifestyle changes may affect the Oncol. 2005;23(32):8165-8169. provide important data on progression of prostate cancer. J Urol. 19. Warlick C, Trock BJ, Landis P, the actual, short-term impact 2005;174(3):1065-1069; discussion 9-70. Epstein JI, Carter HB. Delayed versus of the adoption of a diet that 12. Saxe GA, Major JM, Nguyen JY, immediate surgical intervention and increases vegetable intake and Freeman KM, Downs TM, Salem prostate cancer outcome. J Natl Cancer limits meat and dairy intake.  CE. Potential attenuation of disease Inst. 2006;98(5):355-357. progression in recurrent prostate 20. Parsons JK, Newman VA, Mohler JL, cancer with plant-based diet and Pierce JP, Flatt S, Marshall J. Dietary stress reduction. Integr Cancer Ther. modification in patients with prostate 2006;5(3):206-213. cancer on active surveillance: A 13. Cooperberg MR, Lubeck DP, Meng randomized, multicentre feasibility MV, Mehta SS, Carroll PR. The study. BJU Int. 2008;101(10):1227-1231. changing face of low-risk prostate cancer: Trends in clinical presentation and primary management. J Clin Oncol. 2004;22(11):2141-2149.

OCT 2013 Bulletin American College of Surgeons A look at T13 heOCT JointBUll Commission Finding new solutions to hand hygiene problems

and hygiene is an important when using a consistent and issue for improved surgical reliable measurement system, In a recent hand hygiene Hpatient outcomes in that it their rate of hand hygiene project led by the Joint helps prevent the risk of infection. compliance averaged 48 percent. Commission Center for Nonetheless, compliance with To address the endemic hand hygiene requirements is challenge of hand washing Transforming Healthcare, still a significant problem. compliance, the Joint eight U.S. hospitals and Nearly 2 million health care- Commission Center for associated infections (HAIs) are Transforming Healthcare health systems that reported every year, and one in developed a tool, which has volunteered to measure every 20 inpatients will contract demonstrated 40 percent an HAI. These infections lead to improvement in compliance by their hand hygiene rates 99,000 deaths annually and to an systematically addressing the were surprised to find that, estimated $28 to $34 billion in entire improvement process. when using a consistent additional direct medical costs. The tool leads health care HAIs are a significant public organizations to solutions and reliable measurement health issue, and their prevention that have proven effective in system, their rate of should be at the forefront of mitigating organization-specific 1-4 60 | patient safety efforts. barriers to hand hygiene, leading hand hygiene compliance to higher compliance and lower averaged 48 percent. HAI rates. The tool is available A national challenge free of charge to the 20,000 Improving hand washing among health care organizations in the health care professionals is U.S. that The Joint Commission one of the most effective ways has accredited. For a typical to prevent HAIs, yet national 200-bed hospital, implementing compliance with recommended the Targeted Solutions Tool hand hygiene guidelines is (TST) can annually prevent 130 approximately 40 percent to 50 to 140 HAIs and eight deaths percent.5 To sustain improvement and save $2.3 to $2.8 million and make a difference, a in direct medical costs. simple slogan or campaign is not enough, and demanding that health care workers try The physician champion harder probably is not the Persistent safety issues such as answer either. Comprehensive, hand hygiene compliance are systematic, and sustainable complex and multifactorial. change is the only solution. The TST is a secure, password- In a recent hand hygiene protected, Web-based application project led by the Joint that allows hand hygiene teams to Commission Center for break down the complex problem Transforming Healthcare, of guideline compliance and focus eight U.S. hospitals and health on the specific factors that affect systems that volunteered to an organization’s performance. measure their hand hygiene This targeted approach allows for rates were surprised to find that, customization and sustainability

V98 No 10 Bulletin American College of Surgeons A look at T13 heOCT JoBintUll Commission

HAIs are a significant public health issue, and their prevention should be at the forefront of patient safety efforts.

of the solutions implemented, • Targeting solutions to those References acknowledging that complex specific causes 1. Klevens RM, Edwards JR, Richards problems cannot be addressed CL, Horan T, Gaynes R, Pollock D, using a one-size-fits-all solution. • Using resources effectively and Cardo D. Estimating healthcare- associated infections in U.S. A TST hand hygiene project efficiently to improve compliance hospitals, 2002. Public Health Rep. team should include a strong 2007;122:160-166. physician champion and a project • Making washing hands a habit 2. Centers for Disease Control and leader to facilitate meetings as automatic as looking both Prevention. Healthcare-associated and help gain buy-in from ways when crossing the street or infections (HAIs). The burden. Available at:http://www.cdc. stakeholders. Project teams fastening a seat belt before driving gov/HAI/burden.html. Accessed can be expected to spend up to a car August 19, 2013. four hours a week collecting 3. Scott RD. Centers for Disease and entering compliance data, • Serving as a role model by Control and Prevention. The attending team meetings, and practicing proper hand hygiene direct medical costs of healthcare- associated infections in U.S. | 61 implementing solutions during hospitals and the benefits of the 12 weeks of the project. Team • Holding everyone accountable and prevention. 2009. Available at: members can expect to spend four responsible—physicians, nurses, http://www.cdc.gov/HAI/pdfs/ hours each month sustaining the food service staff, housekeepers, hai/Scott_CostPaper.pdf. Accessed gains achieved through the hand chaplains, technicians, and August 19, 2013. 4. Centers for Disease Control and hygiene improvement strategies. therapists Prevention. Healthcare-associated infections (HAIs). Preventing • Saving lives through the reduction healthcare-associated infections. TST hand hygiene solutions of HAIs Available at: http://www.cdc.gov/ The center’s hand hygiene HAI/prevent/prevention.html. Accessed August 19, 2013. solutions were developed T he TST directly addresses issues 5. McGuckin M, Waterman R, using Lean Six Sigma and of hand hygiene compliance. For Govednik J. Hand hygiene change management tools information on hand washing compliance rates in the United and methods that had proven methods, visit the Centers for States—A one-year multicenter effective in a variety of settings. Disease Control website at collaboration using product/ volume useage measurement and The TST was designed to be www.cdc.gov/hai/organisms/ feedback. Am J. Med Qual. 2009; self-directed and includes the cdiff/cdiff_faqs_hcp.html#a10. 29(3): 205-213. use of video tutorials, training For more information about materials, implementation the TST and hand hygiene, visit guides, change management the Joint Commission Center for tips, and data collection tools. Transforming Healthcare at www. The TST hand hygiene centerfortransforminghealthcare. solutions address: org or e-mail TST_Support@ jointcommission.org.  • Measuring the specific, high- impact causes of hand hygiene failures in a facility

OCT 2013 Bulletin American College of Surgeons NTDB13 ® OCTDATBAUPllointS

London Bridge is falling down

by Richard J. Fantus, MD, FACS

ost of us probably years later, five of the 19 bridge’s remember the nursery arches came “falling down.”† Mrhyme “London Bridge Is Falling Down” from our childhoods. Many of us probably America’s aging bridges sang it or played the game. According to the The Fix We’re In However, we probably did not For: The State of Our Nation’s Bridges The NTDB Annual Report know the origins of the rhyme. 2013, the U.S. has more than 2012 is available on the ACS Many theories exist to 600,000 bridges, with an average website as a PDF file and as explain the origin of this 18th age of 43 years.‡ Of these bridges, a PowerPoint presentation century rhyme.* The first 66,405 (11 percent) are structurally at www.ntdb.org. London Bridge spanned the deficient and require significant In addition, information River Thames in the middle of maintenance, rehabilitation, or regarding how to obtain the first century. The Romans replacement. Approximately NTDB data for more constructed it of wood and mud 260 million trips are made over at Londinium, now known as deficient bridges across the detailed study is available on the website. 62 | London. The London Bridge U.S. each day. Most bridges are referenced in the song was designed and constructed to last commissioned by Henry II 50 years before a major overhaul in the later part of the 12th or replacement. These structurally century and took more than 30 deficient bridges have an average years to complete. According to life of 65 years. In just 10 years, art historian Dan Cruickshank, one in four bridges (170,000) will once the bridge was built, it be more than 65 years old. Earlier needed to be maintained.† To this year, the Interstate 5 Bridge cover the maintenance costs, collapsed into the Skagit River in tolls were placed on people Mount Vernon, WA. An overly and ships using the bridge and tall tractor-trailer carrying a legal waterway. However, sometimes load for the interstate clipped an the money went astray. In overhead support while crossing, the late 1200s, Henry III gave and the bridge collapsed. Although some of the revenue to his wife this bridge was structurally Queen Eleanor (referred to as sufficient, its design was noted “My Fair Lady” in the rhyme), to be fracture-critical—lacking which she spent on herself. Five redundant supporting elements—a design that was common in * Carlisle R, ed. Encyclopedia of Play in bridges before the interstate Today’s Society. Vol 2. Thousand Oaks, highway system was developed.‡ CA: SAGE Publications, Inc; 2009. † The Bridges That Built London with Dan Cruickshank [video]. BBC Four; March 7, 2013. ‡ Transportation for America. The Bridge collapse injuries Fix We’re In For: The State of Our Nation’s Bridges 2013. Available at: http://t4america. To examine the occurrence of org/docs/bridgereport2013/2013Bridge bridge collapse injuries in the Report.pdf. Accessed August 4, 2013. National Trauma Data Bank®

V98 No 10 Bulletin American College of Surgeons NTDB13 ®OCT DATBAUPllointS

Hl ospita discharge status

| 63

(NTDB®) research dataset length of stay of 5.9 days, an After all, there is at least one for 2012, admissions medical intensive care unit (ICU) length London Bridge in America. records were searched using of stay of 5.4 days, an average Throughout the year, we will the International Classification injury severity score of 12, and be highlighting data through of Diseases, Ninth Revision, were on the ventilator for an brief reports in the Bulletin. The Clinical Modification (ICD-9- average of 6.7 days. Twenty- NTDB Annual Report 2012 is CM). Specifically searched was one percent went directly to the available on the ACS website as external cause of injury code operating room while another a PDF file and as a PowerPoint (E-code) E882, fall from or out 37 percent went directly to presentation at www.ntdb. of a building or other structure the ICU from the emergency org. In addition, information (balcony, bridge, building, department (see figure, this page). regarding how to obtain NTDB flagpole, tower, turret, viaduct, data for more detailed study is wall, window, fall through roof). available on the website. If you Those injured due to bridge Rehabilitation needed are interested in submitting your collapse would be included in As the infrastructure of America trauma center’s data, contact this larger group of records. The ages along with its population, Melanie L. Neal, Manager, search uncovered 10,197 records, we cannot put off to the future NTDB, at [email protected].  of which 8,937 contained a the funding and rehabilitation discharge status, including 7,080 of our bridges. We cannot wait patients discharged to home, 991 to cross that bridge when we Acknowledgement to acute care/rehab, and 652 to come to it. Millions of people Statistical support for this article skilled nursing facilities; 214 died. travel each day on bridges that has been provided by Chrystal These patients were 83 percent may be structurally unsound. Caden-Price, data analyst, NTDB. male, on average 37.7 years of Let us learn from Henry III’s age, had an average hospital mistake regarding appropriations.

OCT 2013 Bulletin American College of Surgeons News

ACS joins campaign to encourage use of surgical crisis checklists

by T. Forcht Dagi, MD, DmedSc, MPH, FACS, FAANS, FRCS(Ed), and Gerald B. Healy, MD, FACS, FRCS(Eng)(Hon), FRCS(I)(Hon)

To the outside observer, the and Cooper University Health process of carrying out a The value of checklists System based in Camden, NJ. well-orchestrated operation, The use of checklists has migrated The concept is hardly new. no matter how complex, from the flight line to theO R, but Educational programs, such can appear routine almost the surgical profession has only as the ACS Advanced Trauma to the point of boredom. begun to appreciate the potential Life Support® and Advanced Well-trained members of benefits and applications of this Cardiac Life Support programs 64 | the team do their jobs, and, instrument. The purpose of and the military Combat with the possible exception checklists in the OR is to ensure Casualty Care Course, have used of a few moments that are that critical steps in preparing for checklists as an instructional more tense or difficult than and performing operations are expedient for many years. others, things go smoothly. taken and not left to memory. When a crisis erupts, a Situations most vulnerable to different set of procedures oversight are those that are or The CSPS campaign comes into play. Well- are perceived to be routine and The CSPS, which the ACS was prepared teams usually deal those that arise during crises. instrumental in establishing, with surgical crises in the Checklists provide a parachute. has partnered with Ariadne operating room (OR) just as Simulation laboratories Labs at the Harvard School of effectively. Nevertheless, such have proliferated as a means of Public Health to launch and teams may be unavailable improving surgical training and support a coordinated campaign under certain circumstances, as a way of testing and improving to stimulate the availability and even the best teams processes in the OR. A number and the implementation of may not be well-drilled in of simulation trials have tested crisis checklists. The CSPS is a how to handle every crisis. the applicability and utility unique collaborative of seven To ensure that surgical of crisis checklists. Clinicians organizations representing teams are capable of effectively who used them in simulated health care professionals who are responding to emergency crises expressed a strong involved in perioperative care: the situations, the American College desire to have crisis checklists ACS, the American Association of of Surgeons (ACS), through its available, not just for training, Nurse Anesthetists, the American membership on the Council but in the clinical setting (see Association of Surgical Physician on Surgical and Perioperative related article, page 24). Initial Assistants, the Association Safety (CSPS), is participating implementation projects have of PeriOperative Registered in a campaign to introduce and been initiated at the Brigham Nurses, the American Society of implement crisis checklists in and Women’s Hospital, Boston, Anesthesiologists, the American the OR and perioperative arena. MA; Stanford University, CA; Society of PeriAnesthesia

V98 No 10 Bulletin American College of Surgeons News To ensure that surgical teams are capable of effectively responding to emergency situations, the ACS, through its membership on the CSPS, is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena.

Nurses, and the Association of checklists would take place in a The surgical community Surgical Technologists. The simulated OR environment, with has the opportunity to lead in combined membership exceeds or without a formal simulation the development, adoption, 250,000, and the total number laboratory. Multidisciplinary and implementation of crisis of individuals in the seven staff involvement is an checklists in collaboration professions exceeds 2 million. essential component, and so is with other professionals in the The CSPS intends to launch recognition of local resources, OR and perioperative area. a campaign to inform its needs, and circumstances. Checklists offer additional membership and the surgical The CSPS plans to expose all ways to improve patient care community at large of the members of the perioperative and surgical outcomes using a importance and effectiveness of team to the concept of crisis familiar tool. More information crisis checklists and of strategies checklists through advocacy and will be made available over for introducing them into education on a national level. The the next few months. practice. Early experience points idea is to create a framework to Web resources for the to the critical role of a local implement a multidisciplinary, implementation team champion and a multidisciplinary multi-institutional collaboration. are available at www. implementation team dedicated A coordinated message from the projectcheck.org and at http:// to promoting checklist seven organizations that comprise emergencymanual.stanford. | 65 customization and adoption. the CSPS will support efforts edu, or on the CSPS website at Ideally, training in the use of crisis both nationally and locally. http://www.cspsteam.org. 

Save the Date March 29–April 1, 2014

Make a Difference. Join us in Washington, Dc.

• Advocate for health care improvements • Lead discussions on innovative ways to face leadership and surgical challenges • Engage influential decision makers • Enhance your leadership • Connect with ACS leaders and learn skills by attending professional how to get involved development sessions

Visit www.facs.org/ahp/summit/index.html for schedule of events, registration, hotel, and contact information.

OCT 2013 Bulletin American College of Surgeons News ACS NSQIP® National Conference: Speakers promote professionalism, collaboration to achieve quality improvement

Baumann Photography, San Diego by Jeannie Glickson

More than 1,000 individuals ACS NSQIP, built on a foundation go ie who work in hospital quality of strong data, is the first D an

66 | improvement programs nationally validated, risk-adjusted S y,

participated in the American program to provide external raph og College of Surgeons National benchmarks for measuring t ho

Surgical Quality Improvement the quality of surgical care. P Program (ACS NSQIP®) 2013 In his welcoming remarks, mann u a

National Conference, July 13– Dr. Ko spoke of the changing B 16, at the Bayfront Hilton San definition of surgical Diego, CA. This record-breaking professionalism. “There has number of attendees participated been a shift in our definition of in a variety of sessions aimed at professionalism. We have moved reducing surgical complications, from autonomy to collaboration,” applying quality improvement he said. ACS NSQIP has taken Dr. Ko concepts to difficult surgical what program participants have go ie

problems, and maximizing learned from their experiences D

efficiency and resource use in and applied those lessons to an health care. Many sessions also generate optimal quality surgical S y, offered strategies for adapting raph standards, Dr. Ko explained. He og t

to a changing health care went on to present a vision of the ho P

environment and using evidence- surgeon of the future who will be nn ma

based tools and case studies part of a high-performance team u a to improve hospital culture. that will depend on evidence- B Clifford Y. Ko, MD, MSHS, based measurements. The FACS, Director of the ACS College’s recently published book, Division of Research and Optimal Lessons Learned in the Pursuit of Patient Care and ACS NSQIP, told Quality Surgical Health Care, Dr. Ko surgeon champions (SCs), surgical added, reflects the commitment of clinical reviewers (SCRs), and ACS NSQIP participants, whose Dr. Eastman other conference attendees that evidence-based practice gave

V98 No 10 Bulletin American College of Surgeons News

In his welcoming remarks, Dr. Ko spoke of the changing definition of surgical professionalism. “There has been a shift in our definition of professionalism. We have moved from autonomy to collaboration,” he said.

focus to the lessons. View the reform, and delivery system Systems and Human publication at http://www.facs. redesign. “The whole idea of Accountability in Pursuit org/quality/lessons-learned.pdf. quality and professionalism in of a Culture of Safety, and health care is changing in this focused on professionalism. age of accountability,” he said. “There is no high reliability ACS emphasis on quality “Cost and payment are the of health systems until we know During the opening session, ACS issues getting air time today.” what it means to be professional. President A. Brent Eastman, Surgeons may not be the We’re not going to do that unless MD, FACS, whose leadership drivers of reform, but they are a we have leadership, and each of the College coincides with necessary part of the conversation, of us at some point becomes the organization’s 100-year Dr. Hoyt said. He noted that at the leader,” said Dr. Hickson, anniversary and who has the ACS Inspiring Quality Forum senior vice-president for quality, chosen “The Next 100 Years” in Boston, MA, on June 4, 2012, safety, and risk prevention; as the theme of his presidential economist Stuart Altman, PhD, assistant vice-chancellor for term, borrowed the words of observed that surgeons and other health affairs; and the Joseph former U.K. Prime Minister physicians may not always be C. Ross Chair of Medical | 67 Winston Churchill, noting, on the same page when it comes Education and Administration, “The further back you look, the to health care reform, but they Vanderbilt University School further forward you can see.” “are American health care” and of Medicine, Nashville, TN. “The College started on a are the right people to address “That’s what happens mission of quality,” Dr. Eastman issues of cost and quality of care. in a safety culture,” he said. “Care in hospitals in the “The question becomes continued. “Whenever there early 1900s was hit or miss, and it ‘who will hold the risk?’” Dr. is a disturbance, people must was the ACS leaders who wanted Hoyt said. “The priorities in speak up. Real professionals to standardize care.” He spoke surgical care today are the commit to behavioral models of the cycle of quality health science of measurement, and ask the questions: ‘How care—that the best evidence- quality in surgical health, high- does my performance affect the based practices produce high- quality data, collaboration, people around me?’ and ‘What quality surgical care, which and leadership—not only in behavior undermines safety?’ produces better outcomes. the OR but on Capitol Hill. “At the end of the day,” “The one word that surgeons “Quality is the future of he added, “safety is about agree on is ‘unsustainability’ of health care,” Dr. Hoyt added. team performance. Bullying the current health care system,” “Quality is measurable, and is a problem, but passive- he added. “I believe that ACS high-quality data are essential.” aggressive behavior is most NSQIP is the best answer to destructive. Failure to the situation we face today.” follow up is not professional. ACS Executive Director David Keynote address on Policies will not work if bad B. Hoyt, MD, FACS, in his address promoting a safety culture behaviors are not reported.” to the conference attendees Gerald B. Hickson, MD, To be professional, he during the opening session, delivered the keynote address added, is to be accountable. pointed to three principles that titled The Influence of “We are not asking people to will drive health care in the Culture on Surgical Quality be perfect. Real professionals future: access to care, payment Improvement—Balancing pursue accountability. Surgeons

OCT 2013 Bulletin American College of Surgeons News go go ie ie D D an an y, S y, y, S y, raph raph og og t t ho ho P P nn mann ma u u a a B B

Speaker Oscar Guillamondegui, MD, FACS, from Vanderbilt Dr. Hoyt University, Nashville, TN.

and the nursing staff must Registered Nurses, Denver, chief of minimally invasive work together for quality.” CO, explained that The Joint surgery at Stanford University Commission’s Universal Protocol Medical Center, CA. Dr. calls for OR teams to apply three Morton said the hospital’s ACS NSQIP improves steps before an operation begins: application of ACS NSQIP patient care verify the relevant information helped moved the institution’s Many conference speakers about the case, mark the operative risk-adjusted mortality ranking echoed Dr. Hickson’s emphasis site, and take a “time out.” from average to exemplary. on building a culture of safety Greater use of guidelines In the same session, Scott J. and using ACS NSQIP as the will help prevent surgical never Ellner, DO, MPH, FACS, vice- foundation for improving patient events, which still occur with chairman of surgery and director safety and quality of care. some frequency, according to of surgical quality at Saint At a session on safety, John a 2012 research project led by Francis Hospital and Medical R. Clarke, MD, FACS, professor Martin A. Makary, MD, MPH, Center, Hartford, CT, reported 68 | of surgery at Drexel University, FACS, an associate professor that benchmark data from ACS Philadelphia, and clinical director of surgery at Johns Hopkins NSQIP played a major role in of the Pennsylvania Patient University School of Medicine, the reduction of the number of Safety Authority, said a “never Baltimore, MD. The research urinary tract infections, saving event,” such as a fire in the indicates that more than 80,000 the hospital approximately operating room (OR), occurs such incidents occurred between $53,000 per patient. rarely but is preventable. Dr. 1990 and 2010. In other words, “It’s important to share data Clark went on to say that the major errors occur approximately and recognize and address most frequent cause of OR fires is 80 times per week and about barriers,” Dr. Ellner said. use of electrosurgical equipment 4,082 times per year. In the last “Quality improvement is about while supplemental oxygen is 20 years, these incidents have a shared vision and leadership, present. Fires must always be resulted in medical liability which is not about power.” reported, Dr. Clarke said, and payouts of more than $1.3 Joseph B. Cofer, MD, FACS, the hospital must change its billion, with the payout for each a general surgeon and program practices to avoid recurrences. event averaging $133,055.1 director of the department To avert other types of never of surgery, University of events, The Joint Commission Tennessee College of Medicine, developed a Universal Protocol for Champions of quality Chattanooga, TN, presented Preventing Wrong Site, Wrong improvement highlights of the Tennessee Procedure, Wrong Person Surgery Several ACS NSQIP SCs shared Surgical Quality Collaborative several years ago. Linda Groah, best practices and lessons learned (TSQC), the first ACS RN, MSN, chief executive officer, from their hospitals. Among NSQIP collaborative that is a Association of periOperative the speakers who discussed the partnership between a hospital *Harman K. Scientific American. Jan. 8, power of ACS NSQIP to improve association, health plan, and 2013. Surgical “never” events happen surgical quality was John M. ACS local chapter. TSQC has nevertheless. Available at http://www. Morton, MD, FACS, quality provided proven improvement scientificamerican.com/podcast/episode. cfm?id=surgical-never-events-happen- improvement administrator, in the health of Tennessee nevert-13-01-08. Accessed August 5, 2013. director of surgical quality, and residents, Dr. Cofer said, but

V98 No 10 Bulletin American College of Surgeons News

Baumann Photography, San Diego it takes an effective team for building from the bottom up and about readmissions, calling them this to happen. “A culture of not, as is most common, from “a vital performance metric.” mutual trust is imperative.” the top down, and to engage all Readmissions are expensive, he team members in patient safety. said. They consume associated “Guide the process so that opportunity cost—as the “The way we do things everybody on the team comes readmitted patient takes up a around here” to the conclusion by themselves bed—and they have a major Elizabeth C. Wick, MD, that a cultural change is needed,” adverse effect on the patient. FACS, a colorectal surgeon Dr. Wick said. “This requires Most general surgery patients at Johns Hopkins, described communication at every level, who return to the hospital the hospital’s Comprehensive disseminating information, within 30 days of discharge are Unit-based Safety Program setting forth expectations, and readmitted due to postoperative (CUSP), a perioperative quality holding everyone accountable complications, Dr. Sweeney improvement program that to the same standards.” said. Decreasing complications was the outgrowth of an ACS According to Charles L. Bosk, improves the quality of care and | 69 NSQIP patient safety session. PhD, a medical sociologist at benefits the patient, the hospital, To uncover ways to reduce the University of Pennsylvania, and the payor. ACS NSQIP data surgical site infections (SSI), Philadelphia, CUSP encourages allow participating hospitals members of the Johns Hopkins change at the local level and to review clinical patient data, team completed an anonymous “creates a culture of high compare themselves with other two-question survey that asked reliability through distributed hospitals, learn the reasons for how a colorectal SSI developed, responsibility. The beauty of the readmissions, and determine and how it could be prevented CUSP is that it calls forth our whether the readmission was the next time. The team then better angels,” he added. “The planned or unplanned, he added. developed 95 areas of concern work is never done, the team “The estimated cost to and met monthly, using never stops talking, the staff Medicare for rehospitalization is checklists and monitoring their find value in their work, there more than $17.4 billion a year,” own progress. The SSI rate for is a respect for knowledge, and Dr. Sweeney said, “a number colorectal surgeries dropped 33 work becomes a calling.” that has caught the attention of percent in the first 12 months Capitol Hill.” The Centers for of CUSP’s implementation. Medicare & Medicaid Services Dr. Wick noted that CUSP Reducing complications (CMS), in October 2012, began requires an interdisciplinary team, At a session on the Top 10 to penalize hospitals with including executive involvement, List for Reducing Surgical high readmission rates. which seeks to change the culture Complications, John F. Sweeney, Pascal R. Fuchshuber, MD, in pursuit of patient safety. She MD, FACS, the W. Dean Warren PhD, FACS, The Permanente acknowledged that in most Distinguished Professor of Medical Group, Inc. and the hospitals, culture is defined as Surgery and chief, division of Permanente Medical Group’s lead “the way we do things around general and gastrointestinal ACS NSQIP Surgeon Champion here,” a mentality that impedes surgery, department of surgery, for 21 Northern California quality improvement. She urged Emory University School of Kaiser Medical Centers, noted the audience to approach team- Medicine, Atlanta, GA, spoke that complications are a major

OCT 2013 Bulletin American College of Surgeons News go ie D an y, S y, raph og t ho P mann u a B

factor in postoperative respiratory posters of their abstract topics provided attendees with failure and mortality. Using ACS and were available to answer opportunities to meet with NSQIP data of surgical outcomes, questions about their work. and learn from experts in their Kaiser collaborative participants Awards honored the authors field. Special pre-conference identified a number of problems in four abstract categories: workshops allowed attendees to related to system failures and not • Resident Abstract Winner: learn firsthand from leaders in to the individual performance of Michael Cassidy, MD, Boston surgical quality improvement. a surgeon, nurse, or respiratory University Medical Center, Nestor F. Esnaola, MD, therapist, he said. The lack of MA, Challenges of Sustaining MPH, MBA, FACS, Co-Principal efficient communication between Momentum in Quality Investigator, National Center the treatment team and the Improvement—Lessons from a on Minority Health and Health respiratory therapy team and the Multidisciplinary Postoperative Disparities/National Institutes relative absence of respiratory care Pulmonary Care Program of Health, Washington, DC; during postoperative recovery of and chief, division of surgical patients because of staffing issues • Clinical Abstract Winner: oncology; and vice-chair, clinical 70 | were discussed and presented Cynthia G. Segal, MSN, PhD, and academic affairs, Temple to the individual department MD Anderson Cancer Center, University School of Medicine/ and the hospital leadership. University of Texas, Houston, Fox Chase Center, Philadelphia, Risk Factors Differ byT ype PA, led a pre-conference session of Surgical Site Infection on a pathway to improvement Abstract sessions share that incorporates Lean Six Sigma. best practices • SCR Abstract Winner: Peggy K. Lean Six Sigma is a managerial Each year, ACS NSQIP issues Jeanneault, RN, MAOM, Kaiser process that helps identify sources a call for abstracts to allow Foundation Hospitals, Fresno, of waste and activities that do participating hospitals to submit CA, Team—Together Everyone not add value in the pursuit presentation topics on how Achieves More—The Story of of maximum productivity.† they have used ACS NSQIP the Kaiser Northern California Attendees learned how to to improve patient care. This ACS NSQIP Collaborative combine Lean Six knowledge year, participating sites received with ACS NSQIP reports a record 125 abstracts, with • Abstract Poster Winner: Dan and resources to generate topics ranging from pediatric- W. Gates, Vanderbilt University, successful quality improvement specific quality improvement, to Nashville, TN, Is Pediatric ACS projects and successful change reducing SSI and readmissions NSQIP Review Representative management. “Communicate and team building. Authors of Total Institutional Experience your strategy for change,” Dr. presented their winning for Children with Appendicitis? Esnaola said. “Be concrete in abstracts during 24 sessions your communication, but don’t held throughout the conference. attempt to tackle everything. The authors also displayed Access to experts to help There must be a shared improve patient care ownership of a change initiative.” †Lean Six Sigma and process excellence. at the local level In another pre-conference International Institute for Learning, Inc. Through many educational and session, Joe H. Patton, MD, FACS, New York, NY. Available at http://www. iil.com/catalog.asp?cat=4&parent=4. networking events, the ACS associate chief medical officer Accessed September 2, 2013. NSQIP National Conference and chief of surgical services at

V98 No 10 Bulletin American College of Surgeons News

“Communicate your strategy for change,” Dr. Esnaola said. “Be concrete in your communication, but don’t attempt to tackle everything. There must be a shared ownership of a change initiative.”

Henry Ford Hospital, Detroit, for 10 outcomes, including MD, FACS, FASCRS, chair MI, and Jennifer Ritz, RN, BSN, mortality, any morbidity, of the Center for Minimally Manager of Quality Improvement serious morbidity, pneumonia, Invasive Surgery at Kaiser at Henry Ford Hospital, focused cardiac complications, SSI, Permanente, Los Angeles, on teamwork and improving urinary tract infection, venous director of the Permanente culture to engage leadership thromboembolism, renal failure, National Center of Excellence for and surgeons in the quality and length of stay. The Surgeon Colon and Rectal Surgery, and improvement process. The limited Adjustment Score that the Risk associate professor of surgery, number of attendees in the pre- Calculator generates allows University of California, invoked conference workshops allowed surgeons to adjust the predicted the memory of a historical for a collaborative environment risks if a patient has significant event—the sinking of the RMS focused on sharing and learning risk factors not already included in Titanic in 1912, a catastrophe from fellow attendees. the instrument-provided variables. that resulted in the death of New to this year’s conference The risk calculator is available 1,502 passengers and crew. were “Ask the Expert” sessions, for use at http://riskcalculator.facs. “The outcome was very which allowed attendees to meet o r g/. (See corresponding article, different than expected,” Dr. | 71 in small groups with surgical page 72, for more details.) Abbas said, but there were leaders from around the country Attendees also learned warnings that should have been to discuss areas of interest. Ask that they will receive Interim heeded. The ship was equipped the Expert sessions emphasized Semiannual Reports (ISAR) with the minimum number of the sharing of ideas and involved starting in October. Previously, required lifeboats and the ship’s individuals with expertise in ACS NSQIP hospitals received captain had been advised of a variety of surgical fields, their risk-adjusted outcomes on icebergs in the area, he said. As government regulation, culture a semiannual basis only. The with surgical deaths, he said, the and safety, and team building. ISAR, in addition to real-time Titanic deaths were preventable. risk-adjusted reports for measures The captain of the Titanic went endorsed by the National Quality down with the ship, a fate that New tools to improve care Forum, will enable hospitals to fortunately does not await At the conference, ACS NSQIP monitor quality efforts and act surgeons who participate in ACS introduced two new quality on the results more quickly. NSQIP. “The beauty of ACS improvement tools to help NSQIP is that you can compare attendees with their local quality results to national standards improvement efforts, including Evidence-based measurements and propose intervention,” the ACS NSQIP Surgical Risk improve quality Dr. Abbas concluded.  Calculator. This instrument uses Hospitals that participate in ACS information from more than NSQIP have the opportunity to 400 hospitals and 1.4 million avoid complications and enhance ACS NSQIP patient records to performance by using evidence- provide accurate, patient-specific based measurements, assessing risk information to guide both outcomes, and learning from surgical decision making and past experiences—a lesson that informed consent. The risk was repeated throughout the calculator provides predictions conference. Maher A. Abbas,

OCT 2013 Bulletin American College of Surgeons News

New ACS NSQIP® Surgical Risk Calculator offers personalized estimates of surgical complications

The new American College individual surgeon or small of 22 preoperative patient risk of Surgeons National Surgical studies from other institutions. factors about their patients. Next, Quality Improvement Program Importantly, these risk estimates the risk calculator estimates the (ACS NSQIP®) Surgical Risk have been generic and not specific potential risks of mortality and Calculator is a revolutionary tool to an individual patient’s risk eight important postoperative that quickly and easily estimates factors. To have truly informed complications and displays patient-specific postoperative consent and shared decision these risks in comparison to complication risks for most making with a patient, we need “an average patient’s risks.” operations, according to research the ability to provide customized, The authors worked to ensure findings posted online in the personal risk estimates for patients that the information would be Journal of the American College undergoing any operation,” presented in a patient-friendly of Surgeons (JACS), at h t t p :// according to Karl Bilimoria, way, accommodating a broad www.journalacs.org/article/ MD, FACS, ACS Faculty Scholar, range of health literacy needs. 72 | S1072-7515(13)00894-6/pdf. The director of the Surgical Outcomes The authors also performed study will appear in a print and Quality Improvement rigorous tests to ensure the edition of JACS later this year. Center at Northwestern validity of the risk estimates Surgeons and patients University, Chicago, IL, and provided by the Surgical Risk have long sought an accurate lead author of the study. Calculator. The investigators decision-support tool to estimate For the study, Dr. Bilimoria reported that the ACS NSQIP patients’ risks of complications and colleagues used highly Surgical Risk Calculator yielded after surgical procedures. This detailed and accurate ACS NSQIP excellent prediction results for process is essential for patient- data collected from nearly 400 death, overall complication and centered care, shared decision hospitals and 1.4 million patients serious complication rates, and making with patients, and true to develop a universal surgical risk six additional postoperative informed consent. Furthermore, calculator that covers more than complications: pneumonia, heart the Centers for Medicare & 1,500 unique surgical procedures problem, surgical site infection, Medicaid Services—through across multiple specialties. The urinary tract infection, blood clot, the Physician Quality Reporting authors leveraged outcomes data and kidney failure. In addition, System (PQRS)—may soon collected by ACS NSQIP to create the Surgical Risk Calculator provide a financial incentive for the Surgical Risk Calculator. estimates a customized length surgeons to calculate the risks “The quality and rigor of hospital stay for the patient. of operations using the Surgical of the ACS NSQIP clinical However, other hard-to- Risk Calculator and to discuss outcomes data were critical to measure factors may increase these patient-specific risks with the development and reliability a patient’s risk of postoperative patients before performing of the Surgical Risk Calculator,” complications, so the Web- elective procedures in the U.S. explained study coauthor Clifford based risk calculator includes “Predicting postoperative Y. Ko, MD, MSHS, FACS, Director an important novel feature: a risks, and identifying patients at of the ACS Division of Research Surgeon Adjustment Score that a higher risk of complications, and Optimal Patient Care. allows surgeons to increase the have traditionally been based The Surgical Risk Calculator risk of an operation based on their on anecdotal experience of the allows surgeons to enter a total subjective assessment of a patient.

V98 No 10 Bulletin American College of Surgeons News

“The quality and rigor of the ACS NSQIP clinical outcomes data were critical to the development and reliability of the Surgical Risk Calculator,” explained study coauthor Clifford Y. Ko, MD, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care.

This feature enables surgeons outcomes added to the tool, as department of surgery, Feinberg to better counsel patients using well as release of mobile versions. School of Medicine, Northwestern the modeled estimate along In addition to Dr. Bilimoria University; and the department of with the surgeon’s experience and Dr. Ko, other participants in surgery, University of California, and evaluation of the patient. the study were Yaoming Liu, PhD; Los Angeles, and VA Greater The risk calculator has been Jennifer Paruch, MD; Lynn Zhou, Los Angeles Healthcare System. released publicly and is available PhD; Thomas E. Kmiecik, PhD; This study was supported in part to surgeons, clinicians, and the and Mark E. Cohen, PhD. The by the Agency for Healthcare public at www.riskcalculator.facs. researchers are from the Division Research and Quality.  org. According to Dr. Bilimoria, of Research and Optimal Patient the calculator will be enhanced Care, ACS; Surgical Outcomes regularly with additional and Quality Improvement Center,

Dr. Arden Morris ACS Convention and | 73 appointed to National Meetings Director Quality Forum Committee featured in magazine

The National Quality The difference Forum (NQF) recently at Chicago’s appointed Arden Morris, newly privatized MD, MPH, FACS, McCormick Place colorectal surgeon and is “like day and professor of surgery night,” reports the at the University American College of Michigan, Ann of Surgeons (ACS) Arbor, to serve on Convention the NQF Consensus and Meetings Standards Approval Dr. Morris Director, Felix Committee (CSAC). Niespodziewanski, The American College of Surgeons who appears on the nominated Dr. Morris to serve on the CSAC, cover of the July which is responsible for reviewing and 2013 issue of the Mr. Niespodziewanski approving proposed consensus standards and M & C, Meetings and periodically assessing and recommending Conventions magazine. enhancements to the NQF’s consensus Mr. Niespodziewanski, who has organized development process. Her term began in July. the ACS Clinical Congress since 1990, told the For more information on the committee, magazine that the McCormick Place staff is go to http://bit.ly/NQFCSAC.  smaller but more efficient today. 

OCT 2013 Bulletin American College of Surgeons NEED TO EARN CME CREDIT? THE JACS CME WEBSITE MAKES IT EASY.

Take advantage of the new Journal of the American College of Surgeons (JACS) mobile friendly website to earn Continuing Medical Education (CME) credit when it’s convenient for you.

This site, free to use for all American College of Surgeons Fellows and JACS subscribers, can be viewed on any tablet or mobile device.

Enjoy easy access to the past 24 months of issues. Read the articles, take the tests, and earn CME credit all in one place.

Surgeons have busy schedules. The JACS CME website makes it easy to t earning CME credit into yours.

FOR MORE INFORMATION, VISIT jacscme.facs.org News

Issues discussed at the AMA House of Delegates meeting include definition of surgery, obesity

by John H. Armstrong, MD, FACS, and Jon H. Sutton

The annual meeting of the cosponsored this resolution, payments across outpatient American Medical Association which called on the AMA to settings, the HOD adopted a (AMA) House of Delegates (HOD) recognize obesity as a disease recommendation that the AMA took place June 15–19 in Chicago, with multiple pathophysiological work with states to advocate IL. More than 550 delegates aspects requiring a range for third-party payors to: as well as alternate delegates of interventions to advance converged on the Windy City to treatment and prevention. ȖȖ Assess equal or lower facility consider and adopt policy for the Evidence presented demonstrated coinsurance for lower-cost AMA. Issues such as health care that obesity is a metabolic sites of service (hospital policy were discussed, educational disease that occurs as a result of outpatient department, sessions were presented, and unhealthy behaviors related to ambulatory surgical center, caucuses and elections took place. food and beverage consumption, or office-based facility) lack of sufficient physical | 75 activity, as well as work, school, ȖȖ Publish and routinely update Reports and resolutions and messaging environments. pertinent information related The HOD reviewed more than The resolution further noted to patient cost-sharing 160 resolutions and 65 reports, that obesity leads to chronic including the following, centered diseases, such as hypertension, ȖȖ Allow their plan’s participating on issues of relevance to surgeons: heart disease, diabetes, and physicians to perform outpatient arthritis. The ACS delegation procedures at an appropriate • Invasive procedures: As originally emphasized that metabolic site of service as chosen by submitted to the HOD, this (bariatric) surgeons are on the the physician and the patient report from the AMA Board front lines of treating severe of Trustees called for revising obesity with life-improving • AMA support for states in their the current AMA definition of and lifesaving results. The development of legislation to surgery and guidelines on invasive resolution passed with a 60 support physician-led, team- procedures for the treatment percent majority of the delegates. based care: With a focus on of chronic pain, including physician-led, team-based care, procedures using fluoroscopy. • Payment variations across this resolution was adopted and Efforts to bridge the definitions outpatient sites of service: directed the AMA to assist state for surgery and procedures Cost transparency across medical societies and specialty fell short. A revised report was sites of service was a major organizations with seeking adopted that retained the current point of discussion, which passage of legislation that would AMA definition of surgery but received positive comments in define the valued role of mid- focused only on invasive pain reference committee testimony. level and other health care management procedures. In addition to adopting professionals within a physician- recommendations from the AMA led team that promotes optimal • Recognition of obesity as a Council on Medical Service to quality patient care and patient disease: The ACS and 10 other reaffirm some existing AMA safety. The resolution also medical/specialty societies policies related to Medicare called on the AMA to actively

OCT 2013 Bulletin American College of Surgeons News

The Surgical Caucus of the AMA brings together surgeons, anesthesiologists, and emergency physicians for focused discussions regarding relevant AMA resolutions that affect surgical interventions.

oppose health care teams patients, including proprietary regulation or legislative action that are led by nonphysician information on exposure on the content of the individual health care practitioners. to potentially dangerous clinical encounter between a chemicals or biological patient and physician without • An update on Maintenance of agents that may affect their a compelling and evidence- Certification MO( C), Osteopathic health or the health of their based benefit to the patient, Continuous Certification OC( C), families, sexual partners, and a substantial public health and Maintenance of Licensure other individuals with whom justification, or both. (MOL): A major topic of discussion they have been in contact. was MOC, OCC, and MOL For a complete list of requirements. Many resolutions ȖȖ All parties involved in the HOD actions, go to h t t p :// introduced expressed concerns provision of health care, www.ama-assn.org/ams/ 76 | regarding the implementation, including government, are pub/meeting/index.shtml. cost, and additional exam responsible for acknowledging burdens on physicians that these and supporting the intimacy requirements pose. For the most and importance of the patient- Elections part, these resolutions largely physician relationship and AMA officers, trustees, and recommended that the Council the ethical obligations of the council members are elected on Medical Education continue physician to put the patient first. during the annual meeting. to monitor the requirements and This year, three members of the engage in ongoing dialogues with ȖȖ The fundamental ethical College were elected to serve medical and licensing boards. principles of beneficence, on AMA councils and in other honesty, confidentiality, privacy, leadership positions, as follows: • Government interference in the and advocacy are central to practice of medicine and the the delivery of evidence-based, • Maya Babu, MD, a neurosurgery patient-physician relationship: individualized care and must resident at the Mayo Clinic, The AMA HOD passed several be respected by all parties. Rochester, MN, was elected resolutions that led to the to serve in the resident/ adoption of a Statement of ȖȖ Laws and regulations should fellow trustee position on the Principles concerning the roles not mandate the provision of AMA Board of Trustees. of federal and state governments care that, in the physician’s in health care and the patient- clinical judgment and based • Andrew Gurman, MD, FACS, physician relationship. These on clinical evidence and the a hand surgeon who practices principles include: norms of the profession, is in Altoona, PA, was re-elected either unnecessary or ill-suited as speaker of the HOD. ȖȖ Physicians should not be for a particular patient at the prohibited by law or regulation time services are rendered. • Liana Puscas, MD, FACS, from discussing with or asking an otolaryngologist and their patients about risk factors In addition, the AMA will assistant professor of surgery, or disclosing information to oppose any government Duke University Medical

V98 No 10 Bulletin American College of Surgeons News

ACS Delegates in attendance at the AMA House of Delegates meeting • John H. Armstrong, MD, FACS • Jacob Moalem, MD, FACS • Leigh Neumayer, MD, FACS • Richard Reiling, MD, FACS • Patricia L. Turner, MD, FACS • Timothy Kresowik, MD, FACS (alternate delegate, Society for Vascular Surgery) • Kenneth Louis, MD, FACS (alternate delegate, Florida Medical Association)

School, Durham, NC, was interventions. The Caucus held a IA, and an alternate delegate from elected to the AMA Council one-hour program titled Visiting the Society for Vascular Surgery, on Medical Education. the Surgical Home. Speakers and Kenneth Louis, MD, FACS, a provided a description of the neurosurgeon from Tampa, FL, Ardis Dee Hoven, MD, concept of the surgical home, and an alternate delegate for the assumed the presidency of the discussed how the surgical Florida Medical Association. AMA. An internal medicine home improves coordination of The delegation is open to and infectious disease specialist patient care and relates to other comments and feedback on from Lexington, KY, she is models of coordinated care, and issues before the HOD as well the 168th president of the reviewed some of the benefits of as suggestions for resolutions. organization and only the third implementing the surgical home. The November Interim HOD | 77 woman to hold this office. meeting will take place November Other officers elected 16–19 in National Harbor, MD. are as follows: ACS Delegation For surgeons who would like to The College was well represented become familiar with pending • President-elect: Robert M. Wah, by five delegates. New to the issues and policies, items of MD, reproductive endocrinologist delegation was Leigh Neumayer, business will be posted in early from Bethesda, MD MD, FACS, a general surgeon November on the AMA website from Salt Lake City, UT, and a at http://www.ama-assn.org/ • Board of Trustees: Gerald member of the ACS Board of ama/pub/about-ama/our-people/ E. Harmon, MD, a family Regents. She joined four seasoned house-delegates.page. Fellows physician from Pawleys Island, veterans of the HOD, including: who follow this activity and SC; and David O. Barbe, MD, John H. Armstrong, MD, FACS, have thoughts, comments, or re-elected, a family physician trauma surgeon, chair of the questions may contact the ACS in Mountain Grove, MO delegation, and Surgeon General/ Delegation at [email protected].  Secretary of Health for the State • Vice-Speaker of the HOD: Susan of Florida; Jacob Moalem, MD, R. Bailey, MD, re-elected, an FACS, an endocrine surgeon from allergist in Fort Worth, TX Rochester, NY; Richard Reiling, MD, FACS, a general surgeon from Charlotte, NC; and Patricia Surgical Caucus L. Turner, MD, FACS, a general The Surgical Caucus of the surgeon and Director of the ACS AMA brings together surgeons, Division of Member Services. anesthesiologists, and emergency In addition, the College physicians for focused discussions Delegation was assisted by regarding relevant AMA Timothy Kresowik, MD, FACS, a resolutions that affect surgical vascular surgeon from Iowa City,

OCT 2013 Bulletin American College of Surgeons News

ACS and CoC join Choosing Wisely Campaign to identify overused procedures The American College of Surgeons (ACS) and the Commission on Cancer (CoC) have joined more than 30 leading medical specialty societies in phase III of the Choosing Wisely® campaign initiated by the American Board of Internal Medicine (ABIM) Foundation. The campaign is a response to a 2012 report from the Institute of Medicine, Best Care at Lower Cost, which noted that up to 30 percent of health care spending is duplicative or unnecessary. To date, the campaign has brought together more than 80 organizations, including medical societies, regional health collaboratives, and consumer partners to support important physician- patient conversations about using the most appropriate tests and treatments and avoiding care if its harm outweighs the benefits.T o spark these conversations, leading specialty societies have created lists of evidence-based recommendations that should be discussed to help physicians and patients make wise decisions about the most appropriate care based on a patient’s individual situation. Choosing Wisely currently has put forth a list of more than 130 potentially unnecessary medical tests and will add to that number in late 2013 and early 2014 with the lists submitted by phase III participating groups. The ACS and the CoC have recently developed evidence- based lists of five tests/and or procedures that may be overused in their specific fields. The 78 | ACS and CoC lists were released concurrently on the ACS and Choosing Wisely websites on September 4. For more information, visit http://www.facs.org/choosingwisely/. 

Two ACS NSQIP® collaboratives receive AHA Davidson Quality Awards The American Hospital Association (AHA) presented the Dick Davidson Quality Milestone Award, one of the AHA’s top national awards, to hospital collaboratives in Tennessee and Florida participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The awards were presented July 25 during the AHA’s annual Leadership Summit in San Diego, CA, in recognition of the collaboratives’ leadership in quality improvement. In their nomination entries, the Tennessee Hospital Association (THA) and Florida Hospital Association (FHA) cited their states’ ACS NSQIP results as key quality achievements. The THA helps lead the Tennessee Surgical Quality Collaborative (TSQC), the first ACS NSQIP collaborative that is a partnership between a hospital association, health plan, and an ACS local chapter. The 10 Tennessee hospitals participating in TSQC initially reduced complications by 36 percent and saved more than $5 million. The collaborative has now grown to 22 hospitals. FHA partnered with the ACS to create the Florida Surgical Care Initiative (FSCI), based on four ACS NSQIP measures. The 67 hospitals participating in FSCI reduced complications by 14.5 percent and saved $6.67 million in 15 months. Visit the AHA website at http://www.aha.org/about/ awards/davidson/index.shtml for more information about the Davidson Quality Awards. 

V98 No 10 Bulletin American College of Surgeons Good Medicine Has Its Rewards: $287 Million

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4550_ACSbulletin_Jun2013.indd 1 5/29/13 10:17 AM News

Register now for 2013 ACS Clinical Trials Methods Course

The Clinical Trials Methods C linical TRIALS Methods Course Course will take place December faculty and didactic lectures 6–10 at the American College Faculty Topic of Surgeons (ACS) headquarters Review of Four Clinical Trials Dr. Itani in Chicago, IL. The five-day Ethical Issues in Clinical Trials intensive course, based on Waddah B. Al-Refaie, MD, FACS, 80 | four successfully conducted MedStar Georgetown University Hospital, Interventions and published clinical trials, Washington, DC consists of a combination of Robert J. Anderson, PhD, Experimental Design for a University of Illinois at Chicago School of Public didactic lectures and hands-on Randomized Clinical Trial sessions. A major portion of the Health, IL Joseph F. Collins, ScD, course will occur in small group Statistical Concepts in VA Cooperative Studies Program Coordinating Clinical Trials sessions mentored by leading Center, Perry Point, MD surgeons and biostatisticians Dorothy D. Dunlop, PhD, Statistical Inference, with expertise in clinical trials Northwestern University Feinberg School of Hypothesis Testing, and research. Participants will learn Medicine, Chicago, IL Sample Size the design of a clinical trial based William G. Henderson, MPH, PhD, Statistics I on concepts taught in the course. University of Colorado Health Research Outcomes Course faculty and didactic Program, Aurora, CO Mistakes in Clinical Trials lectures, led by course chair Lawrence T. Kim, MD, FACS, Central Arkansas Veterans Healthcare System, Patient Selection Kamal M. F. Itani, MD, FACS, Little Rock Veteran Affairs (VA) Boston Eric L. Lazar, MD, FACS, Putting It All Together: How Health Care System, MA, are Morristown Memorial Hospital, NJ to Get a Clinical Trial Paid For shown in the table on this page. Peter R. Nelson, MD, FACS, The Question and End Points Course registration is University of Florida School of Medicine, Tampa, FL limited to 50 participants, and ACS members will receive Domenic J. Reda, MS, PhD, Statistics II Edward R. Hines VA Hospital, Hines, IL preference. The course is offered Clinical Trials Analysis Methods only every other year. For Joshua S. Richman, MD, PhD, Trial Management and additional information, visit the Birmingham VA Medical Center, AL Planning Measurements Layton F. Rikkers, MD, FACS, Editor, Surgery News, course website at http://www. Publication of Results facs.org/cqi/src/clintrial.html, University of Wisconsin-Madison or contact Carla Manosalvas George A. Sarosi, Jr., MD, FACS, Overview of Design Options VA Medical Center, Gainesville, FL for Clinical Trials at [email protected]. 

V98 No 10 Bulletin American College of Surgeons News

Chapter news

Italy Chapter. From left: Dr. Gasparri; Dr. Kaafarani; Alberto Montori, MD, FACS(Hon); by Donna Tieberg and Dr. Nigri.

During the meeting, it was been invited to participate in Italy Chapter hosts two announced that Alessio Vinci, the 2013 Clinical Congress. Dr. ACS Presidents MD, department of surgery, Kaafarani is also an instructor The American College of University of Pavia, is the recipient at Harvard Medical School. Dr. Surgeons (ACS) Italy Chapter of the 2013 Resident and Associate Kaafarani was present at the convened in Genoa, Italy, June Society (RAS-ACS) International recent chapter meeting in Genoa, 24–27, during the Congress Exchange Program grant. Dr. where he received an award Giornate Genovesi della Vinci will receive $2,500 from from the Italy Chapter Executive Chirurgia Italiana, organized the RAS-ACS to participate in the Council and presented a lecture by Corradino Campisi, MD, ACS Clinical Congress, October titled Patient Safety in Surgery. FACS. Several other surgical 6–10, in Washington, DC. This For the first time, the Italy societies participated in this RAS-ACS program allows for an Chapter meeting included a | 81 conference, including the Joint exchange of residents and young Student/Resident Competition. National Congress of the Italian surgeons between Italy and the The winners of this competition Society of University Surgeons, U.S. The program was established were first-year resident Paolo Emergency Surgery and Trauma, by the RAS-ACS in 2012 with the Magistri, MD, from Sapienza and Research in Surgery (see support of the ACS International University of Rome, and photo, this page). U.S. and Relations Committee (IRC) third-year resident Teresa European surgeons also attended through the collaboration of Ciamporcero, MD, University the event, which took place at Daniela Molena, MD, assistant of Turin. With funding from the historic Villa Quartara in professor of surgery at Johns the ACS Italy Chapter, the two Genoa, built in the 14th century. Hopkins Hospital, Baltimore, winners will participate in Guests of honor at the MD—who, at that time, was Chief the 2013 Clinical Congress. meeting included ACS President of the RAS-ACS Membership A. Brent Eastman, MD, FACS; Committee—and Giuseppe his wife Sarita Eastman, MD; Nigri, MD, PhD, FACS, assistant Lake of the Ozarks provides and ACS Past-President Patricia professor of surgery at Sapienza backdrop for Missouri Numann, MD, FACS. For the University in Rome, Italy. Dr. Chapter meeting chapter plenary session, Dr. Nigri is the Chapter Treasurer The Missouri Chapter hosted its A. Brent Eastman presented and a member of the IRC. annual meeting May 31–June 2 at a lecture on the “Disaster in In addition, for the first time, the Lodge of Four Seasons on the Haiti.” Dr. Numann presented thanks to the funding support shores of the Lake of the Ozarks, several lectures during the of the ACS Italy Chapter, a MO (see photo, page 82). The meeting, including a talk on young U.S. surgeon, Haytham three-day, well-attended event “Women in Surgery.” Lucio M.A. Kaafarani, MD, a general included many nursing colleagues. Achille Gasparri, MD, FACS, surgeon at Massachusetts The first day of the conference the ACS Governor for Italy, General Hospital, Boston, and featured general surgery/ organized the chapter meeting recipient of the International trauma presentations, and and was an active participant. Exchange Program Award, has on the second day, faculty,

OCT 2013 Bulletin American College of Surgeons News

Missouri Chapter. From left: Residents Christopher Cooper, MD; Jeremy Jensen, MD; Ashley Bartels, MD; and Jared Konie, MD, all from the University of Missouri-Columbia.

fellows, residents, and medical For updated information on the on resident presentations and students gave presentations on second annual Surgical Advocacy giving a presentation titled oncology. During the meeting, Summit, go to www.mcacs.org. Communication Skills: An R. Phillip Burns, MD, FACS, First Important Component on Vice-President of the American the Road to Success. Donna College of Surgeons, provided Residents present research Tieberg, ACS Chapter Services an update on College activities, papers at Tennessee Manager and author of this and Julie Margenthaler, MD, Chapter annual meeting article, also attended the FACS, Barnes Jewish Hospital, St. The Tennessee Chapter convened annual meeting and provided Louis, was installed as Chapter July 26–28 in Nashville, TN, for its the Executive Council with an President. Attendees and their annual meeting (see photos, page update on Chapter Services. families also enjoyed a pool 83). More than 100 registrants The Tennessee Chapter has party and an evening cruise attended multiple sessions, with long recognized the need for on the Lake of the Ozarks. representatives from the College’s resident and young surgeon Next year’s annual leadership, the Commission participation in the annual 82 | meeting will take place at on Cancer, the Committee on meeting. As in previous years, the Lodge of Four Seasons, Trauma, and the Tennessee surgical residents provided May 29–June 1, 2014. Surgical Quality Coalition. paper presentations highlighting R. Phillip Burns, MD, FACS, research in trauma, cancer, and First Vice-President of the ACS clinical surgical science, with Massachusetts Chapter plans and longstanding chair of surgery a total of 25 presentations. second advocacy summit at the University of Tennessee, Finally, a longstanding The Massachusetts Chapter Chattanooga, provided an update tradition for the Tennessee has announced that it will on College activities. C. William Chapter is the Saturday night hold its second annual Surgical Schwab, MD, FACS, from the banquet. This year, a nine-piece Advocacy Summit on November University of Pennsylvania band, Soul Incision, consisting 19 at the Massachusetts State Medical Center, Philadelphia, of physicians, nurses, and House in Boston. At last year’s offered a provocative presentation administrators from Vanderbilt advocacy event, chapter members on firearm violence. University Medical Center, developed a partnership with Dr. Schwab focused on the Nashville, entertained the crowd. state legislators and their staff, research and impact of gun with a focus on ensuring patient violence in the U.S. and advocated access to sustainable high-quality further investigation of gun Michigan Chapter 60th surgical care. The upcoming violence as a public health issue. annual meeting features summit will continue this In addition, Darrell “Skip” difficult surgical situations collaboration and will include Campbell, MD, FACS, director The Michigan Chapter presented a discussion of the response to of the Michigan Surgical Quality its 60th Annual Meeting and 62nd the April 15 Boston Marathon Collaborative, provided an update Resident Surgeons Competition, bombing. All Massachusetts on the Michigan group’s activities, May 15–17, at the Radisson surgeons are invited to attend Patricia Numann, MD, FACS, Plaza Hotel in Kalamazoo, this important event and are Past-President of ACS, was MI (see photo, page 84). More encouraged to invite Fellows, also actively involved with the than 100 surgeons and surgery other colleagues, and residents. annual meeting, commenting residents from around the

V98 No 10 Bulletin American College of Surgeons News

Tennessee Chapter. From left: Joseph Cofer, MD, FACS, incoming Tennessee Chapter President; guest speaker Dr. Campbell; Oscar Guillamondegui, MD, FACS, outgoing Tennessee Chapter President; and guest speaker Dr. Schwab. state participated in this year’s TNoronto, O , gave the Krishna event. The meeting kicked off K. and Pamela E. Sawhney Ethics Wednesday evening with a in Surgery Lecture, Ethics of Remarkable Cases Reception, Surgical Innovation: When Is It which included a discussion of OK to Try Something New? nine unusual cases submitted by A major focus of the practicing surgeons, residents, and annual event is the resident medical students from throughout competition. This year, 66 the state. David B. Hoyt, MD, abstracts were submitted for FACS, ACS Executive Director, consideration, and the top 54 and R. Phillip Burns, MD, FACS, were selected for presentation. | 83 ACS First Vice-President, provided This year’s resident surgeons updates on the College’s quality competition winners are: improvement initiatives and Matthew Ralls, MD, University other activities. Dr. Hoyt also of Michigan, Ann Arbor, winner Tennessee Chapter. Kenneth Sharp, MD, presented the 16th Annual “Mo” of the Frederick A. Coller FACS (left), representing the ACS Foundation Henig Trauma Lecture titled Award, who took First Place at the Tennessee Chapter meeting with Dr. Post Hoc Ergo Propter Hoc: Overall for Acute Nutrient Burns. The Story of the Resuscitation Deprivation and Intestinal Outcomes Consortium. Environmental Variation: The Michigan Chapter Potential Mechanisms that meeting featured speakers from Drive Intestinal Mucocal throughout North America Inflammation. The Alexander to participate in this year’s J. Walt Award, and Second conference, the theme of Place Overall, went to which was Difficult Situations Lindsey Korepta, MD, Grand in Surgery. Expert surgeons Rapids Medical Education shared their troublesome Partners, for Endovascular experiences and offered their Repair of Ruptured advice and feedback during Aneurysms after EVAR. roundtable discussions. Darrell “Skip” Campbell, MD, FACS, director of the Michigan Connecticut Chapter Surgical Quality Collaborative, hosts work/life balance provided an update on the program for residents group’s activities, and Martin The Connecticut Chapter’s McKneally, PhD, Joint Centre Resident Committee hosted for Bioethics, University of an evening session in July on

OCT 2013 Bulletin American College of Surgeons News

Michigan Chapter. Chapter President Donn M. Schroder, MD, FACS, center left, and Immediate Past-President Vijay K. Mittal, MD, FACS, center right, pose with the winners of the Resident Surgeons Competition.

Connecticut Chapter. Dr. LaVorgna, far right, standing, speaking with residents.

84 | the topics of work/life balance Chair, Scott Ellner, DO, FACS, strong peer network as well and organized medicine at attending surgeon, Saint Francis as a senior mentor. Dr. Ellner the Connecticut State Medical Hospital and Medical Center. reminded the residents that Society in New Haven, CT Committee Mentor David postresidency/fellowship life (see photo, this page). The Shapiro, MD, FACS, a general improves markedly and stressed session was well-attended, surgeon at Saint Francis the importance of keeping in with 15 residents present, Hospital and Medical Center, touch with old friends and representing half of the training reminded residents that as long taking advantage of individual programs in Connecticut. as they love what they do, they interests. He concluded by Organized by Committee will evolve in their careers. All telling the residents that he Chairs third-year resident were then asked to share an believes it is important to look Jillian Fortier, MD, University interesting personal fact. What for an area where they may have of Connecticut Health Center, emerged were 15 unique and an impact and then map their Farmington, and fourth- diverse personal portraits, with career path to achieve that goal. year resident Yuk Ming Liu, residents who were a part of At dinner, Dr. LaVorgna MD, Waterbury Hospital, the the same program learning new provided an overview evening featured presentations information about each other. of organized medicine, by Chapter Past-President Dr. Zarfos suggested that explaining how county Kristen Zarfos, MD, FACS, the residents look at life as a and state medical societies attending surgeon, Saint Francis pie chart and that the balance interact with the American Hospital and Medical Center, they achieve will evolve as Medical Association (AMA). Hartford, and assistant professor, their priorities change. She She also explained the role University of Connecticut School also stressed the need to that the ACS plays within of Medicine; Chapter President, devote a piece of your “pie” to the AMA. The evening Kathleen LaVorgna, MD, FACS, maintaining personal health. ended with presenters Norwalk Hospital; and Chapter Dr. LaVorgna emphasized encouraging residents to Committee on Quality Co- the importance of having a become actively engaged in

V98 No 10 Bulletin American College of Surgeons News

Chile Chapter. Seated, from left: Drs. Chomali, Vidal, Csendes, Alcoholado, and Maluenda. Standing: Drs. Korn, San Martin, Nuñez, Catan, Burdiles, Bianchi, and Rivera. their chapter, the College, 15, in Santiago, led by Chapter Patricio Burdiles, MD, FACS; and organized medicine. The President Nelson Vidal Carvajal, Treasurer Felipe Catan, MD, next scheduled session for MD, FACS. Topic highlights FACS; Teresa Chomali, MD, Connecticut residents will at the meeting included the FACS; ACS Governor Attila center on financial planning. prevention of disease, trauma, Csendes, MD, FACS(Hon); Owen and pediatric surgery. Korn, MD, FACS; President- At the meeting, the chapter Elect Fernando Maluenda, Chile Chapter announces announced the 2013–2014 Board MD, FACS; S. San Martin, MD, 2013–2014 Board of Directors of Directors (see photo, this FACS; Hugo Nuñez, MD, FACS; The Chile Chapter of the page). The new Board includes Carlos Rivera, MD, FACS; and  American College of Surgeons Ivan Alcoholado, MD, FACS; Nelson Vidal, MD, FACS. | 85 held its 57th Congress May 12– Victor Bianchi, MD, FACS; Rural Surgery Rural VOLUME 38, NO. 1, 2012 SRGS Rural Surgery Single Issue

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

VOL. 38

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

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

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

ISIO n and password BEFORE you place your order.

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

OCT 2013 Bulletin American College of Surgeons E-mail isn’t for everyone. !@#$%^&*

But it is for Fellows of the American College of Surgeons who want to keep current on the latest news from their professional society.

If we don’t have your current e-mail address, We have a lot to share, here are some examples of what you are missing: so let us connect  NewsScope. The American College of Surgeons (ACS) weekly with you. e-newsletter that brings you the latest developments in Medicare payment reform, electronic health records, coding and You can add or update your e-mail at reimbursement, ACS scholarships, educational programming, and more. www.efacs.org (the ACS member portal).  The ACS Advocate. Our monthly e-newsletter that brings you Go to the home page, click on My Profile, important information on federal and state legislative and regulatory and follow the prompts. initiatives affecting the practice of surgery. Questions? Contact Member Services at  E-mail alerts. Alerts are the most effective and efficient way to get time-sensitive information about College activities and programs [email protected]. to you quickly.  Electronic surveys. These brief electronic surveys allow you to weigh in on the issues that are important to you. If you would like to make sure all e-mail from the College is promptly sent to your current e-mail account(s), and to ensure that we can reach you for years to come, go to http://efacs.org. Registration for this service is quick, easy, and free.

We need your e-mail FINAL revised 06-06-13.indd 1 6/6/2013 2:52:59 PM News

Commission on Cancer announces 2013–2014 cancer research paper competition for physicians in training

The American College of and the mission of the Surgeons (ACS) Commission Commission on Cancer. on Cancer (CoC) is hosting a paper competition for physicians in training Timeline to foster the importance Papers will be accepted July 1, of oncologic research in 2013, through June 30, 2014. support of its mission.

Awards Thesion Mis of the CoC Eligibility* The national award winners will The CoC is a consortium of Entries must adhere to the be announced August 15, 2014. following eligiblity requirements: The winner will receive a $1,000 professional organizations honorarium and travel expenses | 87 • Abstracts by residents and to present his or her research dedicated to improving fellows in training on topics to the Annual Meeting of the survival and quality of life specific to oncology and CoC on October 26, 2014, in San related to the mission of the Francisco, CA. The winning for cancer patients through CoC will be considered. entry will be considered for standard-setting, prevention, publication in the Journal of the • Abstracts that have been American College of Surgeons. research, education, previously presented at a The authors of the second- and state, regional, or national third-place abstracts will receive a and the monitoring of meeting within the last 24 $500 cash award and an invitation comprehensive quality care. months will be considered. for a poster presentation of their research during the 2014 • The manuscript must have not Annual Meeting of the CoC. yet been published in a peer For more information, contact review journal and can only the ACS CoC Cancer Liaison be submitted to one American Program at [email protected], or College of Surgeons chapter. contact your CoC State Chair at Original research is encouraged. www.facs.org/cancer/coc/ statecontact.html. 

Judging criteria Judging is based on originality, scientific merit, and clinical relevance to oncology

*See your specific state chapter announcement for eligibility details and time frames.

OCT 2013 Bulletin American College of Surgeons News

ACS in the

Editor’s note: Media around the Online calculator For surgery, big and famous world, including social media, assesses individual hospitals aren’t always the best frequently report on the work of the American College of Surgeons patient surgical risks Reuters, July 31, 2013 (ACS). Following are brief excerpts FierceHealthIT, August 19, 2013 “The American College from news stories published from “A new tool developed by the of Surgeons collects data on June through August 2013 that American College of Surgeons surgical outcomes, such as the mention key ACS activities and enables physicians and the rate of infections at the surgical initiatives, including research public to more accurately assess site and urinary tract infections, findings that appear in the Journal the risk involved with 1,500 through its National Surgical of the American College of Surgeons. 88 | surgical procedures…. Detailed Quality Improvement Program. To access the news items in their outcomes data from nearly The group will not release the entirety, visit the online ACS 400 hospitals and 1.4 million data to the public because it Newsroom at http://www.facs.org/ patients was collected through promised confidentiality to newsroom/acs-in-the-news.html. the ACS National Surgical hospitals providing the data, Quality Improvement Program. said Dr. Clifford Ko [MD, The creators rigorously tested FACS], a cancer surgeon at [the the calculator and focused on University of California-Los using everyday language that Angeles] Jonsson Comprehensive would make it easy for the Cancer Center who is involved public to understand, according in the project. However, 102 of to an announcement.” about 500 participating hospitals voluntarily report some of their data to the federal Center[s] for Virtual training helps Medicare [&] Medicaid Services.” surgical residents with patient management FierceHealthIT, August 5, 2013 Fight back: When avalanche of “Three-dimensional anxiety and anger take over simulation technology via Grand Rapids Press, July 21, 2013 Second Life could be the “Identifying that level of basis for a new tool to help distress and treating it has such surgical residents fine tune a positive impact on our sticking their patient management with treatment, hastening skills, according to research recovery and even reducing published in the August healthcare costs, that ‘starting edition of the Journal of the in 2015 more than 1,500 cancer American College of Surgeons.” centers will need to screen

V98 No 10 Bulletin American College of Surgeons News

Media around the world, including social media, frequently report on the work of the American College of Surgeons.

patients for distress to maintain standard of codes of managing The Commission on Cancer, their accreditation with the trauma patients, no policies or created by the American American College of Surgeons protocols. It is this exact system College of Surgeons, also has Commission on Cancer.’” put together that allows us to an accreditation process. The practice at the level that we do.’” more than 1,500 accredited cancer facilities make up 30 With Split Grafts, A Donor’s percent of all U.S. hospitals but Liver Can Save Two Lives Cancer Registrars’ Role care for about 70 percent of Medical Daily, July 17, 2013 in the Era of Big Data cancer patients, according to “Split liver transplantation Advance, July 3, 2013 [Daniel] McKellar [MD, FACS], carries no increased risk of failure “In 2012, the American College who chairs the commission.” in either recipient, according of Surgeons Commission on to a new study published in the Cancer (CoC) began pulling Journal of the American College of and pushing its accredited Study: Quitting smoking helps surgical outcomes Surgeons. The process, whereby facilities into an era of big | 89 two partial grafts can be data by setting standards that Nurse.com, June 21, 2013 obtained from a single donated encourage the use of facility-wide “Smoking cessation at least organ, could virtually eliminate data. The 2012 CoC standards one year before major surgery waitlist mortality among young made it clear that the registry eliminates the increased risk children in need of a new liver.” could no longer be an adjunct of postoperative mortality and operation of a facility treating decreases the risk of arterial and cancer patients. The standards respiratory events that are evident Doctors Tested in required an integrated approach in current smokers, according to a Boston Bombings to reviewing the facility’s study…. A total of 125,192 current Gastroenterology & Endoscopy operations and, in particular, and 78,763 past smokers from the News, July 2013 its strengths and weaknesses.” American College of Surgeons “Many surgeons credit the National Surgical Quality contributions of the American Improvement Program database College of Surgeons’ Committee Check Please: Choosing who underwent a major surgery on Trauma (COT) in the success the Best Hospital for were included in the study, which of the surgical response following Your Cancer Surgery was published June 19 on the the bombings. The mission CURE magazine, June 17, 2013 website of JAMA Surgery.”  of the COT is to develop and “One good way to start implement meaningful programs is by searching for a hospital for trauma care in local, national that’s accredited by an external and international arenas, and to organization, such as the National provide professional development Cancer Institute, says John and standards of care. ‘Without Birkmeyer [MD, FACS], who the COT,’ Dr. [George] Velmahos. teaches surgery and directs the [MD, FACS] said, ‘we wouldn’t Center for Healthcare Outcomes have trauma systems; we wouldn’t and Policy at the University of have trauma teams, centers, Michigan in Ann Arbor, Mich.

OCT 2013 Bulletin American College of Surgeons Custom Crafted Commemorative Items

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14412_Centennial_BulletinAd_7.5x10.375in_REV.indd 1 5/10/13 3:06 PM Scholarships

ACS Scholarship Endowment Fund awards Faculty Research Fellowships, 2013–2015

Dr. Costantini Dr. Crago Dr. Bao-Ngoc Nguyen Dr. Kevin Nguyen Dr. Peranteau

The American College of Cancer Center, New York, NY. and manipulation of the fetal Surgeons (ACS) Faculty Research project: Optimizing hematopoietic niche to optimize Research Fellowships for 2013 targeted therapy in liposarcomal— in utero transplantation were awarded earlier this year. Co-amplification of MDM2 and These two-year fellowships are CDK4 in liposarcoma genesis • Kevin T. Nguyen, MD, PhD, offered to surgeons entering assistant professor of surgery, careers in surgery or a surgical • C. James Carrico, MD, FACS, University of Michigan, Ann | 91 specialty and carry awards of Faculty Research Fellow: Arbor. Research project: $40,000 per year from July 1, T odd Costantini, MD, assistant Oncogenic function of 2013, through June 30, 2015. professor in residence, University CD44 in pancreatic cancer The ACS Scholarship of California, San Diego. invasion and metastasis Endowment Fund of the College Research project: Targeting sponsors the Faculty Research the enteric nervous system to The ACS website, http://www. Fellowships. The Franklin H. alter the inflammatory setpoint facs.org/memberservices/acsfaculty. Martin, MD, FACS, Faculty after acute intestinal injury html, lists the description and Research Fellowship of the ACS requirements for this program. honors the founder of the College. • Louis Argenta, MD, FACS, Faculty The application deadline for The C. James Carrico, MD, FACS, Research Fellow: Bao- Ngoc the 2014 Faculty Research Faculty Research Fellowship for Nguyen, MD, assistant professor Fellowships is November 1, 2013. the Study of Trauma and Critical of surgery, George Washington The Scholarship Endowment Care honors the late Dr. Carrico. University, Washington, DC. Fund provides income to fund The one-year Louis Argenta, Research project: The role of scholarships and fellowships MD, FACS, Faculty Research Poly ADP Ribose Polymerase awarded by the Board of Fellowship, presented by Kinetic (PARP) in the Healing Process Regents. Direct contributions Concepts, Inc., supports research of Ischemic/Diabetic Wounds to support the Scholarship in wound healing in honor of Endowment Fund are welcome. Dr. Argenta, a plastic surgeon. Additional Faculty The ACS encourages Fellows The recipients of these Research Fellowships for who would like to make tax- fellowships are as follows: 2013–2015 were awarded to: deductible gifts to fund these vital programs to contact the ACS • Franklin H. Martin, MD, FACS, • William H. Peranteau, MD, Foundation at 312-202-5338.  Faculty Research Fellow: Aimee M. assistant professor, Children’s Crago, MD, PhD, assistant attending Hospital of Philadelphia, PA. surgeon, Memorial Sloan-Kettering Research project: The study

OCT 2013 Bulletin American College of Surgeons Scholarships

ACS Board of Regents awards six 2013 Resident Research Scholarships

Dr. Jeanty Dr. Krampitz Dr. Luciano

Dr. Than Dr. Weber Dr. Yang

92 | Six Resident Research pancreatic surgery. Research • Peter A. Than, MD, Stanford Scholarships for 2013 were project: Identification of University. Projected specialty: awarded by the American neuroendocrine tumor cancer Surgery. Research project: College of Surgeons (ACS) stem cells and development Engineering an autologous Board of Regents earlier this of immunotherapies implantable liver construct year. The scholarships, which from the inside out carry awards of $30,000 for • Erin Weber, MD, University of each of two years, beginning California, Los Angeles. Projected The description and July 1, 2013, encourage specialty: Plastic surgery. Research requirements for these residents to pursue careers project: Reprogramming human research-oriented scholarships in academic surgery. These epidermal and dermal cells for are available on the College scholarships are sponsored de novo hair follicle neogenesis website, http://www.facs.org/ by The ACS Scholarship memberservices/acsresident.html. Endowment Fund. • Cerine Jeanty, MD, University The Scholarship Endowment The recipients of these of California, San Francisco. Fund, which provides income to scholarships are as follows: Projected specialty: Pediatric fund scholarships and fellowships surgery. Research project: awarded by the Board of Regents, • Chi-Fu Jeffrey Yang, MD, Duke Th17 cells and intestinal welcomes direct contributions University Medical Center, inflammation in gastroschisis to the fund. Fellows who want Durham, NC. Projected specialty: to make tax-deductible gifts to Surgical oncology. Research • Jason A. Luciano, MD, University support these vital programs project: Copper reduction for BRaf of Pittsburgh, PA. Projected should contact the ACS mutation-positive melanoma specialty: Critical care. Research Foundation at 312-202-5338.  project: The role of the • Geoffrey Krampitz, MD, Stanford mitochondria and bioenergetics University, CA. Projected in regulating the immune specialty: Hepatobiliary and response following trauma

V98 No 10 Bulletin American College of Surgeons Scholarships Apply by November 1 for Faculty Research Fellowships

The American College of • Recipients may use this award to ACS Faculty Research Surgeons (ACS) is offering two- support their research or academic Fellowships year faculty research fellowships, enrichment in any fashion that through the generosity of they deem maximally supportive Fellows, Chapters, and friends of their investigations. The • Franklin H. Martin, MD, FACS, of the College, to surgeons fellowship grant is intended to Faculty Research Fellowship entering academic careers in support the recipient’s research of the American College of general surgery or a surgical and is not intended to diminish Surgeons. This fellowship honors Franklin H. Martin, specialty. The fellowships are or replace the usual, expected MD, FACS, ACS founder. intended to assist a surgeon compensation or benefits.I ndirect in the establishment of a new costs are not paid to the recipient • C. James Carrico, MD, FACS, and independent research or to the recipient’s institution. Faculty Research Fellowship program. Applicants should have for the Study of Trauma and Critical Care. This demonstrated their potential to • Application for this fellowship fellowship honors C. James work as independent investigators. may be submitted even if Carrico, MD, FACS, and is The fellowship award is $40,000 comparable application has been designated for research in per year for each of two years, to made for other fellowships, trauma and critical care. support the research. The closing such as those available through • Louis Argenta, MD, FACS, the National Institutes of date for receipt of completed Faculty Research Fellowship | 93 applications and all supporting Health (NIH) or industry. If the for the Study of Wound Care. documents is November 1, 2013. recipient is offered a scholarship, This one-year fellowship General policies covering fellowship, or research career honors Louis Argenta, MD, the granting of the ACS Faculty development award from such an FACS, and is designated for Research Fellowships are: agency or organization, it is the research in wound care. responsibility of the recipient to • The fellowship is open to Fellows contact the College’s Scholarships or Associate Fellows of the College Administrator to request approval who have: (1) completed the chief of the additional award.* residency year or accredited fellowship training within the • The College encourages the preceding three years; and (2) applicant to leverage the funds received a full-time faculty provided by this fellowship with appointment in a department of time and monies provided by the surgery or a surgical specialty at a applicant’s department. Formal medical school accredited by the statements of matching funds Liaison Committee on Medical and time from the applicant’s Education in the U.S. or by the department will promote Committee for Accreditation favorable review by the College. of Canadian Medical Schools in Canada. Preference will be • Supporting letters from the head given to applicants who directly of the department of surgery enter academic surgery following (or the surgical specialty) and residency or fellowship. from the mentor supervising the applicant’s research effort must *The Scholarship Committee reserves the right to review potentially overlapping be submitted. This approval awards and adjust its award accordingly. would involve a commitment

OCT 2013 Bulletin American College of Surgeons Scholarships

The fellowships are intended to assist a surgeon in the establishment of a new and independent research program.

to continuation of the academic application. This percentage program on wound care. All of position and of facilities for may run concurrently with the the same requirements apply research. Only in exceptional time requirements of the NIH as for the Martin and Carrico circumstances will more than or other accepted funding. Fellows, except that the time one fellowship be granted period is one year. The Argenta in a single year to applicants • The Martin and Carrico Fellows Fellow will attend and report from the same institution. are expected to attend the 2016 at the 2015 Clinical Congress. ACS Clinical Congress to present • The applicant must submit a report at the Surgical Forum Application forms a research plan and budget and to receive a certificate may be obtained from the for the two-year period of at the annual meeting of the College’s website, www.facs. fellowship, even though renewed Scholarships Committee. org, or upon request from approval by the Scholarships the following address. Committee of the College is • The Dr. Louis Argenta Faculty Send applications to kearly@ required for the second year. Research Fellowship, supported facs.org or to Scholarships Section, by Kinetic Concepts, Inc., is a American College of Surgeons, • A minimum of 50 percent of one-year award in the amount 633 N. Saint Clair St., Chicago, IL the fellow’s time must be spent of $40,000 to help a surgeon 60611-3211.  94 | in the research proposed in the establish an independent research

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CME to ABS ad - June 2010 BULLETIN (4 in deep) REVISED LOGO.indd 1 9/16/2011 1:59:32 PM V98 No 10 Bulletin American College of Surgeons Scholarships

2013 Traveling Fellow to Germany reports on experiences

The Langenbeck-Virchow-Haus in Berlin, by Anneke T. Schroen, MD, MPH, FACS headquarters of the German Surgical Society.

With gratitude to the American a balance between prevention, and made for a welcome College of Surgeons (ACS) and neoadjuvant, adjuvant, and reception just a few hours after the German Surgical Society palliation studies, with an my arrival in Frankfurt. (Deutsche Gesellschaft für emphasis on investigator-initiated Chirurgie, DGC), I report on my trials. Although funding comes experiences as the 2013 Traveling from a combination of public, Berlin—HELIOS Klinik and the Langenbeck-Virchow-Haus Fellow to Germany. The trip philanthropic, and industry | 95 included attendance at the 130th sources, the group is committed The following morning I Congress of the German Surgical to preserving its independence traveled by train to Berlin. The Society and visits to four different and academic orientation. German capital is vibrant and institutions that provide breast Concept-to-activation times for dynamic, offering an abundance surgery services and are involved trial development are significantly of historical and cultural in oncology clinical trial accrual. shorter than those reported for sites. Certainly the city has oncology clinical trial cooperative undergone profound changes groups in the U.S. Trial activation in the last 20 years, rendering Frankfurt—German processes at local institutions places I had seen on my first trip Breast Group use central institutional review there in the summer of 1990 The successes in clinical trial boards (IRBs). Incentives for local virtually unrecognizable. completion that European breast investigator participation include A primary focus of my oncologists have experienced authorship for high recruiters, fellowship was to observe intrigue me. Clinical trials from which is critical for professional multidisciplinary health care Germany and other European advancement; access to the latest delivery for breast cancer in countries have been featured treatment agents; and breast Germany. To this end, I wanted prominently at breast oncology center certification requirements to visit a breast center in both meetings in the U.S. To learn of at least 10 percent of patients a private clinic setting and a more about their efforts, I visited enrolled in clinical trials. university setting. Today, breast the German Breast Group (GBG), I shared with GBG some cancer care in Germany is largely headquartered in Neu-Isenburg of my research in clinical trial delivered in nationally certified near Frankfurt. This cooperative accrual in the cooperative breast centers. To improve group conducts mostly phase II group setting. Our discussion quality-of-care standards and and III trials. More than 5,000 proved to be an informative reduce practice variability in patients participated in their trials exchange of experiences and breast cancer care, the German last year. The GBG maintains ideas. The friendliness of the Cancer Society (Deutsche a robust portfolio that strikes GBG staff was much appreciated Krebsgesellschaft, DKG) and

OCT 2013 Bulletin American College of Surgeons ScholNeawsrships

Inner courtyard of the Women’s Clinic Maistrasse at Ludwig Maximilian University, Campus Innenstadt, Munich.

the German Society of Senology turnover. With each turnover for me. She and her staff are (Deutsche Gesellschaft für well below 30 minutes, and clearly committed to making Senologie, DGS) developed some even less than 15 minutes, the visiting Fellow’s experience evidence-based clinical guidelines I saw a very different workflow a rich and rewarding one. and a program for breast center than I have seen in the U.S. Also certification approximately 10 impressive was the large amount years ago. More than 70 percent of natural light in the ORs. Munich—Ludwig of women with breast cancer The HELIOS Klinik breast Maximilian Universität in Germany are now estimated center enrolls many patients Munich was the next stop. I was 96 | to receive their diagnostic in clinical trials. Two of the fortunate to spend several days and therapeutic interventions five patients I saw in the with the Ludwig Maximilian in a certified breast center. OR were participating in a Universität (LMU) Breast Center Continuous quality improvement therapeutic clinical trial. team at both clinical sites: includes monitoring adherence The following day I visited Campus Innenstadt and Campus to guideline recommendations the Langenbeck-Virchow-Haus to Grosshadern. The Women’s Clinic and process quality indicators. see the DGC’s headquarters (see at Campus Innenstadt is housed Of note, breast cancer surgery in photo, page 95). I received a very in buildings dating to 1916 (see Germany is a clinical domain of kind reception from Rosmarie photo, this page). Many of the gynecology, rather than general Nowoiski, PhD, director of the decorations, clocks, and door surgery as it is in the U.S. DGC. She took time away from inscriptions are the originals. The My first clinical visit was at preparing for the upcoming buildings are constructed around the HELIOS Klinik in Berlin- conference to provide me with a tranquil courtyard and fountain, Buch. Here I was greeted by historical information about the with patient rooms facing inward the chefartz (chief), Prof. Dr. society and the building in which to shield against outside noise. med. Michael Untch, and by it is housed. The DGC first began Open terraces also invite patients oberärztin (attending) Dr. med. hosting meetings in this building to sit outside and take in fresh Christine Mau. After participating in 1915. Following World War II, air. The more modern Campus in the morning report, I was the building became the property Grosshadern constitutes one of thrilled to spend the day in the of the German Democratic the largest hospital complexes and operating room (OR) assisting Republic. The DGC regained teaching institutions in Germany. Dr. Mau. We performed five ownership of the building in Prof. Dr. med. Nadia Harbeck, breast operations, including one 2003, along with the original director of the Breast Center, with intraoperative radiation co-owners, the Berlin Medical made the arrangements for therapy. It was interesting to Society, after a protracted legal my visit. Through interactions observe minor differences in battle. Dr. Nowoiski provided a in the clinic and the OR, I technique. However, most tour of the building and helped was able to observe a high- fascinating was the rapid OR arrange additional meetings functioning multidisciplinary

V98 No 10 Bulletin American College of Surgeons Scholarships

Dr. Schroen with Professor Norbert Senninger at the German Surgical Society President’s Dinner held in the former royal residence in Munich. team. Interestingly, most of the Brigitte Ehrl, breast center nurse Prof. Dr. med. Hans-Joachim gynecologists whom I met had and patient navigator, provided. Meyer, DGC Secretary-General, developed a particular focus also met with me. I very much within breast care, enabling appreciated his time and our them to work together as a 130th Congress of the DGC discussion on the challenges team. Some physicians devote The 130th Congress of the of surgical training in the face their time primarily to medical DGC took place in Munich of work-hour restrictions and therapies and clinical trials, this year with more than 8,000 the challenges of keeping large, others to breast surgery and surgeons and surgical trainees in general surgical conferences reconstruction, and one other to attendance. The first morning, relevant in the setting of image-guided procedures. Again, I presented highlights from increasing subspecialization. a robust portfolio of clinical trials my research in a talk titled The opening ceremonies of was available to patients, and Rethinking Phase III Oncology the DGC Congress took place | 97 offering clinical trial participation Clinical Trial Accrual: Predictors in the assembly hall of the was notably a priority. of Accrual Success. The session on Ludwig Maximilian University. In addition to spending clinical trials was very interesting, The presidential address of considerable time with Prof. and I learned about the successes Prof. Dr. med. Karl-Walter Harbeck, I had the pleasure of and challenges surrounding Jauch introduced the themes of meeting with Oberärztinnen surgical trials in Germany. the conference. The primary Dr. med. Rachel Würstlein Updates on two surgical theme focused on strengthening and Dr. med. Isabelle Himsl. studies nearing completion, professionalism and retaining Through their clinics and PROUD and Synchronous, were public trust through passion and multidisciplinary tumor board given, as were presentations on judgment (sachliche Leidenschaft meetings, I learned about ChirNet and the Studienzentrum und distanziertes Augenmass). the delivery of breast cancer der Deutschen Gesellschaft für Economic pressures and increased screening, treatment plans, Chirurgie (SDGC) in Heidelberg. competition were depicted as and survivorship care in the (I would travel to Heidelberg burdening the specialty’s sense German health care system. Our later to learn more about these of professionalism and, in part, discussions regarding various programs.) Prof. Dr. med. contributing to a recent scandal practice differences between Norbert Senninger, FACS, ACS among certain transplant centers the U.S. and Germany, such Governor for Germany, kindly in Germany. Regaining and as the higher mastectomy rate attended my presentation. As the maintaining public trust would for early stage breast cancer in primary contact for the American require greater accountability, the U.S. and the central role of Traveling Fellows to Germany, more balanced resource the primary care physician in Prof. Senninger also met with me distribution, and further emphasis delivering survivorship care at the start of the conference to on transparent patient outcomes. in Germany, were thought- answer my questions with regard A secondary theme involved provoking. Furthermore, I am to the conference and to ensure care of an aging population. thankful for the time and sample that I was included in all social Although many operations patient resources that Frau events (see photo, this page). have now been shown to be

OCT 2013 Bulletin American College of Surgeons Scholarships

Our discussions regarding various practice differences between the U.S. and Germany, such as the higher mastectomy rate for early stage breast cancer in the U.S. and the central role of the primary care physician in delivering survivorship care in Germany, were thought-provoking.

safely performed even in elderly Alimentary Surgery (Deutsche I presented my research on patients, the surgeon must Gesellschaft für Allgemein- und cancer clinical trial accrual to remain forthright about potential Viszeralchirurgie). The mood their extended team involved complications of and alternatives remained celebratory throughout in clinical trial design and to surgery. Both themes the evening not only due to drink management, as well as surgery developed in this excellent address and camaraderie, but also the residents learning about clinical underscored that our profession 3–0 victory of FC Bayern over trial research. I found our faces similar challenges in the Barcelona in a semi-final game discussions about their processes U.S. and in Germany, despite the of the European Champions for trial concept prioritization differences in health care systems. League soccer tournament. At and design highly informative. The diverse and interesting the conclusion of the Congress, Their processes include formal scientific program concluded I had the honor of attending the systematic literature reviews with special presentations on president’s dinner at the former for each research question, navigating risk and uncertainty. royal residence in Munich. Having with staff dedicated to this Thomas Huber, a professional my father, a Munich native, function. I found this aspect of extreme mountain climber from accompany me to this elegant their operations particularly 98 | Bavaria, gave an inspiring yet gala was a once-in-a-lifetime impressive. Government grant humorous talk on his experiences opportunity (see photo, page 99). funding is commonly sought seeking out the most challenging to support individual trials. In peaks and his personal battle addition to funding, a challenge with cancer. Prof. Dr. Gerd Heidelberg—Studienzentrum for clinical trials in Germany Gigerenzer, director of the Max der Deutschen Gesellschaft includes improving follow- Planck Institute for Human für Chirurgie up compliance. Most patient Development and former visiting After hearing presentations on care after a primary surgical or professor and fellow at my home the Study Center of the German oncologic treatment is completed institution of the University Surgical Society (Studienzentrum reverts to the local primary care of Virginia, Charlottesville, der Deutschen Gesellschaft für physician. I found their efforts to delivered a keynote address Chirurgie—SDGC) and ChirNet conduct well-designed surgical on The Illusion of Certainty. at the Congress, I was delighted trials very laudable and anticipate Professor Gigerenzer spoke on to obtain an invitation to visit that this visit has initiated an how common misunderstanding this program at the University of enduring exchange of ideas. and, in some cases, deliberate Heidelberg. Now in its 10th year, misrepresentation of cancer the SDGC conducts randomized statistics influence medical controlled trials investigating International fellowship decision making and resource use. surgical therapies, techniques, and I extend my thanks to the ACS The conference also featured materials. ChirNet is a network and its International Relations several memorable social events. of eight regional surgical centers Committee for a motivating I participated in a 6K race providing infrastructure for and enlightening experience. through the English Gardens, the implementation of patient- The professional friendships organized to heighten awareness oriented clinical trials in surgery. and collaborative opportunities about organ donation, followed Inga Rossion, physician and forged through this fellowship by a festive evening in the business director of the SDGC, surely represent a highlight Augustinerkeller hosted by the and Dr. med. Markus Diener in my academic career. I German Society for General and were my hosts for this visit. am deeply grateful to Prof.

V98 No 10 Bulletin American College of Surgeons Scholarships

Dr. Schroen and her father, Walter Schroen, enjoying the German Surgical Society’s black-tie gala in the Residenz, Munich.

Senninger, the German Surgical whom are former ACS traveling in the College’s international Society, and my hosts in Berlin, fellows, provided to me. My fellowships. Attending our Munich, Heidelberg, and Neu- gratitude certainly extends to visiting fellows’ presentations Isenburg for welcoming me my colleagues at the University at the ACS annual Clinical to their organizations and of Virginia and my husband for Congress, hosting an allowing me to learn about making my month-long absence international fellow, or their professional activities. I from work and home possible. applying for an ACS traveling appreciate the encouragement Based on this experience, fellowship support the to pursue a traveling fellowship I strongly encourage my important mission of fostering that my chairman, Irving Kron, American colleagues to scholarship and forging MD, FACS, and division chief, visit surgical institutions in professional associations.  Reid Adams, MD, FACS, both of Germany and to participate | 99

2013 tqip aNNual meetiNg Save the Date aNd traiNiNg November 17–19, 2013 arizona Biltmore | Phoenix, az www.acstqip.org

OCT 2013 Bulletin American College of Surgeons Meetings calendar

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit http://www.facs.org/cmecalendar/index.html or http://web2.facs.org/ChapterMeetings.cfm

Maryland Chapter October November 9 January Sheraton Inner Harbor A CS Clinical Congress Baltimore, MD Louisiana Chapter October 6–10 Contact: Jennifer Starkey, January 17–19, 2014 Washington, DC [email protected] New Orleans, LA www.facs.org/ClinCon2013 Contact: Janna Pecquet, Arizona Chapter [email protected], Minnesota Surgical Society— November 9–10 http://www.laacs.org/ a Chapter of the ACS Phoenix, AZ October 18—19 Contact: Joni L. Bowers, Alexandria, MN [email protected], Southern California Chapter Contact: Nonie Lowry, http://www.azacs.org/ January 17–19, 2014 [email protected] Santa Barbara, CA Contact: Jim Dowden, [email protected], DECember http://www.socalsurgeons. November org/acs/index.html Brooklyn-Long Island Chapter 100 | Connecticut Chapter December 4 November 1 Uniondale, NY Farmington, CT Contact: Teresa Barzyz, Future Clinical Contact: Chris Tasik, [email protected], Congresses [email protected], http://ctacs.org/ http://www.bliacs.org/

Keystone Chapter Massachusetts Chapter 2014 November 8 December 7 October 26–30 Danville, PA Boston, MA San Francisco, CA Contact: Lauren Ramsey, Contact: Crystal Beatrice, [email protected], [email protected], 2015 http://www.keystonesurgeons.org/ http://www.mcacs.org/ October 4–8 Chicago, IL Wisconsin Surgical Society— New Jersey Chapter a Chapter of the ACS December 7 2016 November 8 Iselin, NJ October 16–20 Kohler, WI Contact: Andrea Donelan, Washington, DC Contact: Terry Estness, [email protected], [email protected], http://www.nj-acs.org/index.html http://www.wisurgicalsociety.com/

V98 No 10 Bulletin American College of Surgeons