AUGUST 2004 Volume 89, Number 8

______FEATURES Stephen J. Regnier Editor Laparoscopy at sea: Overcoming unique challenges 12 Linn Meyer Lt. Cdr. David S. Thoman, MD, FACS Director of Communications Surgical lifestyles: Fellow fully realizes the art of surgery 18 Karen Sandrick Diane S. Schneidman Senior Editor

Securing the future of general surgery: Tina Woelke A rural surgeon’s perspective 21 Graphic Design Specialist Richard A. Armstrong, MD, FACS Alden H. Harken, The Governors’ Committee MD, FACS on Physician Competency and Health 26 Charles D. Mabry, Lynn H. Harrison, Jr., MD, FACS MD, FACS Jack W. McAninch, The gloves are off: MD, FACS The Aetna and CIGNA settlements: Part II 29 Editorial Advisors Irene Dworakowski Tina Woelke Front cover design Back cover design

DEPARTMENTS About the cover... From my perspective Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director 3 Rough oceanic waters add challenges for U.S. Navy sur- geons attempting to perform Dateline: Washington 6 the intricate laparoscopic Division of Advocacy and Health Policy procedures that allow sol- diers to return to duty safely and quickly. In his article on What surgeons should know about... 8 page 12, Lt. Cdr. David S. ...the next step for quality measurement: Paying for it! Thoman, MD, FACS, de- Jean A. Harris and Barbara Cebuhar scribes his experiences aboard the USS Tarawa during four months of its 2003 Pacific de- ployment, including partici- pation in Operation South- ern Watch and Operation Iraqi Freedom. Cover photos: sea photo © Corbis/Punchstock; laparo- scope photo courtesy of the Laparoscopy Hospital.

04AUGBULLinsidecover.pmd 2 8/5/2004, 3:07 PM NEWS Bulletin of the American College of Surgeons (ISSN Chapter leaders learn about politics and advocacy 33 0002-8045) is published Diane S. Schneidman monthly by the American Col- lege of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. The young surgeon advocate experience 38 It is distributed without Laurel Soot, MD, FACS, and Scott Soot, MD, FACS charge to Fellows, to Associate Fellows, to participants in the Candidate Group of the Dr. Britt receives distinguished educator award 43 American College of Surgeons, and to medical libraries. Peri- odicals postage paid at Chi- Report of the 2004 Australia cago, IL, and additional mail- and New Zealand Travelling Fellow 44 ing offices. POSTMASTER: Joseph J. Cullen, MD, FACS Send address changes to Bul- letin of the American College of Surgeons, 633 N. Saint Clair St., ACS/STS 2003 Health Policy Scholar reports on activities 47 Chicago, IL 60611-3211. Cana- dian Publications Mail Agree- James S. Allan, MD, FACS ment No. 40035010. Canada re- turns to: Station A, PO Box 54, Windsor, ON N9A 6J5. Dr. Schultz to head FDA’s Center The American College of for Devices and Radiological Health 49 Surgeons’ headquarters is lo- cated at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. ACS Scholars to present at the Surgical Forum 49 312/202-5000; toll-free: 800/ 621-4111; fax: 312/202-5001; e-mail:postmaster@ Fellows in the news 51 facs.org; Web site: www.facs. org. Washington, DC, office is located at 1640 Wisconsin NTDB™ data points: “Water and alcohol don’t mix” 53 Ave., NW, Washington, DC by Richard J. Fantus, MD, FACS, and John Fildes, MD, FACS 20007; tel. 202/337-2701, fax 202/337-4271. Unless specifically stated Chapter news 54 otherwise, the opinions ex- Rhonda Peebles pressed and statements made in this publication reflect the authors’ personal observations Education activities strengthen surgery in the Dakotas 55 and do not imply endorsement by Mark O. Jensen, MD, FACS by nor official policy of the American College of Surgeons.

©2004 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a re- trieval system, or transmitted in any form by any means without prior written permis- sion of the publisher. Library of Congress num- ber 45-49454. Printed in the USA. Publications Agreement The American College of Surgeons is dedicated to improving the care of the No. 1564382. surgical patient and to safeguarding standards of care in an optimal and ethical practice environment. Officers and staff of the American College of Surgeons

Rene Lafreniere, MD, FACS, Calgary, AB Officers Vice-Chair Julie A. Freischlag, MD, FACS, Baltimore, MD Claude H. Organ, Jr., MD, FACS, Oakland, CA* Secretary President Donald E. Fry, MD, FACS, Albuquerque, NM Anna M. Ledgerwood, MD, FACS, Detroit, MI Mary Margaret Kemeny, MD, FACS, Jamaica, NY First Vice-President Mark A. Malangoni, MD, FACS, Cleveland, OH Murray F. Brennan, MD, FACS, New York, NY Valerie W. Rusch, MD, FACS, New York, NY Second Vice-President John O. Gage, MD, FACS, Pensacola, FL Secretary Advisory Council to the Board of Regents John L. Cameron, MD, FACS, Baltimore, MD (Past-Presidents) Treasurer Thomas R. Russell, MD, FACS, Chicago, IL W. Gerald Austen, MD, FACS, Boston, MA Executive Director Oliver H. Beahrs, MD, FACS, Rochester, MN Gay L. Vincent, CPA, Chicago, IL John M. Beal, MD, FACS, Valdosta, GA Comptroller Harvey W. Bender, Jr., MD, FACS, Nashville, TN George R. Dunlop, MD, FACS, Worcester, MA C. Rollins Hanlon, MD, FACS, Chicago,IL Officers-Elect (take office October 2004) R. Scott Jones, MD, FACS, Charlottesville, VA M. J. Jurkiewicz, MD, FACS, Atlanta, GA Edward R. Laws, MD, FACS, Charlottesville, VA* LaSalle D. Leffall, Jr., MD, FACS, Washington, DC President-Elect Lloyd D. MacLean, MD, FACS, Montreal, QC Andrew L. Warshaw, MD, FACS, Boston, MA William H. Muller, Jr., MD, FACS, Charlottesville, VA First Vice-President-Elect David G. Murray, MD, FACS, Syracuse, NY Henry L. Laws, MD, FACS, Birmingham, AL David C. Sabiston, Jr., MD, FACS, Durham, NC Second Vice-President-Elect Richard R. Sabo, MD, FACS, Bozeman, MT Seymour I. Schwartz, MD, FACS, Rochester, NY Board of Regents George F. Sheldon, MD, FACS, Chapel Hill, NC G. Tom Shires, MD, FACS, Las Vegas, NV Edward M. Copeland III, MD, FACS, Gainesville, FL* Frank C. Spencer, MD, FACS, New York, NY Chair James C. Thompson, MD, FACS, Galveston, TX Gerald B. Healy, MD, FACS, Boston, MA* Vice-Chair Executive Staff H. Randolph Bailey, MD, FACS, Houston, TX Barbara L. Bass, MD, FACS, Baltimore, MD* Executive Director: Thomas R. Russell, MD, FACS L. D. Britt, MD, FACS, Norfolk, VA Division of Advocacy and Health Policy: Bruce D. Browner, MD, FACS, Farmington, CT Cynthia A. Brown, Director Martin B. Camins, MD, FACS, New York, NY American College of Surgeons Oncology Group: William H. Coles, MD, FACS, Chapel Hill, NC Samuel A. Wells, Jr., MD, FACS, Group Chair A. Brent Eastman, MD, FACS, San Diego, CA Communications: Linn Meyer, Director Richard J. Finley, MD, FACS, Vancouver, BC Division of Education: Josef E. Fischer, MD, FACS, Boston, MA Ajit K. Sachdeva, MD, FACS, FRCSC, Director Alden H. Harken, MD, FACS, Oakland, CA Executive Services: Barbara L. Dean, Director Charles D. Mabry, MD, FACS, Pine Bluff, AR Finance and Facilities: Gay L. Vincent, CPA, Director Jack W. McAninch, MD, FACS, San Francisco, CA Human Resources: Jean DeYoung, Director Mary H. McGrath, MD, FACS, San Francisco, CA* Information Technology: Howard Tanzman, Director Robin S. McLeod, MD, FACS, Toronto, ON* Journal of the American College of Surgeons: Claude H. Organ, Jr., MD, FACS, Oakland, CA Wendy Cowles Husser, Executive Editor Carlos A. Pellegrini, MD, FACS, Seattle, WA Division of Member Services: Karl C. Podratz, MD, FACS, Rochester, MN Paul E. Collicott, MD, FACS, Director John T. Preskitt, MD, FACS, Dallas, TX Division of Research and Optimal Patient Care: J. David Richardson, MD, FACS, Louisville, KY R. Scott Jones, MD, FACS, Director Thomas V. Whalen, MD, FACS, New Brunswick, NJ Cancer: *Executive Committee David P. Winchester, MD, FACS, Medical Director Trauma: David B. Hoyt, MD, FACS, Medical Director Board of Governors/Executive Committee Executive Consultant: C. Rollins Hanlon, MD, FACS Courtney M. Townsend, Jr., MD, FACS, Galveston, TX 2 Chair

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From my perspective

little more than two years ago, the American College of Surgeons established an affiliate organization with a more flex- A ible 501(c)6 tax-exempt status—the American College of Surgeons Professional Asso- ciation (ACSPA). This group’s first and most sig- nificant initiative to date has been the creation of a political action committee (PAC), ACSPA- SurgeonsPAC. This seems like a good time for an update on this restructuring and its achievements.

Why was the PAC formed? The impetus for establishing the ACSPA- SurgeonsPAC was a proposal from the Board of Much of what we need to do Governors’ Socioeconomic Affairs Committee. The today and in the future members of this committee believed that surgery needed a representative PAC to strengthen the profession’s grassroots advocacy efforts and to revolves around influencing bring it in sync with other medical organizations that are attempting to influence health policy. the political climate and Over the course of several years, the Governors’ committee had attempted to encourage the Board creating the will to change. of Regents to form a PAC. During the course of the debate, it became increasingly apparent that surgical practice was becoming more entrenched in politics and that the vast majority of health policy decision makers and advisors were from outside of the surgical community. Hence in 2001, must be able to support political candidates who the Regents acknowledged that we needed to make have a health policy agenda consistent with what the changes that were necessary to establish a PAC we believe is necessary to care for the surgical to represent the surgical perspective. patient. A PAC is one of the most valuable tools Because of its restrictive tax-exempt status as available to accomplish these goals. an educational and philanthropic organization, a Surgeons also need to support colleagues who PAC could not be established within the College’s want to run for political office. So far, ACSPA- existing structure. So an affiliate organization with SurgeonsPAC has given financial assistance to a a different tax status was developed, which could number of surgeons at the federal level, including work independently to cultivate the resources nec- Senate Majority Leader Bill Frist, MD, FACS (R- essary for surgeons to have greater leverage over TN), and Rep. Michael Burgess, MD, FACS (R-TX). the evolving economic and political forces affect- ing the profession. How it functions The ACSPA-SurgeonsPAC is governed by a Why it’s important Board of Directors that determines which mem- Obviously, many of the current dilemmas facing bers of Congress best represent surgeons’ policy the medical profession, such as the professional objectives and, therefore, should receive PAC con- liability crisis, reductions in reimbursement, bur- tributions. At this time, the board is ably chaired densome regulations, and federal funding for by Andrew Warshaw, MD, FACS, and is composed trauma systems, to name a few, must be addressed of 18 members drawn from all of the surgical spe- through political activism, either in Washington, cialties and all areas of the country (see roster on DC, or in the individual states. Therefore, our pro- page 4). In deciding which candidates to support, fession must have access to legislators, and we the board considers their voting record, leadership 3

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS positions, membership on key health care commit- ologists and the American Academy of Ophthal- tees, and whether they are in the medical profes- mology, have found that their success in achieving sion. Since January 2003, the PAC has donated positive results for their specialties has increased $309,000 to 100 candidates and has raised close to partly because their members have supported their $450,000. PACs. ACSPA is currently making telephone calls To donate to the PAC, a surgeon must be an ac- to all its members in an effort to reach this full tive ACSPA member in the U.S. who is still in prac- potential. tice. We anticipate that as surgeons become more All of us can clearly articulate the problems af- comfortable with the PAC and more attuned to fecting the surgical profession, not only in terms the political realities that affect their ability to of quality of care, patient safety, and the adequacy practice, all of the College’s eligible members will of competence of the surgical workforce, but also become involved in this process. with respect to the political, economic, and regu- latory environment in which we practice. It is ap- PAC support propriate that surgeons point out these problems ACSPA has determined that if every eligible and the negative results that are associated with member contributes $250 to the ACSPA- them. However, complaining and whining about SurgeonsPAC, it will supersede the trial lawyers the state of our profession does not generate posi- in their annual giving. Other medical organiza- tive solutions. tions, such as the American Society of Anesthesi- Much of what we need to do today and in the future revolves around influencing the political cli- mate and creating the will to change. To stimu- late a dialogue and to effect change, we must be ACSPA-SurgeonsPAC political players. Clearly, the ACSPA-SurgeonsPAC Board of Directors is one of the more persuasive tools available to surgeons. The ACS cannot be involved in PAC so- Chair: Andrew L. Warshaw, MD, FACS, Boston, licitations, so information about the PAC is avail- MA able on its separate Web site, at http:// www.facs.org/acspa/index.html. Gary Bloomgarden, MD, FACS, New Haven, CT These are turbulent times. Without a robust ef- L.D. Britt, MD, FACS, Norfolk, VA fort to affect the political process, surgeons will Bruce Browner, MD, FACS, Farmington, CT be further disadvantaged. I encourage each of you James Elsey, MD, FACS, Atlanta, GA to become educated about the issues and actively Josef Fischer, MD, FACS, Boston, MA involved in the process in tangible ways. Jean Hausheer, MD, FACS, Independence, MO Jack McAninch, MD, FACS, San Francisco, CA Stephen McBride, MD, FACS, Las Vegas, NV Joseph McLaughlin, MD, FACS, Baltimore, MD Constantine Michas, MD, FACS, Fresno, CA Farouck Obeid, MD, FACS, Detroit, MI Richard Perry, MD, FACS, Phoenix, AZ Paul Weiss, MD, FACS, New York, NY Thomas R. Russell, MD, FACS Thomas Whalen, MD, FACS, New Brunswick, NJ Daryl Wier, MD, FACS, Winter Park, FL Mitchell Willens, MD, FACS, Tyler, TX Paul Wills, MD, FACS, Fort Smith, AR

Staff: Treasurer: Cynthia A. Brown, Director, Advocacy and Health Policy Division, Washington, DC If you have comments or suggestions about this or Manager: Erin LaFlair, Washington, DC other issues, please send them to Dr. Russell at 4 [email protected].

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Career Opportunies The American College of Surgeons’ online job bank

A unique interactive online recruitment tool provided by the American College of Surgeons, a member of the HEALTHeCAREERSJ Network

An integrated network of dozens of the most prestigious health care associations.

Candidates: • View national, regional, and local job listings 24 hours a day, 7 days a week—free of charge. •Post your resume, free of charge, where it will be visible to thousands of health care employers nationwide. You can post confidentially or openly— depending on your preference. •Receive e-mail notification of new job postings. •Track your current and past activity, with toll-free access to personal assistance. Employers: • Nationwide market of qualified surgical candidates. •Resume Alert automatically e-mails notices of potential candidate postings. • Exceptional customer service and consultation. • Online tracking.

Questions? Contact HealtheCareers Network at 888/884-8242 or [email protected] 5

for more information. AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dateline Washington prepared by the Division of Advocacy and Health Policy

In a misguided attempt to fill New Jersey’s budget gap, the state New Jersey to legislature passed and the governor is expected to sign two bills taxing tax surgical cosmetic surgical procedures and gross receipts of ambulatory care fa- cilities, including surgery centers not licensed to a hospital. The bills, procedures A. 3125 and A. 3127, would assess a 6 percent gross receipts tax on cosmetic procedures defined by the state as any treatments that do not meaningfully promote the proper functioning of the body or prevent or treat illness or disease. For ambulatory surgical centers, there would be a 3.5 percent gross receipts tax on facilities with gross receipts higher than $300,000. The College’s New Jersey Chapter has developed a statewide coa- lition effort to overturn both of these arbitrary and discriminatory tax bills and to prevent further expansion of these punitive activi- ties.

The College has submitted comments on a regulation issued by the ACS comments Centers for Medicare & Medicaid Services (CMS) that implements ad- on anti-referral ditional provisions of the physician self-referral law, commonly known as the “Stark” law. In the comments, the College expresses support for regulation several newly created exceptions to the law that should be helpful to surgeons, including physician ownership or investment in rural area providers, intra-family referrals in rural areas, physician investment in publicly traded securities and mutual funds, and participation in a community-wide health information system. Despite the College’s previous protestation, CMS has maintained its proposed definition of “referral” to include “incident to” services, mean- ing that those services performed by a physician’s employees, even if under the direct supervision of the physician, are still subject to the Stark law. The College also reminds CMS that, even with the new ex- ceptions and clarifications provided by the rule, applying the law to particular scenarios will continue to be problematic due to its com- plexity. Accordingly, the comments ask that CMS persist in refining these regulations to further simplify compliance and reduce the risk of unintended violations.

In June, plaintiffs’ attorneys announced that class action lawsuits Uninsured patients have been filed against large not-for-profit hospitals in eight states by sue not-for-profit uninsured patients who claim that the hospitals intentionally failed to provide charitable care as required by their tax-exempt status. The hospitals American Hospital Association (AHA) was named as a conspirator for providing advice and assistance to the defendants on matters such as billing and collection practices involving the uninsured. The uninsured patients allege that the hospitals charged them “sticker” prices for health care that were higher than those paid by any other patient group and then subjected them to harassment and aggressive collection prac- tices. The defendant hospitals are charged with breaches of contract, breaches of good faith and fair dealing, breaches of charitable trust, and consumer fraud and deceptive business practices. They also are 6 accused of violations of the Emergency Medical Treatment and Active

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Labor Act, unjust enrichment, civil conspiracy, conspiring with the AHA, and aiding and abetting in the breach of their tax-exempt agreements. According to the attorneys, similar cases will be filed against major hospitals in other states in the near future. Additional information can be accessed at www.nfplitigation.com or www.cliffordlaw.com/ notforprofit/disclaimer.aspx.

A press conference introducing legislation that would provide for College backs Medicare coverage of ultrasound screening for abdominal aortic aneu- AAA screening rysms (AAA) was held June 23 on Capitol Hill. Robert Zwolak, MD, FACS, was the lead speaker at the press conference. H.R. 4626/S. 2553, initiative the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act, is a bipartisan effort cosponsored by Reps. Jim Greenwood (R-PA) and Gene Green (D-TX) and by Sens. Jim Bunning (R-KY) and Chris Dodd (D-CT). The College is a member of the National Aneurysm Alli- ance (NAA), which was formed to support the passage of a Medicare screening benefit for AAA. More information about this legislation and the NAA can be found at http://www.ScreenAAA.org.

More than 53 million Americans, or 18.6 percent of the population, 53 million were uninsured for at least part of 2003, according to estimates from uninsured for the Centers for Disease Control and Prevention’s (CDC’s) latest Na- tional Health Interview Survey. That includes 23.8 percent of work- part of 2003 ing-age adults and 13.7 percent of children under 18. About 15.2 per- cent were uninsured at the time of the survey, while 10 percent had been uninsured for more than a year, including 2.5 million more work- ing-age adults than in 2002. About one in 10 children were uninsured at the time of the survey, while 13.7 percent were uninsured for at least part of the past year and 5.3 percent for more than a year. The CDC attributed improve- ment in the rate of children’s health insurance coverage since 1997 to an increase in public coverage for poor and near-poor children, includ- ing the State Children’s Health Insurance Program. For more on the survey, visit http://www.cdc.gov/nchs/.

The CMS has several communications tools on its Web site that New Medicare tool hospital staff and others may use to help Medicare patients under- to help patients stand the details of choosing Medicare-approved drug discount cards. The Web site features an 8-½ ϫ 11-inch poster that can be down- loaded and printed in Spanish or English and displayed wherever patients will see it, such as in waiting areas, exam rooms, cafete- rias, lobbies, elevators, and pharmacies. The posters also can be ordered from CMS in 17 ϫ 22-inch versions. The CMS site also in- cludes two “tip” sheets: a Drug Discount Card Enrollment Tip Sheet (#11076) that shows patients how to enroll for a Medicare-approved drug discount card, and a Medicare-Approved Drug Discount Card Tip Sheet (#11071) that provides guidance for counselors, caregivers, and intermediaries who help people with Medicare compare and choose drug discount cards. These and other tools are available at www.cms.hhs.gov/medlearn/drugcard.asp. RM7

AUGUSTJULY 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

...the next step for quality measurement: Paying for it!

by Jean A. Harris, Associate Director, and Barbara Cebuhar, Communications Specialist, Division of Advocacy and Health Policy

n the May 2004 issue of the Bulletin, ACS Ex- contracting efforts for employee health plans. ecutive Director Thomas R. Russell, MD, Leapfrog’s first proposals, which generated sub- IFACS, wrote about the College’s continuing ef- stantial controversy, included encouraging use forts at quality improvement for surgical patients of higher volume facilities for certain procedures, by measuring outcomes in a risk-adjusted way. The of hospitals that have invested in intensivists, and next move is to use quality measures to develop a of hospitals that have computerized physician or- pay-for-performance (P4P) model. The P4P is a der entry software.2 Leapfrog has indicated that concept that was implemented in manufacturing when the College completes validating the U.S. circles in the 1980s and 1990s to increase efficien- Department of Veterans Affairs’ (VA) National cies and reduce costs. This system of paying more Surgical Quality Improvement Program (NSQIP) for services that meet higher measures of quality for use in community hospitals, they are willing and predictability is rooted in the executive com- to drop other process and structural measures and pensation and economic literature by Oliver Hart replace them with NSQIP. See the accompanying and Bengt Holmstrom.1 This article explores some text box on page 9 for a description of NSQIP. concerns about P4P. How many payors are using P4P? Who is advancing P4P and why? Most major health plans are testing primary Employers, faced with rising costs for em- care programs, such as the employer-sponsored ployee health care benefits that add significant “Bridges to Excellence” program, which rewards expense to their products, are concerned about physicians who adhere to diabetes and heart dis- staying competitive in a global economy. Health ease protocols.3 Medicare is partnering with the plans are anxious to reduce complications and Premier Health System, which intends to dem- errors that add to costs and raise the price of onstrate that they can improve 32 clinical mea- health insurance premiums. Certain payors, sures over a three-year period. If these improve- such as Medicare, are faced with providing care ments occur, Premier hospitals will receive up for a growing number of aging baby boomers and to 2 percent more of their Medicare receivables. are trying to find ways to stretch program dol- Those hospitals that fail to make the necessary lars by paying for better outcomes. improvements could be at risk of payments re- To help address some of their concerns, a coa- duced by 1 to 2 percent.4 lition of 154 employers formed the Leapfrog The Center for Studying Health System Change Group, which has proposed standards for large (HSC) regularly makes visits to 12 sites to track purchasers (such as General Motors, 3M, and changes in local markets, ranging from Greenville,

8 other corporate giants) to use as part of their SC, to Orange County, CA. In their 2002-2003 vis-

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS its they found seven sites had P4P programs. They dure varies by provider. A typical arrangement tended to be sponsored by payors that have a large is for providers in the top two deciles to “win,” share of the market. HSC also reported little con- and providers who find themselves in the bot- sistency among the programs in terms of what was tom two deciles to risk loss of money. So far, the measured, the incentive payment structure, or the amounts of money in play have been on the or- size of the incentive.5 der of 1 to 5 percent, although in Great Britain almost one-third of a general practitioner’s in- What kinds of clinical measures or data are come could depend on recently introduced qual- being used? ity incentives.7 There are also plans for a Medicare demon- The National Quality Forum (NQF) develops stration project that divides responsibility and a consensus among the various stakeholders— incentives for quality care between the hospital purchasers, providers, consumers, and research and the surgeon. The Virginia Cardiac Surgery organizations—on standardized quality mea- Initiative plans to use risk-adjusted data from sures. Plans are encouraged to select their qual- the Society of Thoracic Surgery’s database to as- ity measures from among those adopted by NQF.6 sess the quality of outcomes from certain car- Performance is assessed using claims data as well diac procedures. as data obtained through chart review. Physi- cian performance may be tracked by evaluating How do we come up with a discrete set of adherence to preventive protocols (such as im- universally understood quality measures? munizations and cancer screenings) and certain chronic disease interventions (such as retinal There is a real need for standardization of mea- examinations and testing for glycosylated hemo- sures. Although it does not involve P4P, Medi- globin levels for diabetic patients). These mea- sures will be updated or dropped based on the ongoing evaluation of scientific evidence. The National Surgical Quality Improvement Program (NSQIP) Are other factors measured? Developed 11 years ago, NSQIP measures the Some health plans use patient satisfaction performance of all VA hospitals providing sur- measures for both physicians and hospitals. Oth- gical services. NSQIP computes the ratio of ob- served to expected adverse events using data ers use standardized patient safety measures, adjusted for preoperative risk. These results are such as the Safe Practices for Better Healthcare provided to each hospital and used to identify from the NQF. areas for improvement. Hospitals are also anonymously compared to their peer institu- tions. How would payment work? Since NSQIP was implemented, the VA has noted a 28 percent reduction in 30-day postop- Two general approaches are used. One with- erative mortality and a 43 percent reduction in 30-day postoperative morbidity. NSQIP was in- holds a percentage of the payout on individual troduced in 14 academic centers in 2001, and claims to finance periodic bonus payments; the the College intends to begin field-testing the other affects the amount of the annual update a program in 100 community hospitals in 2004. provider gets, so the payment for a given proce- 9

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS care has a three-state pilot project that is a ma- jor step toward the goal of standardization. As a The Medicare Premier result of the collaboration of the Centers for Hospital Quality Incentive: Medicare & Medicaid Services (CMS), the Qual- Demonstration Surgical Measures* ity Improvement Organizations (QIO) in Ari- The Medicare Premier Demonstration zona, Maryland, and New York, and all hospi- covers coronary artery bypass graft (CABG) tals in those states, the pilot project will test and hip and knee replacements (HKR). various methods of public reporting of quality data. • CABG using internal mammary artery The three states will have a standardized set of (CABG only)1,4,P data to report. There will be field-testing of the • Prophylactic antibiotic selection 2,7,8,P survey of patient satisfaction with the hospital and • Prophylactic antibiotic received within one the pilot will test various ways to communicate hour prior to surgical incision1,2,8,P quality information with the public.8 As part of the • Prophylactic antibiotics discontinued within 24 hours after surgery end time1,2,8,P QIO’s 8th Scope of Work, there is a plan to have • Inpatient mortality rate5,O those measures implemented nationwide. • Postoperative hemorrhage or hematoma6,O NSQIP has a single hub where the data are • Postoperative physiologic and metabolic 6,O manipulated in a standardized manner. A single derangement • Aspirin prescribed at discharge (CABG point for data storage and processing has not only)3,P been identified for nonsurgical data. • Readmissions 30 days post discharge (HKR only)7,O

Are individual surgeons measured as part 1. National Quality Forum measure of these P4P efforts? 2. QIO 7th Scope of Work measure 3. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Core Mea- So far, the P4P programs that have received the sure most press attention have been either programs 4. The Leapfrog Group 5. Risk adjusted using 3M™ All Patient Refined that measure quality at hospitals or programs Diagnosis Related Group (DRG) methodology aimed at preventive and chronic care in primary 6. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators and risk ad- care offices. If NSQIP proves to be successful in justed using AHRQ methodology all types of community hospitals and becomes a 7. Medicare beneficiaries only 8. QIOs and/or JCAHO to align with this measure platform for P4P, we anticipate that all surgeons in 2004 on a hospital’s surgical service will receive the P. Process measure same clinical score. Individual surgeons will re- O. Outcomes measure ceive their own patient satisfaction score. *Web site: http://cms.hhs.gov/researchers/demos/ phqidemo.asp; click on “clinical areas & quality What should surgeons do if a payor starts measures.” talking about a P4P system for surgeons?

It seems that, in spite of all the potential prob- lems, P4P is here to stay. But only a valid, well- based, relate to the quality of the service, and designed P4P system should be used. These are on the list of approved measures maintained by some points to consider: the National Quality Forum (NQF). See the list of • All measurements should be evidence- 10 measures at http://www.qualityforum.org.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • Elements measured should be under the 3. Web site: http://www.bridgestoexcellence.org/bte/ programs/index.htm. surgeon’s control rather than the hospital’s con- 4. Web site: http://www.cms.hhs.gov/researchers/ trol. demos/phqidemo.asp; click on “fact sheet.” 5. Strunk BC, Hurley RE: Paying for quality: Health • Start small with P4P, picking a very lim- plans try carrots instead of sticks. Issue Brief No. ited number of measures and have a very small 82, Center for Studying Health System Change, http://www.hschange.org, May 2004. amount of money at risk. 6. Web site: http://www.qualityforum.org. • The money paid out in P4P should go to 7. Epstein AM, Lee TH, Hamel MB: Paying Physi- the surgeon and not to the hospital to be redis- cians for high-quality care. N Eng J Med, 350(4):406-410, 2004. tributed to the surgeons. 8. Web site: http://www.cms.hhs.gov/quality/hospi- • The program should reward both those tal/3StateFactSheet.pdf. with high quality scores and those with the most improvement. • Pay attention to the details and think about whether the concepts would work in the day-to- day practice of surgery.

Has any legislation been considered that has P4P implications?

Sen. Max Baucus (D-MT) recently introduced legislation that would set up two different P4P programs in Medicare in 2008. One would re- ward Medicare Advantage health plans, and the other would reward dialysis facilities. Annual bonuses would go to those centers that had high quality scores as well as those that improved their performance the most. The bill requires that all measures be evidence-based. The bonus system would be budget neutral and financed from a payment withhold of 2 percent. The bill obviously will not be passed this year because Congress is adjourning early for the elections. However, its introduction shows that Congress is ready to debate P4P next year, after the elec- tions. ⍀

References 1. Hart O, Holmstrom B (eds): The Theory of Con- tracts. Advances in Economic Theory: Fifth World Congress. Cambridge, England: Cambridge Univer- sity Press, 1987. 2. Web site: http://www.leapfroggroup.org/FactSheets. htm. 11

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Laparoscopy at sea: Overcoming unique challenges

by Lt. Cdr. David S. Thoman, MD, FACS, San Diego, CA

12

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS urgical procedures may be performed The operating rooms are equipped with modern aboard several different classes of U.S. anesthesia and monitoring equipment, along with Navy vessels. The most advanced are the most instruments required for general, vascular, two hospital ships, the USNS Mercy and the and thoracic operations. Basic orthopaedic and USNSS Comfort. These ships are essentially float- neurosurgical instruments are also available. The ing 1,000-bed hospitals with fully manned 12-room OR houses a laparoscopic tower with camera, light operating suites. There is arguably little difference source, insufflator, and monitor. The USS Tarawa between medical care rendered here and in civil- was fortunate to have both 0° and 30° 5-mm and ian hospitals. However, the aircraft carriers and 10-mm laparoscopes, along with two reusable 5- amphibious assault ships represent more austere mm working ports. Laparoscopic instruments in- environments in which performing operations is cluded several graspers, two Maryland-type dis- possible but with certain limitations. sectors, scissors, and a 10-mm stone scoop (see Fig- The aircraft carrier’s mission is to provide for- ure 1, page 14). Several disposable 5-mm and 10- ward deployed offensive capability. Surgical sup- mm working ports were procured before depar- port, including one operating room and three in- ture. tensive care beds, is intended only for the crew of The table on this page lists the procedures per- the ship and the surrounding support ships in the formed on the USS Tarawa during four months of carrier battle group. Amphibious assault ships are its 2003 western Pacific deployment, which in- either LHA class (general purpose) or LHD class cluded participation in Operation Southern Watch (multi-purpose). The LHD class is newer and and Operation Iraqi Freedom. The following cases larger with six operating rooms and 17 intensive are representative and illustrate how certain care beds. However, the medical manning is iden- unique challenges may be overcome. tical to the LHA class. The amphibious assault ship travels in an amphibious readiness group (ARG), Case number one which typically includes at least two other ships. The ARG transports and supports a Marine expe- An 18-year-old female presented to the medical ditionary unit, along with all of their equipment officer on a nearby ship with severe left lower quad- and aircraft. Similar to the carriers, the amphibi- rant pain. A white blood cell count was taken and ous ships provide medical support to their crew was normal. She was diagnosed with gas pain and and to the smaller ships traveling with them. How- given an injection of ketorolac. This treatment pro- ever, the main reason these ships have surgical vided only minimal relief, and she was flown to capability is to care for the U.S. Marines who may the USS Tarawa for surgical evaluation. On ar- become injured ashore during their missions. rival, the pain had been present for 15 hours and The USS Tarawa is an example of an LHA was unrelenting. Examination revealed evidence class, and is where the subsequently described of peritoneal irritation and she was taken procedures were performed. The LHA class has emergently to the operating room. The presence four operating rooms, of which two are typically functional. The ship deploys with a general sur- geon, nurse anesthetist, two primary care phy- sicians, several general medical officers, an op- Laparoscopic procedures erating room nurse, and a critical care nurse. performed at sea Additionally, approximately 30 hospital corps- men fill roles in various areas including the phar- macy, preventive medicine, X-ray technology, the Procedure Number laboratory, the blood bank, surgical technology, Appendectomy 4 Cholecystectomy 3 and medical records administration. During Inguinal hernia 4 times of conflict, additional personnel may be Salpingo-oopherectomy 1 added, including general surgeons, orthopaedic Varicocele ligation 3 surgeons, anesthesiologists, intensivists, nurses, Diagnostic laparoscopy 1 and corpsmen. 13

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of a 7-foot swell required the surgical team to take some ex- tra measures in securing all equipment and the patient (see Figure 2, page 15). A laparoscope was placed via a 10-mm work- ing port at the umbilicus. Ab- dominal visualization quickly demonstrated the problem, which was an ovarian torsion secondary to a 4-cm cyst. Five- mm working ports were placed on either side of the lower abdo- men. The point of torsion in- volved the Fallopian tube and proper ovarian ligament. An 0- Chromic suture was tied intracorporeally just proximal to the torsion using two Mary- land dissectors. An 0-Vicryl su- ture ligature was then placed past the tie, using the Mary- Figure 1. Laparoscopic instruments available aboard USS Tarawa. land dissector as a needle driver. The tube and ovary were then excised and placed into a plastic sandwich bag, which had been previously sterilized in activated an 0-Chromic tie. The cystic was then partially dialdehyde solution. This facilitated removal incised and a grasper was used to “milk back” from the 10-mm umbilical port with minimal en- bile from the common bile duct. The presence of largement. The patient had only slight incisional free-flowing golden bile without debris gave pain after surgery. She was observed on the ward some reassurance that common duct stones were until postoperative day two, when her pain was not present. controllable with only ibuprofen. She was flown The cystic duct stump was then tied off with a back to her ship on day four and returned to pair of 2-0 silks. The cystic artery was tied off work on postoperative day six. with a 2-0 silk proximal and cauterized distally. Because of the theoretic concern of a power den- Case number two sity being created at the tie when cautery is used in this fashion, it was applied to the individual A 30-year-old male was seen at a Kuwaiti hos- branches just off the gallbladder. The rest of the pital for right upper quadrant pain. A mildly in- procedure was performed routinely. The patient creased bilirubin was noted, and an ultrasound was observed for four days on the ward, at which demonstrated gallstones with a thickened gall- time he required only ibuprofen for pain relief. bladder wall and a normal common bile duct. He was returned to full duty on postoperative Laparoscopy was not available locally, and he was day eight. flown to the USS Tarawa in the Northern Ara- bian Gulf. Laparoscopic cholecystectomy was Case number three performed routinely, although lack of a clip applier or cholangiogram catheter required some A 21-year-old male with three weeks of left in- modifications. The cystic duct was dissected free guinal pain and bulge was transferred from an- 14 and tied-off just under Hartmann’s pouch with other ship for evaluation. He had a history of

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS with a slit and passed into the abdomen to cover either myopectineal orifice. A clip applier was unavailable; therefore, a 2-0 Vicryl suture was used to fix the two pieces of mesh together in the midline at two places, as well as gently tack- ing them to the anterior rectus muscle fibers (Figure 3, page 16). Dessuflation was performed under direct vision to assure the mesh remained in position. He was returned to his ship on post- operative day four and resumed full duty the next day taking only ibuprofen. Case number four

A 22-year-old male was transferred from a nearby ship with a painful scrotal mass. Exami- nation revealed a left, grade III varicocele. An inguinal approach would require a Doppler probe, which was unavailable. However, a Medline search revealed several series report- ing excellent results with a laparoscopic ap- proach.1,2 I explained to the patient that I had no experience with varicocele surgery, but was confident a laparoscopic approach could be per- formed safely. He did not want to be evacuated from the theater of operations and elected to proceed. He was given general anesthesia, and the ab- Figure 2. Securing of the laparoscopic tower during domen was insufflated with a Veress needle. A heavy seas. 5-mm laparoscope was placed at the umbilicus, and 5-mm ports were placed on either side of the lower abdomen. Visualization revealed the left gonadal vessels to be somewhat dilated com- bilateral inguinal hernia repair at age two. Ex- pared to the right. Additionally, he had a small amination revealed a moderate-size left inguinal indirect hernia on the left. The peritoneum was hernia. He was taken the next day for opened above the internal ring as for a transab- laparoscopic bilateral hernia repair. Neither a dominal preperitoneal hernia repair. The her- balloon dissector nor Hasson canula were avail- nia sac was reduced and the gonadal vessels were able. A purse-string suture was placed in the dissected free. Three 2-0 silk ties were placed anterior rectus fascia and generous finger dis- around the vessels intracorporeally, and they section was performed. A 10-mm disposable port, were divided en masse. A 12-cm ϫ 10-cm which had been salvaged and resterilized, was polypropylene mesh was then fashioned and then tied in with the purse string. The laparo- passed into the abdomen after removing one of scope and insufflation were used to create the the 5-mm ports. The mesh was tacked to the an- preperitoneal working space. Five-mm ports terior rectus just above the pubis with a 2-0 were then placed into this space from either side Vicryl. The peritoneum was then closed with a of the lower abdomen. Dissection was performed running 2-0 Vicryl incorporating the mesh so it routinely and a moderate-size left indirect her- would be unlikely to migrate. He had minimal nia was reduced. Two separate pieces of 12-cm incisional pain postoperatively and returned to ϫ 10-cm polypropylene mesh were fashioned work in three days. 15

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Discussion

Laparoscopic surgery may be performed aboard certain U.S. Navy combat vessels. The well- known advantages of a mini- mally invasive approach be- come even more profound at sea. Many procedures can be done through 5-mm wounds with truly minimal postopera- tive pain. At sea, this result is important for several reasons, the most obvious one being that every extra work hour lost degrades the readiness of the ship. Every sailor is critically important to completion of the mission. Extended periods of care not only tie up limited medical resources, but leave the ship understaffed. It has Figure 3. Suturing the two pieces of polypropylene mesh together and been said that the goal of Navy to the anterior rectus muscle. medicine is to keep as many sailors at as many guns for as many hours as possible. Along with a finite number of personnel to run the ship, supplies are lim- the threshold for performing a diagnostic opera- ited. Patients with requirements for large tion when abdominal pathology is suspected. The amounts of pain medicine can quickly deplete entire abdomen can be thoroughly evaluated stores, with resupply at sea always posing a chal- with three 5-mm incisions. It was my policy to lenge. The large amphibious ships deploy with a routinely explore the entire abdomen, even when single nurse capable of assisting in postopera- an obvious source was quickly identified. Al- tive care. There is no patient-controlled analge- though the extra probing may slightly increase sia, and, needless to say, a patient requiring the risk of the procedure, I believe it is neces- around-the-clock morphine injections can cre- sary to maximize the accuracy of the only diag- ate a problem. Our ward nurse, previously un- nostic modality available. If lower abdominal impressed with laparoscopy, soon became its big- pain was present, the appendix was routinely gest advocate. removed in the absence of an alternative source. Probably the hardest adjustment for a young This approach was followed based on at least one surgeon, trained with unlimited access to mod- series demonstrating the inaccuracy of ern diagnostic tests and imaging modalities, is laparoscopically identifying a normal appendix.3 being forced to make decisions based on physi- In three consecutive cases of lower abdominal cal exam and basic blood work. Evacuation to a pain and normal-appearing appendix, the patient hospital is occasionally impossible. When land was pain-free and back to work within a few days is within reach, it is often foreign soil where the after removal. If unexpected pathology is iden- health care standards are not as high as those tified, it can invariably be managed with the lap- of the U.S. Medical evacuation also requires a aroscope. The first case described in this article ride in at least one helicopter, which can present is a good example of diagnostic laparoscopy lead- 16 its own health risks. All of these factors lower ing to a therapeutic intervention.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS There are also several challenges to perform- of the U.S. Department of the Navy, U.S. Department ing laparoscopy at sea. By the time we arrived of Defense, or the U.S. government. in the Arabian Gulf, the ship’s supply of carbon dioxide had been exhausted. An effort to resup- References ply in Singapore had failed. We had to cut through many layers of bureaucratic interfer- 1. Magharby HA: Laparoscopic varicocelectomy for painful varicoceles: Merits and outcomes. J ence to obtain more. The ship has a large supply Endourol, 16(2):107-110, 2002. of nitrous oxide, which could be used as an al- 2. Bebars GA, Zaki A, Dawood AR, et al: Laparoscopic ternative if the proper connectors are available.4 versus open high ligation of the testicular veins for The second problem is the limited number of the treatment of varicocele. J Soc Laparoendosc instruments. This is really more of an inconve- Surg/Soc Laparoendosc Surg, 4(3):209-213, 2000. 3. Greason KL, Rappold JF, Liberman MA: Inciden- nience. Sewing with a Maryland dissector in- tal laparoscopic appendectomy for acute right lower stead of a needle driver is annoying but possible. quadrant abdominal pain. Its time has come. Surg Tying vessels and ducts off, rather than clipping, Endosc, 12(3):223-225, 1998. simply takes more time. The second and third 4. Tsereteli Z, Terry ML, Bowers SP, et al: Prospec- tive randomized clinical trial comparing nitrous cases demonstrate the ability to substitute su- oxide and carbon monoxide pneumoperitoneum for tures for clip appliers or tackers. The lack of a laparoscopic surgery. J Am Coll Surg, 195(2):173- suction-irrigator was harder to overcome. For- 179, 2002. tunately, the ship machinists were able to con- struct a primitive 5-mm valved sucker, and irrigant was simply flushed through the working- port CO2 inlets. I had anticipated the lack of another surgeon or resident to assist, particularly with the camera, as another possible hurdle to overcome. However, I was pleasantly surprised by the proficiency of several of the Navy corpsmen in assisting. These individuals are enlisted sailors, some only a few years out of high school, with no prior experience in the operating room. They were enthusiastic about participating, and at least as capable as the average second- or third-year resident in terms of their ability to follow with the camera and to hold instruments. They informed me that these tasks are less challenging than playing some of the cur- rent video games. There are several unique challenges to per- Dr. Thoman was a forming laparoscopy at sea in an austere envi- general surgeon for Fleet Surgical Team-9, ronment. However, the benefits of reduced pain U.S. Naval Medical and faster return to full function can signifi- Center, San Diego, CA. cantly and positively impact mission readiness. He is now associate To provide optimal care, surgeons should become director of surgical proficient at laparoscopic suturing and education at Santa intracorporeal tying prior to deployment at sea. Barbara (CA) Cottage There should be a low threshold for performing Health System. a thorough diagnostic laparoscopy for acute ab- dominal pain in this environment. ⍀

The views expressed in this article are those of the author and do not reflect the official policy or position 17

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical lifestyles

ellow fully realizes the F art of surgery

ike most artists, Janice F. Lalikos, MD, FACS, has an exquisite sense of per- L ception, noticing how shafts of light illuminate hairline ridges and crevices as they glint off the surface of a leaf and how shadows play along the ground as the wind rustles the branches of a tree. That sensi- tivity to color and form heighten her ap- preciation of the processes of pathology: the ways disease and injury alter underlying anatomy and architecture and mottle the topical landscape. “Artists continually analyze not only what they see but why they see something a certain way,” Dr. Lalikos said. “The Pointillism movement came out of the de- sire to make light fractal, to figure out why a leaf looks this way at this time of day, what colors generate that picture on our retina.” A medical illustrator and associate pro- fessor of plastic surgery at the University of Massachusetts Memorial Health Care, Worcester, Dr. Lalikos has always looked below the surface to find out why patients have certain physical features. Even in medical school at Johns Hopkins Medical School, Baltimore, MD, when she was still learning the names of specific diseases and trying to keep biochemistry formulas from flying out of her head as soon as she fin- ished an exam, Dr. Lalikos easily recognized the manifestations of disease: concavities where softly swelling muscles should be,

Left: Dr. Lalikos. Background art: 1998 drawing 18 by Karen Sandrick, Chicago, IL by Dr. Lalikos for a manuscript.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS protrusions in the place of long flat bones, webs of petechiae on otherwise smooth, clear skin. While all medical students eventually hone their attention to physical nuances, Dr. Lalikos had an almost intuitive sense about patients because of her artistic eye and her training as a medical il- lustrator. “Having observed and drawn the human form in life drawing classes for upwards of five years, I knew when a patient’s color wasn’t right, when the skin wasn’t hanging right, when the veins weren’t where they were supposed to be,” she said. Specializing in plastic surgery was a natural fit because of its appreciation of spatial relationships and esthetics, technical skill, and variety. “Plastic surgery is the most creative of the surgical spe- cialties, where you have guidelines and rules and anatomy as your core, but also variability. In plas- tic surgery, you can do six different things depend- ing on the problem and the patient,” she said. Dr. Lalikos now brings her illustrator’s talents to her patients and her research. “Every day, I draw for my patients. If I’m repairing a facial frac- ture, I draw the skull in front of the patient and the family to show them where all the bone plates are,” she said. She also does the illustrations for Dr. Lalikos’s 1988 drawing of a rabbit head, done for the papers she has published on such topics as the her thesis. healing of surgical scars and bony reconstruction.

Two lifelong interests

Dr. Lalikos has been “bouncing back and forth” freelancing as a medical and biological illustra- between the biological sciences and the biological tor for an orthopaedic surgeon who wanted arts since college. At the time she was graduating stand-alone pieces of art on adhesive capsulitis. from high school, she had difficulty deciding She made a series of drawings of the anatomy of whether to attend a fine arts college or a liberal the shoulder, diagrams of the surgical correction, arts institution. She ultimately enrolled at Case and sketches of the rehabilitation process. “Ev- Western Reserve University in Cleveland, OH, as ery time I came back with sketches, I would have a biology major, but in her sophomore year, she a litany of questions that had nothing to do with learned that the Cleveland Institute of Art, on Case the art: how the surgeon decides whom to oper- Western Reserve’s campus, was graduating bach- ate on, whom to follow, and so on. Finally he elors of fine arts in medical illustration. said to me, ‘Lady, I need you to color the arter- More interested in life drawing, sculpture, and ies in red and the veins in blue. To get the an- basic design than fabric and jewelry making, which swers to all those other questions, you need to were essential courses in the fine arts curriculum, go to medical school.’” Dr. Lalikos tailored a bachelor’s degree course of So, at the eleventh hour, the summer before study more to her liking, focusing on medical il- her senior year in college, Dr. Lalikos decided to lustration and biological sciences and graduat- go to medical school. The summer between her ing with a degree in medical illustration in 1984. junior and senior years, she crash-coursed phys- After two years of college, she started ics and physics lab, took the MCAT the last time 19

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS chair of plastic surgery at Johns Hopkins, Dr. Lalikos created onlay bone grafts from the tibia and the cheekbone and placed them on the calva- rium in rabbits. For her thesis, Dr. Lalikos not only performed the bone grafts and examined them under the microscope, she also made drawings of the operation, stained the bone, and generated graphs of the findings, comparing endochondral and membranous bone grafts. After graduating with a master’s degree in medi- cal illustration and an MD, Dr. Lalikos had to de- cide whether to become a full-time illustrator or move on to internship and residency, and she con- sulted surgeons who were also artists. As she re- calls, heart surgeon and watercolorist Vincent Gott, MD, FACS, advised, “‘If you at all think you want to be a surgeon, you have to do it now. Your art will always be with you; it will be your joy and your avocation, and even a source of a freelance career. But if you want to be a surgeon, you have to do your training now, because you won’t have the stamina for it later.’” Dr. Lalikos went on to a general surgery resi- 1992 drawing of a nasal flap, done in 1992 by Dr. dency at Vanderbilt University, Nashville, TN, a Lalikos. research fellowship at the University of Pitts- burgh, PA, and a plastic surgery residency at the University of Massachusetts. All the while, she continued her art, doing commissioned portraits for surgeons and their wives and families, sketches it was offered that year, and was accepted at for her patients, line drawings for her clinical pa- Johns Hopkins the following summer. pers. While taking anatomy in medical school, Dr. Lalikos became acquainted with master’s degree Similar yet different students in medical illustration. “I started talk- ing to them about their curriculum and found Although medical illustration and plastic sur- there was a great deal of overlap, especially in the gery fit like hands in gloves in many respects, the scientific courses, with what they were doing and two pursuits are decidedly different. “If I’m doing what we were doing as medical students in the a painting or a drawing or a sketch and it’s just first two years.” not working, I can stop, go away for a while, drink Making another connection with art, Dr. Lalikos a cup of coffee, take a walk, and clear my head. arranged with Johns Hopkins School of Medicine Nine times out of ten when I come back, it’ll pop to substitute some courses in medical illustration into my mind: ‘That’s why it’s not working.’ as electives and allow her to pursue a master’s de- “But in surgery, when you are operating on a gree in medical illustration. After match day, while patient with a head injury, the patient is on the other medical students were vacationing until the table, and his nose is bare, you can’t leave and start of their internships in July, she was prepar- come back tomorrow. You have to finish, and it ing her master’s thesis on animal studies of the has to be perfect.” ⍀ treatment of traumatic fractures of the face with bone grafts from other parts of the body. 20 Working with Paul Manson, MD, FACS, now Ms. Sandrick is a freelance writer in Chicago, IL.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Securing the future of general surgery: A rural surgeon’s perspective

by Richard A. Armstrong, MD, FACS, Newberry, MI

any issues challenge the future of this pro- ber of years, regardless of practice location. fession, not the least of which is the Those inhibiting circumstances include reim- steadily declining interest in general sur- bursement reductions, coding hassles, evolving M gery among young people. While this issues in graduate education and training, and trend is of concern to all surgeons, it is particu- new expectations for general surgeons. larly disturbing to those of us who practice in The College is undertaking a number of ini- rural areas of the country, which have long suf- tiatives to address these problems. In light of fered from a dearth of surgeons. these continuing endeavors, I am offering the A number of factors prevent young physicians following thoughts and observations regarding from entering general surgery and confound these matters and their implications for specifi- those of us who have been in practice for a num- cally rural surgeons. 21

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Reimbursement Medicare’s method of setting payment for rural All of my colleagues have expressed concern physicians at a lower rate has the perverse effect about the lack of equity in payment to rural sur- of encouraging surgeons to practice in urban ar- geons as compared with their urban counterparts eas and of avoiding practice in the places where when they provide identical services. The College they are needed the most. My plea to Medicare has been a strong advocate in urging Congress to officials would be to simplify this complex payment change the flaws in the Medicare fee schedule that system, so that surgeons who do the same amount make possible the disparities in payment to rural of work get paid the same amount of money. While and urban physicians. The goal of these negotia- my private practice has not suffered financially in tions should be to raise the level of payment for 18 years, we do know that our volume of cases surgeons in rural areas to match payment to sur- needs to be much greater than our urban counter- geons in urban environments. In other words, re- parts to achieve the same income. ducing reimbursement to urban surgeons would If the Medicare program is insistent on includ- not be a viable solution. ing practice location as an element in its payment It is important to note that private insurance equation, perhaps the program should factor in companies do not set their payment rates on the whether the surgeon has provided the service in basis of the surgeon’s geographic location. Only an academic setting. Without question, perform- the Medicare program makes this distinction. ing a procedure in a teaching hospital with a resi-

In-hospitalIn-hospital practicespractices couldcould expandexpand accessaccess inin ruralrural areasareas

he article that this piece accompanies spotlights nationwide. They must adhere to specific guidelines Tissues that are of concern to all surgeons, with an to remain eligible for special treatment under Medi- emphasis on how they uniquely affect rural practi- care. For example, acute care is limited to 15 beds tioners. In this item, I propose that some of the prob- and an average length of stay of 96 hours. Although lems facing rural health care could be addressed these facilities may maintain emergency services and through the development of general surgery prac- surgical services, they cannot house intensive care tices run within critical access hospitals. or obstetrical services units. They must be 35 miles According to recent estimates, 25 percent of the from the nearest hospital (15 miles over rough ter- U.S. population resides in rural areas. However, only rain) and must have transfer agreements with a lo- 10 percent of general surgeons currently practice in cal referral hospital in place. rural locations, and experts say 19 percent of gen- Many critical access hospitals have no or limited eral surgeons should be practicing in these areas to surgical coverage, and those services that are avail- ensure adequate access to care. able are provided by visiting consultants. In many cases, it is economically infeasible for these hospi- Critical access hospitals tals to offer 24-hour on-call emergent care. However, Critical access hospitals were established in the it is possible for these facilities to provide day surgi- U.S. to allow many small rural facilities to remain cal services based on the freestanding ambulatory open despite continuing financial pressures. Cur- surgery center (ASC), including short inpatient ad- 22 rently, 782 critical access hospitals are operational missions.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS dent learning how to do the operation requires laparoscopic cholecystectomy, and know exactly more time and resources than would be necessary how much would be paid. Under our current sys- when doing the same procedure in a private facil- tem, intermediaries often deny entire claims or ity with fully trained assistants. So, it makes sense “down code” certain billings based on their own that surgeons who operate in a teaching facility payment policies. To secure full and proper pay- should be paid at a higher level. ment, many surgeons need to have a billing and coding expert on staff to negotiate with the payors Coding and billing and to examine each claim meticulously. Nearly all surgeons, regardless of whether they A proposal to ban payors from denying or limit- are practicing in an urban or a rural environment, ing payment for certain facets of a procedure may surely agree that our current billing and coding strike some people as idealistic, anti-competitive, system is too cumbersome and complex. The Col- and, therefore, the rhetoric of socialized medicine. lege has done a superb job of teaching surgeons But the fact of the matter is that Medicare is so- how to code and bill appropriately, largely through cialized medicine, and it makes little sense to run the practice management workshops that the or- the program using anything other than a single, ganization presents. However, a worthy goal would standard payment rate for each service provided be to develop a system that would allow a surgeon to a beneficiary. Capitalism works in the private to send a bill for a certain procedure, say insurance marketplace, where beneficiaries and

Expanding the concept majority of cases would be elective procedures. These facilities could be expanded and put to bet- True surgical emergencies occurring at night or on ter use for rural populations by allowing general sur- weekends would still be transported to the local re- geons to establish in-house practices. The develop- ferral center. Of course, this arrangement would mean ment of in-house general surgery practices at critical that the general surgeon would handle few trauma access hospitals would benefit the facility, the sur- cases, but he or she should be willing to assist in the rounding community, and general surgeons. ER when available and in updating the ER personnel For the hospital, keeping common surgical and en- on current Advanced Trauma Life Support® guide- doscopic services within the facility is a perceived lines. good, and patients and their families would be pleased Furthermore, a general surgeon would be of tre- to avoid driving 35 to 100 miles for a simple proce- mendous importance to the hospital and the commu- dure, such as hernia repair or colonoscopy. Rural hos- nity by offering a myriad of services that would oth- pitals would no longer have to refer virtually all of erwise be unavailable. Virtually all procedures that their surgical consultations and cases to the regional can be performed on an outpatient or short-stay ba- medical center or discuss cases by phone with a con- sis and almost all endoscopy could be done in a criti- sultant at the regional medical center. cal access hospital. Office-based ultrasound for breast and thyroid procedures would be particularly suited How it could work to this type of ambulatory practice. Critical access hospitals are generally staffed by a mix of primary care physicians and physician extend- Conclusion ers, who are used to being on-call for the emergency This proposal to make general surgeons key mem- admissions and may also staff the emergency room. bers of the critical access hospital staff may be one Very few general surgeons would agree to practice in solution to the problem of encouraging surgeons to an environment where they had to be on-call all of practice in rural parts of the country. As we struggle the time. A critical access hospital, because it follows to address some of the most vexing issues regarding the ASC model, would offer an ideal situation for a rural surgical practice, we must open our minds to general surgeon—one free of after-hours emergency new and innovative possibilities. Creating new prac- on-call time requirements. The surgeon would still tice opportunities and pleasant work environments need to be available by pager and on-call to treat any may help us attract surgeons who otherwise might patients admitted after an operation, but the need to avoid rural practice. contact the surgeon would be limited because the —Richard A. Armstrong, MD, FACS 23

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS providers choose which health plans in which to als for rural practice, it is imperative that we pro- participate, but it is contradictory to the aims of vide opportunities for medical students and resi- the Medicare program to have competing inter- dents to attain experience in this setting. Stud- mediaries. We need to develop a system that en- ies indicate that the best time to attract physi- sures that the surgeon in private practice gets paid cians to a specialty or practice type is while they an honest wage for an honest day’s work. are still in the formative stages of their career. An excellent prototype for a training program Education and training that allows young surgeons to get a taste of ru- We live in an exciting time with respect to the ral surgery has been developed by John G. changes taking place in surgical education. It is Hunter, MD, FACS, and Karen E. Deveney, MD, wonderful to witness what is almost a renaissance FACS, at the Oregon Health & Science Univer- in thought regarding the training and continu- sity. (See “Training the rural surgeon: A pro- ing education of all surgeons. As we consider posal,” Bulletin, 88(5):13.) Rural surgeons need means of improving the graduate medical edu- to emphasize to those individuals who do a ro- cation system, we need to focus on the develop- tation under their leadership that practice out- ment of the whole person. The most successful side of metropolitan areas affords them the op- surgeons seem to be those individuals who be- portunity to manage a broad range of cases and gin their careers with healthy minds and bod- to have greater control over their own destinies. ies. Our profession requires mental and physi- cal stamina. As educators, we should be con- General surgeons cerned about the overall fitness of the individu- We need to carefully reconsider the core defi- als who enter surgical training and their ability to nition of what it means to be a general surgeon. cope with periods of major stress. It’s a given that This reexamination of the concept of general sur- medical school is tough and that some people will gery is especially pertinent to any discussion of find this part of their education difficult enough rural practice because physicians in more remote to make them think twice about choosing such a locations so often are called upon to handle cases taxing line of work. Nonetheless, as educators we that require knowledge and skills outside of their need to be able to spot the top performers by tak- traditional purview. For example, they need to ing into consideration not only how well medical be able to perform routine obstetrical-gyneco- students fare academically but also their resil- logical procedures, including cesarean sections. ience when under pressure. They need to have enough orthopaedic trauma Furthermore, we should create a training envi- training to handle common orthopaedic emer- ronment that is conducive to both professional and gencies. Competence in the treatment of criti- personal development. Program directors need to cal care, trauma, vascular, and thoracic proce- be more sensitive to people who want to have fami- dures is essential. Fortunately, I became famil- lies and enter practice at the same time—a topic iar with this broad range of surgical procedures of real concern to the growing number of female while training in the Navy, but I’m not sure that medical school graduates. We also need to promote all training programs offer such wide experience. good health. Some program directors and chiefs One of the greatest challenges in rural areas of surgery have long recognized that residents and is call coverage, especially if a group of less than attending surgeons who are physically fit and well- three surgeons is serving a location. This is a topic rested tend to perform more competently. that requires further discussion, but one poten- Too many of my colleagues complain of being tial solution is to have surgeons in neighboring “burned out” and wish that they could just quit communities network to provide call coverage. Ad- practice. This is a sad comment to hear from people ditionally, rural primary care and emergency room who once were excited and enthusiastic about sur- physicians should be trained to deal with common gery. This disappointing attitude possibly could be surgical problems, to recognize when a surgeon is averted if the surgical lifestyle was less exhaust- truly needed, and to know when to seek the expe- ing and more rewarding. rience and advice of a surgeon. This arrangement 24 In the special circumstance of training individu- would limit the times rural surgeons are called.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Due to the limited number of surgeons who ing to develop this type of computer program practice in rural areas, the few who do decide to until we have a clearer sense of what specific practice outside of metropolitan areas must be information surgeons will be expected to exceptional people with a broad range of surgi- maintain, among other objections. However, I cal interests, a deep sense of self-confidence, and believe we should at least initiate a program plenty of common sense. They should want to that can be modified over time to meet chang- be actively involved in patient care and be will- ing demands. ing and able to do their own critical care man- Surgeons of the future will need to be willing agement, in addition to the technical aspects of and eager to help their medical colleagues and their work. to seek their consult in difficult cases. Likewise, As the health care system evolves, it is evi- they must be amenable to working with hospi- dent that all surgeons will also need to be knowl- tal and practice administrators, as well as pa- edgeable about the entire course of disease pro- tients, with the goal of providing optimal surgi- cesses—not just how to cure a condition by us- cal treatment. Hence, their communication skills ing an operative procedure. For example, I be- should be well developed. Furthermore, surgeons lieve that today’s residents should be exposed must understand the vital importance of humil- to a broad range of pathology. ity. They must guard against their ego getting in the way of sustaining productive relation- Future survival skills ships. All surgeons of the future also will need to have While in the Navy, I had the opportunity to a better understanding of quality of care issues, develop a relationship with excellent mentors of how to monitor their outcomes, of interper- and role models. These individuals demonstrated sonal and communication skills, and of what it the ability to remain calm under pressure. In means to be a leader. fact, most of them instilled in us the belief that All surgeons, of course, must be able to arrive the most important time to remain in control of at sound judgments and be committed to achiev- your emotions is when dealing with a crisis. As ing the highest quality in the performance of all a result, I don’t have any tolerance for surgeons the daily tasks we carry out. In fact, a surgeon’s who lose their temper in the OR. We must keep success depends completely on his or her devo- these negative feelings in check, particularly when tion to quality. No other aspect of daily practice dealing with trainees. is as important as delivering optimal care in and out of the operating room. Conclusion Keeping track of one’s cases and outcomes is We have the opportunity at this time to create a subject that has received considerable atten- an environment that encourages surgeons to pro- tion lately as part of the quality debate and the continued on page 43 development of best practices. Surgeons must get in the habit of monitoring their practice pat- Dr. Armstrong is terns. Maintaining these records can serve as clinical assistant professor of surgery, our best defense against those individuals who College of Human would limit our privileges. This case log does not Medicine, Michigan have to be anything fancy or particularly for- State University, and a mal. I have kept track of my morbidity and mor- general surgeon tality data in a notebook that I store in my practicing in Newberry, changing room locker, adding cases after each MI. operation. Perhaps the College could help surgeons just getting started in this area by developing a software program for maintaining a case log that is user-friendly and portable. Of course, some people might say we are better off wait- 25

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The Governors’ Committee on

Physician Competency and Health By Lynn H. Harrison, Jr., MD, FACS, New Orleans, LA

he Board of Governors’ (B/G) Committee on Clinical Congress program Physician Competency and Health is the prod- At the 2004 Clinical Congress in New Orleans, uct of the recent merger of the previous B/G LA, the committee will sponsor a panel discus- TCommittee on Physician Competency and Li- sion entitled Issues Surrounding the Decision ability and the Committee on Physician Health. to Retire. Lazar J. Greenfield, MD, FACS, will Because it is new, the committee is still evolving moderate the session and will present a talk with respect to its charge and focus. Nonetheless, entitled Recognizing Disability at the Operat- the following summary of our current and future ing Table. Additionally, Arthur J. Donovan, MD, activities should convey which issues are of great- FACS, will present on economic planning for est concern to the committee at this time. retirement; Thomas L. Dent, MD, FACS, will talk about applying the years of hard-won expe- The impaired surgeon rience; and Wallace P. Ritchie, Jr., MD, FACS, The relationship between physician compe- will give a talk entitled “What to Do with All tency and physician health is obvious, and many That Time.” of the committee’s efforts in the past have fo- cused on disruptive behavior and substance Core competencies abuse as reflected in the Out of Control video. The committee conducted an ongoing discus- The College distributes the video to surgeons, sion in parallel with a Regents’ task force that other physicians, and surgical residents to help has been investigating the Accreditation Coun- them understand what it means to be out of con- cil on Graduate Medical Education’s core com- trol with regard to alcohol and drug use and to petencies, and the means available to practicing provide confidential resources that people in surgeons to assess their capabilities in these 26 trouble can turn to for help. areas in a helpful and confidential way. Although

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Governors’ Committee on Physician Competency and Health

Lynn H. Harrison, Jr., MD, FACS, Chair Mark A. Malangoni, MD, FACS Thoracic surgery, New Orleans, LA General surgery, Cleveland, OH [email protected] [email protected]

Kenneth W. Sharp, MD, FACS, Vice-Chair Charles H. McCollum, MD, FACS General surgery, Nashville, TN Vascular surgery, Houston, TX [email protected] [email protected]

Harry Appelbaum, MD, FACS Edward H. Phillips, MD, FACS Pediatric surgery, Los Angeles, CA General surgery, Los Angeles, CA [email protected] [email protected]

Anurag K. Das, MD, FACS William J. Purkert, MD, FACS Urological surgery, Boston, MA General surgery, Fairfax, VA [email protected] [email protected]

Dennis L. Fowler, MD, FACS Ajit K. Sachdeva, MD, FACS, FRCSC, Ex-Officio General surgery, New York, NY General surgery, Chicago, IL [email protected] [email protected]

Paul S. Fox, MD, FACS Charles H. Scudamore, MD, FACS General surgery, Waukesha, WI General surgery, Vancouver, BC

Lazar J. Greenfield, MD, FACS, Consultant R. James Valentine, MD, FACS Vascular surgery, Ann Arbor, MI Vascular surgery, Dallas, TX [email protected] [email protected]

C. Rollins Hanlon, MD, FACS, Consultant Lawrence D. Wagman, MD, FACS Thoracic surgery, Chicago, IL General surgery, Claremont, CA [email protected] [email protected]

Stephen H. Haynes, MD, FACS Martin H. Wennar, MD, FACS General surgery, Clovis, NM General surgery, Milton, VT [email protected] [email protected]

Howard Holderness, Jr., MD, FACS William C. Wood, MD, FACS Plastic surgery, Greensboro, NC General surgery, Atlanta, GA [email protected] [email protected]

John V. LaManna, MD, FACS Kent T. Yamaguchi, MD, FACS Plastic surgery, Reading, PA Plastic surgery, Fresno, CA [email protected] [email protected]

Anna M. Ledgerwood, MD, FACS, Consultant General surgery, Detroit, MI [email protected]

27

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the task force and the Governors’ committee were occasion of the annual Clinical Congress in Oc- working independently, we came to remarkably tober. At the upcoming meeting in New Orleans, similar conclusions. To avoid duplication of effort, blood pressure screening will be performed. In the committee has agreed to leave this issue in the future years, simple blood test screenings for capable hands of Ajit Sachdeva, MD, FACS, FRCSC, prostate cancer or noninvasive vascular ultra- Director of the ACS Division of Education. sound screenings might be made available.

Quality assurance Work hours Fellows of the College have expressed a clear On the horizon, the 80-hour workweek for resi- need for disinterested external review of individual dents in training will surely be brought to bear surgeons’ practices when local hospital quality as- on practicing surgeons. The committee antici- surance (QA) committees conclude that a problem pates the need to address this issue as well. ⍀ may exist. Traditionally, the results of their delib- erations have been undiscoverable in lawsuits; however, recently the courts have sided with plain- tiff attorneys, who allege that members of the QA committee were, in fact, in competition with the surgeon being reviewed and for that reason those deliberations were discoverable. To help address this problematic situation, ACS Past-President Claude Welch, MD, FACS, estab- lished the American Medical Foundation for Peer Review and Education, a not-for-profit agency for medical staff peer review. Although it is well staffed and well financed, this foundation is not widely known, particularly among practicing Fellows. The committee is currently considering a means by which the College might provide a similar service, as it is to this organization that most surgeons and hospitals turn for assistance when these in- ternal conflicts of interest arise. Although these plans are currently in only the discussion phase, it is foreseeable that the College could identify panels of experts in the various ar- eas of surgical practice. These panels might, at the inviting institution’s expense, review patterns of practice that have been brought into question by Dr. Harrison is local QA committees. Any opinion that these pan- professor of surgery els render would be undiscoverable by virtue of and chief, section of cardiothoracic surgery, the fact that the panel members would not be in Louisiana State direct or indirect competition with the surgeon be- University, New ing reviewed. They would be useful to hospitals Orleans. He also is the and surgical departments as well as to individual Chair of the Governors’ practitioners in the improvement of surgical Committee on Physi- practice at their institutions. cian Competency and Health. Health screenings The committee has initiated what we hope will be the first of many general health screenings 28 that will be made available to the Fellows on the

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS THE GLOVES ARE OFF:

The Aetna and CIGNA settlements: Part II

by Irene Dworakowski, Regulatory and Coding Associate, Division of Advocacy and Health Policy

uring the 1990s, a number of lawsuits were disclosure and business practice changes estab- filed across the country on behalf of physi- lished in the Aetna settlement. It establishes a Web cians against managed care organizations. portal through which CIGNA participating physi- DThese lawsuits alleged that the health plans cians may check patients’ eligibility, status of conducted improper contracting and payment claims, fee schedules, policies, and procedures, as practices. In October 2000, the lawsuits were con- well as any updates and changes to these items. solidated and transferred to the U.S. federal court CIGNA is providing $15 million in funding for The in Florida as a class action lawsuit. Two of the de- Physicians’ Foundation for Health Systems, which fendants, Aetna and CIGNA, agreed to settlements is charged with developing health care initiatives rather than continue the litigation. The other man- for patients and providers. CIGNA has also estab- aged care companies that are defendants in this lished a physician advisory committee to advise litigation have not agreed to settlements at this the company on national health care issues. time and the lawsuit against those organizations Surgeons who are party to the class action should continues to move toward a trial, which is cur- have received CIGNA’s formal notice of commence- rently scheduled to begin in March 2005. ment of claims period that was mailed on July 8, The first article in this two-part series provided 2004. During the claims period, which begins Au- information about the Aetna settlement (July gust 23, 2004, and ends February 18, 2005, class 2004, page 12). This second article continues with action members may apply for compensation from a discussion of physician compensation available the funds established by the settlement. Claims under the CIGNA settlement, the appeals process, for denials of or reductions in payment that were a and the enforcement procedures established to en- result of payment and benefit limitations (such as sure that Aetna and CIGNA comply with the pro- coordination of benefit rules, violations of visions of the settlements in the future. preauthorization or referral requirements, limita- The final order for the CIGNA settlement was tions cited in capitation agreements, and services issued in April 2004. The elements of prospective excluded from coverage under the CIGNA member’s relief provided by the settlement are similar to the plan) are ineligible for compensation. Poorman- 29

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Douglas Corporation, the settlement administra- cal necessity denial. Requests for payment may be tor for CIGNA, will handle all compensation submitted under any or all of the three separate claims. Physicians may apply for compensation categories. from either the Category A settlement fund or the Category One applies to claims that are defined claims distribution fund. by a negotiated list of code edits published as part of the settlement.* This option requires a valid Category A settlement fund proof of claim that the procedures were denied by CIGNA. The code edits for which additional pay- All class members may apply for compensation ment is due that may be of most interest to sur- from CIGNA’s Category A settlement fund regard- geons are: less of whether they have submitted any claims to • Biopsy of skin, subcutaneous tissue and/or CIGNA HealthCare during the period from Au- mucous membrane that were bundled into destruc- gust 4, 1990, through September 5, 2003, as long tion of skin lesions (codes 17000-17999 paid; code as they have submitted claims for payment dur- 11100 not paid). ing that period to Aetna, Aetna-USHC, Anthem, • Destruction of lesion(s) that were bundled CIGNA, Coventry Health Care, Health Net, into shaving or excision of epidermal/dermal le- Humana Health Plan, Humana, PacifiCare Health sions (codes 11300-14000 paid; code 17000-17004 Systems, Prudential Insurance Company of not paid). America, United Health Care, United Health • Chemical cauterization of granulation tissue Group, or Wellpoint Health Networks. that was bundled into collection of venous blood Physicians who opt to apply to the Category A by venipuncture (code 36415 paid; code 17250 not settlement fund are not expected to produce docu- paid). mentation in order to receive compensation, which • Upper gastrointestinal endoscopy with biopsy will be distributed according to a formula con- that was bundled into upper gastrointestinal en- tained in the settlement. They must complete and doscopy with insertion of guidewire and dilation return a Category A claim form to the settlement or balloon dilation of esophagus (codes 43248- administrator. All payments from the Category A 43249 paid; code 43239 not paid). settlement fund will be made approximately two • Sigmoidoscopy with removal of tumor(s), weeks after the claims period has ended. Please polyp(s), or other lesion(s) by hot biopsy forceps note that, in lieu of receiving payment, physicians or bipolar cautery that was bundled into sigmoi- may contribute their share of the settlement fund doscopy by snare technique (code 45385 paid; code to The Physicians’ Foundation for Health Systems 45384 unpaid). or to a similar entity established by any medical A complete list of Category One code edits can society that signed or joined the settlement. be downloaded in Adobe Acrobat (.pdf) format at http://www.cignaphysiciansettlement.com/ Claim distribution fund categoryone.htm. Category Two compensation applies if the pay- Surgeons who believe they were specifically de- ment denial or reduction was a result of the appli- nied appropriate payment for services by CIGNA cation of CIGNA’s proprietary coding and bundling Corporation or its subsidiary entities (CIGNA edits that are unspecified as eligible for Category Healthcare, Connecticut General, Healthsource, One compensation. CIGNA has provided the settle- Lovelace Health Systems, Ross Loos Hospital) ment administrator with a facilitation list that from August 4, 1990, through April 22, 2004, may identifies provider claims for which payment was choose to forgo compensation through the Cat- denied or reduced because code edits were applied, egory A settlement fund and apply to CIGNA’s modifiers and add-on codes were not recognized, claim distribution fund. A complete list of the or multiple procedure rules were applied incor- CIGNA entities can be found at http:// rectly. To determine whether to pursue payment www.cignaphysiciansettlement.com/entities.htm. There are three categories of the claim distribu- *All specific references to CPT terminology and phraseology 30 tion fund: Category One, Category Two, or medi- are: © 2003 American Medical Association. All rights reserved.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS through the Category Two list, physicians should edit software when those codes were exempt from request a facilitation list for their claims from the multiple procedure reduction. settlement administrator. Some practice management software maintains To request compensation for claims that were electronic records that contain information that improperly denied by CIGNA as not medically nec- would be included on a HCFA-1500 form and can essary or as experimental or investigational, phy- generate a print image file. Practices that use this sicians should apply to the medical necessity de- software can submit claims documentation elec- nial compensation fund. tronically to a Web portal that is being operated by Infinedi LLC, which will create HCFA-1500 Applying for compensation forms containing the claims information. If sup- porting documentation is required for a claim and Physicians requesting compensation from the it is possible to create a .pdf or .tif file, that docu- claim distribution fund must submit the appro- mentation can be uploaded to the Infinedi site, and priate proof of claim form. (Proof of claim forms the complete file will be transmitted to CIGNA by should not be submitted until the claims period Infinedi. Proof of claim forms must be completed begins.) CIGNA advises claimants that they should and signed prior to electronic submission. For more use only the “official version” of the proof of claim information about electronic submission of com- form (bar-coded) when submitting request for pay- pensation claims, please go to www.cignaeclaims. ment. A single proof of claim form may be used com. for more than one compensation request. A sepa- If CIGNA denies compensation for a Category rate cover sheet and the required documentation Two or medical necessity compensation request for each request must be attached to the form. based on its determination that the original deci- Copies of the official forms (including the cover sion to reduce or deny payment was appropriate, sheets for Category One, Category Two, and medi- that request will automatically be forwarded to an cal necessity denial claims) can be found at http:// independent review entity (IRE) to determine the www.cignaphysiciansettlement.com/ appropriateness of the decision. documents.htm or requested from the settlement The settlement administrator for any of the administrator. items cited in this article can be contacted by e- The required documentation for Category Two mail at http://www.cignaphysiciansettlement.com/ and medical necessity denial requests consists of contact.htm, by phone at 1-877/683-9363, or by a copy of the original HCFA-1500 form or the rel- mail at CIGNA Physicians Settlement, Settlement evant CIGNA remittance form. (If those forms are Administrator, P.O. Box 3170, Portland, OR 97208- unavailable, printouts of accounts receivable or 3170. paid account records will be accepted.) Claimants also must provide clinical information relevant to The enforcement process each claim. For denial of claims for surgical proce- dures, claimants must provide clinical notes and Both Aetna and CIGNA have revised their ap- operative notes. To view the list of documentation peals processes as a result of the settlements. If requirements for other CPT codes, please go to physicians believe that any claims submitted af- http://www.cignaphysiciansettlement.com/ ter the deadlines for compensation under the clinicalDocumentation.htm. Two exceptions have settlements have been improperly denied or paid, been made to the clinical information requirement. they will have to first appeal those disputes with No clinical documentation is required if: (1) the Aetna or CIGNA. The CIGNA agreement allows request for payment is for a claim where CIGNA for two levels of internal appeal. If the determina- HealthCare failed to recognize modifiers 50, RT, tion of initial appeal is unsatisfactory, physicians LT, FA-F9, or TA-T9, and denied payment for one may request that the claim be reviewed by a mem- or more CPT codes as duplicative of other CPT ber of the same specialty as the performing physi- codes reported; or (2) CIGNA HealthCare incor- cian. The review of and response to claim disputes rectly processed one or more modifier 51 exempt must be completed within 45 days. If the response CPT codes and/or add-on CPT codes due to CIGNA to an appeal is also unsatisfactory, independent 31

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS review mechanisms have been created to offer binding if used. Physicians are free to pursue rem- physicians additional avenues for reconsideration edies independent of the established processes, and to ensure that Aetna and CIGNA are comply- such as resolution of a dispute by arbitration. The ing with the settlements. They are as follows: Aetna settlement establishes a cap of $1,000 for • Billing dispute resolution process. The IRE arbitration fees for solo and small practices. process may be used for retained claims (defined • Compliance dispute resolution process. The below), coding, and other payment rule disputes, settlements provide a mechanism whereby non- including disputes over burdensome record re- compliance by Aetna or CIGNA to the obligations quests, after completion of the Aetna or CIGNA set forth in the agreements may be reported. This internal review process. process would most likely be used if a pattern of For CIGNA, retained claims are ones that either behavior was identified. Compliance disputes may were filed but not adjudicated (including any in- be filed by any class member who has been ad- ternal appeals) as of April 22, 2004, or claims that versely affected by a breach of the settlement have not yet been filed but for which the filing pe- agreements or by a signatory medical society on riod has not expired. The settlement agreement behalf of a physician or a practice. Any compli- stipulates that claims that involve the application ance disputes will be reviewed by an appointed of CIGNA’s coding and payment rules and meth- compliance dispute officer. If the compliance dis- odologies that were finally adjudicated between pute officer finds that noncompliance has occurred, March 24 and April 21, 2004, are also considered the offending party will have 30 days to resolve retained claims. Detailed information on the sub- the problem. Failure to remedy the noncompliance mission of retained claims to the billing dispute could result in legal intervention to force compli- external review process can be found at ance. All Aetna and CIGNA compliance disputes www.CIGNAforHCP.com. will be handled by the compliance dispute facilita- For Aetna, billing disputes for $500.01 or more tor. may be submitted to the IRE within 90 days of an As a reminder, the state and local medical soci- Aetna appeal decision. (Physicians may request eties and associations that are signatories to the that the IRE aggregate similar claims for up to one settlement agreements may represent physician year to reach the required $500.01.) The filing fee members who have future disagreements with for the service is a minimum of $50 and an addi- Aetna and CIGNA through the compliance dispute tional 5 percent of amounts in dispute over $1,000, process for violations of the terms of the settle- capped at 50 percent of the IRE’s charge for the ment as well as violations of state law relating to review. In most cases, the IRE will issue its deci- such terms. Physicians who choose to opt out of sion within 60 days of the date the appeal is filed. the class action may not use the compliance dis- • Medical necessity dispute resolution process. pute process. Surgeons should contact the appro- If a physician receives a denial based on Aetna’s priate medical or specialty society in their area for or CIGNA’s determination that the services were more specific information about the effects of the not medically necessary or were experimental or settlement on their practices. ⍀ investigational, the decision may be appealed to the appointed external review organization. (If a The information contained in this article is based on patient has filed an Employee Retirement Income documents provided by the American Medical Associa- Security Act of 1974 lawsuit in a federal court, this tion in March 2004 and supplemented with informa- review is not an option.) For Aetna, this process tion contained on the Aetna provider Web site, the should be available this month, and there is a fil- CIGNA Healthcare physician settlement Web site, the ing fee of $50 or up to $250 for cases requiring HMO Crisis Web site maintained by the Law Offices of prior authorization. Archie Lamb, and the HMO settlements Web site main- tained by Milberg Weiss Bershad & Schulman LLP. The The date for the initiation of CIGNA’s process Law Offices of Archie Lamb and Milberg Weiss Bershad and any fees associated with filing of billing dis- & Schulman LLP represented physicians in the Aetna pute or medical necessity dispute claims have not and CIGNA health care litigation. been announced. 32 These processes are optional with Aetna but

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Chapter leaders learn about politics and advocacy by Diane S. Schneidman, Senior Editor

The second Chapter Officers and Young Surgeons Leadership Conference took place May 16- 18 in Washington, DC, and fea- tured an insider’s look at health policy advocacy. Approximately 150 Chapter Officers, Chapter Executives, and Young Surgeon Representatives attended the meeting, which was coordinated by the Division of Member Ser- vices and the Washington Office of the Division of Advocacy and Health Policy. Highlights in- cluded: a preconference “profes- sional speaking lab”; concurrent sessions tailored to the specific needs of the attendees; a key- note address on the uninsured; a panel discussion on quality im- provement; a perspective on the upcoming presidential elections; and Capitol Hill visits.

Young surgeons’ program The first day of meetings fea- tured concurrent sessions tar- geted at each category of meet- Left to right: H. Stephen Fletcher, Robert E. Hawkins, Sherry Marie Wren, ing participants—Young Sur- Dr. Russell, and James B. Atkinson (all MD, FACS) pass the Capitol Building geon Representatives, Chapter on their way to meeting with members of the U.S. House of Representatives. Officers, and Chapter Execu- tives. The Young Surgeon Rep- resentatives’ program focused said, ‘You can make a differ- gan agreed that the theme of his on cultivating surgical leader- ence.’” Presidential term would be “the ship skills. Dr. Organ said the College is year of the resident.” One effort In welcoming the Young Sur- trying harder than ever to ap- under way to guarantee that geon Representatives, Claude H. peal to young surgeons and to young surgeons play more Organ, Jr., MD, FACS, 84th get them involved in ACS activi- prominent roles within the or- President of the American Col- ties early on in their careers. To ganization is the creation of resi- lege of Surgeons, said, “We need spotlight this movement, ACS dent seats on College commit- your help. I meant it in my Executive Director Thomas R. tees. Presidential Address when I Russell, MD, FACS, and Dr. Or- In addition, Dr. Organ noted 33

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS that the College is reaching out with change, diminishing career be patient, educate yourself, and to medical, surgical, govern- satisfaction, and egocentrism, don’t underestimate your capa- ment, and private sector groups Dr. Evans said. bilities to implement significant to build consensus on how best Overall, though, “surgeons are change,” he said. to improve patient care. “The well-positioned to implement • Arenas for change. Dr. College is no longer a ‘sleeping change,” Dr. Evans concluded. Russell explained how the Col- giant,’” he said. “We don’t stand “Choose your battles carefully, lege is attempting to create a alone any more.” • Leading change. Stephen R.T. Evans, MD, FACS, profes- sor and chair, department of sur- gery, Georgetown University, Washington, DC, spoke about leadership during times of change. Dr. Evans said that change allows institutions and individuals to do more than merely survive. It allows them to connect with others in a way that makes life better, to be part something great, and to make a difference in the lives of others. According to Dr. Evans, indi- viduals who want to initiate change need to take four steps: (1) make observations about existing challenges; (2) ask constituents for their perspec- Mr. Rothenberg (right) discussing the Senate races with conference attendees. tives; (3) offer interpretations about the problems and pos- sible solutions; and (4) take action. “Let the issue ripen. Find out what else is on people’s minds, how deeply people are affected by the prob- lem, and how much people need to learn,” he advised. Dr. Evans noted that surgeons possess several characteristics that make them strong “vehicles for change.” They are intelli- gent, tenacious, hard-working, high-profile members of their institutions, who are trained to identify and fix problems. On the other hand, a number of traits may work against sur- Left to right: James Harris, MD, FACS; Jeffrey Lanford, MD, FACS; Dr. geons as leaders, including elit- Russell, Rep. Joe Wilson (R-SC); and Chad Rubin, MD, FACS (South Carolina ism, a tendency to overextend Chapter). 34 themselves, lack of experience

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS “tipping point” in the future de- would have done it,” Dr. U.S. Army Trauma Training livery of surgical services by be- Russell noted. Center, Miami, FL, and assistant ing active in several arenas, in- The College also is leading ef- professor of surgery, Uniformed cluding political advocacy. Dr. forts to improve patient safety Services University of the Health Russell noted that the ACS and quality of care, including Sciences, Bethesda, MD, offered formed the American College of bringing the Department of his perspective on how young Surgeons Professional Associa- Veterans Affairs’ National surgeons can achieve organiza- tion (ACSPA) in 2002. The Safety and Quality Improve- tional change. He said that ACSPA functions under 501(c)6 ment Program to the private young surgeons who want to tax status and, therefore, was sector. “We at the College re- have an impact should focus on able to establish a political action ally think this is our issue,” Dr. issues that they have strong feel- committee (PAC). The ACSPA- Russell said. ings about, join organizations SurgeonsPAC actively seeks fi- Furthermore, the College that represent their views, and nancial contributions, which are strives to help surgeons ac- be active in the local surgical used to help fund the candidacy quire the skills they will need community. of legislators who support the to deliver care to patients in the Young surgeons who want to College’s views. future, Dr. Russell added. For ex- make a difference need to “get Additionally, the ACSPA has ample, the next generation of to the right place within the or- joined with other medical and surgeons will provide disease- ganization to effect change,” Dr. surgical specialty societies to specific rather than specialty- Armstrong added. They need to form Doctors for Medical Li- specific services. As a result, sur- understand the internal and ex- ability Reform (DMLR), Dr. geons will need new skills and ternal processes of the associa- Russell said. DMLR is spread- will find themselves working in tion. After attaining some influ- ing the message in states with teams of professionals. ence within an organization, ad- a U.S. senator who is blocking • Getting involved. John H. vocates for change must send a passage of liability reforms Armstrong, MD, FACS, director, message that resonates with that the malpractice insurance crisis affects access to care. The College also is helping to promote evidence-based medi- cine that will lead to scientifi- cally sound guidelines for sur- gical procedures and best prac- tices. “To get this idea into practice is no small task,” Dr. Russell said. “We are trying to get surgeons involved in out- comes research.” Surgical education and train- ing are another arena in which the College is involved, Dr. Russell said. For example, the College worked with the Ac- creditation Council on Gradu- ate Medical Education to de- velop the 80-hour workweek for residents to ensure that the Left to right: Dr. Russell, Barry Brown (chief of staff for Rep. Burgess); Rep. rules were crafted by the medi- Michael Burgess (R-TX); Joseph Kuhn, MD, FACS (Texas Chapter); and Mrs. cal community. “Had we not Kuhn. been involved, the government 35

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS other members of the society pants to polish their presenta- and “negotiate with respect and tion skills. Topics covered dur- courage,” Dr. Armstrong said. ing the session included cap- turing the audience’s interest, Chapter Officers’ program delivery styles, and responding The program for Chapter Of- to hostile questions. ficers focused on “Member Is- sues and Strategies.” Paul Health policy initiatives Collicott, MD, FACS, Director, All of the meeting partici- ACS Division of Member Ser- pants gathered together on the vices, chaired the program and second day of the meeting to provided an update on trends in learn about health policy and the College’s membership. Ray the legislative process. Dr. Price, MD, FACS, Past-Presi- Russell opened this portion of dent of the Utah Chapter, de- the meeting by explaining the scribed how that chapter was College’s activities. able to “kick start” its activities Dr. Russell said the College and revitalize the membership. is focusing on the complexities Mary E. Maniscalco-Theberge, of a new health care system, MD, FACS, Immediate Past- rather than pining for the rela- President of the Metropolitan tive simplicity of times past. Washington Chapter, discussed “We’ve got to look forward. how education programs for We’ve got to look at the fu- surgical residents brought new ture,” he said. energy to that chapter. Finally, In Dr. Russell’s view, the Col- Michael J. Demeure, MD, FACS, at Dr. Organ explained why he lege functions as both a trade the office of Sen. Jon Kyl (R-AZ). chose to make “the year of the association and a professional resident” the theme of his association. As a trade associa- Presidential term. tion, the College’s policies pro- tect the rights of its members, Chapter Executives’ program ensuring their fair treatment Health Policy Steering Com- Henry Schaffer, JD, Jenner & with respect to reimbursement mittee is examining the future Block, Chicago, IL, provided an and government regulation. As configuration of the health update on legal issues affecting a professional association, the care system, and the ACSPA- tax-exempt corporations, in- College seeks to educate its SurgeonsPAC is helping the cluding non-dues revenues, as members, to promote ethics, organization to establish con- well as regulatory and compli- and to ensure patient safety tacts on Capitol Hill. ance issues. In addition, the and quality of care. To carry out these initiatives, Chapter Executives partici- Hence, the College’s pro- the College is working with a pated in a roundtable discus- grams include developing sur- range of other groups, including sion of their “greatest chal- geon leaders, promoting prac- the American Medical Associa- lenges” and how they overcame tice-based learning and out- tion, business consortiums, and them. comes studies, working with other organizations that are con- training program directors to cerned about access to quality Preconference session help them apply the 80-hour care, Dr. Russell said. Most im- Preceding the concurrent workweek standards, develop- portantly, however, “We really sessions, J. Robin Wright, ing guidelines and best prac- want to get the membership in- president, Wright Communica- tices, and conducting clinical volved. It’s the membership that tions, Inc., Evanston, IL, led a trials, Dr. Russell reported. In drives the College’s health policy 36 workshop that allowed partici- terms of politics, the College’s initiatives,” he added.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The uninsured that individuals obtain health to promote outcomes and pay for Keynote speaker Shoshanna insurance for themselves and performance. “This is your op- Sofaer, PhD, professor, Baruch their families and provide a tax portunity,” Dr. Jencks added. College, New York, NY, said, “We credit for purchasing insurance. Offering the workers’ perspec- cannot afford not to cover the The fourth prototype would es- tive, Gerry Shea, assistant to the uninsured.” Dr. Sofaer co- tablish a single-payor system. president for government affairs chaired the Institute of “Any of the prototypes could do at the AFL-CIO, Washington, Medicine’s (IOM’s) Committee better than the status quo,” Dr. DC, said that because many em- on the Consequence of Uninsur- Sofaer said. ployers are shifting costs for ance. Dr. Sofaer encouraged sur- health care coverage to employ- Dr. Sofaer noted that the 43.8 geons to play an active role in the ees, consumers are going to more million Americans without development of a reformed closely scrutinize quality indica- health care coverage tend to health care system. “We need tors. Therefore, “a robust set of have poorer health and shorter political intelligence and leader- measures that makes sense to lives than individuals with insur- ship. We need champions of consumers and clinicians” is ance and, hence, are major con- many kinds participating,” she needed, Mr. Shea added. tributors to the rising costs of said. “You need to recognize that Surgeons have been pioneers health care. Uninsured individu- you’re part of the polity.” in quality measurement for de- als use $99 billion in total health cades, noted Allan M. Korn, MD, care services annually. One-third Panel on quality FACP, senior vice-president/chief of those expenses are paid out- R. Scott Jones, MD, FACS, Di- medical officer, Blue Cross and of-pocket; the rest is paid rector of the College’s Division Blue Shield Association, Chi- through tax revenues and other of Research and Optimal Patient cago, IL. “What we need is for types of public funding, she said. Care, moderated a plenary ses- you to take over. None are in a The committee determined sion examining how current ef- better position than you” to lead that any plan to extend coverage forts to improve surgical care this movement, Dr. Korn said. to the uninsured should be uni- will affect the future delivery of “You have the track record and versal, continuous, affordable, surgical services. the will to make it work.” and sustainable, Dr. Sofaer said. The health care delivery sys- Although Dr. Korn said that It also should enhance the well- tem is ready for a transforma- surgeons should take the lead in being of all Americans by pro- tional change, according to quality improvement, he noted moting access to effective, effi- Stephen Jencks, MD, MPH, di- that implementing a quality- cient, safe, timely, patient-cen- rector, Quality Improvement based health care delivery sys- tered, and equitable care. Group, Office of Clinical Stan- tem will require collaboration Using these criteria, the IOM dards and Quality, Centers for between all stakeholders. “We’re committee developed four proto- Medicare & Medicaid Services not the solution. You’re not the types of a reformed health care (CMS), Washington, DC. Specific problem,” he said. delivery system. One would ex- transformations that need to oc- Helen Darling, president of the pand existing public programs cur, according to Dr. Jencks, in- National Business Group on (Medicare, Medicaid, and the clude: (1) changing the way Health, Washington, DC, echoed State Children’s Health Insur- people think about performance; a similar sentiment, saying, “We ance Program) and provide a tax (2) supporting and creating part- all have to work together to cre- credit for moderate-income indi- nerships; (3) promoting team- ate a system that is safe and ef- viduals. The second model would work; (4) defeating secrecy; (5) ficient.” require employers to offer cov- improving information systems; Ms. Darling also said that the erage and to contribute to their (6) helping health professionals business community believes workers’ premiums; employers to recognize that guidelines and that the most serious problems of low-wage workers would be protocols “are not mindless ex- in the nation’s health care sys- eligible for premium subsidies. A ercises”; and (7) basing payment tem are rising costs and uneven third proposal would mandate on performance. Surgeons need continued on page 40 37

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The young surgeon advocate experience

by Laurel Soot, MD, FACS, and Scott Soot, MD, FACS, Portland, OR

Several months ago, we were in- our education now that we are at- and how they affect our ability to vited to serve as Young Surgeon Rep- tempting to take on various leader- practice medicine. resentatives for the Oregon Chap- ship roles and to institute policy and All of the ACS Fellows who par- ter at the College’s 2004 Chapter practice changes in our respective ticipated in the Capitol Hill visits Officers and Young Surgeons Lead- hospitals. had the opportunity to discuss medi- ership Conference in Washington, During the conference, we learned cal liability reform, Medicare reim- DC. As recently initiated Fellows of that competent leadership requires bursement, and trauma funding the College, we were pleasantly sur- a willingness to embrace change. with their respective senators, rep- prised that the organization was in- Although this point may seem obvi- resentatives, and/or their health leg- terested in including young sur- ous, the frenetic pace of surgical islative assistants. We met with the geons in this forum. practice makes it easy to forget that aides to our legislators and found We did not know what to expect if surgeons and other members of these individuals to be very knowl- at the meeting but thought the the medical community don’t make edgeable and genuinely interested in agenda looked interesting. Nowhere the decisions about practice and pa- our agenda, despite some differences on it were sessions regarding the tient care, someone else will make of opinion about how to solve the utility of a new device, drug, or pro- them for us. As surgeons we often problems. For example, Capitol Hill cedure. Instead it addressed change, feel that we lack the time and en- staff cited a variety of reasons for the foundation of medicine, and how ergy to address these issues. Some- their legislators’ unwillingness to we can effectively play a role in the thing else always appears to be more support liability reform. Imperfec- evolution of surgical practice in this important, or at least more urgent. tions in the current bill were the country. Unfortunately, because we have not most common reason, along with a invested a serious group effort in the moral dilemma about setting caps on The leadership challenge political arena, the government and noneconomic damage awards. We Importantly for us, the program other parties often make these came upon similar explanations for for Young Surgeon Representatives choices for us, and their decisions opposition to the current attempts outlined the role of an effective are not necessarily the ones we at Medicare reform. leader at the local, regional, and na- would make ourselves. Although we cannot say whether tional levels. The talks entitled our discussions will have any bear- “Dealing with Change—Leadership Capitol Hill visits ing on the way our members of Con- Skills to Overcome Obstacles” and Capitol Hill runs a lot like a large gress vote in the future, we are cer- “New Arenas for Achieving Change” hospital. People come and go, per- tain that we would not have had any certainly dealt with issues that we forming a myriad of jobs and pro- influence with regard to change encounter almost daily as surgeons moting many different, and some- without these conversations. The in Oregon, where the socioeconomic times opposing, agendas. When we immediate resistance that we en- climate continues to become more visited Capitol Hill, people were lob- countered may be discouraging, but hostile toward medicine. bying on behalf of just about every surgeons must bear in mind that we As we have noted in conversations special interest imaginable. are one of many voices trying to with some of our peers, although Traditionally, surgeons have had bend an ear in this very charged and our surgical residencies trained us a rather muted voice in the offices competitive environment. well in the workup of esophageal of our respective legislators, but we Furthermore, politics is a differ- disorders and in how to compe- can play an important political role. ent game than the one we play in tently perform a Whipple, none of We need to express our concerns the operating room, so we are out our training programs had provided because very few nonphysicians will of our element. Washington oper- us with formal background in lead- pick up the torch for our cause. No ates under a set of rules governing ership skills. We have become pain- one is better able to educate politi- the advancement of any agenda. fully aware of this omission from cians and society about these issues Politicians think about not only

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VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS what is the best for society, but about what will ensure their reelec- tion as well. We may not understand it, but most elected officials and their staffs like being part of the government and want to enjoy an- other term. If that means casting a vote in opposition to their personal beliefs, they sometimes are willing to pay the price. Our job as advocates is to show them just how important those votes regarding health care are to us and, ultimately, to society. We must par- ticipate in the political promotion of medicine. It is important that we succeed, but it is even more vital that we try. Participation and “grassroots movements” are the foundation of our government. Arm- chair quarterbacks sitting in the Drs. Laurel and Scott physicians’ lounge pining for the Soot at the 2003 “good old days” will accomplish Convocation. nothing meaningful.

Only the beginning Since returning from the meet- ing in Washington, we have sent follow-up letters and plan to visit our Oregon representatives when educate Congress on these impor- sistence, patience, and a positive they are in the local area. All sena- tant issues, and their access to con- attitude are all that is necessary. tors and representatives have of- gressional leadership has improved As ACS Executive Director Tho- fices in their home states, and sur- as a result of the contributions from mas R. Russell, MD, FACS, so suc- geons should arrange visits with ACSPA-SurgeonsPAC. cinctly said, “You cannot practice sur- their elected officials when they are gery effectively while looking through in town. Conclusion the rear view mirror.” Change is in- Surgeons also should contribute Surgeons are all leaders by the evitable. As Fellows of the American to the American College of Sur- very nature of the profession they College of Surgeons, we must stand geons Professional Association’s po- have chosen. We frequently man- up and voice our perspectives to pro- litical action committee (ACSPA- age life-threatening emergencies, tect our patients and what we have SurgeonsPAC), which contributes to and consulting physicians often worked so hard to obtain. the campaigns of candidates who look to us for guidance. Politics is support our views. The PAC is an a different arena than the hospi- Drs. Laurel and Scott Soot are easy and effective way to ensure that tal, but it is one where we can use both clinical professors of surgery at surgery’s voice is heard. The College these same skills to become very the Oregon Health and Science Uni- has a cadre of lobbyists who work to effective community leaders. Per- versity, Portland.

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AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS quality. To help overcome these problems, the business sector has developed a strategy based on the Nominations sought following guiding principles: (1) cost sharing is important but is During the 2003 Leadership only one part of the strategy; (2) Conference, the College estab- greater efficiency is needed; (3) lished the Arthur Ellenberger consumers should have options; Award for Excellence in State and (4) the public needs informa- Advocacy. During this year’s tion that will allow them to make conference, ACS State Affairs better decisions and experience staff submitted the process for improved outcomes. nominating candidates for the award. Presidential election Over the summer, nomina- Stuart Rothenberg, a Wash- tion forms will be mailed to Chapter Presidents, Gover- ington, DC, political analyst, nors, and Administrators. A spoke about the factors affecting committee that will evaluate the upcoming Presidential elec- the nominations will be com- tion. Mr. Rothenberg said that posed of the Chair of the Board the national mood is the primary of Governors, the College’s Ex- driver of people’s voting deci- ecutive Director, and the Direc- sions, and “the current mood is tor of the Division of Advocacy bad and getting worse.” Exem- and Health Policy. plifying people’s dissatisfaction Recipients of the award will with the current state of affairs be announced periodically dur- ing future Chapter Leadership Mr. Ellenberger (left) and Dr. are polls showing that most Conferences. Russell. Americans believe the country is on the wrong track. When people believe that the nation is being misdirected, they tend to vote against the incumbent. Even so, the polls show that the upcoming presidential election is 2003 and is busy carrying out a year, it is unlikely that major re- almost a dead heat. Mr. number of activities this year, form of federal programs will Rothenberg said that voters according to Cynthia A. Brown, occur. Hence, the College is haven’t turned away from Presi- Director of the Division of Advo- maintaining momentum and dent Bush because Sen. John cacy and Health Policy. preparing to make a major push Kerry (D-MA) has failed to warm In 2003, the College won a two- in 2005 for the following types to the public and to take advan- year reprieve from negative of legislation: liability reform; a tage of the president’s slide in the Medicare adjustments, actually requirement that CMS fix the polls. Of course, it’s too soon to securing a 1.5 percent increase problems inherent to the Medi- predict how the election will turn in payments, Ms. Brown said. care payment system, which are out. “A day from now, we could The ACS also helped to achieve expected to result in -5 percent have an event that will change ev- passage of medical liability re- decreases 2006 to 2012; funding erything,” Mr. Rothenberg said. form legislation in the House for trauma systems; patient and led a movement for contin- safety; graduate medical educa- Advocacy update ued trauma systems funding, tion loan repayments; and scope The College made some signifi- Ms. Brown said. of practice. cant inroads toward achieving Because the November elec- In terms of regulatory activity, 40 surgeons’ health policy agenda in tions dominate Capitol Hill this the College is focusing on public

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS and private sector payment poli- on important issues, they need their meetings was funding for cies and the five-year review of to follow up on their Capitol Hill trauma care systems. In this in- the Medicare fee schedule, which visits by meeting with their sena- stance, too, a letter is circulat- will take place next year, Ms. tors or representatives when ing in the House and Senate. The Brown said. The College also is they are in town. “Nothing letter expresses the signers’ sup- working on a number of issues works as well as seeing them port for increased funding of the that play out at the state level, when they’re at home,” she said. Trauma Care Systems Planning including office-based surgery, Successful advocacy is “about and Development Act. liability, and expert witness tes- what you can do to wake up the timony. grassroots.” Rubbing elbows “The most important thing In between briefing sessions, for the Fellowship is to stay in- Preparing for visits participants participated in a formed,” Ms. Brown said. “Do To help prepare for Capitol reception on Capitol Hill, express your views to members Hill visits, Christian Shalgian, which was attended by several of Congress, but do express ACS Manager of Congressional members of Congress, includ- your views to us as well.” Affairs, led two briefings on is- ing Reps. Sherwood Boehlert Means at the Fellows’ disposal sues for the Chapter leaders to (R-NY), Michael Burgess (R- for boosting their awareness discuss when meeting with leg- TX), Howard Coble (R-NC), and effectiveness include ac- islators and/or their health policy and Joe Wilson (R-SC). cessing the Web-based Legisla- staff and on what to expect dur- Another member of Con- tive Action Center and contrib- ing the visits. gress, Rep. John Thune (R- uting to the ACSPA-Surgeons- One issue that he encouraged SD), made a special guest ap- PAC, she added. meeting participants to address pearance during the briefings is medical liability reform. Mr. that took place immediately Be heard Shalgian noted that approxi- before meeting participants Ilona Nickels, congressional mately 19 states are experienc- conducted their Capitol Hill scholar for the Center on Con- ing a malpractice insurance cri- visits. Representative Thune gress at Indiana University, sis, and another 25 are approach- said he is running for the Sen- Washington, DC, provided the ing one. He noted that the House ate this year because he be- meeting participants with a con- passed bills in 2003 and this year lieves that branch of Congress text for understanding Capitol that would enact federal reforms “has become, for all intents Hill. “There isn’t a single issue similar to those in California’s and purposes, a dysfunctional you can name that isn’t going to Medical Injury Compensation place,” which needs to be revi- arrive at Congress without some Reform Act. However, the Sen- talized with some new mem- controversy or conflict,” Ms. ate has repeatedly blocked com- bership. Nickels said. panion bills. In the sidebar on pages 38- To resolve those conflicts, leg- Additionally, Mr. Shalgian sug- 39, two Young Surgeon Repre- islators often look to their con- gested that the meeting partici- sentatives describe their expe- stituents. “Legislators don’t pants ask their legislators to sign rience on Capitol Hill. The view issues strictly through an letters circulating on Capitol Hill Capitol Hill visits concluded intellectual lens. They respond requesting that the CMS make this year’s meeting. from a local, provincial point of adjustments in the Medicare fee view,” Ms. Nickels said. “Mem- schedule. These “fixes” would bers can and do vote contradic- help to avert further pay cuts tory to their own intellectual and ensure that physicians con- knowledge if it opposes their con- tinue to participate in the Medi- stituents’ demands,” she added. care program. Hence, Ms. Nickels said that The third topic that Mr. if surgeons want their federal Shalgian called upon the chap- legislators to hear their position ter leaders to discuss during 41

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 42

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Britt receives distinguished educator award

ACS Regent L.D. Britt, MD, MPH, FACS, was awarded the Distinguished Educator Award by the Association for Surgical Education at its annual meeting, on April 2, 2004, in Houston, TX. This award is the most presti- gious honor presented by the association to a surgical educa- tor for a lifetime record of out- standing achievement in surgical education. It may be presented to an individual only once. During the presentation cer- emony, Dr. Britt was recognized for his many significant contri- butions to surgical education throughout his distinguished Dr. Britt (right) receives the Distinguished Educator Award from Myriam J. academic career. Dr. Britt’s piv- Curet, MD, FACS, chair of the Association for Surgical Education’s Excellence otal leadership role in taking in Teaching Awards Committee. educational activities of many prestigious national organiza- tions to new heights and his nu- his stellar mentorship of many Award, and the Dean’s Out- merous contributions to surgical surgeons, surgical residents, and standing Faculty Award. education were cited. Dr. Britt’s medical students throughout his Upon receiving the honor, Dr. contributions to the educational illustrious career, were high- Britt recognized the previous endeavors of the American Col- lighted. recipients of this prestigious lege of Surgeons, National Board Dr. Britt has previously re- award and dedicated his award of Medical Examiners, Associa- ceived other prestigious educa- to his late mother, who served tion of Program Directors in Sur- tion awards, including the highly with distinction as a high school gery, Residency Review Commit- coveted Alpha Omega Alpha teacher for many years. For fur- tee for Surgery, and the Associa- Robert J. Glaser Distinguished ther information about this tion for Surgical Education were Teaching Award of the Associa- award, please contact Ajit K. especially mentioned. Dr. Britt’s tion of American Medical Col- Sachdeva, MD, FACS, FRCSC, at leadership and vision, as well as leges, the Sir William Osler [email protected]

A RURAL SURGEON’S PERSPECTIVE, from page 25 vide quality patient care and that promotes the level of care as city dwellers and that rural sur- rewards of practicing surgery in all geographic lo- geons receive payment that matches that of their cations. We have a chance to work with urban counterparts. These are exciting times, and policymakers to develop a system that ensures that I anticipate that they will yield positive changes ⍀ patients in rural areas have access to the same for all surgeons and their patients. 43

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Report of the 2004 Australia and New Zealand Travelling Fellow

by Joseph J. Cullen, MD, FACS, Iowa City, IA

As the 2004 Australia and New Zealand Travelling Fellow, my family and I had the unique opportunity to both explore Aus- tralia and to meet some out- standing members of our profes- sion. After flying into Sydney, and taking a few days to recover from the jet lag, we flew to Cairns and stayed in Port Dou- glas, allowing us to visit the rain forest, the Great Barrier Reef, and the Aboriginal Cultural Center, where we learned how to throw a boomerang.

Sydney We then flew back to Sydney, and I met with Prof. Stephen Deane, President of the Austra- lia New Zealand Chapter of the American College of Surgeons, and gave surgical grand rounds and medical grand rounds at the Liverpool Health Service Unit of the Southwestern Sydney Area Health Service. My topic was Preventing Postoperative Infec- tions Due to Staphylococcus Aureus.1 Sydney was outstanding. We toured the opera house and went to a performance later that evening. We also visited the Blue Mountains to the west of Sydney, the AMP Tower, the National Maritime Museum, the Sydney Aquarium, Manly Beach, and Taronga Zoo. My wife Laura and oldest daughter Jessica did the famous “bridge Dr. Cullen and his family in front of the Twelve Apostles. 44 climb” up the Sydney Harbor

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Bridge, which stands 439 meters stopped at Tower Hill to view during halftime. It was quite a above sea level and took 1,439 the wildlife. It was difficult to thrill for an Iowa kid to play in steps to ascend. convince our youngest daughter front of 50,000 in the Telstra Meredith that we could not Dome. Adelaide bring home a koala due to the Our next stop was Adelaide, lack of eucalyptus trees in Iowa. Conclusion where I made surgical rounds We made a short excursion to Australia is an outstanding with Adrian Anthony, consult- Tasmania, where I presented to place for Americans to visit be- ant in surgery, and the regis- Bob Linacre and staff at the cause of the unusual wildlife (of trars and medical students at Royal Hobart Hospital in which many species are capable the Queen Elizabeth Hospital. Hobart. While in “Tazzy,” we of killing you), the beautiful cit- Later that morning I was able visited the Cadbury chocolate ies and scenery, and the great to listen to numerous presen- factory and Port Arthur penal climate. However, it was the tations by surgical investiga- colony. We then made the short people we met who made our tors and surgical fellows, who flight to Melbourne for the last visit truly memorable. They demonstrated the wide scope of stop on the trip. were gracious, helpful, and both basic science and clinical friendly, ranging from professors research projects being con- Melbourne of surgery to volunteers in infor- ducted within the department. While in Melbourne for the mation centers in the smallest I presented recent work from Royal Australasian College of of towns. They made us feel at our laboratory on the role of Surgeons (RACS) meeting, I co- home and were excited to show antioxidant enzymes in pancre- chaired the rural surgery section us the best Australia has to of- atic cancer growth2-4 at the de- with Rodney Judson and was an fer. We are truly grateful for this partment of surgery research invited discussant for the sym- experience. meeting at Royal Adelaide Hos- posium, “The Abdominal Catas- pital. trophe,” chaired by Graeme References Later that evening, our fam- Campbell of Bendigo. The next ily had dinner with Profs. Peter day I gave the American College 1. Perl TM, Cullen JJ, Wenzel RP, Devitt and Glyn Jamieson and of Surgeons’ lecture, Preventing et al: Intranasal mupirocin to prevent postoperative Staphy- the latter’s wife. On the week- Postoperative Infections Due to lococcus aureus infections. N end, Prof. Guy Maddern and his Staphylococcus Aureus. My final Eng J Med, 346:1871-1877, family gave us a tour of the hills two presentations included Di- 2002. surrounding Adelaide. That ex- agnosis and Management of Bil- 2. Cullen JJ, Weydert C, perience was delightful. We also iary Dyskinesia for the rural Hinkhouse MM, et al: The role of manganese superoxide had a typical Australian barbe- surgery section and The Pendu- dismutase in the growth of cue with a visiting surgical re- lum of the Nasogastric Tube for pancreatic adenocarcinoma. search fellow from Belfast, Ire- the surgical history section. Can Research, 63:1297-1303, land, Gary Spence, and his wife The RACS meeting was spe- 2003. 3. Wydert C, Roling B, Liu J, et Susan. I repeated my talk on the cial because I had met so many al: Suppression of the malig- role of antioxidant enzymes in surgeons during our travels and nant phenotype in human pancreatic cancer growth at the was able to meet and talk with pancreatic cancer cells by the Queen Elizabeth Hospital before them again at the meeting. Per- overexpression of manganese observing Profs. Jamieson and haps the highlight of this leg of superoxide dismutase. Molec Can Therapeut, 2:361-369, Devitt perform an esopha- the trip was when Tracy 2003. gectomy in less than three Bucknall and Andrew O’Kane, 4. Liu J, Hinkhouse MM, Sun W, hours. Impressive. friends of ours in Melbourne, et al: Redox regulation of pan- We then left for Kangaroo Is- took us to an Australian rules creatic cancer cell growth: Role of glutathione peroxidase in the land, the Great Ocean Road, and football game and arranged for suppression of the malignant the Twelve Apostles (see photo, my son Brendon to play for the phenotype. Hum Gene Ther, page 44). During this drive, we Melbourne Kangaroos juniors 15:239-250, 2004. 45

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS How Good Is Your Cancer Program?

Display This And Everyone Will Know. Does your facility offer Take The Next Step • Get recognition from other national health care organiza- high-quality, multidisciplinary, tions, including the JCAHO, as having established performance measures for high-quality cancer care. and comprehensive cancer care? • Receive a model for organizing and managing your can- cer program to ensure multidisciplinary, integrated, and comprehensive oncology services. Find out. Take The Next Step. • Participate in a network of quality cancer programs that provide care to 80 percent of newly diagnosed cancer patients. Participate in the Approvals Program • Get FREE marketing by partnering with the CoC and Ameri- can Cancer Society (ACS) in the Facility Information Profile sponsored by the Commission on Cancer (CoC) System (FIPS)—an information sharing effort of resources and services and cancer experience for the ACS National Call of the American College of Surgeons and receive Center and Web site. • Participate in the National Cancer Data Base (NCDB)— notable benefits that will enhance your cancer a nationwide oncology outcomes database for 1,500 hospitals in 50 states—and get benchmark reports containing national program and the quality of your patient care. aggregate data and individual facility data to assess patterns of care and outcomes relative to national norms. Programs already participating in the Approvals Program have made the investment to benefit their patients, com- munity, institution, and health care providers. If your facil- For more information, call 312/202-5085 ity is committed to providing high-quality cancer care, then Take The Next Step and become one of the more than 1,500 or visit our Web site at: CoC-approved programs in the United States and Puerto Rico 46 that can display the CoC stamp of Approval. http://www.facs.org/cancer/index.html. VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS/STS 2003 Health Policy Scholar reports on activities by James S. Allan, MD, FACS, Boston, MA

It was an honor and a privi- My first day at the Kennedy lege to have been named the first School began with an exercise Health Policy Scholar of the designed to help us understand American College of Surgeons the various components of the and the Society of Thoracic Sur- federal budget. I remember geons (STS). I am also grateful meeting in groups with the as- to both societies for the oppor- signed task of freeing up a given tunity to serve on their respec- amount of money to improve ac- tive health policy committees. cess to health care by cutting Prior to accepting this schol- other discretionary budget out- arship, I had no formal experi- lays. This exercise not only fa- ence in the areas of health policy Dr. Allan miliarized us with the federal and public administration. budget itself, but also acquainted Nonetheless, like most surgeons, us with the type of horse-trad- I was (and remain) quite con- ing that is inherent in the allo- cerned about the overall direc- ful for the opportunity that it has cation of limited public funds. tion of America’s health care sys- provided. The next major focus of the tem, both from the perspective The American College of Sur- course centered on the structure of a practicing professional and geons/Society of Thoracic Sur- and economics of the American from that of a potential patient. geons Health Policy Scholarship health care system. Our class As we all know, a considerable is composed of two complemen- delved deeply into the adminis- portion of the health care dollar tary elements. First, the recipi- tration and financing of our is currently spent on administra- ent spends nine days in residence nation’s major health care en- tive expenses, defensive medical at Harvard University’s titlement programs, and com- practices, and the costs associ- Kennedy School of Government, pared our system of health care ated with spurious litigation. At taking an intensive executive administration to that of other a time when adequate access to course in health care policy en- nations. Also, we learned various health care is limited for many titled Skills for the New World concepts in health care insur- people in our country, it is dis- of Health Care. ance, such as moral hazard and tressing that the financial re- This program is a joint offer- adverse selection, and worked to sources devoted to our medical ing between Harvard Medical develop an understanding of how system are not being used in a School, the Harvard School of these drivers guided resource more productive way. Public Health, the John F. allocation under various insur- It was with this general sense Kennedy School of Government, ance schemes. Central to this of concern that I sought to learn and the Harvard Division of discussion was the notion that more about the formulation of Health Policy Research and Edu- “insurance” is a bit of a misno- health care policy and the means cation. The second component of mer for what is provided by our by which surgeons can take a the scholarship consists of an patchwork of third-party payors. leadership role in this process. I opportunity to serve for one year Traditionally, insurance pro- was, therefore, delighted when I as an ex officio member of the vides relief to someone who suf- learned that I had won this health policy committees of both fers the rare catastrophic event. scholarship and am again grate- societies. It represents the pooling of re- 47

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS sources in small amounts by the ment of present circumstances. The second component of the many to protect the unlucky few. Perhaps this is why Plato American College of Surgeons/ In contrast, it can reasonably be thought that a benevolent dicta- Society of Thoracic Surgeons expected that we will all some- torship would be the best form Health Policy Scholarship was day endure illness to a predict- of government. Unfortunately, as the opportunity to serve for one able catastrophic end. Thus, our Lord Acton observed, benevolent year on the health policy com- system of health insurance is dictators are hard to come by. mittees of both societies. The really a cumbersome mechanism The final several days of our American College of Surgeons to force savings and to transfer intensive program discussed a Health Policy Steering Commit- wealth from one person to an- number of current proposals to tee is ably led by Josef E. Fischer, other, and from the future to the optimize the health care system MD, FACS; and the Society of present. with a focus on issues such as Thoracic Surgeons Workforce on Our discussions then turned to evidence-based practice, profes- Health Policy, Advocacy, and Re- some of the newer trends in sional liability reform, preven- form is in the capable hands of health care reimbursement with tive care, and the limitation of Kevin D. Accola, MD, FACS. attention to the much ballyhooed end-of-life care, which is often Both of these physicians went pay-for-performance concept. futile and expensive. Finally, our out of their way to integrate me This reimbursement strategy is nine-day program was peppered into the functions of the commit- designed to encourage the prac- with a variety of colloquia de- tees, providing an outstanding tice of evidence-based medicine signed to develop leadership practical experience in health by rewarding certain practice skills in the areas of conflict reso- policy formulation and advocacy. patterns while penalizing others. lution and change management. Over this past year, both com- Unfortunately, like many previ- All in all, the program at the mittees have tackled a number ous attempts at controlling Kennedy School provided a com- of difficult issues in health care health care expenditures, this re- prehensive introduction to the policy. The American College of imbursement model primarily arena of health care policy, Surgeons Health Policy Steering redistributes the current health taught by a superb and diverse Committee formulated a posi- care dollar, without truly ad- faculty, all with considerable pro- tion statement on the structure dressing the major drivers of fessional experience and exper- of America’s future health care wasteful expenditure in the de- tise. system, which preserves patient livery of health care. On a personal note, my brief choice while simultaneously ad- The next phase of our inten- stay at the Kennedy School was dressing the restrictions on ac- sive program involved an exami- the first time that I had re- cess to care that many of our nation of how our government turned to Cambridge in any of- country’s citizens face. This po- and political system functions. ficial capacity since graduating sition statement advocates li- This phase consisted of a very college in the mid-1980s. I found ability reform and evidence- practical series of symposia de- the experience of going back to based practice as mechanisms to signed to help us understand the classroom on a full-time ba- fund increased access to care for strategies and mechanisms for sis to be intellectually stimulat- those individuals who are cur- influencing both public opinion ing, and I eagerly looked forward rently underserved by our and political action. I vividly re- to each successive day—a feel- health care system. member a colloquium with a lo- ing that stood in sharp contrast The Society of Thoracic Sur- cal politician who was quite to a number of memorable col- geons Workforce on Health frank about the fact that politi- lege mornings when I had to Policy, Advocacy and Reform cians are principally beholden to drag myself out of bed to attend also weighed in heavily on the the short-term interests of their my premedical classes. I guess toll that escalating liability pre- constituency. As such, there is it is one of the ironies of youth miums are having on the prac- little political reward for long- that one cannot wait to finish tice of surgery. This situation is term planning, particularly school in order to enter the particularly troublesome when 48 when its costs are to the detri- workforce. one realizes that the majority of

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS malpractice awards do not pro- forms to limit medical errors and tients. As of late, we have become vide redress for patients who enhance patient safety. victims of our own apathy, while have been aggrieved and that Over the past year, the Ameri- those not directly charged with most patients with legitimate can College of Surgeons/Society patient care have taken advan- claims never receive fair com- of Thoracic Surgeons Health tage of our altruism and our po- pensation. Policy Scholarship has given me litical naiveté. It is imperative Both societies also lobbied a broad and substantive acquain- that each of us works with our strongly to prevent catastrophic tance with the many facets of professional societies in their reductions in health care reim- health policy. Most importantly, advocacy efforts on behalf of our bursement and to encourage it has made me aware of the im- profession and our patients. Congress to revise in a durable portance of becoming active in fashion the manner in which the public sector, so that we can Dr. Allan is assistant professor of health care reimbursements are regain control of our own profes- surgery, Harvard Medical School, calculated. Finally, both societ- sion and appropriately shepherd division of thoracic surgery, Massa- ies have come out strongly in limited health care resources for chusetts General Hospital, Boston, support of systems-based re- the optimal benefit of our pa- MA.

Dr. Schultz to head FDA’s Center for Devices and Radiological Health

Daniel G. Schultz, MD, FACS, medical device marketing appli- versity of New Mexico, and com- Gaithersburg, MD, has been se- cations and sets performance pleted his general surgery resi- lected to lead the division of the goals for those reviews. dency at the Public Health Ser- Food and Drug Administration Dr. Schultz started his career vice Hospital in San Francisco, (FDA) that is responsible for the with the FDA in 1994 and has CA. In October 1981, he moved review of all medical devices and served as an officer in the Gen- to Denver to finish his general radiation-emitting products, eral Surgery Branch, the Divi- surgery training and a fellowship such as magnetic resonance im- sion of Reproductive, Abdominal in pediatric surgery. He main- aging equipment and X-ray ma- and Radiological Devices, and as tains board certification in gen- chines. Dr. Schultz will also be Director of the Office of Device eral surgery and family practice. responsible for overseeing the Evaluation. He received his Additional information regard- continued implementation of the medical degree from the Univer- ing Dr. Schultz’s appointment is Medical Devices User Fee Act of sity of Pittsburgh (PA), finished available online at http://www. 2002, which authorizes the FDA a combined internship in pedi- fda.gov/bbs/topics/news/2004/ to collect user fees for review of atrics and medicine at the Uni- NEW01093.html.

ACS Scholars to present at the Surgical Forum

The International Relations China, respectively, will give years) of the Scholarships Committee is pleased to report presentations at the Surgical Committee, plus the ACS/RCS that one current and one Forum during the 2004 Clini- Research Exchange Fellow, former International Guest cal Congress in New Orleans, Wai-Yee Li of London, UK, will Scholar, Dan D. Hershko, MD, LA. also present at the Surgical of Haifa, Israel, and Mingqiang In addition, 22 U.S. and Ca- Forum in October of this year. Xie, MD, FACS, of Guangzhou, nadian awardees (various 49

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS

• DIVISION OF EDUCATION •

ONLINE CME: Courses from the American College of Sur- geons’ Clinical Congresses are available online for surgeons. The online courses feature printable written course transcripts, audio of sessions, video of the introduction of each session, post-test and evaluation, and printable CME certificates upon successful comple- tion. Several of the courses are offered FREE OF CHARGE. The courses are accessible at: www.acs-resource.org.

BASIC ULTRASOUND COURSE: The ACS and the National Ultrasound Faculty have developed this course on CD- ROM to provide the practicing surgeon and surgical resident with a basic core of education and training in ultrasound imaging as a foun- dation for specific clinical applications. It replaces the basic course offered by the ACS and is available for CME credit. The CD can be purchased online at http://www.facs.org/education/usoundCDROM. html or by calling ACS Customer Service at 312/202-5474.

BARIATRIC SURGERY PRIMER: Developed by Henry Buchwald, MD, PhD, FACS, and Sayeed Iramuddin, MD, FACS, the primer addresses the biochemistry and physiology of obesity; identifies appropriate candidates for bariatric surgery; and discusses the perioperative care of the bariatric patient, basic bariatric procedures, comorbidity and outcomes, surgical training, and the bariatric surgical and allied sciences team, along with facilities, aspects of managed care, liability issues, and ethics. The These fine CD-ROM is available by contacting ACS Customer Service at 312/ 202-5474.

educational SYLLABI SELECT: The content of select ACS Clinical Congress postgraduate courses is available on CD-ROM. These CD- products ROMs are able to run in the PC and Mac environments and offer you the ability to word-search throughout the CD, along with the convenience of accessing any of the courses when you want, and are available for your where you want. The CDs can be purchased by calling 312/202- 5474 or through the College’s Web site at https://secure.facs.org/com- learning convenience merce/2003/current.html. The 2004 CD will be available in October.

Please visit our E-LEARNING CENTER at www.acs-resource.org 50 to view new products available from the ACS Division of Education.

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS For more information contact Dawn Pagels at [email protected], or tel. 312/202-5185. Fellows in the news

• The American Medical physicians, and other readers • Cerebrovascular surgeon Association’s Board of Trustees with some science education but Robert H. Rosenwasser, elected John H. Armstrong, no previous exposure to medical MD, FACS, has been named MD, FACS, to serve as the history. The text, which is listed chair of the department of neu- board’s secretary, making him on amazon.com, features a 40- rosurgery at Jefferson Medical the first young physician trustee page index, detailed biblio- College, Thomas Jefferson elected to serve on the body’s graphy,and over 550 footnotes— University, Philadelphia, PA. executive committee. Dr. Arm- most of them references to origi- He succeeds William Buch- strong is an assistant professor nal articles. heit, MD, FACS, who is retir- of surgery at the Uniformed Ser- • Eugene Myers, MD, ing. At press time, Dr. Rosen- vices University of the Health FACS, professor and chair of the wasser continued to serve as Sciences, Bethesda, MD. eye and ear foundation of the de- professor of neurosurgery and • Edmond B. Cabbabe, partment of otolaryngology at director of the division of cere- MD, FACS, a plastic surgeon in the University of Pittsburgh brovascular neurosurgery and St. Louis, MO, was installed as (PA) School of Medicine, recently neuroradiology at Jefferson the 2004-2005 president of the participated in a number of in- Medical College and Thomas Missouri State Medical Society ternational meetings. More spe- Jefferson University Hospital. during the organization’s 146th cifically, he was a guest lecturer Dr. Rosenwasser is an expert in annual meeting in April. Dr. at: the Asia-Oceania Otolaryn- preventing and treating life- Cabbabe is chief of plastic sur- gology-Head and Neck Surgery threatening brain aneurysms. gery at St. Anthony’s Medical Congress in Kuala Lumpur, Ma- • Carl Snyderman, MD, Center in St. Louis and DePaul laysia, the III Curso Inter- FACS, William Welch, MD, Health Center in Bridgeton and nacional Teorico-Pratico de FACS, and Amin Kassam, MD, is a clinical professor of surgery Cirurgia da Laringe, in Rio de recently performed the first en- in the division of plastic surgery Janeiro, Brazil; and the annual doscopic resection of the odon- at Saint Louis University School meeting of the Hungarian Soci- toid process of C1 in a patient of Medicine. ety of Otolaryngology in Sopron, with brain stem compression • Capt. Dana C. Covey, Hungary. secondary to rheumatoid ar- MD, FACS, recently received • Frederick W. Reckling, thritis of the odontoid process. the Sir Henry Wellcome Medal MD, FACS, along with Janolyn Drs. Snyderman and Kassam Prize, which is awarded to the G. Lo Vecchio and JoAnn B. are co-directors of the center author of an essay that reports Reckling, are co-authors of a new for cranial base surgery at the on original research work in the biography about the late University of Pittsburgh Medi- field of military medicine. At Leonard F. Peltier, MD, PhD, cal Center and are considered press time, Captain Covey was FACS (1920-2003). Onward and pioneers of minimally invasive serving at a U.S. Marine Corps Upward: The Career Trajectory procedures for tumors of the surgical hospital in Fallujah, and Memories of Leonard F. brain base. Dr. Snyderman is Iraq. Peltier, MD, PhD, is published by associate professor of otolaryn- • Asklepiad Press announces the Clendening History of Medi- gology at the University of the new text, A Brief History of cine Library and Museum at the Pittsburgh School of Medicine, Disease, Science, and Medicine, University of Kansas Medical PA, and Drs. Kassam and by Michael T. Kennedy, MD, Center, Kansas City. Dr. Reckling Welch are both in the FACS. Dr. Kennedy has turned is professor emeritus, depart- institution’s department of a series of lectures into a brief ment of orthopaedic surgery, neurosurgery. history of medicine for medical University of Kansas School of and nursing students, young Medicine. 51

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 52

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NTDBTM data points “Water and alcohol don’t mix” by Richard J. Fantus, MD, FACS, Chicago, IL, and John Fildes, MD, FACS, Las Vegas, NV

Summer is in full swing, and in the Midwest that means that Watercraft injured patients tested for alcohol the best months for boating are here. Operating a boat on a lake or inland waterway is often a peaceful and relaxing venture. Unfortunately, recreational boating is not immune to human indiscretions. In order to take a boat out on the lake, all you need is the vehicle. There are no for- mal licensing processes, no test- ing requirements, no “rules of the road,” or any traffic signs. There is just a lot of water, sun- shine, and plenty of cool bever- the lines over the dock cleats freak accidents, boating-related ages to be consumed. to secure the boat. Now imag- fatalities now rank second only Let’s take a closer look at the ine this exercise after having to car crashes as the cause of kinematics of watercraft inju- consumed several alcoholic bev- transportation-related deaths in ries. For those persons who have erages. It is easy to see where the U.S. More people die in boat- not boated before, certain as- torso crush injuries can occur. ing accidents every year than in pects often require a fair amount Now let’s take the boat out of airplane crashes, train wrecks, of skill. Take the process of the marina and onto the lake. or bus accidents. docking a power boat. I liken High speeds, endless water, the As with “drinking and driving” that procedure to getting into lack of proper safety gear, and responsibly, we need to make a luxury automobile and pull- the consumption of alcohol can sure that we exhibit a high level ing up alongside a guard rail. be a formula for disaster. There of caution when consuming al- Slow the vehicle down to five are only a couple of thousand cohol and venturing onto the miles per hour, and then place water craft injury records con- three-fourths of the earth’s sur- the shifter into neutral. You tained in the National Trauma face that is covered by water. are now coasting in a 20,000 Data Bank’s Annual Report Throughout the year we will pound vessel without brakes 2003. But of those records tested, be highlighting these data while trying to rub up against almost one-third had consumed through brief monthly reports in the guard rail ever so slightly alcohol. The results are depicted the Bulletin. For a complete copy to slow down the boat’s mo- in the chart on this page. of the National Trauma Data mentum, while trying not to According to the U.S. Depart- Bank Annual Report 2000, visit mar the arctic white fiberglass ment of Homeland Security, U.S. us online at our new Web ad- finish. The first mate will at- Coast Guard Boating Statistics dress: http://www.ntdb.org. If tempt to get off of the slow Report, over one-third of all you are interested in submitting moving boat, assuming that is boating fatalities involved the your trauma center’s data, con- has been brought close enough consumption of alcohol. Consid- tact Melanie L. Neal, Manager, to the dock, in order to place ered by some individuals to be NTDB, at [email protected]. 53

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chapter news

by Rhonda Peebles, Chapter Services Manager, Division of Member Services

To report your chapter’s news or to share pho- tos of your chapter’s events, please contact Rhonda Peebles toll-free at 888/857-7545 or via e-mail at [email protected].

Maine meeting focuses on practice management

Members of the Maine Chapter met June 4-6 to examine various topics related to practice man- agement. The first day of the education program, which was planned by William R. Horner, MD, FACS, Immediate Past-President, focused on cod- Ohio Chapter: Michael S. Nussbaum, MD, FACS (left), ing and financial issues, and the following day in- presents the chapter’s Distinguished Service award to cluded an examination of models for data collec- Dr. Irons. tion to measure outcomes. Thomas R. Russell, MD, FACS, ACS Executive Director, updated the chap- ter on the College’s involvement with the National Surgical Quality Improvement Program. Ohio meeting centers on advocacy

The Ohio Chapter’s annual meeting, which took place May 4-5, followed a new format and focused on advocacy activities. After briefings on state leg- islation by ACS staff and the Ohio Chapter’s lob- byist, Dan Jones, chapter members headed to their state capitol in Columbus to meet with legislators and their staff. The first day of events concluded Brooklyn & Long Island Chapter, left to right: Michael with a reception that many state legislators at- O. Bernstein, MD, FACS, Vice-President; Robert F. tended. On the second day of the meeting, the Ohio D’Esposito, MD, FACS, President; Dr. Organ; and James Chapter awarded its Distinguished Service Award W. Turner, MD, FACS, Secretary-Treasurer. to D. Ross Irons, MD, FACS, who has served the chapter in many leadership capacities over the years (see photo, top right). Sessions during the annual meeting addressed taling more than $14,000 during its first year of several topics of importance to Ohio Fellows, in- operation. cluding: • Plans to conduct a study to examine the ex- • The results of a survey of Ohio Fellows show- tent to which surgical residents leave the state af- ing that some surgeons are partnering with hos- ter training. pitals to help address concerns related to profes- • Endorsement of a protocol to ensure correct sional liability insurance. site surgery, which was developed by the Ohio Pa- • An update on the chapter’s political action tient Safety Institute. 54 committee, which has received contributions to- • Election of the following new officers: Michael

VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS E. Stark, MD, FACS, President; Gary B. Williams, MD, FACS, President-Elect; and John A. Education activities Howington, MD, FACS, Secretary. strengthen surgery Brooklyn-Long Island conducts in the Dakotas young surgeons’ dinner by Mark O. Jensen, MD, FACS, Fargo, ND The Brooklyn-Long Island Chapter conducted its The education programs presented jointly by the 32nd Young Surgeons’ Dinner, which was held in North Dakota Chapter and South Dakota Chap- conjunction with the chapter’s 2004 annual meet- ter of the College have helped to strengthen sur- ing. Claude H. Organ, Jr., MD, FACS, ACS Presi- gery in both states by: dent, represented the College at the event (see • Analyzing what local surgeons are doing in photo, opposite page). their ORs. Despite grand rounds and morbidity and mortality conferences, the procedures being Chapter anniversaries performed locally and regionally may surprise some surgeons and will define their communities’ “standards of care.” Month Chapter Years • Providing a venue for community surgeons and academic surgeons to report on unique aspects July Southwest Missouri 52 of their practices. Surgeons in private practice of- New Jersey 53 ten lead the way in technology applications and Keystone (PA) 52 new procedures. West Virginia 54 • Mentoring residents and medical students. August Georgia 54 Since the North Dakota Chapter began to focus Hawaii 53 its activities on these two groups of young sur- Illinois 54 geons, the University of North Dakota has in- Brooklyn-Long Island, NY 54 creased its match rate in surgery and other surgi- Northwest Pennsylvania 54 cal specialties by 30 percent. Rhode Island 52

New York continues by several statewide medical and surgical profes- advocacy agenda sional societies representing ophthalmology, obstet- rics and gynecology, orthopaedic surgery, thoracic In May, the New York Chapter wrote to Gov. surgery, emergency medicine, and internal medi- George Pataki (R), urging him to apply for a 2005 cine, as well as the Medical Society of the State of grant from the hospital preparedness program to New York. For more information on the survey, or support the state’s trauma system and registry. to participate, contact the New York Chapter at Then in June, the chapter convened a group of pro- 518/433-0397. gram directors to hear presentations from the New York State Department of Health and Regulations, Dakota chapters unite and from the New York State Council on Graduate Medical Education. John D. Nicholson, MD, FACS, The North Dakota and the South Dakota Chap- the Immediate Past-President of the chapter, noted ters met April 30-May 2. These two chapters have that this new Program Directors Committee would been meeting jointly and sharing education pro- provide opportunities to frame problems related gram planning responsibilities since 1997. This to work-hour restrictions and to work on solutions year, Keith Lillemoe, MD, FACS, served as the vis- together. iting professor, and during the joint social event, Finally, the New York Chapter is conducting a Miles E. Tieszen, MD, FACS, delivered a stunning survey related to premiums for professional liabil- presentation on his experiences in Iraq. In addi- ity insurance. The survey is a joint effort sponsored tion, the South Dakota Chapter recognized several 55

AUGUST 2004 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Past-Presidents (all Fellows of the College): Samir the Illinois Chapter contributed $2,500 to the Abu-Ghazaleh, Terry Alstiel, Mary Milroy, Gary American College of Surgeons Professional Timmerman, Peter Andreone, Edward J. S. Picardi, Association’s SurgeonsPAC (political action com- Gregg Tobin, and Greg Schultz. mittee). Under the leadership of Lorin D. Whittaker, Jr., MD, FACS, Immediate Past-Presi- Illinois contributes to PAC dent, the Illinois Chapter is the first to make such a contribution. Additionally, the Illinois Subsequent to the 2004 Leadership Conference, Chapter became a Life Member of the Fellows which was held May 16-18, in Washington, DC, Leadership Society in 2003.

Next month in JACS The September issue of the Journal of the American College of Surgeons will feature:

Original Scientific Articles •New Transanal Excision for Rectal Tumors •Open vs. Closed Sphincterotomy for Anal Fissure •Fatalities Associated with Surgical Staplers

Collective Review •Accelerated Partial Breast Irradiation

What’s New in Surgery •General Surgery: Endocrine Surgery •Urology

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VOLUME 89, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS