JANUARY 2010 Volume 95, Number 1

FEATURES Stephen J. Regnier The role of civilian surgical teams Editor in response to international disasters 13 Linn Meyer Susan M. Briggs, MD, MPH, FACS Director, Division of 2010 Medicare Physician Fee Schedule final rule Integrated Communications contains important changes 18 Tony Peregrin Vinita Ollapally, JD Associate Editor Meeting the challenge—A surgeon-centered quality program: Diane S. Schneidman The American Society of Breast Surgeons Contributing Editor Mastery of Breast Surgery Pilot Program 23 Tina Woelke Alison L. Laidley, MD, FACS, FRCSC; Eric B. Whitacre, MD, FACS; Howard C. Snider, MD, FACS; and Shawna C. Willey, MD, FACS Graphic Design Specialist Alden H. Harken, Highlights of the 95th annual Clinical Congress 31 MD, FACS ACS Officers and Regents 46 Charles D. Mabry, MD, FACS Jack W. McAninch, MD, FACS Editorial Advisors DEPARTMENTS Tina Woelke Front cover design Looking forward 4 Editorial by David B. Hoyt, MD, FACS, ACS Executive Director Future meetings What surgeons should know about... 6 Current Procedural Terminology changes for 2010 Clinical Congress Albert Bothe, Jr., MD, FACS; Linda M. Barney, MD, FACS; 2010 Washington, DC, and Debra Mariani, CPC October 3-7 What surgeons should know about... 9 2011 San Francisco, CA, 2010 changes to Medicare payment for consultation services October 23-27 Elizabeth Hoy, MHA 2012 Chicago, IL, September 30– October 4

Letters to the Editor should be sent with the writer’s name, address, e-mail ad- dress, and daytime tele- phone number via e-mail to [email protected], or via mail to Stephen J. Regnier, Editor, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or On the cover: Civilian surgeons have worked with military teams throughout clarity. Permission to publish letters is assumed unless the history, and continue to offer significant aid today, during times of national need author indicates otherwise. such as war or international disasters. (See article, page 13.) NEWS Bulletin of the American College of Surgeons (ISSN David B. Hoyt, MD, FACS, 0002-8045) is published becomes ACS Executive Director monthly by the American Col- 50 lege of Surgeons, 633 N. Saint College supports American Cancer Society Clair St., Chicago, IL 60611. It screening mammography guidelines 51 is distributed without charge to Fellows, Associate Fellows, Call for nominations for the ACS Board of Regents 53 Resident and Medical Student Members, Affiliate Members, Call for nominations for ACS Officers-Elect 53 and to medical libraries and al- lied health personnel. Periodi- cals postage paid at Chicago, Heller School Executive Leadership IL, and additional mailing Program scholarships available 54 offices. POSTMASTER: Send address changes to Bulletin of Nominations sought for 2010 the American College of Sur- volunteerism and humanitarian award 55 geons, 633 N. Saint Clair St., Chicago, IL 60611-3211. Cana- ACOSOG news: dian Publications Mail Agree- Patient advocates: “Our job is purely about patient safety” 57 ment No. 40035010. Canada Heidi Nelson, MD, FACS; and David M. Ota, MD, FACS returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. ACS leaders visit key senators 58 The American College of Surgeons’ headquarters is Report on ACSPA/ACS activities, October 2009 59 located at 633 N. Saint Clair Michael J. Zinner, MD, FACS St., Chicago, IL 60611-3211; tel. 312-202-5000; toll-free: A look at The Joint Commission: 800-621-4111; fax: 312-202- 2009 Eisenberg Award recipients named 63 5001; e-mail:postmaster@ facs.org; Web site: www.facs. Letters 66 org. Washington, DC, office is located at 1640 Wisconsin NTDB® data points: Annual Report 2009: A hip report 71 Ave., NW, Washington, DC 20007; tel. 202-337-2701, fax Richard J. Fantus, MD, FACS; and Avery B. Nathens, MD, PhD, FACS 202-337-4271. Unless specifically stated otherwise, the opinions ex- pressed 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.

©2010 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

Looking forward

am excited to have been selected to serve as the next Executive Director of the American

College of Surgeons, and I look forward to

I getting to know the staff, the leaders, and as many Fellows as possible during the next few months. There has never been a better time in medicine ’’ to deliver the highest quality surgical care. We can do more for our patients than has ever been possible in the past. However, we also have many complex and difficult issues facing us, and we have much work to do. We have become an As I take over this responsibility, I am humbled by the comprehensive and transformative ac- organization that offers complishments Tom Russell has achieved over the last 10 years. As a salute to him, I would something for everyone. like to highlight some of the important things he accomplished during his 10 years of service Tom let people in. and the values he used to lead us. First, Tom gave a new face to the College’s leadership and to American surgery. His positive ’’ force of personality and enthusiasm for what we do every day as surgeons created an inspiring leadership model. Tom’s success rests on the to finding the leaders to carry out the plan, Tom fact that he truly believes surgeons strive for believed in the importance of us moving forward excellence in providing care for their patients, on as a profession. an understanding of what surgeons need if they Today, we are measuring quality outcomes are to continue to achieve that end, and on the and developing clinical trials like never before. conviction that the College’s role is to provide We have embraced patient safety, educational support to its member surgeons to help them reform, and even some limitations on the work achieve that goal. we do. From these changes has emerged the When I would run into Tom at a meeting, he value of teamwork, and we have broadened our would always be complimentary about my surgi- attractiveness to young people and women in cal colleagues and have something positive to say, particular. We have seen educational and com- or he would make some positive comment about munications programs flourish, and activities our challenges and/or our accomplishments. His focusing on professionalism, leadership develop- positive attitude may be his greatest legacy. His ment, and volunteerism have emerged in a way enthusiasm rubbed off on our member surgeons that is unparalleled in our College’s history. We and encouraged them to share their ideas and have become an organization that offers some- to participate in our discussions and activities. thing for everyone. Tom let people in. Tom made them feel their voices were heard and Tom looked out for the individual surgeon and that someone in leadership truly was listening. his or her practice in this complex world. He Participation by Fellows has never been stronger has stressed that surgeons have to work with in College activities due to this openness. the other members of the medical community Tom Russell is a steward of change. Change is in order to achieve what is best for our patients. not easy, and requires vision and follow through He has supported what is best for surgeons by to bring it about. From developing the frame- advocating for us on many difficult and challeng- work for the strategic plan he brought forth to ing socioeconomic issues. He has built bridges the Regents for review and discussion, which throughout the house of medicine and among all determined how the College is now organized, players in the health care field. He is respected 4

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS broadly as a thinker, a leader, and a collabora- previous Directors of the American College of tor in dealing with issues such as quality, ef- Surgeons as I have learned what each of them fectiveness, tort reform, payment reform, and has accomplished. The era of leadership under the surgical workforce—issues important to all Tom Russell has brought us to the forefront of surgeons. The new home for our Washington, the modern world of medicine. He has set the DC, office and the focus on health policy will tone for going forward, and attitude is every- be critical to maintaining our leadership role. thing. Along with our headquarters in Chicago, IL, our Tom: On behalf of the Fellowship and the enhanced presence in our nation’s Capitol will leadership, thanks for all that you have done. make us ideally positioned to lead and advocate To Fellows of the College: I promise I will for surgery at the broadest level. work hard to continue this tradition. I welcome During the last 10 years, there have been sev- your thoughts, your ideas, expression of your eral additional programs that owe their success fears, and your criticisms going forward. to Dr. Russell’s leadership and his relationship Please don’t hesitate to contact me by mail, with the Regents, the Governors, the Officers, e-mail, or phone, and please stop by the office if the members, and the staff. you are in town. I have developed great admiration for all the

David B. Hoyt, MD, FACS

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at [email protected]. 5

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

Current Procedural Terminology changes for 2010 by Albert Bothe, Jr., MD, FACS; Linda M. Barney, MD, FACS; and Debra Mariani, CPC, Practice Affairs Associate, Division of Advocacy and Health Policy

his article summarizes changes in the 2010 Current Procedural Terminology (CPT)* Consultation codes and CMS Tcodebook that are relevant to general Beginning January 1, the Centers for Medicare & surgery and closely related specialties. This in- Medicaid Services (CMS) will eliminate the use of formation should be useful not only to surgeons, all consultation codes (inpatient and office/outpa- but also to the office staff performing coding tient codes for various places of service except for functions. telehealth consultation G-codes). Please take special care this year to note that The details of this change can be found in the final several CPT codes are intentionally out of nu- payment rules published in the Federal Register on merical sequence. Resequencing is used to allow November 25, 2009, entitled “Payment Policies un- placement of related codes in appropriate con- der the Physician Fee Schedule for CY 2010.” CMS ceptual locations, regardless of the availability of is implementing this change in a manner that will be “budget neutral” and therefore will not increase sequential numbers. The resequenced codes are or decrease overall physician expenditures under identified with the “#” symbol and with a refer- Medicare. Therefore, CMS will increase the work ence placed numerically as a means of directing relative value units (RVUs) for new and established readers to the location of the reordered code. For office visits by 6 percent and increase the work RVUs example, see CPT code 21554 in the 2010 CPT for initial hospital and initial nursing facility visits Professional Edition Codebook. by 0.3 percent. Physicians will use these codes in place of consultation codes for all Medicare patients. Integumentary system CMS is also incorporating the increased value of the E/M codes into E/M visits included in 10- and CPT code 14300 has been deleted and replaced 90-day global procedures. This rule will require physicians to cease submitting the consultation with codes 14301 and add-on code +14302. codes on their Medicare claims only, and to employ These codes have been established to more ac- the appropriate visit codes in their place. The con- curately distinguish extensive adjacent tissue sultation codes are still valid codes for non-Medicare transfer services from existing codes: CPT code payors. You should consult third-party payors about 14301, Adjacent tissue transfer or rearrange- their payment policy. ment, any area; defect 30.1 sq cm to 60.0 sq cm For more information, see the related articles on and +14302, Adjacent tissue transfer or rear- pages 9 and 18. rangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). Use 14302 in conjunction with 14301. ous new codes and revisions in the “Excision” category for each body area related to soft tissue Musculoskeletal system tumor excisions, including the following: • Under “Head” there are five new codes and Throughout the musculoskeletal system sub- one revision; see codes 21011– 21016. section of the CPT Codebook there are numer- • Under “Neck (Soft Tissues) and Thorax” •All specific references to CPT (Current Procedural Terminology) there are three new codes and three revisions; terminology and phraseology are © 2010 American Medical see codes 21552–21558. Association. All rights reserved. • Under “Back and Flank” there are four new 6

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS codes and two revisions; see codes 21930–21936. Cardiovascular system • Under “Abdomen” there are five new codes and one revision; see codes 22900–22905. CPT has revised one code and created one • Under “Shoulder” there are three new codes new code to distinguish standard from radical and six revisions; see codes 23071–23078 and ligation of perforator veins. The revised code is codes 23200–23220. CPT code 37760, Ligation of perforator veins, • Under “Humerus (Upper Arm) and Elbow” subfascial, radical (Linton type), including skin there are three new codes and five revisions; see graft, when performed, open, 1 leg. For endo- codes 24071–24079 and codes 24150–24152. scopic procedure, use 37500. The new CPT code • Under “Forearm and Wrist” there are is 37761, Ligation of perforator vein(s), subfas- three new codes and four revisions; see codes cial, open, including ultrasound guidance, when 25071–25078 and code 25170. performed, 1 leg. Do not report 37760, 37761 in • Under “Hand and Fingers” there are three conjunction with 76937, 76942, 76998, 93971. new codes and six revisions; see codes 26111– If you perform this procedure bilaterally, code 26118 and codes 26250–26262. 37761 with modifier –50 (Bilateral Procedure). • Under “Pelvis and Hip Joint” there are For endoscopic ligation of subfascial perforator three new codes and seven revisions; see codes veins, use 37500. 27043–27059 and codes 27075–27078. • Under “Femur (Thigh Region) and Knee Digestive system Joint” there are three new codes and four revi- sions; see codes 27327–27339 and codes 27329– CPT 2010 has two new codes for laparoscopic 27365. repair of paraesophageal hernias. CPT 43281, • Under “Leg (Tibia and Fibula) and Ankle Laparoscopy, surgical, repair of paraesophageal Joint” there are three new codes and eight revi- hernia, includes fundoplasty, when performed; sions; see codes 27615–27634 and 27640–27647. without implantation of mesh, and CPT code • Under “Foot and Toes” there are three new 43282, Laparoscopy, surgical, repair of para- codes and six revisions; see codes 28039–28047, esophageal hernia, includes fundoplasty, when also 28171–28175. performed; with implantation of mesh. For There is a new CPT code for multi-layered transthoracic paraesophageal hernia repair, use dressings used for difficult lower leg wounds. It code 39520. For transabdominal paraesophageal is 29581, Application of multi-layer venous wound hernia repair, use code 39502. Do not report compression system, below knee. Do not report 43281, 43282 in conjunction with 43280, 43450, 29581 in conjunction with 29540, 29580. 43453, 43456, 43458, 49568. These codes have a 90-day global period. Thoracic surgery • Bariatric surgery. CPT has a new code for bariatric surgery, 43775, Laparoscopy, surgical, CPT has created two new codes and revised one gastric restrictive procedure; longitudinal gas- code. The CPT code 32560 now reads as 32560, trectomy (ie, sleeve gastrectomy). For open gastric Instillation, via chest tube/catheter, agent for restrictive procedure, without gastric bypass, pleurodesis (eg, talc for recurrent or persistent for morbid obesity, other than vertical-banded pneumothorax). The new CPT codes are 32561, gastroplasty, use code 43843. The code 43775 has Instillation(s), via chest tube/catheter, agent for a 90-day global period. fibrinolysis (eg, fibrinolytic agent for break up of • Colorectal surgery. Two new CPT codes have multiloculated effusion); initial day, and 32562, been created to reflect the depth of the excision Instillation(s), via chest tube/catheter, agent for by replacing the deleted CPT code 45170 (Exci- fibrinolysis (eg, fibrinolytic agent for break up sion of rectal tumor, transanal approach). 45171, of multiloculated effusion); subsequent day. All Excision of rectal tumor, transanal approach; three codes use the same parenthetical: (For not including muscularis propria (ie, partial chest tube insertion, use 32551). And all three thickness), and 45172, Excision of rectal tumor, codes have a zero-day global billing period. transanal approach; including muscularis pro- 7

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS pria (ie, full thickness). For destruction of rectal has changed and now all end with the following tumor, transanal approach, use 45190. Also in the sentence: Digestive System subsection for Anus under the heading “Excision,” see CPT codes 46200–46288. Physicians typically spend minutes at the The section containing hemorrhoid procedures bedside and on the patient’s facility floor or unit. has been extensively revised and is resequenced. This section includes 14 revised codes. Prolonged physician service

Evaluation and management (E/M) Guidelines under the Prolonged Physician Service Without Direct (Face-To-Face) Patient • Consultations: Inpatient and outpatient. Contact have been revised (codes 99358 and The guidelines for consultations and inpatient 99359). There is clarification that prolonged ser- consultations have changed. vices may be reported on a different date than the The consultation definition included within primary service to which it is related. Also, the the introductory notes under the Evaluation add-on code status was removed from code 99358, and Management section subheading, “Consul- Prolonged evaluation and management service tations,” has been revised to outline the two before and/or after direct (face-to-face) patient circumstances under which consultations pro- care (eg, review of extensive records and tests, vided at the request of another physician or ap- communication with other professionals and/or propriate source may be rendered: (1) to provide the patient/family); first hour (List separately in an opinion and services for a specific condition addition to code(s) for other physician service(s) or problem, or (2) to allow a determination to and/or inpatient or outpatient Evaluation and be made whether to accept the ongoing manage- Management service).  ment of the patient’s entire care or for the care of a specific condition or problem (for example, transfer of care). Documentation of the written or verbal request for a consultation may be accomplished by either the consultant or by the requesting physician or other appropriate source. These new guidelines also clarify the reporting of services provided to a patient who is admitted to a hospital or nursing facility in the course of an encounter in the office or other ambulatory facility. Please review the new guidelines for Inpatient Consultations. The CPT Codebook explains how to code for certain circumstances that involve places of service. • Transfer of care. Services that constitute transfer of care (for example, services that are provided for the management of the patient’s entire care or for the care of a specific condition or problem) are reported with the appropriate new or established patient codes for office or Dr. Bothe is chief quality officer, Geisinger Health System, Danville, PA. other outpatient visits, domiciliary, rest home services, or home services. Dr. Barney is associate professor and associate program • Nursing facility services. All the codes director for general surgery, department of surgery, under the Nursing Facility Services section of Wright State University Boonshoft School of Medicine, the E/M section have been revised to clarify the and member, Wright State Surgeons, Miami Valley Hos- time component. The descriptor for each code pital, Dayton, OH. 8

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

2010 changes to Medicare payment for consultation services by Elizabeth Hoy, MHA, Assistant Director, Regulatory Affairs and Quality Improvement Programs, Division of Advocacy and Health Policy

he final rule on 2010 Medicare physician cially under these rules as under the previous payment contains a significant change in system of consult codes, because of the increase Tbilling practices for consultation codes. in work RVUs for office and hospital visits and This article explains what surgeons and their the impact of increases in RVUs for practice ex- billing staffs will need to do in order to comply pense and medical liability. CMS estimates the with the rule. Other highlights of the regulation, combined effect of these changes will be approxi- which was published in the Federal Register on mately +1 percent in 2010 for general surgeons. November 25, 2009, is summarized in the article on page 18 of this issue. Medicare previously prohibited anyone but the attending physician from billing What did Medicare change about billing for an initial hospital visit or initial nursing consultation codes? home visit. Has that changed?

Beginning January 1, the Centers for Medicare Yes. CMS has created a modifier (–AI) to iden- & Medicaid Services (CMS) will eliminate the use tify the admitting physician of record for hospital of all consultation codes (inpatient and office/ inpatient and nursing facility admissions. For op- outpatient codes for various places of service erational purposes, this modifier will distinguish except for tele-health consultation G-codes) on the admitting physician of record who oversees a budget-neutral basis. To compensate for this the patient’s care from other physicians who change, CMS is increasing the work relative value may be furnishing specialty care. The admitting units (RVUs) for new and established office visits, physician of record will be required to append the increasing the work RVUs for initial hospital and –AI modifier to the initial hospital care or initial initial nursing facility visits, and incorporating nursing facility care code, which will identify him the increased use of these visits into practice or her as the admitting physician of record who expense and malpractice RVU calculations. is overseeing the patient’s care. For inpatient consultations, physicians will bill Subsequent inpatient care visits by all physicians an initial hospital visit or initial nursing facility will be reported as subsequent hospital care codes visit code for their first visit during a patient’s and subsequent nursing facility care codes. Ad- admission to the medical institution. In lieu of ditional outpatient care visits will be billed using outpatient consultation codes, physicians will established patient outpatient/office visit codes. bill either new or established patient office visit codes, depending on whether the patient has How do I choose which codes to bill? been seen for professional services within the practice in the last three years. You must comply Table 1 on page 10 shows the Current Proce- with existing guidelines for coding and billing dural Terminology (CPT)* guidelines for select- office visits. ing which level of consult code to bill. These are The American College of Surgeons anticipates the codes previously used to bill for consultation that most surgeons will do at least as well finan- services that will no longer be paid by Medicare. •All specific references to CPT (Current Procedural Terminology) Table 2 on page 10 shows the guidelines for se- terminology and phraseology are © 2010 American Medical lecting which level of office visit to bill. These Association. All rights reserved. are the codes you will have to select from to bill 9

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 1: CPT Evaluation and Management (E/M) services guidelines for consultations Physical Complexity of medical CPT estimate of HCPCS Description History exam decision making time (minutes) 99241 Office consultation pf pf str 15 99242 Office consultation epf epf str 30 99243 Office consultation det det low 40 99244 Office consultation comp comp mod 60 99245 Office consultation comp comp high 80 99251 Inpatient consultation pf pf str 20 99252 Inpatient consultation epf epf str 40 99253 Inpatient consultation det det low 55 99254 Inpatient consultation comp comp mod 80 99255 Inpatient consultation comp comp high 110

pf = Problem focused epf = Expanded problem focused det = Detailed comp = Comprehensive str = Straightforward decision making low = Low complexity decision making mod = Moderate complexity decision making high = High complexity decision making

Table 2: CPT E/M services guidelines for office and facility visits 2010 proposed Physical Complexity of medical CPT estimate of Description History HCPCS exam decision making time (minutes) 99201 Office/outpatient visit, new pf pf str 10 99202 Office/outpatient visit, new epf epf str 20 99203 Office/outpatient visit, new det det low 30 99204 Office/outpatient visit, new comp comp mod 45 99205 Office/outpatient visit, new comp comp high 60 99211 Office/outpatient visit, established N/A N/A N/A 5 99212 Office/outpatient visit, established pf pf str 10 99213 Office/outpatient visit, established epf epf low 15 99214 Office/outpatient visit, established det det mod 25 99215 Office/outpatient visit, established comp comp high 40 det or det or 99221 Initial hospital care comp comp str or low 30 99222 Initial hospital care comp comp mod 50 99223 Initial hospital care comp comp high 70 det or det or 99304 Nursing facility care, initial comp comp str or low 25 99305 Nursing facility care, initial comp comp mod 35 99306 Nursing facility care, initial comp comp high 45 10

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 3: Medicare payments for office and facility visits in 2010

2010 proposed 2010 proposed 2010 proposed pay HCPCSMod Description total RVUs (CF = 36.0666)†

99201 Office/outpatient visit, new 1.08 $38.95 99202 Office/outpatient visit, new 1.87 67.44 99203 Office/outpatient visit, new 2.71 97.74 99204 Office/outpatient visit, new 4.19 151.12 99205 Office/outpatient visit, new 5.28 190.43 99211 Office/outpatient visit, established 0.53 19.12 99212 Office/outpatient visit, established 1.08 38.95 99213 Office/outpatient visit, established 1.82 65.64 99214 Office/outpatient visit, established 2.73 98.46 99215 Office/outpatient visit, established 3.68 132.73 99221 Initial hospital care 2.72 98.10 99222 Initial hospital care 3.70 133.45 99223 Initial hospital care 5.42 195.48 99304 Nursing facility care, initial 2.33 84.04 99305 Nursing facility care, initial 3.27 117.94 99306 Nursing facility care, initial 4.17 150.40 †This table assumes that Congress will enact a freeze on Medicare payment rates for 2010. for consultation services beginning January 1. consideration that Medicare will no longer recog- Select the office visit code that most accurately nize consultation codes submitted on bills, whether reflects the level of history, physical exam, medi- those bills are for primary or secondary payment. cal decision making, and time involved in the If Medicare is the primary payor, physicians consultation. In unusual circumstances, when a must submit claims with the appropriate consultation extends beyond the usual service, visit code in order to receive payment from you have the option of reporting one of the pro- Medicare for these services. In these cases, longed physician services codes (99354–99357 physicians should consult with the secondary with face-to-face contact, or 99358–99359 with- payors in order to determine how to bill those out face-to-face contact). services to receive secondary payment. If Medicare is the secondary payor, physi- How will this affect payment by non- cians and billing personnel will first need to Medicare payors? determine whether the primary payor con- tinues to recognize the consultation codes. If CMS does not determine which services other the primary payor does continue to recognize third-party payors will recognize and reimburse. those codes, the physician will need to decide Some payors may choose to adopt the new CMS whether to bill the primary payor using visit policy subsequent to this final rule. In cases where codes, which will preserve the possibility of other payors do not adopt this policy, physicians receiving a secondary Medicare payment, or and their billing personnel will need to take into to bill the primary payor with the consulta- 11

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS tion codes, which will result in a denial of program requirements (per the Medicare instruc- payment for invalid codes by Medicare as the tions), resulting in improper payments. secondary payor. • Beginning January 1, 2008, CMS ceased to recognize office/outpatient consultation CPT What are the new payment rates for E/M codes for payment of hospital outpatient visits codes? under the outpatient prospective payment sys- tem. CMS instructed hospitals to bill a new or As proposed, this change will be implemented established patient visit CPT code, as appropriate in a budget-neutral manner, meaning that it will to the particular patient, for all hospital outpa- not increase or decrease aggregate Medicare phy- tient visits. sician fee schedule expenditures. CMS will make • “The payment for both inpatient consulta- this change budget-neutral for the work RVUs, tion and office/outpatient consultation services by increasing the work RVUs for new and estab- is higher than for initial hospital care and new lished office visits by approximately 6 percent to patient office/outpatient visits. However, the reflect the elimination of the office consultation associated physician work is clinically similar. codes, and the work RVUs for initial hospital and Many physicians contend that there is more work facility visits by approximately 0.3 percent, to involved with a new patient visit than a consulta- reflect the elimination of the facility consultation tion service because of the post work involvement codes. CMS is also increasing the incremental with a new patient.”* work RVUs for the E/M codes that are built into • “[T]he rationale for a differential payment the 10-day and 90-day global surgical codes. for a consultation service is no longer supported CMS is also implementing changes to practice because documentation requirements are now expense RVUs and medical liability RVUs. Table 3 similar across all E/M services.”* on page 11 shows the national Medicare payment rates for these services in 2010, taking all these How will this change affect 10-day and 90- changes into effect. day global payments?

Why did Medicare make this change? In our response to the proposed regulations, the ACS argued that CMS should increase the According to the final rule, CMS is basing this bundled payments for postoperative visits oc- change on the following points: curring over a 10-day or 90-day global period. • The American Medical Association and spe- We argued that arbitrarily changing the work cific national physician specialty societies have RVUs for some E/M codes without adjusting the repeatedly claimed that physicians are dissatis- E/M components of other procedural codes un- fied with CMS documentation requirements and dermines the relative value scale on which phy- guidance that distinguish a consultation service sician payment is based. CMS agreed with this from other E/M services, such as transfer of care. and increased the payments for those services. • CPT’s instructions pertaining to the defi- However, the increases in the payments for these nitions of a consultation, transfer of care, and 10-day and 90-day global services due specifi- documentation requirements are unclear and cally to this change are minor because visits are ambiguous. a relatively small proportion of the total global • A March 2006 report from the Office of the payment amount.  Inspector General indicated that Medicare al- lowed approximately $1.1 billion more in 2001 than it should have for services billed as consul- tations. Approximately 75 percent of services paid as consultations did not meet all applicable

*Federal Register. Available at http://www.federalregister.gov/ inspection.aspx#special. Accessed December 8, 2009. 12

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS by Susan M. Briggs, MD, MPH, FACS

13 istorically, civilian surgeons have pro- was so moved by the tragedy and the death of vided significant surge capacity, which more than 500 children that he subsequently has been critical to meeting medical devoted all his energy to the care of children needs during international disasters, and the establishment of pediatric surgery as H 2 both natural and man-made. Prior to the last his specialty. decade, war and natural disasters were the most frequent international disasters requiring civil- Challenges of disaster medical response ian surgical teams. In World War I, the fledgling American College of Surgeons and its founder, The demands of international disaster relief Franklin H. Martin, MD, FACS, played a major have changed over the past decade, both in the role in organizing the nation’s surgeons to aid in scope of medical care, the spectrum of threats, the war effort. American civilian surgical units and the field of operations. Increasingly, civilian were deployed in World War I more than two surgical teams are being asked to respond to years before the arrival of U.S. combat troops, complex international disasters, with a spectrum illustrating an appreciation of the necessity for of threats ranging from war to natural and man- medical preparedness in wartime. One of the made disasters, including terrorism.3–5 first civilian surgical units was stationed at the Many of today’s international disasters occur in Ambulance Americaine in Paris, France, under austere environments. An austere environment the leadership of George Crile, MD, FACS, and is a setting where access, transport, resources, Harvey Cushing, MD.1 or other aspects of the physical, social, economic, During World War II, the U.S. War Department or political environments impose constraints on again asked academic institutions to organize the adequacy of care for the population in need. surgical units that could be mobilized for active The provision of sophisticated surgical care in duty. The novel use in World War II of ancillary austere environments is a significant challenge surgical groups that could be rapidly mobilized for disaster providers. (See photo, page 15). and sent to installations in need of additional Contemporary international disasters follow surgical manpower has become a model for con- no rules. No one can predict the time, location, temporary civilian and military disaster medical or complexity of the next disaster. All disasters, response.1 regardless of etiology, have similar medical and Surgeons also have a rich history of medical public health concerns. A consistent approach to response to man-made disasters other than war. international disasters, based on an understand- On December 6, 1917, a French munitions ship ing of their common features and the response and a Norwegian relief steamship collided in the expertise they require, is becoming the accepted harbor of Halifax, Nova Scotia. The explosion practice throughout the world. This strategy —the largest man-made explosion until the is called the Mass Casualty Incident Response. Hiroshima bomb—killed more than 2,000 indi- Similar to the ABCs of trauma care, Mass Casu- viduals and injured more than 9,000. Teams of alty Incident Response includes four components: surgeons from the Northeast, including the re- search and rescue, triage and initial stabilization, nowned surgeon William E. Ladd, MD, provided definite medical care, and evacuation.4 much of the immediate medical relief. Dr. Ladd Surgeons are uniquely qualified to participate in all four aspects of disaster medical response Overleaf: Main photo: In the wake of the tsunami, because of their expertise in triage, care of Banda Aceh, Indonesia, 2004, civilian and military critical patients, and rapid decision making. surgical teams from many countries were part of the International civilian surgical disaster teams international disaster relief efforts. are designed and trained to provide specific Left-hand photos, top to bottom: (1) Bam, Iran, 3,5–7 site of a 2003 earthquake; (2) a U.S. civilian surgical functional areas of disaster care. team performing emergency surgery in Bam; Clinical competencies, not titles, determine (3) Field Hospital, U.S. IMSuRT, working after the the role of civilian surgeons in international di- Bam earthquake; (4) Search and rescue teams at work saster relief. The complexity of today’s disasters in the aftermath of an earthquake in Turkey, 1998. demands civilian and military surgical partner- 14

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In the aftermath of the Bam, Iran, earthquake: 15 countries, including the U.S., provided field hospitals with both civilian and military surgical teams.

ships, which are key to effective international generally include the following: disaster response. • A cadre of medical/surgical specialists • Technical specialists knowledgeable in haz- Search and rescue ardous materials, structural engineering, heavy equipment operation, and technical search and In disasters involving large numbers of vic- rescue methodology tims trapped in collapsed structures, the local • Trained canines and their handlers response team may lack the technical equipment and expertise to facilitate extraction of the vic- Triage and initial stabilization tims. Many countries, including the U.S., have developed specialized search and rescue teams as Triage is the most important—and often the an integral part of their national disaster plans. most psychologically taxing—mission of interna- Members of these teams, which receive special- tional disaster response teams, especially with ized training in confined space environments, disasters occurring in austere environments 15

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Left: A crush injury patient in the wake of the Bam earthquake.

Medical evacuation by civilian surgical teams utilizing converted military aircraft, El Salvador earthquake, 1989.

and involving a large number of casualties. complexity of today’s international disasters. Triage is the rapid categorization of victims at Disaster care is initially “minimally acceptable casualty sites by experienced medical personnel care” due to the large number and diversity of with knowledge of various injuries (for example, victims. Surgical care may be rendered at fixed burns, blast and crush injuries, and exposure or mobile facilities. Many countries have mobile to hazardous materials). (See left-hand photo, field hospitals with the full spectrum of surgi- this page.) cal care. In the U.S., the National Disaster Medical Sys- Definite medical care tem (NDMS) is part of the U.S. Federal Response Plan under the auspices of the Department of The increasing need for multidisciplinary sur- Health and Human Services. The NDMS has gical teams to assist in international disasters created three rapidly deployable international is rapidly expanding due to the diversity and disaster teams, called International Medical 16

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical Response Teams (IMSuRTs). Each team stitute a successful disaster response. Surgeons is sponsored by an academic trauma center: Mas- must be clinically competent and understand the sachusetts General Hospital, Boston,MA; Ryder general principles of disaster response such as Trauma Center, Miami, FL; and Harborview Medi- incident command, disaster triage, and decon- cal Center, Seattle. WA.3,7 tamination. Intercultural effectiveness remains The IMSuRT teams are composed of multi- the ultimate key to successful international disciplinary surgical specialists and designed to disaster response.  provide the full spectrum of medical care at the disaster site, especially in austere environments. References Each team possesses a deployable, rapid assem- bly field hospital with the capacity for initial 1. Churchill, ED. Surgeon to Soldiers. Philadelphia, PA: J.B. Lippincott Company; 1972. stabilization, operative interventions, critical 2. Nance ML. The Halifax disaster of 1917 and the care, and evacuation. The team logistical cache birth of North American pediatric surgery. J Ped contains flexible and mobile equipment and sup- Surg. 36(3):405-408, 2001. plies, including ventilators, monitors, ultrasound 3. Briggs SM, Schnitzer JJ. The World Trade Center 3,7 terrorist attack: Changing priorities for surgeons in machines, blood, and pharmaceuticals. disaster response. Surgery. 2001;132(3):506-512. 4. Briggs SM, Brinsfield KH. Advanced Disaster Evacuation Medical Response, Manual for Providers. Boston, MA: Harvard Medical Press; 2003. Evacuation can be useful in a disaster as a 5. Born CT, Briggs SM, Ciraulo DL, Frykberg ER, Hammond JS, Hirshberg A, Lhowe DW, O’Neill means of decompressing the disaster scene. PA: Disasters and mass casualties: I. General Evacuation of victims with serious injured principles of response and management. J Am casualties to off-site medical facilities not only Acad Orthop Surg. 2007;15(7):388-396. improves their chances of survival but also 6. Lhowe DW, Briggs SM: Planning for mass civilian ca- sualties overseas: IMSuRT-International Medical/ allows increased attention to the remaining Surgical Response Teams. Clin Orthop Relat Res. casualties at the disaster site. (See right-hand 422:109-113, 2004. photo, page 16.) 7. Schnitzer JJ, Briggs SM. Earthquake relief: The U.S. medical response in Bam, Iran. N Eng J Med. Conclusion 2004;350(12):1174-1178.

International disaster response presents unique challenges: geographic, organizational, ethnic, cultural, and political. Politics, more than a lack of personnel or the availability of supplies and equipment, often limit the ef- fectiveness of international disaster response. The political players might include the affected Dr. Briggs is associ- ate professor of surgery country, other donor governments, international at Harvard Medical relief organizations such as the United Nations, School, and director and not-for-profit organizations. Too often the of the International needs of the international relief organizations, Trauma and Disaster not the medical needs of the disaster, dictate Institute, Massachu- the international response, further complicating setts General Hospital, the disaster scene. Rapid assessment of disaster Boston, MA. needs by experienced disaster responders should determine the need for civilian surgical teams to provide surge capacity. Today’s civilian surgeons continue a century- old tradition of excellence in international disas- ter response. Good intentions alone do not con- 17

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he Centers for Medicare & Medicaid Services (CMS) Treleased the Medicare phy- 2010 sician fee schedule final rule for calendar year (CY) 2010 on Octo- Medicare ber 30, 2009. This final rule enacts physician fee schedule certain concepts set forth in the Medicare physician fee sched- final rule ule proposed rule issued early last summer. The final rule also contains responds to comments that the American College of Surgeons and important changes other physician groups submitted regarding the proposed rule. by Vinita Ollapally, JD, This article summarizes key Senior Regulatory Associate, provisions of interest to surgeons Division of Advocacy and Health Policy and describes the College’s views on these provisions.

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2010 conversion factor rent practice patterns. Up-to-date and accurate The final rule states that the update to the data are needed for all specialties. The report also physician fee schedule conversion factor (CF) is notes that concerns have been raised regarding a little less than –21.3 percent for CY 2010. This the use of the SMS data to derive PE RVUs. The results in a reduction in the current CY 2009 CF SMS data represent practice costs from 1995 to of $36.0666 to the CY 2010 CF of $28.4061. This 1999, and do not account for the increased costs 21.2 percent cut is required by the Balanced Bud- that practices now face. get Act of 1997, which established the sustainable growth rate (SGR) formula. However, at press Physician-administered drugs time, Congress was expected to intervene to block and the definition of “physician services” this payment cut. The final rule implements CMS’ proposal to remove physician-administered drugs from the E/M codes for consultations definition of “physician services” for the purposes Effective January 1, CMS will eliminate the use of computing the SGR and levels of allowed ex- of all evaluation and management (E/M) codes for penditures and actual expenditures in all future consultations, directing specialists to instead bill years. CMS also finalized its proposal to remove office, hospital, and nursing home visit E/M codes physician-administered drugs from the calculation for both new and established patients. However, of allowed and actual expenditures for all prior CMS is also increasing the payment for office, hos- years. This change would not affect the nearly pital, and nursing home visit E/M codes to offset –21.3 percent update for CY 2010, but would likely the change for disallowing consultation codes. For reduce the number of years in which physicians more information, see page 9 of this issue, “What are expected to receive a negative update. surgeons show know about...2010 changes to Medi- The College strongly supported CMS’ proposal care payment for consultation services.” to remove physician-administered drugs from the definition of “physician services” for the purposes Practice information survey of computing the SGR, and agreed that the inclu- The final rule implements CMS’ proposal to use sion of drugs has had a significant and dispropor- the American Medical Association (AMA) Physi- tionate effect on the SGR system. Physician fee cian Practice Information Survey (PPIS) in place schedule rates are updated using the SGR formula, of the AMA’s Socioeconomic Monitoring Survey which requires that growth in total expenditures (SMS) data and supplemental survey data to de- for physicians’ services be limited to sustainable velop practice expense (PE) relative value units levels. Under the SGR system, physicians’ ser- (RVUs). Based on comments recommending a vices include items and services, specified by the transition due to the significant payment reduc- Secretary of the U.S. Department of Health and tions for some specialties, CMS will transition to Human Services, that are commonly performed the PPIS data over four years. In our comments, by a physician or in a physician’s office. At the the College fully supported the use of the PPIS time that CMS decided to include physician- to update practice expense RVUs. Implementa- administered drugs in the definition of “physician tion of the PPIS data to develop practice expense services,” these drugs represented a much smaller RVUs results in a slight increase in payment for volume of Medicare spending, but in subsequent surgeons. years the growth in cost of physician-administered The PPIS is a highly scientific and controlled drugs has far outpaced growth in the cost of other survey instrument that expanded the SMS instru- physician services. As a result, CMS finalized its ment. The College, along with the Government proposal to remove physician-administered drugs Accountability Office and the Medicare Payment from the definition of physician services. Advisory Commission (MedPAC), recognized the need for CMS to update PE data. In its June 2005 Advanced imaging services Report to the Congress, MedPAC indicated that Section 135 of the Medicare Improvements for the data source that CMS uses to estimate total Patients and Providers Act (MIPPA) requires practice costs is dated and may not reflect cur- that, beginning January 1, 2012, Medicare 19

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS payment may only be made for the technical • Coronary artery disease with acute myocar- component (TC) of advanced diagnostic imaging dial infarction services for which payment is made under the • Hip fracture fee schedule to a supplier who is accredited by • Community-acquired pneumonia an accreditation organization (AO) designated by • Urinary tract infection the Secretary. “Advanced diagnostic imaging” is • Diabetes defined as diagnostic magnetic resonance imag- In response to comments, CMS also stated that ing, computed tomography, nuclear medicine, the agency will offer the following: and positron emission tomography. MIPPA also • Paper and electronic delivery of feedback required that by January 1, CMS designate AOs reports to accredit suppliers furnishing the TC of ad- • Investigation of the feasibility of capturing vanced diagnostic imaging services. readmissions in the feedback reports In the final rule, CMS stated that it still ex- • The pursuit of further research to deter- pected to meet the January 1 statutory deadline mine how to accurately attribute E/M services to designate AOs to accredit suppliers furnishing in surgical bundles for purposes of attributing the TC of advanced diagnostic imaging services. patients to specific physicians or groups In response to comments, CMS confirmed that • Investigation of the feasibility of using a ultrasound is specifically excluded by MIPPA Medicare-specific public domain episode grouper from the accreditation requirement. CMS also in the program stated that the agency would make certain that The College supports the use of physician all AOs have provisions for reducing the ac- feedback reports that measure resources used creditation burden and costs for small and rural in furnishing care to Medicare beneficiaries. In suppliers. CMS also stated its belief that at least addition, we recommended that CMS (or its con- three entities would apply to become AOs for tractor) develop algorithms for specialty-specific advanced diagnostic imaging: the American Col- pathways, such as for surgery that would include lege of Radiology, the Intersocietal Accreditation the treatment of conditions such as hip frac- Commission, and The Joint Commission. ture and appendicitis. The ACS also suggested that collaboration with the member boards of Resources use the American Board of Medical Specialties, as As required by MIPPA, CMS established, and well as with the College and other professional is in the process of implementing, the Physician organizations, could lead to integration of the Resource Use Measurement and Reporting Pro- Physician Resource Use Reporting process into gram, using Medicare claims and other data to the Maintenance of Certification process. This provide Medicare physicians with confidential would bring government, payor, and physician feedback reports that measure their resource needs into alignment and reduce the burden of use. CMS previously stated that this would be data collection and reporting for physicians while a multi-year program. In the final rule, CMS helping to maintain and improve quality. moves forward with several aspects of Phase I of In the proposed rule, CMS had also indicated the program, including specifying the conditions, that the agency is reviewing and considering physician specialties, and geographic areas on multiple attribution methodologies for assigning which the program will focus, and the episode-of- costs to be measured by the program. The Col- care methodologies and cost-of-service categories lege commented that the attribution methodolo- that the program will employ. gies used should be transparent. Specifically, we In the final rule, CMS added diabetes to the recommended that the entire algorithm used to episodes of care included in the program. The generate the reports be in the public domain, current list now includes: along with clear plans for evaluating the impact • Congestive heart failure of the reports. In addition, physicians should • Chronic obstructive pulmonary disease be closely involved with the program from the • Prostate cancer beginning, in order to review the methodology • Cholecystitis for creating the reports and to provide input. 20

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The College also believes that the attribution applicable code for 2010 will be assigned at some methodologies used should be risk-adjusted to point this year. At least one prescription created prevent physicians from being penalized for car- during the encounter was generated and transmit- ing for sicker patients. Risk adjustment should ted electronically using a qualified electronic pre- include the recognition that a patient popula- scribing system. A new G-code will be assigned by tion’s socioeconomic factors and co-morbidity CMS for 2010 and will be included in the measure affect a provider’s ability to achieve ideal patient specifications. The removal of code G8446 makes outcome goals. These recommendations corre- it difficult for surgeons to participate in the incen- spond with MedPAC’s guiding policy principles tive program for 2010, because this code provided for the program. a means to report the prescription of controlled substances that cannot be e-prescribed due to Physician Quality Drug Enforcement Administration rules. CMS Reporting Initiative (PQRI) also finalized a proposal to allow three reporting The final rule makes a number of changes to mechanisms (claims, registry, and EHR-based) for the PQRI. CMS finalized a proposal to move for- 2010 e-prescribing. In addition, CMS finalized its ward with electronic health records (EHR)-based proposal to permit certain group practices with reporting, but because the agency has not yet 200 or more eligible professionals to qualify as a completed the 2009 EHR data submission test- group for e-prescribing incentive payments, pro- ing process at this time, CMS cannot guarantee vided that the group has been selected to partici- that qualified EHR vendors will be available for pate in the PQRI group practice reporting options. 2010 reporting. Nonetheless, CMS does anticipate To qualify for e-prescribing incentive payments, continuing to offer claims-based reporting options at least 10 percent of an eligible professional’s for PQRI beyond 2010. CMS did not finalize a Medicare-allowed charges for services provided proposal to add a minimum patient sample size during the reporting period must be for services criterion for satisfactory reporting of data on reported by the recognized denominator codes, individual quality measures, but did finalize a which include codes for office and other outpa- minimum patient sample size requirement of 15 tient services. In the final rule, CMS rejected and eight for 12-month and six-month reporting requests to lower this 10 percent threshold. CMS for measures groups, respectively. also finalized a proposal to define a successful e- CMS also finalized a proposal to allow eligible prescriber for 2010 as one who reports at least 25 professionals to report on measures groups for e-prescribing events during the reporting period. any 30 patients, rather than a consecutive patient sample. In addition, CMS finalized a proposal that Panel to review the work of the RUC would allow physician practices of 200 or more CMS took no action in the final rule on Med- individual eligible professionals to report PQRI PAC’s recommendation to establish a panel of measure data as a group. CMS also finalized its experts separate from the AMA Relative Value proposal to include the following three new mea- System Update Committee (RUC) to review sures applicable to surgery for 2010 PQRI: RVUs. CMS indicated that it will take comments • Cataracts: 20/40 or better visual acuity with- into consideration as it continues to explore this in 90 days following cataract surgery (registry) issue. In its March 2008 Report to the Congress, • Cataracts: Complications within 30 days MedPAC recommended that CMS establish such following cataract surgery requiring additional a group of experts to augment the RUC. surgical procedures (registry) The College strongly opposes the establishment • Perioperative temperature management of such a panel and believes that the current (claims, registry) RUC structure has adequate representation and applies a thoughtful and deliberative process for E-prescribing evaluating relative work RVUs. The College also CMS finalized its plan to use a single numerator believes that an additional panel could evolve into G-code for reporting e-prescribing events in 2010 an extra layer of bureaucracy without adding real (rather than the three current codes). The only value to the process of determining work RVUs. 21

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Potentially misvalued services 23-hour stay The AMA RUC is involved in an ongoing ef- The final rule does not finalize CMS’ proposal fort to identify potentially misvalued services that would have disallowed additional E/M ser- through identifying codes with site-of-service vices to be billed for care furnished during the anomalies, high intraservice work per unit time, postprocedure period, when care is furnished and services with high-volume growth. Two of for an outpatient service requiring less than a the issues addressed in the final rule of interest 24-hour hospital stay. Because CMS considers to surgeons include site-of-service anomalies and services that are performed in the outpatient set- 24-hour stays. ting and that require a hospital stay of less than 24 hours to be outpatient services, the agency Site-of-service anomalies believes that the use of inpatient E/M codes for The final rule does not implement CMS’ services rendered in the postservice period for proposal to change the work RVUs for certain procedures requiring less than a 24-hour hospital codes with site-of-service anomalies; rather, stay would result in overpayment for preservice CMS accepted the RUC-recommended work and intraservice work that would not be provided. RVUs for these codes. In the proposed rule, Accordingly, CMS proposed to disallow inpatient CMS had expressed concern regarding the valu- E/M services for an outpatient service requiring ation methodology that the RUC used to review less than a 24-hour stay. certain services, and that may have resulted in In its comment letter, the College disagreed the removal of hospital days and the deletion or with CMS’ rationale and opposed the agency’s reallocation of office visits without extraction of proposal regarding 23-hour stay because it would the associated work RVUs from the valuation of result in surgeons not being paid for the work the code. Accordingly, CMS proposed changes to they perform. The College’s letter also clarified several of the codes for which valuation has been that the phrase “23-hour stay” for many of the adjusted to reflect changes in site-of-services. codes in question are not actually 24 hours or Specifically, CMS proposes to change the codes less, and all of the codes affected by the proposal for which the AMA RUC review process deleted require at least an overnight stay in a hospital. As or reallocated preservice and postservice times, a result, the services associated with these codes hospital days, office visits, and discharge day require additional work in a facility on the day of management services, but for which the agency the procedure, combined with discharge services believed the AMA RUC-recommended values one or more days after the procedure. Therefore, do not reflect the extraction of the associated because all of the codes at issue require at least RVUs. an overnight stay, and because the standard of In its comment letter, the College strongly care requires a surgeon to follow up with the opposed CMS’ recalculation of work RVUs and patient, the College opposed CMS’ proposal, supported the use of the RUC-recommended and believes it is inappropriate for CMS not to values for the codes at issue. We support the recognize surgeons’ work while the patient is in RUC’s thoughtful and deliberative process for the hospital. As a result of the comments CMS evaluating codes, which uses standard physician received regarding this proposal, the agency has work estimation surveys to set physician work decided to work with the RUC and the Current RVUs relative to reference codes, both within and Procedural Terminology* Editorial Panel on al- between specialties; and the College believes that ternative E/M coding solutions. CMS’ recalculation method discounts the key cri- To view the final rule, go to http://edocket. teria that both Harvard and the RUC have used access.gpo.gov/2009/pdf/E9-26502.pdf.  in making work RVU recommendations, namely, relative total work.

•All specific references to CPT (Current Procedural Terminology) terminology and phraseology are © 2010 American Medical Association. All rights reserved. 22

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Meeting the challenge— A surgeon-centered quality program:

T H E A M E R I C a N SOCIE t Y O F B R E as t S URGEON s Mastery of Breast Surgery Pilot Program

by Alison L. Laidley, MD, FACS, FRCSC; Eric B. Whitacre, MD, FACS; Howard C. Snider, MD, FACS; and Shawna C. Willey, MD, FACS

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS urgeons occupy a central role in the man- Osteopathic Association is required, unless the agement of both benign and malignant surgeon has completed a breast surgery fel- breast disease. Breast cancer is the most lowship. Completion of a combined American commonly diagnosed cancer in women, Society of Breast Disease, American Society of withS an estimated one in eight chance for an Breast Surgery, Society of Surgical Oncology- American woman to develop breast cancer dur- approved breast fellowship also confers eligibility. ing her lifetime. Numerous organizations have Surgeons who were initially board certified, but developed quality measures for breast cancer have not recertified because of a more focused care, and although breast cancer care is multi- practice, are also eligible to apply. disciplinary, many of the quality measures are Participation in the pilot program requires a the responsibility of the breast surgeon. However, minimum of eight hours of breast-specific AMA/ no standard, readily accessible mechanism for PRA category 1 continuing medical education surgeons to report adherence to these measures (CME) credits within the previous year, or 16 currently exists. hours within two years prior to application. The The American Society of Breast Surgeons CME credits can be obtained through a variety (ASBrS) recently developed the Mastery of Breast of courses, including education in breast surgical Surgery Pilot Program, A Continuing Quality techniques, breast imaging, radiation physics, Improvement Initiative. It was developed in breast disease risk assessment, radiation or medi- response to the urgent need for ongoing quality cal oncology, practice management for breast improvement in the practice of breast surgery. surgical practices, quality improvement, and The goal of the program is to provide the sur- public-reporting of quality measures programs. geon with Web-based tools to document quality Breast-specific CME can also be obtained through outcomes in patient care. attending breast disease-specific meetings and In December 2008, the ASBrS introduced the other surgical meetings. pilot phase of the program, which allows indi- Participating surgeons are required to enter vidual surgeons to report and receive feedback data for a minimum of three months on three on a limited number of quality measures for specific quality measures on all open breast sur- open surgical procedures for benign or malig- gical procedures for both benign and malignant nant breast disease. The program has met with disease. The simple, but critically important, remarkable success, with 709 physicians regis- surgeon-controlled quality measures include: tered to participate. In the first 12 months of data 1. Was a needle biopsy performed to evaluate collection, more than 380 surgeons have entered the breast lesion at some time prior to this pro- nearly 35,000 cases. The following is a description cedure?1,2,3 of the initial participation in the pilot program. 2. Was the surgical specimen oriented?1,4,5 3. If a non-palpable lesion was localized with The pilot program image guidance, was there intraoperative confir- mation of its removal?1,6,7 The pilot phase of the Mastery Program is It is expected that surgeons will continue to open to all surgeons who meet the eligibility participate by entering data on all of their cases requirements, regardless of practice setting or after the initial three-month period. Ongoing volume of breast surgery. These criteria are participation will maintain their standing in the based on recommendations of the Mastery of Mastery of Breast Surgery Pilot Program as it Breast Surgery Committee and approved by the grows and develops new quality measures. board of directors of the ASBrS, and represent minimum requirements for surgeons caring for Data entry breast patients. Additional requirements may be added as further information becomes available The Web-based Mastery data entry screen (see on best practices in breast care. Board certifica- Figure 1, page 25) requires input of limited de- tion by the American Board of Surgery (ABS), mographic data in addition to responses for the its international equivalent, or the American three quality measures. Although the patient’s 24

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 1: Data entry screen tion to be selected from a “Why not?” drop-down menu. There are valid clinical reasons why a needle biopsy might not be done prior to surgery. For example,

Home Enter New Case View/Edit Cases Reports Tools Contact Us Logout the lesion might be too close to the skin, chest wall, or implant. Enter Case Efforts were made to include in First Name * the drop-down menu the valid Middle Name clinical reasons the quality in- Last Name * dicator was not met, in order Case Number FAQ to provide meaningful data for Date of Birth : * Format: mm/dd/yyyy FAQ analysis. Additional explana-

Gender * Female Male tory comments, if necessary, Date of Procedure * Format: mm/dd/yyyy can be made for each of the FAQ 12/02/2009 measures in the “Other” space. Procedure * Select one... Other Beside each quality measure are links that supply answers Was a needle biopsy performed to evaluate the Yes No FAQ References to frequently asked questions. targeted lesion at some time prior to this procedure? *

If not, why not? Select one... In addition, links to references Other that support the validity of the quality measures appear beside Was the surgical specimen oriented ? * Yes No FAQ References

If not, why not? Select one... all three measures. If any data Other is entered incorrectly, it can be

Yes No or N/A FAQ References corrected by selecting “View If a non-palpable lesion was localized with image guidance, was there intraoperative confirmation of its removal? Cases/Edit” from the toolbar.

* Reports If not or N/A, why not Select one... Other It is expected, as the program Comments continues to develop and be re- fined, that many more quality Enter Cancel reports useful to the surgeon will be available. Selecting “Reports” on the toolbar can Powered by Whispercom currently access two reports. The “Summary of Procedures” report (Figure 2, page 27) al- lows the surgeon to compare name and date of birth are required fields, the the frequency of his or her operations with peers, surgeon may enter a self-generated number or for example, mastectomy rate. The “Summary even identifiers such as “x” or “y” in place of the of Quality Measures” (Figure 3, page 28) allows patient’s name. The procedure that most closely a comparison of how often the quality measures matches the one performed is selected from a are met compared with the entire group. The drop-down menu, or the surgeon can enter un- reasons for variance from the quality measures listed procedures in the “Other” space. may also be compared. For patients in whom all three quality mea- It is expected—and strongly encouraged—that sures have been met, three “Yes” clicks quickly the surgeon will continue to participate in the complete the data entry. Frequently, a “No” program by entering data on all of their open response is appropriate but requires an explana- surgical breast cases. 25

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Confidentiality of the data ing the largest group (31 percent). The majority of surgeons, 69 percent, are in private practice, All necessary legal work has been completed 42 percent are in group practice, and 27 percent to allow surgeons to report on patients using are in solo practice. Hospital-employed surgeons a secure server and encrypted identification (21 percent) and academic surgeons (10 percent) numbers. Each individual surgeon’s data is kept comprise the remaining participants. Almost strictly confidential, and only the de-identified half of the surgeons (48 percent) limit their data is available to the ASBrS staff and appropri- practice to breast surgery, and 76 percent devote ate committee and board members. The ASBrS at least half of their practice to breast problems. will not make individual surgeon data available Most of the participants perform ultrasound to the public, insurance companies, advocacy (96 percent), ultrasound-guided office procedures groups, credentialing bodies, or any other in- (92 percent), and intraoperative ultrasound terested parties except in strict accordance with (90 percent). Seventy-one percent of the surgeons the Business Associate Agreement that must be perform stereotactic-guided breast procedures. signed to participate in the program. Neverthe- Many participate in other quality improvement less, the ASBrS cannot guarantee that it will not programs. be forced to release data, including individual surgeon data, requested under the compulsion of Discussion a legally enforceable subpoena, search warrant, or court order. The Mastery of Breast Surgery Pilot Program was developed on a “proof of principle” basis— Benefits of participation essentially a feasibility project. Could we design a Web-based, self-reporting program that would It seems inevitable that surgeons will be re- be user-friendly and allow the surgeon to report quired in the near future to document the quality on open breast surgical cases, whether outpatient of their work in order to obtain reimbursement. or inpatient? Could the data entry site be easily The ABS has recently recognized the Mastery of accessible and usable by the participant? Would Breast Surgery Pilot Program as an acceptable surgeons be interested in participating in the pro- quality initiative to meet the requirements of gram? Clearly the wide acceptance by surgeons, Part 4 (Evaluation of Performance in Practice) and the volume of data entered in a short period for ABS Maintenance of Certification. All sur- of time, answered these questions affirmatively. geons who successfully fulfill the requirements The choice of the initial quality measures to of continuous case reporting for a minimum of launch this program was made after much dis- three months, complete the Mastery application, cussion with members of the Patient Safety and and have the appropriate level of CME credits Quality Improvement Committee and the Mas- will receive a printed certificate attesting to their tery of Breast Surgery Committee of the ASBrS. participation in the Mastery of Breast Surgery The initial three quality measures were selected Pilot Program. for the pilot program, not only because of their importance in patient care, but also because they Current status are under the complete control of the surgeon. Breast surgery has become less invasive and The program was designed to be inclusive more precise, with emphasis on procedures that of all surgeons who perform breast surgery minimize morbidity and deformity. The optimal because of the belief that community or rural approach for diagnosis is no longer excisional general surgeons, regardless of the volume of biopsy or needle-localized excisional biopsy, but breast cases, will benefit from participation in percutaneous needle biopsy. After a tissue diag- the program as much as will dedicated breast nosis is made and the results are determined to surgeons. Participants in the program represent be concordant, appropriate surgical management a broad cross-section of surgeons throughout the can proceed, usually with a single operation. U.S., with surgeons in the Northeast represent- Performing a preoperative needle biopsy (quality 26

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 2: Summary of Procedures

Home Enter New Case View/Edit Cases Reports Tools Contact Us Logout

SSuummmmaarryy ooff PPrroocceedduurreess

AAllll YYoouurr SSuummmmaarryy ooff PPrroocceedduurreess YYoouurr TToottaall AAllll MMeemmbbeerrss MMeemmbbeerrss %% %%

All 0 34902

Open surgical biopsy palpable lesion without image guidance 0 4119 0 12

Open surgical biopsy following image guided localization 0 5587 0 16

Nipple exploration with duct excision 0 1111 0 3

Lumpectomy without image guidance 0 743 0 2

Lumpectomy without image guidance and SLN only 0 1137 0 3

Lumpectomy without image guidance and SLN followed by 0 254 0 1 immediate ALND

Lumpectomy without image guidance and ALND 0 182 0 1

Lumpectomy with image guidance 0 3871 0 11

Lumpectomy with image guidance and SLN only 0 5228 0 15

Lumpectomy with image guidance and SLN followed by 0 591 0 2 immediate ALND

Lumpectomy with image guidance and ALND 0 331 0 1

Re-excision of lumpectomy site (prior surgery by myself) 0 1609 0 5

Re-excision of lumpectomy site (prior surgery by another 0 101 0 0 surgeon)

Total mastectomy 0 2081 0 6

Total mastectomy and SLN only 0 3784 0 11

Total mastectomy and SLN followed by immediate ALND 0 938 0 3

ModiÞed radical mastectomy (without SLN procedure) 0 1210 0 3

SLN dissection (separate procedure) 0 422 0 1

Axillary LN dissection (separate procedure) 0 465 0 1

Other 0 1138 0 3

Powered by Whispercom 27

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 3: Summary of Quality Measures measure 1) is consistent with the recommendations made by the International Consensus Conference II on Image De- tected Breast Cancer: State of

Home Enter New Case View/Edit Cases Reports Tools Contact Us Logout the Art Diagnosis and Treat- ment.1 The Mastery of Breast Surgery Pilot Program does not SSuummmmaarryy ooff QQuuaalliittyy MMeeaassuurreess require the surgeon to perform

AAllll the needle biopsy, but it does re- YYoouurr AAllll QQuuaalliittyy MMeeaassuurree:: YYoouurr %% MMeemmbbeerrss TToottaall MMeemmbbeerrss quire that a physician, surgeon, %%

WWaass aa nneeeeddllee bbiiooppssyy ppeerrffoorrmmeedd ttoo eevvaalluuaattee tthhiiss ttaarrggeetteedd or radiologist do a needle biopsy Yes 0 25403 0 73 lleessiioonn aatt ssoommee ttiimmee pprriioorr ttoo tthhiiss pprroocceedduurree??:: prior to the surgical procedure No 0 9497 0 27 when appropriate. IIff nnoott,, wwhhyy nnoott?? (not required) Orientation of the surgical Clinical and imaging Þndings consistent with a benign lesion 0 2057 0 6

Lesion too close to skin, implant, chest wall, etc. 0 1634 0 5 specimen (quality measure 2)

Patient refused needle biopsy 0 1013 0 3 allows the pathologist to assess Lesion could not be adequately visualized for needle biopsy 0 994 0 3 the margins of the specimen Patient condition prevents needle biopsy (weight, breast thickness, etc.) 0 460 0 1 to determine the adequacy of Appropriate needle biopsy not available in my community 0 34 0 0 excision and allow precise re- Open biopsy was previously performed by another physician 0 273 0 1 excision if the margins are not Duct excision without imaging abnormality 0 913 0 3

Prophylactic mastectomy 0 799 0 2 clear. There are reasons why

Other 0 1169 0 3 the surgeon would not orient a specimen—such as excising a benign lesion, lymph node WWaass tthhee ssuurrggiiccaall ssppeecciimmeenn oorriieenntteedd ?? Yes 0 29287 0 84

No 0 5613 0 16 procedures, or situations where IIff nnoott,, wwhhyy nnoott?? (not required) orienting the specimen would Clinical and imaging Þndings consistent with a benign lesion 0 2928 0 8 add no value to subsequent Tissue fragmented during removal 0 290 0 1 management decisions. Speci- Specimen handling precluded orientation (moved from surgical Þeld, etc.) 0 106 0 8 men orientation will minimize Orienting specimen would add no value (recurrent disease,etc.) 0 807 0 2 deformity caused by excessive Lymph node procedure 0 521 0 1

Other 0 675 0 2 tissue removal from the breast when margin re-excision is necessary. The surgeon can IIff aa nnoonn--ppaallppaabbllee lleessiioonn wwaass llooccaalliizzeedd wwiitthh iimmaaggee gguuiiddaannccee,, Yes 0 16340 0 47 wwaass tthheerree iinnttrraaooppeerraattiivvee ccoonnÞÞ rrmmaattiioonn ooff iittss rreemmoovvaall?? orient the specimen or request No the pathologist to do so in the or 0 18560 0 53 NA operating room, but orientation IIff nnoott oorr NN//AA,, wwhhyy nnoott? (not required) is under the surgeon’s control. Lesion was palpable pre-operatively 0 5911 0 17 Intraoperative confirmation Additional surgery for margins 0 1926 0 6 of removal of an image-guided Duct excision without a lesion that could be imaged 0 1038 0 3

The patient had a mastectomy 0 7057 0 20 lesion (quality measure 3) is an-

Appropriate imaging modality was not available for conÞrmation 0 224 0 1 other part of precise, directed Lymph node procedure 0 547 0 2 surgery that minimizes the risk Other 0 890 0 3 of removing the wrong tissue or an inadequate amount of

Powered by Whispercom tissue. Intraoperative confir- mation of excision of the lesion can be done by specimen radio- graph, intraoperative ultra- sound, palpation of the lesion, 28

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS immediate serial sectioning by the pathologist, For surgeons to participate in the pilot pro- or direct visualization of the surgical specimen gram, they are invited to go to the ASBrS Web by the surgeon. If the target lesion is a cluster of site, http://www.breastsurgeons.org, to complete microcalcifications, a specimen radiographmust a brief registration form. They will then be given be done to confirm calcifications. Depending on a link to a data collection software program for the location of the targeted lesion within the entering cases. The Web site has an online ap- specimen, more tissue can be removed to increase plication form that must be completed, including the likelihood of clear margins. Surgeons are reporting the required CME. Surgeons who at- responsible for verifying the targeted lesion has tend the annual meeting of the ASBrS automati- been removed before moving the patient from cally meet the CME requirements. the operating table. There are links to the Mastery Program Web site on the ASBrS Web site for easy access to the Future directions of the program program. All documents regarding the Mastery Program are available on the ASBrS Web site and Self-reporting is a fundamental step in improv- the Mastery Web site. The documents include: ing quality of care. It is evident that a mechanism • Frequently asked questions (FAQ) for data collection is needed in the field of breast • Background and history of the program surgery, and breast cancer in particular. Through • User agreement data collection and analysis, a method for defin- • Participation agreement ing and validating quality measures for breast surgical care can be established. Furthermore, through the development of a comprehensive re- Dr. Laidley is a breast porting system, surgeons will be given the tools to surgeon at Breast Sur- geons of North Texas, improve the care given to each patient, improve Dallas, TX. their individual practice, and incorporate quality measures into daily practice. The ASBrS will now transition the success of reporting on the initial quality measures in the pilot phase to a more robust program. Additional quality measures will be introduced with input from ASBrS members, reviewed by the Mastery Committee, and receive approval by the board of directors. There are plans to collect data specific to breast cancer, and to develop a more com- prehensive and sophisticated quality reporting system. Mechanisms are currently under develop- ment that should allow surgeons to track their Dr. Whitacre is direc- needle biopsy data for practice accreditation in tor of the Breast Center of Southern Arizona, ultrasound and stereotactic procedures. Plans are Tucson, AZ. also under way to develop a series of “synoptic reports” for reporting breast procedures. Getting started

Participation in the pilot program is free to members of the ASBrS at this time. Applicants who are not members of the ASBrS must submit an application fee. Nonmembers are encour- aged to join the ASBrS and enjoy the benefits of membership. 29

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS All queries received from participants are www.asbd.org/downloads/American_Society_of_ acknowledged by e-mail from the ASBrS, via a Breast_Disease_Statement_on_Breast_Specimen_ Orientation.pdf. Accessed December 21, 2009. member of the Mastery Committee. The program 5. Fleming FJ, Hill AD, Mc Dermott EW, O’Doherty has changed significantly in response to these A, O’Higgins NJ, Quinn CM. Intraoperative questions and from other feedback from our par- margin assessment and re-excision rate in ticipants. All queries are stored for reference to breast conserving surgery. Eur J Surg Oncol. 2004;30(3):233-237. ensure continuity of answers, as well as to update 6. Dixon JM, Ravi Sekar O, Walsh J, Paterson D, the FAQ documents and brochures.  Anderson TJ. Specimen-orientated radiography helps define excision margins of malignant lesions Acknowledgments detected by breast screening. Br J Surg. 1993; 80(8):1001-1002. The authors wish to thank the members of the Mas- 7. Chagpar A, Yen T; Sahin A, Hunt KK, Whitman tery of Breast Surgery Committee for their dedication GJ, Ames FC, Ross MI, Meric-Bernstam F, Babiera GV, Singletary SE, Kuerer HM. Intraoperative to the development and implementation of this project. margin assessment reduces reexcision rates in The members of the committee are: Victor J. Zannis, patients with ductal carcinoma in situ treated MD, FACS, Breast Care of the Southwest, Phoenix with breast-conserving surgery. Am J Surg. AZ; Helen A. Pass, MD, FACS, assistant professor of 2003;186(4):371-377. clinical surgery, Lawrence Hospital, Bronxville NY; Richard E. Fine, MD, FACS, Advanced Breast Care, Marietta, GA; Arthur G. Lerner, MD, FACS, Dickson Cancer Treatment Center, White Plains NY; Lorraine Tafra, MD, FACS, Anne Arundel Medical Center, An- napolis MD; and John West, MD, FACS, Breast Care Dr. Snider is medical Center of Orange County, Orange CA. Special thanks director of the Alabama go to ASBrS staff members Sharon Grutman and Breast Center, Mont- Christina Lucara, and to Jane Schuster, the executive gomery, AL. director of the ASBrS, for their expert coordination and implementation of this project.

References 1. Silverstein MJ, Lagios MD, Recht A, Allred DC, Harms SE, Holland R, Holmes DR, Hughes LL, Jackman RJ, Julian TB, Kuerer HM, Mabry HC, McCready DR, McMasters KM, Page DL, Parker SH, Pass HA, Pegram M, Rubin E, Stavros AT, Tripathy D, Vicini F, Whitworth PW. Image- detected breast cancer: State of the art diagnosis and treatment. J Am Coll Surg. 2005; 201(4):586- 597. Dr. Willey is director of 2. The American Society of Breast Surgeons. Ameri- the Betty Lou Ouris- can Society of Breast Surgeons position statement; man Breast Health Percutaneous needle biopsy for image detected Center, Georgetown breast abnormalities. Approved June 12, 2006. University Hospital, Available at: http://www.breastsurgeons.org/ Washington, DC. statements/mibb.php. Accessed December 14, 2009 3. Brenner RJ, Bassett LW, Fajardo LL, Dershaw DD, Evans WP, Hunt R, Lee C, Tocino I, Fisher P, McCombs M, Jackson VP, Feig SA, Mendelson EB, Margolin FR, Bird R; Sayre JJ. Stereotactic core-needle breast biopsy: A multi-institutional prospective trial. Radiology. 2001; 218(3):866-872. 4. Policy Statement on Routine Orientation of Ex- cised Breast Specimens. June 6, 2005. American Society of Breast Disease. Available at: http:// 30

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Highlights of the 95th annual Clinical Congress

31 t the 2009 Clinical Congress in Chicago, IL, a wide selection of presentations covering subjects from education to A practice to clinical considerations—in addition to poster presentations, papers sessions, and special-interest meetings—were offered. The meeting was attended by 13,869 participants, including 8,638 physicians; the remaining at- tendees included exhibitors, spouses, guests, and convention personnel.

Convocation LaMar S. McGinnis, Jr., MD, FACS—a general and oncologic surgeon from Atlanta, GA, and a senior medical consultant and advisor Outgoing ACS President John L. Cameron, MD, for the National American Cancer Society and FACS (right), passes the Presidential Medallion to Dr. a clinical professor of surgery at Emory Uni- McGinnis during the Convocation. versity, Atlanta, GA—was installed as the 90th President of the American College of Surgeons during Convocation ceremonies that denoted the official opening of the Clinical Congress (see MAAC, FACS; and Adelola Adeloye, MB, photo, this page). (See the December 2009 issue MS, FRCP(Edin), FRCS(Eng), FACS, FICS, of the Bulletin for the Presidential Address.) FWACS, FMCS(Nig), FAS, FCOSECA. Other officers installed during the Convoca- tion were Kirby I. Bland, MD, FACS, as First Named Lectures Vice-President, and Karen E. Deveney, MD, As was the case last year, the Martin Memorial FACS, as Second Vice-President. Dr. Bland, who Lecture and the American Urological Association became a Fellow in 1980, is chair of the depart- Lecture were combined for presentation during ment of surgery at the University of Alabama- the Opening Ceremony of the Clinical Congress. Birmingham. In addition to his participation Glenn D. Steele, MD, FACS, delivered his lec- in various College committees, he has been a ture, Re-engineering Systems of Care—Surgical member of the ACS Board of Governors, a mem- Leadership, immediately following the Open- ber and Vice-Chair of the Executive Committee ing Ceremony on Monday morning (see photo, of the Board of Governors, and a liaison for page 33). Also on Monday, The Intraoperative the Board of Governors’ Committee on Surgi- Myocardial Protection: Still Important? was cal Practice. Dr. Deveney, a Fellow since 1984, presented as the John H. Gibbon, Jr., Lecture has served as Secretary of the Board of Gover- by William A. Gay, MD, FACS, and John E. nors. She is currently professor, department of Connolly, MD, FACS, presented Personal Re- surgery, Oregon Health & Science University, flections on the First 50 Years of Cardiovascu- Portland, OR. lar Surgery as the Charles G. Drake History of Honorary Fellowship was conferred on the fol- Surgery Lecture. The Excelsior Surgical Society lowing five prominent surgeons: Masaki Kita- Edward D. Churchill Lecture, which until 2008 jima, MD, FACS, FRCS(Hon), FASA(Hon); had been presented at the ACS Spring Meeting, Sir Bruce Edward Keogh, KBE, BSc, MD, convened Tuesday with George F. Sheldon, FRCS, FESC, FETCS; Ingemar Ihse, MD, MD, FACS, presenting The Surgeon Short- PhD, FRCS; Vicente P. Gutierrez, MD, age: Constructive Participation during Health Reform. Other Named Lectures that convened Opposite, top: Dr. McGinnis presides over the Opening Tuesday were the Scudder Oration on Trauma, Ceremony. Bottom: Meeting attendees enter the exhibit during which A. Brent Eastman, MD, FACS, hall at the advent of the meeting. presented Wherever the Dart Lands: Toward 32

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the Ideal Trauma System; and the Olga M. Jonasson Lecture, Leadership Development and Mentoring in the Age of Restricted Work Hours, presented by Karin M. Muraszko, MD, FACS. Wednesday’s Named Lectures included the Eth- ics and Philosophy Lecture, Can General Sur- geons and Transplant Surgeons Work Together to Improve the Supply and Ethical Standard of Living Organ Donations? presented by Mark Siegler, MD, FACP; A Community Cancer Center Program: Getting to the Next Level, the Commission on Cancer Oncology Lecture, presented by Nicholas J. Petrelli, MD, FACS (see photo, this page); the I.S. Ravdin Lecture in Basic Sciences, where Michael T. Longaker, MD, FACS, delivered Reparative, Replacement, Martin Memorial/AUA Lecturer Dr. Steele (center), with and Regenerative Medicine; the Herand Abcar- Dr. McGinnis (left) and Howard M. Snyder III, MD, ian Lecture, The Little Engine That Did, offered FACS, who introduced the lecture. by David Schoetz, MD, FACS; and Health Care Reform in the United Kingdom, the Dis- tinguished Lecture of the International Society of Surgery presentation by Ara W. Darzi, MB, BCh, FACS.

Awards, honors, celebrations The 2009 ACS/Pfizer Inc Surgical Volunteer- ism and Surgical Humanitarian Aware winners were honored at a general session sponsored by the College’s Operation Giving Back program. Edgar Rodas, MD, FACS, was presented with the humanitarianism award, and Douglas P. Grey, MD, FACS; William P. Schecter, MD, FACS; Glenn W. Geelhoed, MD, FACS; Vance J. Moss, MD, FACS; Vincent L. Moss, MD, FACS; and Awori J. Hayanga, MD, MPH, COC Oncology Lecturer Dr. Petrelli. received the volunteerism awards (see photo, page 34). Also Monday, Richard Reiling, MD, FACS, and Mrs. Elizabeth Reiling were presented ducted a large cohort study of the effects of cold with the Fellows Leadership Society’s Distin- ischemia time (CIT) on live donor outcomes dem- guished Philanthropist Award in recognition of onstrating that the anticipated CIT resulting their personal contributions, along with Dr. Reil- from cross-country kidney transport was safe. ing’s tireless work to raise philanthropic support This procedure is now accepted as viable, has on behalf of the College (see photo, page 34). been performed numerous times, and has been Dorry Segev, MD, PhD, FACS, an associ- included in both the U.S. and Canadian national ate professor with the department of surgery kidney paired donation protocols. at Johns Hopkins University, Baltimore, MD, The National Safety Council Surgeons Award was presented with the Joan L. and Julius H. for Service to Safety was conferred at the meet- Jacobson II Promising Investigator Award (see ing. Martin R. Eichelberger, MD, FACS, was photo, page 35). Dr. Segev and colleagues con- presented with his plaque for his undaunting 33

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS American College of Surgeons/Pfizer Inc Surgical Humanitarian Award and Surgical Volunteerism Awards. Michael J. Zinner, MD, FACS, Chair of the Board of Governors (left) and Jack Watters, MD, vice-president of external medical affairs, Pfizer Inc (far right), are pictured with award recipients (left to right) Dr. Geelhoed, Dr. Hayanga, Dr. Vincent Moss, Dr. Vance Moss, Dr. Schecter, Dr. Grey, and Dr. Rodas.

commitment to the prevention and treatment of children’s injuries, and in recognition of his contributing influence on countless lives (see photo, page 35). The 2009 Owen H. Wangensteen Surgical Fo- rum was dedicated to Hiram C. Polk, Jr., MD, FACS (see photo, page 36). Residents honored with the Surgical Forum Excellence in Research Awards included Sonal Arora, MB, BS, MRCS, Surgical Education, Imperial College, London, UK; Elliott R. Brill, MD, Targeted Therapies, Memorial Sloan-Kettering Cancer Center, New York, NY; Benjamin S. Brooke, MD, Quality, Outcomes and Costs, Johns Hopkins University, Baltimore, MD; Bettina M. Buchholz, MD, Alimentary Tract, University of Pittsburgh, Pittsburgh, PA; Antoine L. Carre, MD, Plastic/ Maxillofacial Surgery, Stanford University, Stanford, CA; Claudius Conrad, MD, PhD, Progenitor Cells and Cell-Based Therapies, 2009 Distinguished Philanthropist Award recipients Massachusetts General Hospital, Boston, MA; Mrs. Reiling and Dr. Reiling (right), with ACS Executive Amanda Feigel, MD, Vascular Surgery, Yale Director Thomas R. Russell, MD, FACS. University School of Medicine, New Haven, CT; Georg N. Herlitz, MD, JD, Critical Care, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, pital, Boston University, Beth Israel Deaconess New Brunswick, NJ; Onkar Khullar, MD, Car- Medical Center, Boston, MA; Marcus M. Malek, diothoracic Surgery, Brigham & Women’s Hos- MD, Pediatric Surgery, Children’s Hospital of 34

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS National Safety Council Surgeons’ Award for Service to Safety recipient Dr. Eichelberger (center), with, left to right: Dr. Eastman; John Fildes, MD, FACS, ACS COT Chair; M. Margaret Knudson, COT Vice-Chair; Joan L. and Julius H. Jacobson II Promising Investigator and J. Wayne Meredith, Medical Director, ACS Trauma Award recipient Dr. Segev (center), with Mrs. Jacobson Programs, Division of Research and Optimal Patient (left) and Dr. Jacobson. Care.

ATLS: Carlos Carvajal Hafeman, MD, FACS (center), ATLS: Francisco De Salles Collet E. Silva, MD, FACS Chair of the Chile COT, with an award presented to (center), Chair of the Brazilian COT, with an award the Chilean Chapter for training doctors in ATLS, presented to the Brazilian Chapter for training doctors the Advanced Trauma Course for Nurses, and the in ATLS, the Advanced Trauma Course for Nurses, and Prehospital Life Support courses. Also pictured are Dr. the Prehospital Life Support courses. Also pictured are Fildes (left), and Dr. Meredith. Dr. Fildes (left), and Dr. Meredith.

Pittsburgh, University of Pittsburgh Medical the College’s highest honor, was presented to Center, Pittsburgh, PA; Douglas A. Murrey, F. Dean Griffen, MD, FACS, a professor of Jr., MD, Urology and Reproductive Surgery, clinical surgery and director of undergraduate The Ohio State University Medical Center, Co- surgical education at Louisiana State Univer- lumbus, OH; and Robert Sucher, MD, Immu- sity Health Services Center, Shreveport (see nity, Transplantation, and Tissue Engineering, top photo, page 37). This award was given in Innsbruck Medical University, Innsbruck, Tirol recognition of his staunch and devoted service Austria (see photo, page 36). as a Fellow of the American College of Surgeons, The 2009 Distinguished Service Award, and for his leadership roles as Chair of the Board 35

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of Regents’ Committee on Patient Safety and mittee on Professional Liability. Dr. Griffen is Professional Liability, Vice-Chair of the Public also acknowledged for his superb clinical activity Profile and Communications Steering Commit- as a Lieutenant Commander in the U.S. Navy, his tee, President of the ACS Louisiana Chapter, and service as a general-thoracic-vascular surgeon member of the ACS Board of Governors’ Com- at the Highland Clinic in Shreveport, LA, and, most recently, his services as a clinical professor of surgery at Louisiana State University Medical Center in Shreveport. Dr. Griffen is further rec- ognized for his leadership role with the American College of Surgeons in bringing to the attention of its membership—through his ground-breaking work on the ACS Closed Claims Study—insights into ways to improve surgical care and decrease liability through professional behavior, conduct- ing numerous seminars, postgraduate courses, and mock trials at the Clinical Congress on the issues of liability and professionalism. The Committee on Cancer Liaison recognized three Commission on Cancer State Chairs for outstanding performance and significant contri- butions to the Liaison Program in 2008. Honored were Daniel P. McKellar, MD, FACS, Good Samaritan Hospital, Dayton, OH; James J. The 2009 Surgical Forum volume dedication recipient Hamilton, Jr., MD, FACS, St. Francis Health Dr. Polk (center) with Michael T. Longaker, MD, FACS Center, Topeka, KS; and Mary Milroy, MD, (left), Chair of the Surgical Forum Committee, and Tien FACS, Avera Sacred Heart Hospital, Yankton, C. Ko, MD, FACS, a committee member.

Surgical Forum Excellence in Research Awards. Front row, left to right: Dr. Carre, Dr. Conrad, Dr. Feigel, Dr. Khullar, and Dr. Herlitz. Back row: Dr. Brill, Dr. Murrey, Dr. Brooke, Dr. Buchholz, Dr. Sucher, and Dr. Longaker. Not pictured: Dr. Arora and Dr. Malek. 36

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS SD (see lower left photo, this page). Nathan C. Kanning, MD, a surgeon from Sandpoint, ID, received the 2009 Nizar N. Oweida, MD, FACS, Scholar- ship at the Rural Surgeons meeting (see photo, lower right, this page). The seventh annual ACS Resident Award for Exem- plary Teaching was presented to Susan Skaff Hagen, MD, a PGY-4 resident in general surgery at the University of Iowa Hospitals and Clinics. The award is sponsored by Distinguished Service Award recipient Dr. Griffen (third from left) with his the Division of Education family and Mrs. Julia McGinnis (second from right) and Dr. McGinnis. to recognize excellence in teaching by a resident and to highlight the importance of teaching in residents’ daily lives. Dr. Hagen named Best Scientific Exhibit (see bottom photo, was selected by an independent review panel page 38). of the Committee of Resident Education (see The International Guest Scholar program top photo, page 38). welcomed its 2009 guest scholars, including the “Improving Rural Maine’s Access to Emer- following: Lohfa B. Chirdan, MBBS, FWACS, gency Trauma Services Through Telemedicine,” Jos, Nigeria; Paisarn Vejchapipat, MD, authored by Joan-Marie Pellegrini, MD, was Bangkok, Thailand; Jaqueline Cruz Vargas,

Oweida Scholarship recipient Dr. Kanning (left), with Stephen E. Olson, MD, FACS, Chair of the Rural Surgery COC State Chair award winners, left to right: Dr. Subcommittee of the Advisory Council for General McKellar, Dr. Hamilton, and Dr. Milroy. Surgery.

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Australia; Fernando Bur- dio, MD, Barcelona, Spain; Grant R. Christey, BSc, MBChB, FRACS, Hamilton, New Zealand; Patricio R. Andrades, MD, FACS, Vi- tacura, Santiago, Chile; and Germany Exchange Fellow Bjorn Bruecher, MD, PhD, FACS, Tübingen, Germany (see photo, page 39). The ACS Committee on Video-based Education spon- sored a session to highlight outstanding surgical vid- eos, which were nominated Resident Award for Exemplary Teaching awardee Dr. Hagen (center), by prominent international with (left to right) Glenn T. Ault, MD, FACS, Chair, Resident Award surgeons and previously Program, Committee on Resident Education; Dr. Britt; Dr. McGinnis; presented at various inter- and Dr. Russell. national meetings. At the conclusion of the session, chaired by Horacio J. As- bun, MD, FACS, members of the audience voted on the most outstanding video. The 2009 outstanding video was Laparoscopic Total Meso- rectal Excision Based on the Recent Interpretation of Sur- gical Anatomy, presented by Yoshiharu Sakai, MD, from Kyoto, Japan (see photo, page 40).

New this year A new format for the Clinical Congress Program Book was Best Scentific Exhibit award recipient Dr. Joan-Marie Pellegrini (center), introduced at this year’s meet- with ACS Regent Barbara L. Bass, MD, FACS (left), Chair of the Program ing, which included a larger Committee; and judge and ACS Regent Robin S. McLeod, MD, FACS. ACS trim size and an easy-to-read Regent Carlos A. Pellegrini, MD, FACS (not pictured), also served as a judge. two-column format. A Pocket Guide was also un- veiled, which featured a conve- nient schedule of Sessions-at- MD, Lima, Peru; Giuseppe R. Nigri, MD, a-Glance by Day as well as a Sessions-at-a-Glance PhD, FACS, Rome, Italy; Kelvin K. Ng, by Track schedule. The tracks were as follows: MBBS, MS, PhD, FRCS(Ed), Hong Kong, Basic/Translational Research, Cardiothoracic China; Sanjeev Misra, MBBS, MChir, Luc- Surgery, Colon and Rectal Surgery, Education/ know, India; Andrew P. Barbour, MBBS, Outcomes & Safety, Ethics, General Sur- PhD, FRACS, Woolloongabba, Queensland, gery, Health Policy: Practice Management/ 38

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The International Guest Scholars for 2009, International Relations Committee members, and guests gathered for a luncheon during the Congress. Pictured front row, left to right: Dr. Chirdan, Dr. Vejchapipat, Dr. Cruz Vargas, and Dr. Nigri. Back row: Dr. Ng, Dr. Misra, Dr. Barbour, Dr. Burdio, Dr. Christey, Dr. Andrades, and Germany Exchange Fellow Bjorn Bruecher, MD, PhD, FACS, Tübingen, Germany.

Reimbursement/Liability Issues, International, Advisory Council for Colon and Rectal Surgery; Neurosurgery, Obstetrics and Gynecology, the International Relations Committee; the Ad- Orthopaedic Surgery, Otolaryngology–Head visory Council for Cardiothoracic Surgery; and and Neck Surgery, Pediatric Surgery, Plas- the Committee on Emerging Surgical Technology tic and Maxillofacial Surgery, Residents/ and Education. Medical Students, Surgical Oncology, Trauma/ Meet the Expert Luncheons (formally known Critical Care, Urology, Vascular Surgery, and as Meet the Professor Luncheons), informal Volunteerism. The 2010 Clinical Congress will gatherings where attendees had the opportunity follow a similar format with the track system; to discuss a topic with experts in that given however, note that each year the tracks will con- field, were once again offered this year. These 30 tinue to be more defined and developed. luncheons (an increase of five expert luncheons Seven new Town Hall Meetings took place, over the previous Clinical Congress meeting) during which issues and news relevant to specific were once again very popular this year, and in interest and practice areas were discussed. The fact, nearly sold out. meetings were sponsored by the Advisory Coun- The Board of Regents approved the formation cil for General Surgery; the Advisory Council for of the College’s 34th and 35th international Vascular Surgery; the Resident and Associate chapters: the ACS Pakistan Chapter and the Society of the American College of Surgeons; the ACS Austria-Hungary Chapter. This brings the 39

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS total number of ACS chapters to 102: 35 international, two Canadian, and 65 U.S. The Young Fellows Associa- tion (YFA) held its inaugural meeting during the Clinical Con- gress on Monday, October 12. Mark A. Malangoni, MD, FACS, a former Chair of the former Committee on Young Surgeons, provided the wel- coming remarks at the meeting (see photo, page 42). The YFA consists of four workgroups: Advocacy, Communications, Education, and Member Ser- vices. Nearly 100 Fellows have Video-Based Education winner Dr. Sakai (second from right) with (left to joined a workgroup at this right): 2007 and 2008 winner Augusto C. Tinoco, MD; Dr. Asbun; Tonia time. For more information, Young-Fadok, MD, FACS, Chair, Committee on Video-based Education; and visit the new YFA Web page at W. Scott Melvin, MD, FACS. Doctors Tinoco, Young-Fadok, and Melvin served http://www.facs.org/member as panelists on this session. services/yfa/. The Scientific Papers ab- stract session offered topic- specific sessions that incorporated the tracks was given the Resident Award for Exemplary system. The 2009 Clinical Congress hosted 18 Teaching. Scientific Paper Sessions with approximately 150 papers presented. New Offers-Elect At the Annual Business Meeting of Members, College governance new Officers-Elect were named. L.D. Britt, MD, At the Annual Business Meeting of Members MPH, FACS, FCCM, was named President- on Wednesday, where Dr. McGinnis presided, Elect; he will begin his tenure as the 91st ACS L.D. Britt, MD, FACS, presented the Report President at the 2010 Clinical Congress in Wash- of the Chair of the Board of Regents; Michael ington, DC. Dr. Britt is a general and trauma J. Zinner, MD, FACS, presented the Report surgeon from Norfolk, VA. of the Chair of the Board of Governors; and Richard J. Finley, MD, FACS, FRCSC—a Thomas R. Russell, MD, FACS, presented the general thoracic surgeon, and professor and Report of the Executive Director of the College. head of the division of thoracic surgery at the Henri R. Ford, MD, FACS, presented the Re- University of British Columbia—was named port of the Chair of the Nominating Committee First Vice-President-Elect. Named as Second of the Board of Governors, during which the Vice-President-Elect was Frederick L. Greene, elected Regents and Board of Governors offi- MD, FACS, a general surgeon and chairman of cers were announced; and Linda G. Phillips, the department of general surgery, Carolinas MD, FACS, presented the Report of the Chair Medical Center, in Charlotte, NC. of the Nominating Committee of the Fellows and announced the nomination and election Board of Regents/Board of Governors of Governors. It was also at this meeting that The Board of Governors elected Rene Lafre- Dr. Griffen received his Distinguished Ser- niere, MD, FACS, Calgary, AB; Leigh A. Neu- vice Award, Dr. Segev was presented with the mayer, MD, FACS, Salt Lake City, UT; and Mar- Promising Investigator Award, and Dr. Hagen shall Z. Schwartz, MD, FACS, Philadelphia, 40

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the Board of Governors (1998– 2004), the Executive Commit- tee of the Board of Governors (2001–2004; Vice-Chair, 2003– 2004), the Program Committee (2003–2007), the Committee on Emerging Surgical Technology & Education (2004–2007), and the Committee on Development (2005–2007). Dr. Lafreniere served as Chair of the Commit- tee on Operating Room Envi- ronment (2001–2002) and the Committee on Perioperative Dr. Zinner (second from right) was recognized for his outstanding leadership Care (2002–2003). as the founding course director for the Surgery Resident Program, offered Dr. Neumayer, a general sur- each year at the Clinical Congress to help prepare residents for the geon, is professor of surgery at transition to practice. Also pictured are (left to right): Ajit K. Sachdeva, the University of Utah; Jon and MD, FACS, FRCSC, Director, Division of Education; Gayle E. Woodson, Karen Huntsman Presidential MD, FACS, Chair, Committee on Resident Education; Dr. Russell; and Thomas V. Whalen, MD, MMM, FACS, Regent and new course director for Professor of Cancer Research, the Surgery Resident Program. Huntsman Cancer Institute; and co-director, Integrated Breast Program, Huntsman Cancer Hospital, all in Salt Lake City. A Fellow since 1994, Dr. Neumayer has served on the Committee on Medical Student Education (1996–2003; Chair 2001–2003); the Program Committee (2002– 2004); the Advisory Committee on SESAP (2003–2005); the Committee for the Forum on Fundamental Surgical Problems (2003–2009); and the Women in Surgery Committee (2005– present). Dr. Schwartz, a pediatric sur- W. Lynn Weaver, MD, FACS (second from left), was recognized for his geon, is professor of surgery and outstanding leadership as the founding course director for the High pediatrics, Drexel University School Student Program, offered each year at the Clinical Congress for College of Medicine, Temple underrepresented and underserved students interested in the health University School of Medicine, professions. Also pictured are (left to right): Dr. Sachdeva, Mrs. Kay Weaver, Philadelphia, PA. He is also and Dr. Russell. surgeon-in-chief, chief of pedi- atric surgery, and director of the Pediatric Surgery Research PA, to the ACS Board of Regents. Laboratory at St. Christopher’s Hospital for Dr. Lafreniere, a general surgeon, is profes- Children, Philadelphia. A Fellow since 1982, Dr. sor of surgery, oncology, and anesthesia at the Schwartz served as Chair of the Advisory Coun- University of Calgary, AB. A Fellow of the Col- cil for Pediatric Surgery (2002–2008) and as lege since 1989, Dr. Lafreniere has served on Chair of Advisory Council Chairs (2004–2008). 41

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS YFA inaugural meeting. Dr. Malangoni (left) makes opening remarks. On the panel, left to right (all MD, FACS): Perry Shen, Immediate Past-Chair; Mark Savarise, Chair; Laurel Soot, Chair, Communications Work Group; Wayne Frederick, Chair, Education Work Group; and Sanjay Parikh, YFA Vice-Chair and Chair, Advocacy Work Group.

YFA Governing Council. Left to right (all MD, FACS): Adam Cohen; Dr. Savarise; Juan Paramo; Dr. Frederick, Cecelia Boardman, Michael Sutherland, Danielle Katz, Dr. Soot, Rob Todd, Steven Chen, Dr. Shen, Dinakar Golla, and Sanjay Parikh. Not pictured: Keith Amos, Nancy Baxter, and Patricia Turner.

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS He is a member of the Public Profile and Communications Steering Committee (2007– present). A. Brent Eastman, MD, FACS, was elected Chair of the Board of Regents. A gen- eral, vascular, and trauma surgeon, Dr. Eastman is chief medical officer of Scripps Health and the N. Paul Whit- tier Endowed Chair of Trauma at Scripps Memorial Hospital, La Jolla, CA. He is also a clinical professor of surgery- trauma at the University of California, San Diego. In his role as Chair of the Board of Regents, Dr. Eastman will work closely with the ACS The Past-Presidents of the College and guests met during the Clinical Executive Director and will Congress. Front row, left to right (all MD, FACS): John L. Cameron, C. Rollins chair the Regents’ Finance Hanlon, and W. Gerald Austen. Back row: Dr. Russell; R. Scott Jones; LaSalle and Executive Committees. D. Leffall, Jr.; and Gerald B. Healy. Elected to additional three- year terms on the Board of Regents were H. Randolph Bailey, MD, FACS, Houston, TX; Bruce D. Browner, MD, FACS, Farmington, CT; Mar- tin B. Camins, MD, FACS, New York, NY; Julie A. Freis- chlag, MD, FACS, Baltimore, MD; Raymond F. Morgan, MD, FACS, Charlottesville, VA; Karl C. Podratz, MD, FACS, Rochester, MN; J. David Rich- ardson, MD, FACS, Louisville, KY; Mark C. Weissler, MD, FACS, Chapel Hill, NC; and Thomas V. Whalen, MD, FACS, Allentown, PA. The Board of Governors reelected Michael J. Zinner, MD, FACS, Boston, MA, as Recipients of the College’s highest honor, the Distinguished Service Award, Chair. Timothy C. Flynn, met during the Clinical Congress Front row, left to right (all MD, FACS): MD, FACS, Gainesville, FL, LaMar S. McGinnis, Jr.; Paul E. Collicott; Murray F. Brennan; and David L. was elected Vice-Chair, and Nahrwold. Back row: Richard B. Reiling, Patricia J. Numann, Frank Padberg, James K. Elsey, MD, FACS, and C. Barber Mueller. Lawrenceville, GA, was re- elected Secretary. 43

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Members of the ATLS international community met to discuss pertinent issues related to the program. The ATLS program is in more than 40 countries worldwide.

Members of the Board of Regents (B/R), the Board of Governors (B/G) Executive Committee, and ACS Officers met for their annual luncheon. Pictured (with their titles prior to the Congress) front row, left to right (all MD, FACS): Dr. Russell; Andrew L. Warshaw, Treasurer; Julie A. Freischlag; A. Brent Eastman, B/R Vice-Chair; L. D. Britt, B/R Chair; John L. Cameron, President; Valerie W. Rusch; LaMar S. McGinnis, Jr., President-Elect; and James K. Elsey, B/G Secretary. Middle row: Michael J. Zinner, B/G Chair; Barbara L. Bass; John T. Preskitt; Charles D. Mabry; Martin B. Camins; Robin S. McLeod; Richard J. Finley; Mark A. Malangoni; Carlos A. Pellegrini; Richard B. Reiling, Second Vice-President; and Jack W. McAninch, First Vice-President. Back row: Courtney M. Townsend, Jr., Secretary; Thomas V. Whalen; H. Randolph Bailey; J. David Richardson; Howard M. Snyder III; Karl C. Podratz; Raymond F. Morgan; Mark C. Weissler; Bruce D. Browner; and Lenworth M. Jacobs, Jr., B/G Vice-Chair. 44

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS A special luncheon was held during the Congress in honor of the Distinguished Lecture of the International Society of Surgery. Attending the luncheon were, left to right: Dr. Russell; Dr. Numann; Michael G. Sarr, MD, FACS; Dr. McGinnis; Lecturer Professor Lord Ara W. Darzi, MB, BCh, FACS; Ronald V. Maier, MD, FACS; and Carlos A. Pellegrini, MD, FACS.

Where to find more information Also elected to the Board of Governors’ Ex- ecutive Committee were Henri R. Ford, MD, These highlights include news items that have been FACS, Los Angeles, CA, and Lena M. Napoli- discussed in more detail in previous issues of the Bul- tano, MD, FACS, Ann Arbor, MI. letin. Following is a list of where to find these articles. Clinical Congress 2010: Washington, DC September 2009 It’s never too early to start planning for the • Full description of the humanitarian achievements 96th annual Clinical Congress, scheduled for of Surgical Volunteerism Award recipients, page 31. October 3–7, 2010, in Washington, DC—the first time the meeting has ever been held in the na- • Dr. Griffen’s Distinguished Service Award, page 29 tion’s capital. ACS event planners said it was the ideal time to have the Clinical Congress meeting November 2009 in Washington, DC, because the College is con- • Biography of Dr. McGinnis, page 36 tinually striving to have a more visible presence on Capitol Hill. Nearly all educational sessions • Citations for Honorary Fellows presented at the will be held in the new, state-of-the-art Walter Convocation, page 38 E. Washington Convention Center. 

December 2009

• Dr. McGinnis’ Presidential Address in its entirety, page 8 • Dr. Eastman selected as Chair, Board of Regents, page 26

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Officers and Regents Officers/Officers-Elect

LaMar S. McGinnis, Jr. Kirby I. Bland President First Vice-President General surgery General surgery Clinical professor of surgery, Chair, department of surgery, Emory University University of Alabama– Atlanta, GA Birmingham Birmingham, AL

Karen E. Deveney Courtney M. Townsend, Jr. Second Vice-President Secretary General surgery General surgery Professor of surgery John Woods Harris and director, surgical education, Distinguished Professor, Oregon Health & Science department of surgery, University Hospital The University of Texas Portland, OR Medical Branch Galveston, TX

Andrew L. Warshaw L. D. Britt Treasurer President-Elect General surgery General surgery W. Gerald Austen Professor Brickhouse Professor and of Surgery, chair, department of surgery, Harvard Medical School; and Eastern Virginia Medical surgeon-in-chief and chairman, School department of surgery, Norfolk, VA Massachusetts General Hospital Boston, MA

Richard J. Finley Frederick L. Greene First Vice-President Elect Second Vice-President-Elect General surgery General surgery Professor and head, Chairman, department of division of thoracic surgery, general surgery; director, University of British surgical residency program, Columbia Faculty of Medicine Carolinas Medical Center; Vancouver, BC and clinical professor of surgery, University of North Carolina School of Medicine, Chapel Hill Charlotte, NC 46

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Board of Regents

A. Brent Eastman Carlos A. Pellegrini Chair Vice-Chair General surgery General surgery Chief medical officer, Scripps Henry N. Harkins Professor Health, and N. Paul Whittier and chairman, Chair of Trauma, department of surgery, Scripps Memorial Hospital, University of Washington La Jolla, CA; Seattle, WA and clinical professor of surgery, University of California, San Diego San Diego, CA

H. Randolph Bailey Barbara L. Bass Colon and rectal surgery General surgery Clinical professor and Chair, department of surgery, chief, division of colon Methodist Hospital and rectal surgery, Houston, TX University of Texas Health Science Center Houston, TX

Bruce D. Browner Martin B. Camins Orthopaedic surgery Neurological surgery Gray-Gossling Professor and Clinical professor of chairman emeritus, and resi- neurological surgery, dency program director, depart- Mount Sinai Hospital and ment of orthopaedic surgery, Medical School University of Connecticut New York, NY Health Center, Farmington, CT; and director of orthopaedics, Hartford Hospital Hartford, CT

Julie A. Freischlag Barrett G. Haik Vascular surgery Ophthalmic surgery William Stewart Halsted Chair, department of Professor and ophthalmology, surgeon-in-chief, University of Tennessee The Johns Hopkins Hospital Health Science Center, Baltimore, MD College of Medicine Memphis, TN

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Board of Regents

Rene Lafreniere Charles D. Mabry General surgery General surgery Professor of surgery, oncology, Private practice and anesthesia Pine Bluff, AR; University of Calgary and assistant professor of Calgary, AB surgery, practice management advisor to the chairman, department of surgery, University of Arkansas for Medical Sciences Little Rock, AR

Mark A. Malangoni Robin S. McLeod General surgery Colon and rectal surgery Chair and surgeon-in-chief, Professor of surgery and department of surgery, health policy, management, MetroHealth Medical Center; and evaluation, and professor of surgery, University of Toronto; Case Western Reserve and head, division of University School general surgery, of Medicine Mt. Sinai Hospital Cleveland, OH Toronto, ON

Raymond F. Morgan Leigh A. Neumayer Plastic surgery General surgery Milton T. Edgerton Professor Professor of surgery, and chair, department of University of Utah; plastic surgery, Jon and Karen Huntsman University of Virginia Presidential Professor of Health Sciences Center Cancer Research, Charlottesville, VA Huntsman Cancer Institute; and co-director, Integrated Breast Program, Huntsman Cancer Hospital Salt Lake City, UT

Karl C. Podratz J. David Richardson Gynecology (oncology) Vascular surgery Joseph I. and Barbara Ash- Professor of surgery kins Professor of Surgery, and vice-chairman, and professor of obstetrics department of surgery, and gynecology, University of Louisville Mayo Clinic School of Medicine Rochester, MN Louisville, KY

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Board of Regents

Valerie W. Rusch Marshall Z. Schwartz Chief, thoracic service, Pediatric surgery Memorial Sloan-Kettering Professor of surgery and Cancer Center; pediatrics, Drexel University and professor of surgery, College of Medicine, Temple Cornell University University School of Medicine; Medical College and surgeon-in-chief, New York, NY chief of pediatric surgery, and director, Pediatric Sur- gery Research Laboratory, St. Christopher’s Hospital for Children Philadelphia Philadelphia, PA

Howard M. Snyder III Mark C. Weissler Urology Otolaryngology Associate director Joseph P. Riddle of pediatric urology, Distinguished Professor of The Children’s Hospital Otolaryngology, professor of Philadelphia; of otolaryngology–head and and professor of urology, neck surgery, and University of Pennsylvania professor and chief of head School of Medicine and neck oncology, Philadelphia, PA University of North Carolina Neurosciences Hospital Chapel Hill, NC

Thomas V. Whalen Pediatric surgery Chair, department of surgery, Lehigh Valley Hospital Allentown, PA

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

David B. Hoyt, MD, FACS, becomes ACS Executive Director

David B. Hoyt, MD, FACS, (1977–1979), research fellow former chairman, department (1979–1980), and senior and of surgery; executive vice-dean, chief resident (1982–1984) at school of medicine; and John E. the UC San Diego School of Connolly Professor of Surgery, Medicine. He served as direc- University of California, Irvine tor of the division of trauma, (UCI), Medical Center, has burns, and critical care at the become the new Executive Di- UC San Diego Medical Center rector of the American College from 1989 to 2006. Dr. Hoyt of Surgeons. The appointment also served as assistant profes- of Dr. Hoyt, who is a former sor of surgery (1984–1989), Medical Director of the Col- associate professor of surgery lege’s Trauma Programs, was (1989–1995), and professor of approved and announced by the surgery (1995–2006) at UC San ACS Board of Regents at their Diego School of Medicine. October 15, 2009, meeting. A nationally recognized trau- Dr. Hoyt succeeds Thomas ma surgeon, Dr. Hoyt has been R. Russell, MD, FACS, who has president of the Pan American completed his second term and Trauma Society, the American a full decade of service as Execu- Dr. Hoyt Association for the Surgery of tive Director of the American Trauma, the Shock Society, and College of Surgeons. the San Diego Society of Gen- An ACS Fellow since 1987, eral Surgeons. He has served Dr. Hoyt has been an active on Informatics. He was also as chairman of the Trauma leader in a number of College actively involved with the Advisory Committee for the activities. He has been involved San Diego/Imperial County state of California’s Emergency with the work of the ACS Com- Credentials Committee for Services Authority. Dr. Hoyt mittee on Trauma (COT) since 12 years. has received numerous recog- 1980, and was Chair of the COT Prior to his position at UCI, nition awards throughout his 1998–2002. He is a member of Dr. Hoyt was The Monroe E. distinguished career, includ- the national faculty for the Col- Trout Professor of Surgery and ing the Trauma Service Award lege’s Advanced Trauma Life vice-chairman of the depart- from the Society of Trauma Support® (ATLS®) course, and ment of surgery at the Uni- Nurses and the Robert Danis is a coordinator, instructor, and versity of California (UC), San Lifetime Research Award from director of training for ATLS. Diego, CA; he was also on the the International Society of Dr. Hoyt was awarded the staff at the Veterans Adminis- Surgery. College’s highest honor, its tration Medical Center in San Dr. Hoyt’s research inter- Distinguished Service Award, Diego and at Thornton Hospital ests and past research experi- in 2007. He was a member of in La Jolla, CA. ence have involved basic and the ACS Board of Governors’ Dr. Hoyt obtained his medi- clinical work in a variety of Committee on Blood-Borne cal degree from Case Western important areas related to Infection and Environmental Reserve University, Cleve- trauma patients and trauma Risk, the Program Committee, land, OH, in 1976. He was care systems, including cyto- and the Regents’ Committee intern (1976–1977), resident kine regulation, the isolation of 50

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS trauma active peptides, trauma the principal or co-investigator boards of the World Journal of registries, violence preven- for trauma-related research Emergency Surgery, Surgery, tion, crash investigation, and throughout his career, and has Journal of the American Col- long-term outcomes research. been the author or co-author lege of Surgeons, Journal of He has been awarded several of more than 480 publications. Trauma, Shock, and Open Ac- research grants from the Na- In addition, Dr. Hoyt holds cess Emergency Medicine. tional Institutes of Health as membership on the editorial

College supports American Cancer Society screening mammography guidelines

The American College of Breast Centers. Dr. Winchester “Many surgeons in this coun- Surgeons strongly supports was particularly concerned try have the tremendous re- the current American Can- about the panel’s belief that sponsibility and privilege of cer Society’s (ACS) screening mammography may cause an caring for breast cancer pa- mammography guidelines that increased risk of false-positive tients each day. While recogniz- recommend women get a mam- results in younger women ing that mammography is not mogram every year, starting who have denser breast tis- perfect and supporting con- at age 40. The College is sup- sue, observing that “the term tinuing research for improved porting the ACS guidelines ‘unnecessary biopsy’ is mis- methods, the surgical commu- despite the recommendations leading.” “In most cases,” he nity believes that the American from the U.S. Preventive Ser- said, “biopsy—done by either Cancer Society’s screening vices Task Force stating that surgeons or radiologists—is the mammography guidelines offer women should have regular reliable way to rule out cancer an optimal approach to detect- mammograms once every two at any age.” ing breast cancer early, when years beginning at the age of The College notes that the it can be most successfully 50. The College believes the ACS has long recognized mam- treated,” LaMar S. McGinnis, ACS guidelines have resulted mography as the gold standard Jr., MD, FACS, President of in an effective approach toward for early detection of breast the American College of Sur- dealing with the possibility of cancer, and encourages women geons and former president of breast cancer and that women to take an active role in part- the American Cancer Society, should continue to follow them nering with their physicians said. “Mammography is a good in consultation with their phy- to determine at what age, and and safe tool, which we will sicians. at what interval, they should continue to improve. In the The federal panel’s position undergo screening mammog- meantime,” he added, “let’s that regular mammography raphy. The College agrees with save lives as best we can. The screening in women under the the ACS that factors such as a lives of women, mothers, and age of 50 may do more harm woman’s family history of the grandmothers are invaluable. than good was dismissed by disease, and her overall medi- Our progress has been signifi- David P. Winchester, MD, FACS, cal condition, are some of the cant, and it will continue. Let Medical Director of the Ameri- issues that should be addressed, us not confuse our patients can College of Surgeons Cancer particularly for women who are and the public with mixed mes- Programs, and chair of the Na- known to be at an increased risk sages.” tional Accreditation Program of for developing the disease. 51

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NEW AMERiCAN COllEgE OF SURgEONS ♦ DiViSiON OF EDUCATiON U l t r a s o U n d for sUrgeons: THE BASiC COURSE, 2nd EDiTiON

The National Ultrasound Faculty of the American College of Surgeons has developed “Ultrasound for Surgeons: The Basic Course, 2nd Edition” on CD-ROM for surgeons, surgical residents, and anyone interested in ultrasound imaging.

The 2nd Edition includes: ♦ Updated graphics using 3-D medical modeling devel- oped by NASA researchers to teach ultrasound and rapidly demonstrate key ultrasound skills ♦ Targeted clinical applications are highlighted, including Head and Neck, Breast, Vascular, Abdominal, Thoracic, Critical Care/Trauma, Foreign Objects, and Fractures ♦ Cue Cards to view and print to prompt learners on three commonly performed scans ♦ Easier navigation and support of the CD-ROM ♦ Four CME credits available

UltrasoUnd for sUrgeons: The CD-ROM provides the learner the BASic courSe, 2nd eDition with basic education and train- ing in ultrasound imaging as a foundation for specific clinical applications.

To purchase the NEW edition,

goThomas toR. Russell, www.acs-resource.org MD, FACS Executive Director, American College of Surgeons Ajit K. Sachdeva, MD, FACS, FRCSC Director, Division of Education orKathleen call A. Johnson, 888-711-1138. EdM Senior Manager, Accredited Education Institutes and Skills Courses Olivier Petinaux, MS Senior Manager, Distance Education and E-Learning Sangkhom Ratsavong Administrator, Distance Education and E-Learning Margaret Goslin Administrative Assistant

The ACS acknowledges the National Aeronautics and Space Administration (NASA), the U.S. Olympic Committee and the National Space Biomedical Research Institute for contributing images. AmericAn college of SurgeonS ♦ DiviSion of eDucAtion

52 -Learning products: ♦ ♦ VOLUMEE 95, NUMBERE F 1, FBULLETIN E C OF T THE I V AMERICAN E COLLEGE EFFICIENT OF SURGEONS EXCEPTIONAL

UltrasoundAd 2009 BULLETIN.indd 1 9/22/2009 2:33:53 PM Call for nominations for the ACS Board of Regents

The 2010 Nominating Com- reflected by service and active Nominations should in- mittee of the Board of Gover- participation on ACS commit- clude a paragraph or two on nors has the task of selecting tees or in other components of the potential contributions two nominees for pending the College each candidate can offer in vacancies on the Board of • Recognition of the impor- terms of what he or she can Regents, to be filled during tance of their representing all do for the members of the Col- the 2010 Clinical Congress in who practice surgery lege. Submit nominations to Washington, DC. The follow- Also to be taken into consid- [email protected] by ing guidelines are used by the eration are geography, surgical Friday, February 26. Nominating Committee when specialty balance, and aca- If you have any questions, reviewing the names of candi- demic or community practice. please contact Patricia Spreck- dates for potential nomination The College encourages con- sel, Staff Liaison for the Nomi- to the Board of Regents. sideration of women and other nating Committee of the Board • Loyal members of the underrepresented minorities. of Governors, at psprecksel@ College who have demonstrat- Individuals who are no lon- facs.org. ed outstanding integrity and ger in active, surgical practice For information only, the cur- medical statesmanship along should not be nominated for rent members of the Board of with an unquestioned devo- election or reelection to the Regents who will be considered tion to the highest principles Board of Regents. Priority for re-election are as follows: of surgical practice consideration should be given Barrett G. Haik, MD, FACS; • Demonstrated leader- to representatives of general and Howard M. Snyder III, ship qualities that might be surgery. MD, FACS.

Call for nominations for ACS Officers-Elect

The 2010 Nominating Com- ed outstanding integrity and underrepresented minorities. mittee of the Fellows has the medical statesmanship along Nominations should in- task of selecting nominees for with an unquestioned devo- clude a paragraph or two on the three Officer-Elect posi- tion to the highest principles the potential contributions tions of the American College of surgical practice each candidate can offer in of Surgeons: President-Elect, • Demonstrated leader- terms of what he or she can First Vice-President-Elect, and ship qualities that might be do for the members of the Col- Second Vice-President-Elect. reflected by service and active lege. Submit nominations to The following guidelines are participation on ACS commit- [email protected] by used by the Nominating Com- tees or in other components of Friday, February 26. mittee when reviewing the the College If you have any questions, names of potential candidates • Recognition of the impor- please contact Patricia Spreck- for nomination as Officers of tance of their representing all sel, Staff Liaison for the Nomi- the College. who practice surgery nating Committee of the Fel- • Loyal members of the The College encourages con- lows at [email protected]. College who have demonstrat- sideration of women and other 53

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Heller School Executive Leadership Program scholarships available

The American College of Surgeons is offering • Applications for this scholarship consist of scholarships to subsidize attendance and par- the following items: ticipation in the Executive Leadership Program —The applicant’s current curriculum vitae in Health Policy and Management at the Heller —A one-page essay, discussing why the appli- School for Social Policy and Management (http:// cant wishes to receive the scholarship heller.brandeis.edu/academic/execed/index.html) • Application for this award may be submitted at Brandeis University, in Waltham, MA. The even if comparable application to other organi- 2010 course takes place June 13–19, and the zations has been made. If the recipient accepts $8,000 award is to be used toward the cost of a similar scholarship from another agency or tuition, travel, housing, and subsistence dur- organization, the scholarship will be withdrawn. ing the period of the course and the post-course It is the responsibility of the recipient to notify follow-up period. the Scholarships Section of the ACS, which ad- Two 2010 scholarships are reserved for general ministers this program, of competing awards. surgeons and are fully funded by the College. In • The scholarship must be used in the year for addition, the College is very pleased that a large which it is designated. It cannot be postponed. number of the surgical specialty societies have • The selected scholar is required to provide partnered with the ACS to co-sponsor a schol- one year’s health policy-related assistance to arship for a member in good standing of both the ACS and the cosponsoring society, attending the College and his or her surgical society. The meetings, reviewing applications, and so forth, participating societies supporting scholarships as requested by either organization. are the American Association of Neurological • A brief report of the scholar’s experiences Surgeons, the American Association for the Sur- and activities is due at the conclusion of the gery of Trauma, the American Pediatric Surgical course and again at the end of the scholarship Society, the American Society of Breast Surgeons, period. A simple accounting is also required. the American Society of Colon and Rectal Sur- The closing date for receipt of applications is geons, the American Society of Plastic Surgeons, February 1. All applicants will be notified of the the American Surgical Association, the American outcome of the selection process by March 31. Urogynecologic Society, The Society of Thoracic Questions may be directed to the ACS Scholar- Surgeons, and the Society for Vascular Surgery. ships Administrator at 312-202-5281. Require- The American Urological Association (AUA) ments for the scholarships are available at: http:// will also cosponsor a health policy scholarship www.facs.org/memberservices/research.html. with the College, via the mechanism of the AUA’s Send applications for this scholarship to Schol- Gallagher Scholars program (visit www.AUAnet. arships Section, American College of Surgeons, org/Gallagher). 633 N. Saint Clair St., Chicago, IL 60611-3211. General policies covering the granting of the scholarships are as follows: • The award is open to surgeons who are general surgeons or members in good standing of one of the listed societies and of the American College of Surgeons. • The award is to be used to support the recipi- ent during the period of the course and the period of service following. Indirect costs are not paid to the recipient or to the recipient’s institution. 54

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Nominations sought for 2010 volunteerism and humanitarian award

The American College of Surgeons, in associa- and ongoing operations of a charitable organiza- tion with Pfizer, Inc, is accepting nominations tion dedicated to providing surgical care to the for the 2010 Surgical Volunteerism Award(s) and underserved, or a retirement characterized by the Surgical Humanitarian Award. surgical volunteer outreach. Having received a The ACS/Pfizer, Inc Surgical Volunteerism compensation for this work does not preclude a Award is given in recognition of those surgeons nominee from consideration, and, in fact, may committed to giving something of themselves be expected, based on the extent of the profes- back to society by making significant contribu- sional obligation. tions to surgical care through organized volun- Nominations will be evaluated by the Com- teer activities. The awards for domestic, inter- mittee on Socioeconomic Issues of the Board of national, and military outreach are intended for Governors, with final approval of award win- ACS surgeons in active surgical practice whose ners by the Executive Committee of the Board volunteerism activities go above and beyond of Governors. the usual professional commitments, or retired Potential nominees should make note of the Fellows who have been involved in volunteer- following: ism during their active practice and into retire- • Supplemental materials should be kept to ment. Surgeons currently in residency who have a minimum and will not be returned been involved in significant surgical volunteer • Self-nominations are permissible but re- activities are eligible for the resident award. quire an outside letter of support Surgeons of all specialties are eligible for each • Previous nominees can be re-nominated but these awards. require an updated application For the purposes of these awards, “volunteer- The nomination forms will be available for ism” is defined as professional work in which download from the “Announcements” sec- one’s time or talents are donated for charitable tion of the Operation Giving Back Web site clinical, educational, or other worthwhile activi- during January and February at http://www. ties related to surgery. Volunteerism in this case operationgivingback.org. Nomination forms can does not refer to pro bono or uncompensated care also be requested by mail, if preferred. Contact provided as a matter of necessity in most prac- Uriah Melchizedek, Operation Giving Back tices. Instead, volunteerism should be character- Program Coordinator, with such requests or ized by the prospective, planned surgical care any questions. to underserved patients with no anticipation of Completed nomination forms should be ad- reimbursement or economic gains. dressed to the attention of Robert M. Zwolak, The ACS/Pfizer, Inc Surgical Humanitarian MD, FACS, Chair, Board of Governors’ Commit- Award is given in recognition of those surgeons tee on Socioeconomic Issues, and can be submit- who have committed a substantial portion of ted electronically, or by mail c/o Uriah Melchize- their career to ensuring the provision of surgi- dek, American College of Surgeons, 633 N. Saint cal care to underserved populations without Clair St., Chicago, IL 60611; 312-202-5458; fax expectation of commensurate reimbursement. 312-202-5021; [email protected]. All nominations This award is intended for a surgeon who has must be received by Friday, February 26. dedicated a significant portion of his or her surgical career to full-time or near full-time humanitarian efforts rather than routine sur- gical practice. This effort may reflect a career dedicated to missionary surgery, the founding 55

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Did you ever wish you could be in 5 places at once?

1 2 3 4 5

NOW YOU CAN…95th Annual ACS Clinical Congress Webcast and audio packages are still available!

The ACS Clinical Congress is packed with Purchase the Audio Package valuable educational programming, All Panel Sessions and most Named Lectures from but busy annual meeting attendees the 2009 Clinical Congress will be audio recorded can’t be in five places at one time. live and available for purchase as a DVD-ROM with The burning question has always MP3 downloads, making it an excellent training tool been, “Which one to attend?” and an informative resource for sessions missed due to scheduling conflicts. CME credit not available.

Purchase the Webcast Package $210 (ACS Member)/$245 (Non-Member) Webcast sessions contain audio fully synchronized to session PowerPoints, and offer more than 100 hours of CME (BONUS: 2008 & 2007 Webcast Purchase Both the Webcast Packages included and accessible immediately). Package and the Audio Package (Complete Package) $129 (ACS Member)/$135 (Non-Member) Includes 2009 Webcast sessions, 2008/2007 Webcast Again this year, Clinical Congress attendees can sessions AND audio sessions from 2009 Congress. experience selected sessions online long after the actual event, via the ACS E-Learning Resource $289 (ACS Member)/$329 (Non-Member) Center. Selected online Webcasts (over 55 CME hours) will contain the audio fully synchronized to the speaker’s PowerPoint presentation, providing attendees with a true multimedia recreation of those sessions. A CME examination, evaluation, and certificate, providing attendees with CME credits for each available session, is included. Division of EDucation

To purchase the Webcast and Audio Packages, visit www.acs-resource.org or e-mail [email protected]

WEBCAST ad.indd 1 10/22/2009 10:38:03 AM ACOSOG news Patient advocates: “Our job is purely about patient safety” by Heidi Nelson, MD, FACS; and David M. Ota, MD, FACS

In the last issue of the Bul- a patient’s medical condition. work with Ms. Green on the letin (Bull Am Coll Surg. Cancer advocacy groups try to ACOSOG committee and about 2009;95(12):29), we discussed raise public awareness about the role of the committee the role of the American Col- important cancer issues, such in promoting the science of lege of Surgeons Oncology as the need for cancer sup- ACOSOG. Group (ACOSOG) in promot- port services, education, and “The Patient Advocacy Com- ing patient safety. We described research. Such groups work to mittee of ACOSOG is consti- how ACOSOG is charged with bring about change that will tuted with rich diversity,” said conducting clinical trials that help cancer patients and their Ms. Green. “The 13 members ensure the safe introduction families. of the committee are people of effective new therapies. We from different backgrounds also outlined, in brief, how To examine the day-to-day with different experiences the complex system of over- contributions of patient advo- and expertise. For example, sights and the team of patient cates engaged in cancer trials, the ACOSOG Patient Ad- advocates work together to we invited Bettye Green, RN, vocacy Committee includes safeguard patients enrolled in the chair of the ACOSOG Pa- Native Americans, African- clinical trials. In this article, tient Advocacy Committee, to Americans, Hispanics, women, we provide a more in-depth offer her insights. We started men, old and young individu- examination of the ACOSOG by asking Ms. Green why, als. Folks are from different patient advocates—who they and how, a person decides to parts of the country and have are and what they do to con- become a patient advocate, as experience in teaching, fund- tribute to the scientific effort well as what is required to be- raising, and recruiting. All of ACOSOG. come certified or credentialed. who serve ACOSOG have some Who are patient advocates? “Just by desire, they de- personal connection with Since ACOSOG is sponsored cide they want to work with cancer so the desire to serve by the National Cancer Insti- a researcher to find a cure for is strong.” tute (NCI), we offer the NCI cancer,” said Ms. Green. “Once Ms. Green continued, “The definition of the patient advo- they decide to become an ad- job of ACOSOG patient ad- cate as a starting point: vocate, they voice that desire; vocates is to represent the they seek out and find the patient at all steps along the A person who helps a pa- opportunities to work with re- ACOSOG decision-making tient work with others, who searchers who work on cancer. process and to promote pa- [has] an effect on the patient’s There is no credentialing yet tient safety. To accomplish health, including doctors, for patient advocates. There are this aim, patient advocates are insurance companies, em- colleges working on developing fully integrated into ACOSOG ployers, case managers, and programs that would award scientific committees and ac- lawyers. A patient advocate degrees for advocacy, but they tivities.” helps resolve issues about are not available at this time.” Ms. Green explained that health care, medical bills, and We also enquired about the process starts with the job discrimination related to the patient advocates who advocate reviewing the study 57

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS idea or concept. They critically logistics of the proposed meth- ties to spread the word about address the first key question, ods. Will the study methods trials, and they keep their eye which is: will patients find be something a patient can on the accrual goal target.” the idea appealing enough to reasonably achieve? And finally, in order to put enroll into the trial? Once a study is approved, safety first during the conduct If the answer is “yes,” the the patient advocates work of the trial, patient advocates next step in the process is the on the dissemination phase. are part of the ACOSOG Data Peer Review Committee. While “You need to reach out to Monitoring Committee. “We the scientists are critically patients in a culturally sensi- are the patient at the ACOSOG appraising the study methods tive manner…and you have to table,” Ms. Green added. and endpoints for what they reach out into the community,” need to learn from the study, explained Ms. Green. “The Dr. Nelson, of Rochester, MN, the patient advocates on the ACOSOG advocates train local and Dr. Ota, of Durham, NC, are committee are considering the advocates to reach communi- ACOSOG Co-Chairs.

ACS leaders visit key senators In the midst of the health care reform debate, leaders of the College traveled to Washington, DC, to meet with House and Senate congressional leaders, including Sen. Max Baucus (D-MT), Chairman of the powerful Senate Finance Committee. The December 9, 2009, meetings were held as part of the College’s long-term, strategic advocacy efforts to advance the College’s top legislative priorities within comprehensive health care reform. Pictured from left to right: A. Brent Eastman, MD, FACS, Chair of the ACS Board of Regents; Senator Baucus; LaMar S. McGinnis, Jr., MD, FACS, ACS President; and David B. Hoyt, MD, FACS, then incoming Executive Director of the College.

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS American College of Surgeons Professional Association (ACSPA)

As of September 15, 2009, the ACSPA- SurgeonsPAC (political action committee) raised $465,709. Forty-two percent of the U.S. Governors contributed $42,820, and 44 percent of the U.S. Officers and Regents contributed as well. PAC contributions were made to 45 candi- dates, leadership PACs, and party committees.

American College of Surgeons

Board of Governors The Executive Committee of the Board of Governors held its five telephone conference calls scheduled for the year. In addition, two face-to-face meetings were held during the Clinical Congress in Chicago, IL. The Board of Governors annual survey com- municates the concerns and recommendations of the Fellows regarding major issues related to surgery to the College’s leadership. The results of the survey are presented to the Board of Re- gents as it considers future College endeavors. The top five issues of concern to the Fellows of the College in 2009, as reported by the Gover- nors, are as follows: • Health care reform • Physician reimbursement • Professional liability/malpractice • Workforce issues • Graduate medical education The Board of Governors and the Board of Report on Regents held a joint session during the annual business meeting of the Governors. The session ACSPA/ACS focused on the College’s 2009 draft statement on health care reform. The draft was a major activities topic of discussion at both the business and adjourned meetings of the Board of Governors. The 2009 draft evolved, in part, from the 2008 October 2009 ACS Statement on Health Care Reform, with added emphasis on medical liability reform. As the College did with its 2008 statement, it by Michael J. Zinner, MD, FACS, will use its finalized 2009 statement to form the basis of its interactions with Congress on Chair, ACS Board of Governors health care policy. The finalized document was expected some time in November.

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Health Policy Research Institute Addition of “procedural skills” to the (ACS HPRI) ABMS/ACGME core competencies The ACS HPRI is engaged in a variety of Since the American Board of Medical Spe- projects, including analysis of surgery work- cialties (ABMS) and the American Council force trends. The HPRI is also engaged in the for Graduate Medical Education (ACGME) development of an interactive atlas of the U.S. defined the six core competencies several surgical workforce. years ago, there has been widespread con- The HPRI launched its Web site in July, and cern about the omission of technical skills it is accessible at: http://www.acshpri.org/. The from the list of competencies. The College site links to the ACS Web site, http://www.facs. addressed this gap by focusing specifically on org/. technical skills through a variety of innovative competency-based educational programs that ACS Health Policy and Advisory Council addressed psychomotor skills, cognitive skills, The Board of Regents approved the forma- judgment, and teamwork. Leaders from across tion of a Health Policy and Advisory Council, the surgical specialties have supported the which will be a subgroup of the Health Policy notion of adding a seventh core competency and Advocacy Group. The establishment of this to address technical skills, or have addressed council will allow for better outreach to, and this competency through approaches similar input from, the Fellows on health policy mat- to the one adopted by the College. The ABMS ters. The council will be composed of Governors, and the ACGME appointed a Joint Task Force Young Fellows, ACS Resident and Associate on Technical Skills to discuss this matter and Society members, ACS Health Policy Scholars, develop appropriate recommendations. The and other Fellows with expressed interest or Task Force unanimously endorsed inclusion expertise in health care policy. of technical skills as a core competency, and named the new core competency “procedural ACS National Surgical Quality skills.” Subsequently, the Board of Regents Improvement Program (ACS NSQIP) voted to approve the addition of procedural While important and substantial advances skills as the seventh core competency. are being made in both the program’s technical and clinical aspects, the most progress has been Journal of the American College achieved through the joint quality improvement of Surgeons (JACS) efforts of a variety of different groups. The Online and fax JACS CME submissions cur- shared efforts with the Centers for Medicare rently exceed 278,000 credits; the program is & Medicaid Services (CMS) to develop ACS provided as a member benefit. The efficiency NSQIP-based performance measures, working and economics of the JACS CME-1 program with The Joint Commission to improve surgi- is beneficial to all members, especially in this cal safety, and collaborating with many surgi- time of heightened emphasis on Maintenance cal societies to further expand ACS NSQIP’s of Certification. It would benefit the ACS content and reach, are some examples of these chapters to include information about the joint quality improvement efforts. Overall, JACS CME-1 program for their members ACS NSQIP is reaching an important “tip- during their meetings. ping point” as the program’s proven technical aspects are advancing, clinical improvement is New chapters building on the expertise of internal initiatives, The Board of Regents approved the forma- and surgical improvement efforts are being tion of the College’s 34th and 35th interna- shared with organizations such as CMS, The tional chapters: the ACS Pakistan Chapter Joint Commission, the Institute for Healthcare and the ACS Austria-Hungary Chapter. This Improvement, and others. brings the total number of ACS chapters to

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 102: 35 international, two Canadian, and 65 content targeted to main interests of mem- U.S. bers of the College.

HealtheCareers (a.k.a. Job Bank) Operation Giving Back (OGB) As of September 2, 2009, there were 1,072 In the past year, there have been nearly active jobs listed on the Web site, with 265 23,000 unique visitors who have conducted posted résumés. This is a valuable service for more than 93,500 page views of the OGB Web all members of the College. site at http://www.operationgivingback.facs. org/. Since June, there have been 51 new vol- Resident and Associate Society unteer opportunities posted to the Web site, of the American College of Surgeons (RAS) with 196 opportunities currently, actively The RAS gave special recognition to Mark D. available. Boyer, MD, FACS, for his efforts on behalf of the Surgical Jeopardy program. Jacob Moalem, Executive Director MD, FACS, hosted the first RAS Town Hall Thomas R. Russell, MD, FACS, retired from Meeting, during which the discussion focused his College position as Executive Director on on resident work hour restrictions. The RAS December 31. Dr. Russell has been the Col- continues to focus on educational opportuni- lege’s Executive Director for 10 years. During ties and is thankful for the fund that has sup- its business meeting in October, the Board of plied scholarships for the resident members. Governors expressed its appreciation for all New ideas continue to be generated on how to of Dr. Russell’s accomplishments on behalf of increase those funds and offer new opportuni- surgery and patient care. ties for deserving young surgeons. The Board of Regents met in Executive Ses- sion during the Clinical Congress and heard Young Fellows Association (YFA) presentations from finalists for the position The YFA held its inaugural meeting during of Executive Director of the American College the Clinical Congress on Monday, October 12, of Surgeons. After all candidates made their 2009. Mark A. Malangoni, MD, FACS, a for- presentations, the Regents voted to approve mer chair of the former Committee on Young the selection of David B. Hoyt, MD, FACS, of Surgeons, provided the welcoming remarks Orange, CA, as the next Executive Director of at the meeting. The YFA consists of four the College. The College welcomes Dr. Hoyt workgroups: Advocacy, Communications, as he begins his new venture. Education, and Member Services. Nearly 100 Fellows have joined a workgroup. Visit the new YFA Web page at http://www.facs.org/ Dr. Zinner is memberservices/yfa/. Moseley Professor of Surgery, Harvard Medical School; Web portal clinical director, Top pages visited during the second quar- Dana-Farber/BWH ter of 2009 included My Page, My Profile, Cancer Center; My Cases, and My CME, closely followed by and surgeon-in- Member Services, Member Tools, and Mem- chief, Brigham and ber Benefits. The most visited communities Women’s Hospital, were Minimally Invasive Surgery, Rural Boston, MA. Surgeons, General Surgery, Breast Cancer Surgery, and Residents and Associate Fel- lows. The Communities & Specialties area of the portal continues to provide quality

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JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS .gov .net .com .edu .gov .net .com .e .gov .net .com .edu .gov .net .com . We need edu .gov .net .com .edu .gov .net .com om .edu your help!.gov .net .com .edu .gov .net et .com .edu .gov Don’t miss out on important communications from.net the .com .edu .gov .net .com .edu .gov .net American College of Surgeons..com .edu .com .edu .gov .net .com .edu .gov .net .gov .netSend us .com your .edu .gov .net .com .e e-mail address today. .gov .netCurrent .comevents in Washington, .edu DC, and in all.gov sectors .net .com . of our society are changing with dizzying rapidity, edu .gov .net and .com the College is working .edu to keep you .gov informed. .net .com om .edu The most timely and efficient way to do that is via e-mail. So it’s very important that we have .gov .net .com .eduyour current e-mail.gov address in our.net database. et .com .edu .gov Not sure if we have your current address? Go to the “My Page” area .net .com .edu .gov.of the .net ACS Members-only .com Web portal .eduat .gov .net .com .edu .com .edu .govwww.efacs.org .net .com .edu .gov to see what’s currently in our database and .net .gov .net .com .edu .govto make necessary .net changes. .com .edu If you have questions or problems, contact [email protected]. .gov .net .com .edu gov .net@Include your.com Fellowship ID number.edu in your .govnote. .net .com .edu .gov .net .com om .edu .gov .net

.com .edu .gov .net et .com .edu .gov .net .com Important note: the american College of .edu .gov .net .com .edu .gov .net .com .edu .gov Surgeons does not provide your e-mail address to outside entities. e-mail addresses are used .net .com .edu .gov .net com .edu .gov .net .com only for College communications. .edu .gov .net com .edu .gov .net .com .edu .gov E-mail 2009 ad - Bulletin.indd 1 8/18/2009 3:15:30 PM A look at The Joint Commission 2009 Eisenberg Award recipients named

The National Quality Forum the patient first. Introducing collaborative to focus on in- (NQF) and The Joint Commis- breakthrough changes derived terventions to improve patient sion presented the 2009 John from the Toyota Production safety and prevent harm in M. Eisenberg Patient Safety System, Dr. Kaplan spear- intensive care units (ICUs). and Quality Awards in Octo- headed the creation of the Two of the interventions ber at NQF’s Annual National Virginia Mason Production —eliminating central line- Policy Conference on Quality in System. The patient safety associated bloodstream in- Washington, DC. and quality achievements fections (CLABSIs) and the The patient safety awards realized at Virginia Mason as Comprehensive Unit-Based program, launched in 2002 by a result of consistently apply- Safety Program (CUSP)—have NQF and The Joint Commis- ing these innovative methods produced notable results in sion, honors John M. Eisen- have attracted the interest eliminating CLABSIs in Michi- berg, MD, former administrator and attention of health care gan ICUs. More than 1,800 of the Agency for Healthcare leaders nationally and inter- lives have been saved, more Research and Quality (AHRQ). nationally. than 140,700 excess hospital Dr. Eisenberg was one of the • Research: Tejal Gandhi, days avoided, and more than founding leaders of the NQF MD, Brigham and Women’s $271 million health care dol- and sat on its board of direc- Hospital, Boston, MA. Dr. Gan- lars have been saved in the five tors. In his roles both as AHRQ dhi has been instrumental years since the interventions administrator and chair of the in increasing knowledge and were first implemented. federal government’s Qual- awareness of safety issues in • Innovation in patient ity Inter-Agency Coordination the outpatient setting and safety and quality at the local Task Force, he was a passionate in designing improvement level: Mercy Hospital Ander- advocate for patient safety and strategies for this setting, son, Cincinnati, OH. Mercy health care quality, and person- particularly through the use Hospital Anderson developed ally led AHRQ’s grant program of information technology. Her and implemented an automated to support patient safety re- groundbreaking work to better Modified Early Warning System search. Honorees were selected understand the epidemiology (MEWS), a simple scoring sys- in all five award categories, of a wide range of ambulatory tem that is applied to the physi- including a new international safety concerns is responsible ological vital signs routinely category. for drawing national attention measured by nurses. MEWS The 2009 honorees, by award to safety issues and potential provides nurses with a tool to category, are as follows: prevention in this important evaluate subtle signs that pre- • Individual achievement: patient-care setting. dict the patient’s likelihood of Gary S. Kaplan, MD, Virginia • Innovation in patient deterioration. Mason Medical Center, Se- safety and equality at the na- • International: Noreen Za- attle, WA. Dr. Kaplan, a prac- tional level: Michigan Health far, MD, FRCOG, Lahore, Paki- ticing physician, is credited & Hospital Association (MHA) stan. Dr. Zafar’s vision is to of- for guiding Virginia Mason Keystone Center for Patient fer high-quality gynecological Medical Center through a Safety & Quality, Lansing, MI. care and empower women to transformation that explic- The MHA Keystone Center become good decision makers itly placed the interests of used a quality improvement regarding their own health and 63

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS their family’s health. Dr. Zafar umbrella of the Girls and A. Campbell, Jr., MD, FACS, has worked independently to Women Health Initiative, such senior associate director and promote wellness among girls as Say No to Osteoporosis, chief of staff, Henry King and women, without assistance Beat Menopause, Prioritize Ransom Professor of Surgery, from the government or any Pink, Folic Acid Campaign, University of Michigan Hospi- other outside support. She has Women Matter, and The Paki- tals and Health Centers, Ann overcome many social taboos in stan Group for Pediatric and Arbor, MI. her quest, and has established Adolescent Gynecology, in an Updated information for the health awareness programs effort to improve girls’ and 2010 Eisenberg submissions related to precancer screening, women’s health. will be available February 1. teenage gynecological health, Surgeons are eligible to re- To view past winners visit and reproductive health. ceive the awards. In 2007, http://www.jointcommission. Dr. Zafar has initiated nearly the individual category award org/PatientSafety/Eisenberg a dozen campaigns under the was bestowed upon Darrell Award/#1.

The Residency Assist Page of the American College of Surgeons offers a medium for program directors to acquire updates and advice on topics relevant to their needs as administrators and teachers.

Our goals are to offer practical information and approaches from summaries of published articles, invited editorials, and specific descriptions of lessons learned from program directors’ successful and not-so-successful strategies. Through the development of the Residency Assist Page, the ACS intends to support program directors and faculty by providing succinctly presented information helpful in addressing the challenges associated with administering state-of-art residency education. www.facs.org/education/rap For additional information, please contact Olivier Petinaux, MS, at [email protected], or tel. 866/475-4696

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VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

to the following programs programs following the to

2010 Clinical Congress of the American College of Surgeons of College American the of 2010Congress Clinical welcomes submissions submissions welcomes The American College College American The Education of Division for presentation at at presentation for October 3–7, 2010, 3–7, October Clinical Congress, Congress, Clinical

considered be to the 96th annual annual 96th the DC Washington, Surgeons of

h h h

312-202-5325, [email protected] 312-202-5325, arenotallowed. sameabstracttomorethanoneprogram) submission. theACS Web siteat www.facs.org/education/. eachindividual willbepostedon program [email protected] 312-202-5262, American Surgeons College (JACS) of the September the Supplement of Accepted Surgical Forum abstracts will be published in h Oral presentations mansuscripts to JACS. *Accepted authors are tosubmitfull encouraged h h h h h h information Submission h presentation Video h presentation Poster h were given in 2009) givenin were Awards Research in Excellence $1,000 (12 [email protected] 312-202-5336, 312-202-5385, [email protected] 312-202-5385, Surgical Forum Surgical Duplicate submissions(submittingthe Abstract specifications and requirements for Late submissionsarenot permitted. Deadline:5:00pm(CST),March1,2010. November Submissionperiodbegins 2,2009. Abstractsaretobesubmittedonlineonly. Video-Based Education Scientific Exhibits Program Coordinator: Beth Brown, Beth Coordinator: Program Papers Session Papers Review the information carefully priorto Dykman, GayLynn Coordinator: Program Program Coordinator: L.Matousek, Kathryn Program Program Coordinator: Kay Anthony, Kay Coordinator: Program * * ora ftheJournal of Letters

The following comments were its high cost. Thus, the value of our aspects of existing nongovernment received in the mail or via e-mail health care system is abysmally low. health care facilities. regarding recent articles published It is politically correct, but timid, 2. Decrease costs by changing in the Bulletin and the “From my to say, “The U.S. has a high-quality practice patterns. During my re- perspective” column written by for- health care system. We should do cent outpatient hernia repair in a mer Executive Director Thomas R. all we can to protect it as well as voluntary hospital, and whenever Russell, MD, FACS. to improve it.” Let us stop being I visit a doctor’s office, the number Letters should be sent with the timid and let us admit that our of paid people I encounter and the writer’s name, address, e-mail health care system is broken and forms I complete are excessive and address, and daytime telephone inadequate. The evidence indicates repetitive. Who knows how many number via e-mail to sregnier@ that nations with single-payor or CMS and Anthem Blue Cross bill- facs.org, or via mail to Stephen multiple-payor national systems ing and collection people handle the Regnier, Editor, Bulletin, American are providing more value for their complicated, excessive paper work? College of Surgeons, 633 N. Saint citizens than we are providing for There is clearly fat to be trimmed Clair St., Chicago, IL 60611. Letters most of ours. So, let’s stop primar- in practice patterns in hospitals and may be edited for length or clarity. ily protecting the status quo. Let doctors’ offices. Permission to publish letters is as- those of us who are privileged to 3. Give physicians who have sumed unless the author indicates practice surgery in this greatest of personal experience in the practice otherwise. all nations lead in selecting changes of medicine definitive leadership that promise to be as beneficial as roles in advising the government. The health care debate: We possible for our patients and the The merit of this suggestion is il- mean well but we are too timid future of health care. lustrated by the success of the Mayo In “Does the U.S. have the best Health care reform is neither a Clinic, the Cleveland Clinic, and the health care system in the world?” Democratic nor a Republican issue, Kaiser-Permanente systems. Well- (Bull Am Coll Surg. 2009;94(7):8- nor is it new. President Theodore selected medical practitioners have 15) there are four tables: (1) Health Roosevelt was the first to propose more to offer than administrators. care system attainment, (2) Overall universal health care, and Presi- John R. Benfield, MD, FACS, performance, (3) Life expectancy dent Richard Nixon had it among Los Angeles, CA and health expenditures, and (4) his highest priorities. Republican Infant mortality rates. The article and Democratic presidents have Changes in practice patterns includes a section entitled “U.S. been held down, much as the Lil- Dr. Russell, we met in New Orleans system is very good, but could liputians successfully restrained at the lunch for Mark Puder, MD be better” and it ends with “The Gulliver. —the most promising investiga- U.S. has a high-quality health care Reality indicates that sweeping, tor that year. Since that meeting, system. We should do all we can to all-inclusive reform will not happen I have left my private practice of protect it as well as to improve it.” promptly. To start somewhere is more than 20 years, for many of In the tables we are ranked required, and as part of this I offer the reasons outlined by you in a number 15 in attainment, and our three suggestions: recent column (Bull Am Coll Surg. overall performance rank is 37. 1. Initiate change within entities 2009;94(6):4-5), for an employed The life expectancy of American the government already controls. position at Emerson Hospital newborns is 1.7 years less than the Centers for Medicare & Medicaid in Concord, MA, this May. The non-U.S. average, and less than Services (CMS) patients often have scramble that private practice had each of 18 other nations. Our per- limited access to care, and they become to make a living (including capita health care expenditure of face a billing morass. The federal covering two hospitals, an office 4,887 is the highest among 19 na- government controls certain health in a third location, fewer surgeons tions. In fact, it is more than double care systems, e.g., Veterans Affairs, willing to care for all comers— the average expenditure of 2,295 military, Public Health Service. The especially trauma) led to a breaking in the other 18 nations. The infant federal government also controls point for me. mortality rate in the U.S. is the Medicare. Reform could promptly General surgery is an essential highest among 16 nations. So where begin by allocating the required service and the sacrifices being is the evidence that our system is resources to government-controlled made to provide it to my commu- very good? Even if one considers health care systems, giving Medi- nity, albeit professionally satisfying, the positive evidence regarding our care patients access to these sys- became too demanding personally. system (and I agree that there is tems, and adapting these systems so Professionally, I wasn’t growing as such evidence), one cannot escape that they could provide the positive 66 a surgeon, either. It was all about

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS just doing, and there wasn’t enough and the windows of opportunities ing a new paradigm for the training time for reflecting on the process are open now for many if they are of the future generation of surgeons or the new abilities I should be able to change. by increased non-bedside clinical developing to stay current with the Thomas R. Russell, MD, FACS training. As quality improvement technological advances. There was Former Executive Director, lessons from the aviation industry certainly a need for another body ACS are increasingly applied in operat- here, but in the right model there is ing rooms around the country, so, time for peer review and education, Surgical tourism too, can the model of flight simula- and these things are perhaps more The article on surgical tourism tion training be applied to surgical valued in this situation than in the published in the April 2009 issue education. eat-what-you-kill private practice. of the Bulletin is ironic, as sur- At last year’s Medicine Meets There is more to surgery than geons have worked hard to provide Virtual Reality Conference, several the next case, and we need to have accountability and efficacy to the presentations described the current the flexibility in our practices to health care process and costs (Bull state of the art and the science lead the way to better care for our Am Coll Surg. 2009;94(4):18). The behind the development of so- patients. I don’t know that I have institution of “surgery,” as opposed called serious video games, which any specific solutions, but I know to “medicine,” is historically found- are basically wholly computer- when I made my wish list of what ed on the principle: one disease, one based surgical simulators. These my ideal practice would be like, my operation and one cure (for one fee, programs have several distinct private practice didn’t resemble it presumably). advantages over the more classic in the least. This comes from a guy General surgeon fees in this model of a simulation-center based who developed the first Level III country are priced very reasonably, model; specifically, these programs trauma center in Massachusetts and hardly exceed fees for mechanic are portable, and as they do not and served as president of the medi- work or plumbing, based on my require any additional equipment cal staff for eight years, finishing experience. other than a personal computer, are my last two-year term last Decem- What underlies this rebellion on cost-effective. ber [2008]. I don’t regret my early our patients’ part is not surgeon Dr. Jan Cannon-Bowers from the decisions about where and how to fees but the hospital charges. We University of Central Florida stated practice, but the ACS is doing well know that these charges are driven that although video games are the to recognize the changes in practice by cost-shifting to cover shortfalls most popular form of entertain- patterns and think about why it is of Medicare funding for hospital ment (more popular than movies happening. care. I propose that such charges for and television combined), currently Brian T. Callahan, Jr., MD, FACS non-Medicare or Medicaid individu- there are not many medical video Concord, MA als would be cut at least in half, if games, and a lack of guidelines for every patient simply paid for the their development. However, one Brian, services he or she received. of the key features of such games Thank you for your recent com- Is it ethical for surgeons, as a is that they provide “pattern build- munication and I do remember group, to participate without pro- ing for adaptive expertise.” Dr. meeting you in New Orleans. test in a system that is detrimental Cannon-Bowers went on to say Thank you so much for your com- to us and our working-age patients, that such simulators can provide ments about the article in the Bul- when the public sees us as greedy variations on a theme for different letin regarding changing practice co-conspirators, and when, in fact, scenarios, and even provide for patterns. I really admire your abil- the opposite is clearly the case? “over-learning” of cognitive skills, ity to see the changes and make an F. A. Morfesis, MD, FACS making them automatic and sub- adjustment in your private practice Fayetteville, NC conscious, thus potentially helping so that now you are in an employed to “take up the slack” regarding position. I see more and more sur- Surgical serious video games work-hour restrictions and the loss geons doing this, for the obvious Although the use of simulators of clinical experiences. reasons such as you have identi- in surgical education is a recently Although funding of these proj- fied and that I have tried to write growing trend, the science behind ects remains an issue, by focus- about. I congratulate you on your these technologies is mature. Work- ing on cognitive content, decision abilities to make this change after hour restrictions and decreased making, and role-playing instead of so many years in private practice. It public and political tolerance for graphics, the development of these is clear that there are some ways of “never-event” and other potentially programs can be done for reason- practicing that are not sustainable, avoidable medical errors are creat- able costs, especially within aca- 67

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS demic environments where student its Residency Assist Page, has pub- For 63 of 121 types of procedures programmers may be available. In lished a “book” entitled Life after considered essential for graduating addition to being used for resident Residency; A Guide for the New chief residents by a survey of pro- education, these decision-making Physician and Surgeon. This is also gram directors, the mode reported scenarios can also be used to assess being distributed by Ethicon free was zero cases. competency. In fact, such digital of charge to all fourth- and fifth- In November 2008, one of the last case-based games are currently be- year residents and surgical fellows. cases I did before leaving the faculty ing developed for recertification of Expansion of this to include all of a residency program was inser- practicing surgeons. physicians, regardless of specialty tion of a port for chemotherapy. In In addition, in the future, these or field, would be admirable (and her fifth month of her PGY-1 year, case-based scenarios will likely be is needed). Congratulations on ad- the resident who scrubbed with linked with skills trainers, such dressing a truly important subject; me had not only never performed as those currently commercially maybe this should be a regular part/ a subclavian vein cannulation, she available, and will likely be in use subsection of the Bulletin. had seen only one such procedure. in many surgery residencies across Craig J. Schaefer, MD, FACS Today’s residents feel the need the country. Providing a case-based Trappe, MD to take fellowships, and not just environment will help to contextu- because they are looking for a alize skills-based learning, allowing As a former general surgery niche. I believe many are not ready students to practice the cognitive residency program director for for independent practice and they skills associated with the work-up, more than 23 years, I would like to know it. I am not sure if the solu- treatment, and even follow-up, as comment on the article by Moalem tion is early differentiation into virtual patients can be seen for six- on residency training in the June subspecialty tracks, but no doubt month follow-up immediately after 2009 issue of the Bulletin (Bull Am something needs to be done. the virtual procedure is completed. Coll Surg. 2009; 94;(6):12-14). Dr. James E. Barone, MD, FACS, Thus, even continuity of care can Moalem states that patients today FCCM be practiced before a student phy- are “older and sicker than ever.” Stamford, CT sician treats an actual live patient. Older, maybe, but is there evidence Clearly, surgical video games will be that patients are sicker now than, I enjoyed reading the articles a part of surgical education for the say, 30 years ago? If so, please pro- from young surgeons regarding the next generation of surgeons. vide a reference. modern surgical lifestyle and the Stefan Holubar, MD I agree that the number of in- fate of the surgical generalist in Associate Fellow, American patients has declined. But I do not the June 2009 issue of the Bulletin. College of Surgeons see how that results in more work It’s been painful for me to watch Member, RAS-ACS for residents today. Back in the day, the decline of general surgery as a Education Committee herniorrhaphy and cholecystectomy specialty to which a young doctor Rochester, MN patients were not only admitted might aspire. I believe that much the day before surgery (necessitat- of the dissatisfaction with general Resident issues ing a full history and physical by surgery relates to the commitment Thank you for addressing a seri- the resident), they also stayed in young doctors have to lifestyle, and ous shortcoming in our resident the hospital for five to seven days the difficulties that the general training programs—the practical postoperatively. This created much surgery community call presents business of medicine. As virtually more work, not less. in achieving that. every resident will verify, while we I agree that the demise of resi- Two of the six general surgeons are well-trained in the complexities dent autonomy has contributed in our group have recently experi- of caring for patients (as we should to the deterioration of residency mented with a modification of our be, since this is our main focus), training. However, something else usual call schedule. We take call we cannot deliver that care if we is going on. Bell et al (Ann Surg. every other day for two weeks, and cannot establish and run a finan- 2009;249:719-724) recently pub- then spend the next four weeks free cially viable practice. The articles lished data showing a distressing of call responsibilities. Taking call by Nair, et al (Bull Am Coll Surg. lack of resident exposure to many every other day requires a change 2009;94(6):15), Cooke, et al (Bull key operative procedures. For ex- in one’s thinking if you are to sur- Am Coll Surg. 2009;94(6):19), and ample, the mode (most common) vive it. The old idea of “eating what the comments by Dr. Russell are number of common bile duct ex- you kill” is not a part of our call both appropriate and long overdue. plorations reported by graduating service. Cases are handed off and I might point out that the ACS, on chief residents in 2005 was one. assumed each morning. Rounding 68

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS in the morning is the responsibility surgery is the backbone of the ACS. we join that brings on a fair treat- of the on-call surgeon. It is a “shift If it were to disappear, the College ment throughout this process,” mentality” service that requires might go the way of the Spring but later admit that “some end up you to accept the fact that your Meeting. trapped in a malignant practice, colleague can do as good a job as George N. Beito, MD, FACS which a properly negotiated con- you can. Kirkland, WA tract could have prevented.” Since It is important to designate a pe- all groups eventually dissolve (or riod of time the day after call that An article published in the June turn over individuals), an exit is free of clinical responsibilities in 2009 issue of the Bulletin, titled strategy should be built into any order to recuperate. Communica- “Building a surgical career” was contract; as the authors note, “both tion is critical between my partner interesting and well done (Bull Am parties should be able to get out of and me in order to provide conti- Coll Surg. 2009; 94;(6):9-11). The the contract.” Restrictive covenants nuity for the inpatients generated article titled “Compensation, con- favor the employer at the expense from the call service. It has been tracts and covenants: A surgeon’s of the employee (with a third party, painful at times, but we have made guide to successful job negotiation,” the patient, not spoken for at all), adjustments that have made the published in the same issue (pages and should be avoided at all cost. situation tolerable. In fact, some 15–18) also caught my attention, The statement that “unfair non- of the new generation of doctors especially the section titled “Cove- compete covenants are typically might find a version of the call ser- nants to not compete.” I agree with not enforceable” is false. I was vice an acceptable lifestyle in the the authors that “there is no such run out of a Midwest city by a form of a surgical hospitalist. But thing as a ‘standard’ contract.” restriction that specified a 25-mile the biggest revelation for me has Indeed, a “restrictive covenant” be- radius around 12 hospitals scat- not come from the time taking call. tween physicians is illegal in several tered around a large metropolitan It has come from the time off call. states (as noted by the authors) and area of 1.5 million (essentially a The practice of general surgery should not be allowed in physician 100-mile radius), which held up in without community call provides a contracts. District Court, but I somehow sur- very enjoyable lifestyle by anyone’s Furthermore [I agree that], the vived these severe restrictions long standards. The days are varied, yet “[AMA] and patients dislike re- enough to overturn the decision on predictable. One can wake up in strictive covenants because they… appeal two years later. Of interest, the morning without worry of be- prevent patients from following the legal profession believes that ing interrupted by the emergency up with their physician of choice.” the client should have the right to room or an urgent consult from the This is precisely why the ACS’ Com- see the attorney of their choice, so floor. There is never a need to can- mittee on Young Surgeons brought it is unethical to include a restric- cel clinic appointments or add on this issue to the Board of Regents, tive covenant in a contract among cases that extend your operating resulting in ACS Position State- lawyers. Moreover, such a covenant room day into the evening. Most ment 49 which reads, in part, “any not-to-compete between attorneys importantly to me, after 23 years restrictive covenant that interferes has never held up in a U.S. court- of practice, there is no worry about with the uninterrupted delivery of room. I believe that (at least on completing a full day of surgery qualified surgical care to patients is this issue) lawyers in this country after working all night taking care considered unethical.” are on a higher ethical plane than of emergencies. The experience has Many general surgery program we doctors, who continue to “eat convinced me that the only way directors instruct their graduat- their young” using weapons such general surgery can survive into ing chief residents not to sign a as “covenants against competition.” the next generation of doctors is contract that includes a restrictive William C. Cirocco, MD, FACS through the development of the covenant. The old adage, “every- Shawnee Mission, KS surgical hospitalist. thing is negotiable” holds true. If The ACS should lead the way in a prospective employer demands providing guidelines for the devel- the inclusion of a covenant not-to- opment of the surgical hospitalist. compete in an employee contract, The College is our only hope for this should be a red flag not to molding the specialty of general enter into an association with that surgery into something that is individual or group. attractive to future doctors. This The authors state in the opening should be viewed as a matter of paragraph of the article that “it is self-preservation, because general only empathy from the colleagues 69

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What is the ?

The CSPS is a unique multidisciplinary coalition of seven professional organizations representing key members of the surgical team:

• American Association of Nurse Anesthetists • American Association of Surgical Physician Assistants • American College of Surgeons • American Society of Anesthesiologists • American Society of PeriAnesthesia Nurses • Association of periOperative Registered Nurses • Association of Surgical Technologists

The CSPS envisions a world in which all patients receive the safest surgical care provided by an integrated team of dedicated professionals.

And why should you be interested? • Because you are concerned about the safety of your patients. • Because you want a caring perioperative workplace environment. • Because you want integrated teamwork and improved communication to result in better patient outcomes. • Because you care!

For more information, visit www.cspsteam.org, or call the CSPS Administrative Director, Denise Goode, at 312-202-5700

Recent activities: • The CSPS released a statement on violence in the workplace • The CSPS cosponsored the second National Conference on Perioperative Care and Safety: “Improving, Enhancing & Sustaining Positive Patient Outcomes,” in Chicago, IL, May 8–9, 2009, in collaboration with Joint Commission Resources, Inc.

CSPS Bulletin ad 2009-FINAL.indd 1 12/16/2009 11:41:48 AM NTDB® data points Annual Report 2009: A hip report by Richard J. Fantus, MD, FACS; and Avery B. Nathens, MD, PhD, FACS

The 2009 Annual Report of the National Trauma Data Facilities by hip fracture inclusion criteria Bank® (NTDB) is an updated analysis of the largest aggre- gation of U.S. trauma registry data that has ever been as- sembled. This is the second year that the data collection was undertaken utilizing the National Trauma Data Stan- dard (NTDS) format. In an ongoing effort to improve the overall quality of the report, the “Validator’s” (previously reported in the September 2008 Bulletin) level of error checking of submitted files was increased by adding new data filters to weed out files with bad or missing data. In total, the NTDB now contains more than 3 million records. The 2009 Annual Report is based on 627,664 records—submitted by 567 facilities—from the single breakdown of facilities report- persons in our country. It has admission year of 2008. ing hip fractures in their data implications in many areas, A new aspect of this year’s submission. including epidemiology, injury report is an expanded section The mission of the American control, research, education, on facility information. This College of Surgeons Committee acute care, and resource al- section includes information on Trauma (COT) is to develop location. on registry inclusion criteria and implement meaningful Many dedicated individuals for participating hospitals. programs for trauma care. In on the ACS COT, as well as This information allows the keeping with this mission, the at trauma centers around the reader to consider differences NTDB is committed to being country, have contributed to in case mix across hospitals the principal national reposi- the early development of the while reading the report. For tory for trauma center registry NTDB and its rapid growth example, isolated hip fractures data. The purpose of this report in recent years. Building on may or may not be captured by is to inform the medical com- these achievements, our goals an individual trauma center munity, the public, and decision in the coming years include im- based upon local, regional, or makers about a wide variety proving data quality, updating state inclusion criteria. The of issues that characterize the analytic methods, and enabling figure on this page illustrates a current state of care for injured more useful interhospital com- 71

JANUARY 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS parisons. These efforts will information is available on our Medicine, Chicago. He is Chair of be reflected in future NTDB Web site about how to obtain the ad hoc Trauma Registry Advi- reports to participating hospi- NTDB data for more detailed sory Committee of the Committee tals, as well as in the Annual study. If you are interested on Trauma. Reports. in submitting your trauma Throughout the year, we center’s data, contact Melanie Dr. Nathens is Canada Research Chair in Systems of Trauma will be highlighting these data L. Neal, Manager, NTDB, at Care, division head of general through brief reports that will [email protected]. surgery and director of trauma of be published monthly in the St. Michael’s Hospital, and medi- Bulletin. The National Trauma cal director at Ontario Criticall Dr. Fantus is director, trauma Data Bank Annual Report 2009 Program, Toronto, ON. He is also services, and chief, section of chair of the National Trauma Data is available on the ACS Web surgical critical care, Advocate Bank Subcommittee of the Commit- site as a PDF file and a Power Illinois Masonic Medical Center, tee on Trauma. Point presentation at http:// and clinical professor of surgery, www.ntdb.org. In addition, University of Illinois College of

SaVe The DaTeS! American College of Surgeons Session at the Southeastern and Southwestern SoutheaStern Surgical Congresses Surgical congreSS The american college of February 20–23, 2010 Surgeons will be sponsoring Westin Savannah harbor Golf resort and Spa Savannah, Ga half-day symposia at these prestigious events. For more information, visit www.sesc.org or call 800-558-8958

SouthweStern Surgical congreSS March 21–24, 2010 Loews Ventana canyon resort Tucson, aZ For More inForMaTion, For more information, visit contact Julie Tribe, MSed, Senior Manager, www.swscongress.org educational Programs, Division of education, or call 913-402-7102 [email protected], or 312-202-5433.

For inForMation on the acS, visit www.facs.org or call 800-621-4111.

72 Save the Date SE SW 2010-Bulletin HALF ad.indd 1 8/18/2009 11:18:53 AM

VOLUME 95, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS