JUNE 2001 Volume 86, Number 6

______FEATURES Stephen J. Regnier Patient safety initiatives following the IOM report 8 Editor Christian Shalgian Linn Meyer Director of Advanced surgical technology experience valuable to Communications the basic education of general surgery residents 11 Charles T. Klodell, MD, Robert C. G. Martin II, MD, Jeff W. Allen, MD, and Hiram C. Polk, Jr., MD, FACS Diane S. Schneidman Senior Editor

New technology and new approaches to surgical education 16 Tina Woelke Robert S. Rhodes, MD, FACS Senior Production Editor

Save the charts: For whom and for what? 18 Alden H. Harken, Robert Kerin, MD, FACS MD, FACS Charles D. Mabry, MD, FACS Jack W. McAninch, MD, FACS Editorial Advisors DEPARTMENTS Tina Woelke From my perspective Front cover design Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director 3 Bernie Kagel Back cover design FYI: STAT 5

Dateline: Washington 6 About the cover... Health Policy and Advocacy Department This month’s cover story and an accompanying article Keeping current shed light on possible mecha- nisms for training general sur- Using ACS Surgery: Online tips and tools 21 gery residents in the use of sur- Adrienne M. Stoller gical technology. “Advanced surgical technology experience valuable to the basic education Socioeconomic tips of the month 23 of general surgery residents,” Record retention (p. 11-15) focuses on how one program is ensuring that sur- gical residents will be prepared The Journal page 40 to perform operations requir- Seymour I. Schwartz, MD, FACS ing the use of new technology. Robert S. Rhodes, MD, FACS, responds to the concepts set forth in that article in his piece, “New technology and new ap- proaches to surgical educa- tion” (p. 16-17). (Cover photo by Hoby Finn.) NEWS Bulletin of the American College of Surgeons (ISSN Philip Sandblom, MD, PhD, FACS, dies 25 0002-8045) is published C. Rollins Hanlon, MD, FACS monthly by the American Col- lege of Surgeons, 633 N. Saint Fellows and facts 26 Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, to Associate Fellows, Biography of Richard J. Field, Jr., MD, FACS, published 27 to participants in the Candi- date Group of the American College of Surgeons, and to Letters 29 medical libraries. Periodicals postage paid at Chicago, IL, and additional mailing offices. College launches CME Joint Sponsorship Program 31 POSTMASTER: Send ad- dress changes to Bulletin of the Disciplinary actions taken 31 American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3211. Faculty career development award available 32 The American College of Surgeons’ headquarters is lo- cated at 633 N. Saint Clair St., Update your information online 33 Chicago, IL 60611-3211; tel. 312/202-5000, fax: 312/202- 5001; e-mail: postmaster@ Chapter news 34 facs.org; Web site: www.facs.org. Rhonda Peebles Washington, DC, office is lo- cated at 1640 Wisconsin Ave., NW, Washington, DC 20007; tel. 202/337-2701, fax 202/ 337-4271. Unless specifically stated otherwise, the opinions ex- pressed and statements made in this publication re- flect the authors’ personal observations and do not im- ply endorsement by nor offi- cial policy of the American College of Surgeons.

©2001 by the American Col- lege of Surgeons, all rights re- served. Contents may not be re- produced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. Officers and staff of the American College of Surgeons

Timothy C. Fabian, MD, FACS, Memphis, TN Officers G. Wilkins Hubbard II, MD, FACS, Norfolk, VA David S. Mulder, MD, FACS, Montreal, PQ Harvey W. Bender, Jr., MD, FACS, Nashville, TN President Lazar J. Greenfield, MD, FACS, Ann Arbor, MI Advisory Council to the Board of Regents First Vice-President (Past-Presidents) LaMar S. McGinnis, Jr., MD, FACS, Atlanta, GA Second Vice-President W. Gerald Austen, MD, FACS, Boston, MA Kathryn D. Anderson, MD, FACS, Los Angeles, CA Henry T. Bahnson, MD, FACS, Pittsburgh, PA Secretary Oliver H. Beahrs, MD, FACS, Rochester, MN John L. Cameron, MD, FACS, Baltimore, MD John M. Beal, MD, FACS, Valdosta, GA Treasurer George R. Dunlop, MD, FACS, Worcester, MA Thomas R. Russell, MD, FACS, Chicago, IL C. Rollins Hanlon, MD, FACS, Chicago,IL Executive Director James D. Hardy, MD, FACS, Madison, MS Gay L. Vincent, CPA, Chicago, IL M. J. Jurkiewicz, MD, FACS, Atlanta, GA Comptroller LaSalle D. Leffall, Jr., MD, FACS, Washington, DC William P. Longmire, Jr., MD, FACS, Los Angeles, CA Lloyd D. MacLean, MD, FACS, Montreal, PQ Officers-Elect (Take office October 2001) William H. Muller, Jr., MD, FACS, Charlottesville, VA David G. Murray, MD, FACS, Syracuse, NY R. Scott Jones, MD, FACS, Charlottesville, VA* Jonathan E. Rhoads, MD, FACS, Philadelphia, PA President David C. Sabiston, Jr., MD, FACS, Durham, NC Kathryn D. Anderson, MD, FACS, Los Angeles, CA Seymour I. Schwartz, MD, FACS, Rochester, NY First Vice-President George F. Sheldon, MD, FACS, Chapel Hill, NC Claude H. Organ, Jr., MD, FACS, Oakland, CA G. Tom Shires, MD, FACS, Las Vegas, NV Second Vice-President Frank C. Spencer, MD, FACS, New York, NY Ralph A. Straffon, MD, FACS, Shaker Heights, OH Board of Regents James C. Thompson, MD, FACS, Galveston, TX

C. James Carrico, MD, FACS, Dallas, TX Executive Staff Chair* Jonathan L. Meakins, MD, FACS, Montreal, PQ Executive Director: Vice-Chair* Thomas R. Russell, MD, FACS Harvey W. Bender, Jr., MD, FACS, Nashville, TN* American College of Surgeons Oncology Group: L. D. Britt, MD, FACS, Norfolk, VA Samuel A. Wells, Jr., MD, FACS, Group Chair William H. Coles, MD, FACS, New Orleans, LA Cancer Department: Paul E. Collicott, MD, FACS, Lincoln, NE* Monica Morrow, MD, FACS, Director Edward M. Copeland III, MD, FACS, Gainesville, FL* Communications Department: Richard J. Finley, MD, FACS, Vancouver, BC Linn Meyer, Director Josef E. Fischer, MD, FACS, Cincinnati, OH Executive Services Department: Alden H. Harken, MD, FACS, Denver, CO Barbara L. Dean, Director Gerald B. Healy, MD, FACS, Boston, MA* Fellowship and Graduate Education Departments: Edward R. Laws, Jr., MD, FACS, Charlottesville, VA Karen S. Guice, MD, MPP, FACS, Director Margaret F. Longo, MD, FACS, Hot Springs, AR Finance and Facilities Department: Jack W. McAninch, MD, FACS, San Francisco, CA Gay L. Vincent, CPA, Director Mary H. McGrath, MD, FACS, Maywood, IL Health Policy and Advocacy Department: David L. Nahrwold, MD, FACS, Chicago, IL Cynthia A. Brown, Director John T. Preskitt, MD, FACS, Dallas, TX Human Resources Department: Ronald E. Rosenthal, MD, FACS, Wayland, MA Jean DeYoung, Director Maurice J. Webb, MD, FACS, Rochester, MN Information Services Department: *Executive Committee Howard Tanzman, Director Journal of the American College of Surgeons Department: Wendy Cowles Husser, Director Board of Governors/Executive Committee Organization Department: John P. Lynch, Director Barbara L. Bass, MD, FACS, Baltimore, MD Surgical Education and Research Department: Chair Olga Jonasson, MD, FACS, Director; Gerald O. Strauch, J. Patrick O’Leary, MD, FACS, New Orleans, LA MD, FACS, Director Vice-Chair Trauma Department: William F. Sasser, MD, FACS, St. Louis, MO Gerald O. Strauch, MD, FACS, Director Secretary Executive Consultant: 2 Sylvia D. Campbell, MD, FACS, Tampa, FL C. Rollins Hanlon, MD, FACS

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From my perspective

lthough it may have been a number of years since many of you were seniors in medical school, I’m sure you remember A the anticipation of participating in the National Residents Matching Program. Through this system, you selected various specialties, ranked your preferences, and then you were matched with a program. The results of the 2001 match were announced recently, and there was a good, strong pool of can- didates for many of the surgical specialties. In talk- ing to the Regents who represent the various spe- cialties, it was clear to me that many of them had a good experience this year. Indeed, ophthalmol- WWWe must be committed to ogy, otolaryngology, and urology reportedly did influencing, in all possible better than in previous years. Other surgical spe- ‘‘ cialties were also satisfied with their match rates. Alarmingly, however, many excellent programs did ways, the surgical career path not fill their general surgery training positions. Another concern is that studies indicate that the of bright medical students. surgical specialties attract around 10 percent of medical school graduates, which is, collectively, ’’ lower than the number of individuals who select internal medicine, family practice, and pediatrics. Finally, academic medical centers report that the attrition rate in surgical programs has increased dramatically to nearly 25 percent. Clearly, the American College of Surgeons is keenly interested in making sure that a surgical career is attractive to “the best and brightest” U.S. dents. While many attendings may reflect back on medical students. the lengthy hours and competitiveness of their residencies with fond memories, today’s medical Deterrents to surgical training students may not see the allure. What factors are deterring medical students Other issues inherent in surgical training also from choosing a surgical career or finishing a resi- may prevent some medical students from enter- dency program? Certainly, one possibility is the ing surgery. These possible drawbacks include the lack of exposure to the surgical discipline during length of training, the need to obtain a breadth of medical school. Medical schools have reduced sur- cognitive and technical skills, the aggressiveness gical rotations in both the junior and senior years of the health care marketplace, and the economic and in the didactic components of surgical educa- burdens engendered by many years of training, tion. Without the proper exposure during those especially when coupled with continuing reduc- formative years, outstanding medical students are tions in reimbursement for surgical services. less likely to be attracted to surgical careers. All of these factors, to a greater or lesser extent, Moreover, the surgical experience that medical may dissuade capable students from embarking students do undergo may not always encourage on a surgical career. them to elect surgery as their career choice. The long hours that surgical residents work, the diffi- The College’s efforts culty of the tasks, and the environment in the op- The College has always been interested in main- erating room and intensive care unit may be taining the integrity of surgical training. For many daunting and disconcerting to some medical stu- years, we have carried out longitudinal studies of 3

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS surgical residents and have tracked resident data. riences are rewarding, and that their assignments Also, through the Committee on Surgical Educa- are constructive. tion in Medical Schools, we have attempted to in- Further, although we may sometimes be frus- culcate the principles of the practice and ethics of trated by our health care system, we must not a surgical career during medical school. Further, project our feelings onto our medical students. In- the committee has attempted to encourage all of stead, we must be committed to influencing, in all its Fellows to accept responsibility for teaching possible ways, the surgical career path of bright medical students and for formulating a solid cur- medical students. riculum of the surgical disciplines in medical Taking this year’s match in general surgery as a school. (Thomas G. Lynch, MD, FACS, of Omaha, wake-up call, I hope to energize the College to fo- NE, and Leigh Anne Neumayer of Salt Lake City, cus more attention on this important area. If you UT, are the Chair and Vice-Chair, respectively, of have any suggestions as to how the College might this important committee.) In addition, each year stimulate enthusiasm for a surgical career among the College sends a number of medical students to medical students, please contact me. I would ap- the Clinical Congress at no cost to them. preciate hearing your thoughts. Although the College has done much to monitor surgical residents and to encourage medical stu- dents to choose surgical careers, there is much we could do in the future to have a positive influence on medical students. For example, the chapters could make a greater effort to reach medical stu- dents on the local level and to offer career coun- seling in a uniform fashion across the country. Thomas R. Russell, MD, FACS Because medical students are sophisticated com- puter users, we could enhance the College’s Web site to help medical students engage in more per- sonal contact with Fellows. Other possible inno- vations include developing a surgical career packet for dissemination to all medical students, present- ing awards to outstanding medical students, and appointing medical student representatives to ar- ticulate the College’s position and promote oppor- tunities in surgery.

Strategies for the future Educators must be very sensitive to the needs of medical students when they rotate through surgi- cal services. We must shield them from activities that could dissuade them from entering surgery simply because of the long hours or the amount of work. They should not be intimidated or over- whelmed by the clinical experience, and surgeons must take an interest in them personally and pro- fessionally, pointing out the many positive aspects of a surgical career. The days of subjecting medi- cal students to overwork, abuse, demeaning atti- tudes, and unrealistic demands must end. To make surgical training more attractive to medical stu- If you have comments or suggestions about this or dents, we must make every effort to ensure that other issues, please send them to Dr. Russell at 4 they are treated with compassion, that their expe- [email protected].

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS FYI: STAT

his column provides brief reports on important items of interest Tto members of the College. It will appear in the Bulletin when there is “hot news” to report. In-depth coverage of activities announced here will appear in columns and features published in the Bulletin and in the College’s weekly electronic newsletter, ACS NewsScope.

❖ The College’s Office of Continuing Medical Education has announced the launch of a CME Joint Sponsorship Program. The program will be conducted by the College as a national accrediting organization under the Accreditation Council for Continuing Medical Education and will offer cost-effective joint sponsorship to surgical organizations na- tionwide for their CME programs. For further information, contact [email protected].

❖ In recent weeks, Thomas R. Russell, MD, FACS, Executive Director, represented the College at several surgical meetings. In mid-April, he visited the France Chapter and the Royal College of Surgeons of England. Later that month, he participated in the annual scientific meeting of the Society of American Gastrointestinal and Endo- scopic Surgeons and of the Southwestern Surgical Congress.

❖ The Regental Health Policy Steering Committee held its second meeting in Washington on May 7. Issues on the agenda included man- aged care reform, burdens imposed on surgeons by the Emergency Medi- cal Treatment and Active Labor Act, and Medicare reform.

❖ Slide presentations of program highlights from the College’s an- nual Spring Meeting are now online on the College’s Web site at http://www.facs.org/spring_meeting/presentations.html. Planned by the Advisory Council for General Surgery, the Spring Meeting is intended to promote advances in surgery and other areas of science.

❖ On May 21, members of the Regental Patient Safety and Profes- sional Liability Committee participated in a congressional staff briefing in Washington, DC, on the need for medical liability reform.

5

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS DatelineWashington

prepared by the Washington Office, Health Policy and Advocacy Department

On April 23 and 24, an interagency task force of the U.S. Depart- HHS holds summit ment of Health and Human Services (HHS) convened a “National on patient safety Summit on Patient Safety Data Collection and Use.” The Patient Safety Task Force, which HHS Secretary Tommy Thompson formally intro- duced at the beginning of the summit, is composed of the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, and the Health Care Financing Administration (HCFA). The summit served as a forum for discussing methods of collecting and using data for patient safety efforts, as well as for reviewing topics such as confidentiality, administrative burdens, and the means for trans- lating data into actual safety improvements. In addition, the task force presented a broad outline of a proposed patient safety reporting sys- tem, the details of which were still being developed by both Congress and the Administration at press time.

Three organizations sent a petition to the Occupational Safety and OSHA petitioned to Health Administration (OSHA) on April 30, requesting that new fed- regulate resident eral regulations be implemented to govern work hours for medical resi- dents and fellows. The petition was submitted by: Public Citizen, a con- work hours sumer and health advocacy group; the Committee of Interns and Resi- dents, a house staff union representing medical students; and the Ameri- can Medical Student Association, an organization that represents phy- sicians-in-training. The organizations are calling for work hour limits more stringent than those currently effective in New York, including: • An 80-hour work week. • No more than 24 consecutive hours worked in one shift. • On-call shifts only every third night. • At least 10 hours off-duty between shifts. • At least one 24-hour period off-duty each week. • No more than 12 consecutive hours on-duty each day for emer- gency medicine residents working in hospitals receiving more than 15,000 unscheduled patient visits per year. The petitioners are requesting these regulations “on the grounds that work hours in excess of the requested limits are physically and mentally harmful to medical residents and fellows, and that a federal work-hour standard is necessary to provide them with safe employ- ment.” The petition connects a typical resident’s work schedule to harm in three specific areas: motor vehicle accidents, mental health, and pregnancy. This petition was sent to OSHA, which deals with safety in the work- place, because, in November 1999, the National Labor Relations Board (NLRB) overturned a 1976 precedent and ruled that medical residents are primarily employees rather than students. If OSHA decides that it does, in fact, have authority over residents’ working conditions, its pro- cedures require an advisory panel to be formed with equal representa- tion from both the “employer” and “employee” sides of the issue. That 6 panel will debate and make recommendations to the agency. Then, if

VOLUME 86, NUMBER 4,6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS OSHA decides there is a case, the matter will proceed through the nor- mal rulemaking process with a notice published in the Federal Register and opportunity for public comment.

On May 9, former College President LaSalle D. Leffall, Jr., MD, FACS, Former ACS testified before the U.S. Senate Appropriations Subcommittee on La- President testifies bor, Health and Human Services, Education, and Related Agencies. Along with Dr. Leffall, representatives from the National Cancer Insti- before Congress tute, the CDC, and the National Breast Cancer Coalition gave testi- mony to encourage Congress to increase its current funding initiatives for breast cancer research. Although the budget resolution for fiscal year (FY) 2002 includes a $3.4 billion, or 11.8 percent, increase for the National Institutes of Health (NIH), witnesses told subcommittee chair Arlen Specter (R-PA) that a 20 percent increase was needed to stay on track to complete the five-year target to double the NIH budget by 2003. Dr. Leffall, Charles R. Drew Professor of Surgery at Howard Univer- sity, will begin a two-year term as chair of the Susan G. Komen Breast Cancer Foundation in 2002. An advocate for increased public aware- ness of the new scientific advances in technology and therapy, Dr. Leffall is especially concerned about the plight of minorities and the medi- cally underserved.

The approximately 4,800 acute care hospitals that are paid under Hospital payment Medicare’s prospective payment system (PPS) would experience a 2.55 increases percent increase in reimbursement rates in fiscal year 2002 under a proposed rule issued on May 4 by HCFA. The proposed increase is announced based on a formula enacted into law and would become effective Octo- ber 1, 2001. The draft regulation also contains provisions to imple- ment a number of mandates under the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), including a proposed mechanism to facilitate access to high-cost new services and technologies by authorizing special payments to cover increased costs. In addition, HCFA intends to make revisions to the diagnosis-related group (DRG) classifications, including the addition of two new pan- creas transplant DRGs. The text of the proposed inpatient PPS rule can be found on HCFA’s Web site, www.medicare.gov, under “What’s New.”

RM7

APRILJUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Patient safety

initiatives by Christian Shalgian, Senior Government Affairs Associate, following the IOM report Health Policy and Advocacy Department

atient safety has always been a concern and a prior- ity among all physicians and other health care pro- viders, but the 1999 Institute of Medicine (IOM) re- port made the issue front-page news. As a result, the reduction of medical, or health system, errors con- P tinue to be the focus of countless efforts both from a policy perspective in Washington, DC, and from a practical perspective in operating rooms throughout the country. In November 1999, the IOM released its report To Err Is Human: Building a Safer Health System, which took a critical look at patient safety and con- cluded that 44,000 to 98,000 Americans die each year because of medical errors. These statistics were de- rived from two studies that were conducted in the late 1980s and early 1990s. In its widely publicized report, the IOM offered a series of recommendations on ways to reduce medi- cal errors, including the creation of a Center for Pa- tient Safety within the Agency for Healthcare Re- search and Quality (AHRQ) to establish and track progress toward meeting national patient safety goals. In addition, the IOM called on Congress to extend peer review protections to data related to patient safety and quality improvement. The IOM also recommended that two reporting systems be established to encourage health care or- ganizations to identify errors, evaluate their causes, and take appropriate actions to improve future per- formance. The most controversial recommendation was the development of a mandatory reporting sys- 8

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS tem for all errors that lead to serious injury (which • Information sharing. Reporting systems was never defined) or death. The data from this should facilitate the sharing of patient safety in- reporting system would be available to the pub- formation among health care organizations and lic. The IOM report also called for all additional foster confidential collaboration with other health errors to be reported voluntarily through a sys- care reporting systems. tem that would be closed to the public. • Legal status of reported information. The ab- While these recommendations appeared novel sence of federal protection for information sub- when they surfaced, the American College of Sur- mitted to patient safety reporting systems discour- geons has devoted considerable attention to patient ages the use of such systems, which reduces the safety for many years. For example, the College opportunity to identify trends and implement cor- initiated a Hospital Standardization Program in rective measures. Information developed in con- 1918 that served as the foundation for establish- nection with reporting systems should be privi- ing the Joint Commission on the Accreditation of leged for purposes of federal and state judicial pro- Healthcare Organizations (JCAHO). Additionally, ceedings in civil matters, and for purposes of fed- the College offers surgeons a variety of educational eral and state administrative proceedings, includ- opportunities to ensure that they maintain their ing discovery, subpoena, testimony, or any other skills and learn about current practice standards. form of disclosure. One such opportunity is the Surgical Education and Self-Assessment Program (SESAP), which Patient safety efforts in Congress provides practicing surgeons with the opportunity ACS Executive Director Thomas R. Russell, MD, to stay abreast of current standards in surgical FACS, brought many of these positions to the at- practice by reproducing the diagnostic and treat- tention of Congress last year when he testified be- ment challenges faced in the practice of surgery. fore a joint hearing of the Senate Health, Educa- tion, Labor, and Pensions Committee and the Sen- Medicine unites around common agenda ate Appropriations’ Subcommittee on Labor, The College was concerned about the IOM’s ap- Health and Human Services (HHS), Education, proach to reporting systems. In an effort to pro- and Related Agencies. During his testimony, Dr. vide policymakers with a clearer understanding Russell highlighted the College’s long history of of what must be included in an effective patient involvement with patient safety and urged Con- safety reporting system, the College joined the gress not to create a mandatory reporting system. American Medical Association, the JCAHO, and Instead, he urged Congress to give physicians and U.S. Pharmacopeia to draft a set of General Prin- health care providers the tools they need to re- ciples for Patient Safety Reporting Systems. Sum- duce health system errors at the local level. maries of the principles, which have now been Following the hearings, several members of Con- endorsed by more than 90 physician and other gress introduced patient safety legislation. Sens. health care organizations, follow. • Creating an environment for safety. There should be a nonpunitive culture for reporting health care errors that focuses on systems failures For further information and not on individual or organizational culpabil- ity. • Data analysis. Information submitted to pa- The Agency for Healthcare Research and tient safety reporting systems must be compre- Quality http://www.ahrq.gov hensively analyzed to identify actions that would minimize the risk of reported events recurring. The Institute of Medicine Report: To Err Is • Confidentiality. Confidentiality protections Human: Building a Safer Health System for patients, health care professionals, and health http://books.nap.edu/books/0309068371/html/ care organizations are essential to the ability of index.html any reporting system to obtain information about errors and effect their reduction. 9

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Charles Grassley (R-IA) and Joseph Lieberman safety research, information dissemination, and (D-CT) introduced legislation last year that fol- education. lowed the IOM’s recommendations very closely. This year, the Administration and Congress have That legislation did not gain much support, but kept patient safety high on their respective agen- other bills introduced by Sens. James Jeffords (I- das. On March 1, the IOM released its latest re- VT) and Edward Kennedy (D-MA) gained consid- port, Crossing the Quality Chasm. While this re- erable attention and sponsorship. Their legisla- port focused more broadly on health system re- tive proposals are very similar. Both include a re- form, some specific references were made to pa- porting system that is comparable to the volun- tient safety and the recommendations in the pre- tary reporting system proposed in the IOM report. vious IOM report. In addition, the Health Care In addition, both bills provide peer review protec- Financing Administration (HCFA) began provid- tions. At press time, however, the two senators ing grants to the local peer review organizations were still unable to agree on whether the legisla- in order to stimulate patient safety efforts at the tion should include whistleblower protections and local level. Moreover, on April 9, President Bush if the system should be administered at the fed- released his 2002 budget proposal, which earmarks eral or local level. another $53 million for patient safety research for At the end of last year (also the end of the con- the coming fiscal year. gressional session), Congress could agree only to designate $50 million to the AHRQ for the pur- What’s next? pose of patient safety research. No other patient In Congress, Senators Jeffords and Kennedy safety proposals were acted upon. have been attempting to reach a compromise that would allow them to jointly introduce patient AHRQ moves forward on patient safety safety legislation. It is possible that such legisla- To identify the appropriate areas for patient tion could be attached to the passage of a Patients’ safety research and take preliminary steps toward Bill of Rights. setting national patient safety goals, AHRQ held Meanwhile, the Bush Administration is moving two meetings: a National Summit on Medical Er- forward in anticipation of some directions from rors and Patient Safety Research in September Congress. Tommy Thompson, the Secretary of and a meeting on Patient Safety at the Clinical Health and Human Services, has created a Interface in November. Both meetings were at- multiagency Patient Safety Task Force to address tended by a diverse group of public and private the issue of medical errors. The task force consists organizations, including the College. They con- of representatives from the AHRQ, HCFA, the Cen- sisted of breakout sessions that included discus- ters for Disease Control and Prevention, and the sion of topics such as the epidemiology of medical Food and Drug Administration. In the near future, errors, communicating with patients and families the task force is expected to release a proposed er- about the risks of medical errors, and the meth- ror-reporting system. ods for training clinicians and health care man- The College will continue to closely examine all agers in improving safety. of the proposals put forth by both the Administra- These meetings generated a series of grants tion and Congress. In addition, the College will from the AHRQ that are aimed at improving pa- continue to devote considerable resources to the tient safety and reducing errors. These grants area of patient safety. For example, the Board of target research in a variety of areas, including Regents recently expanded the jurisdiction of the the effect of working conditions on patient safety College’s Committee on Professional Liability to and the use of clinical informatics to improve include patient safety. This committee has already patient safety. In addition, AHRQ will fund up begun the process of developing new resources and to 13 demonstration projects that assess the ef- tools to help surgeons participate in developing fectiveness of various methods of collecting and workable solutions to current and emerging pa- using information to reduce medical errors and tient safety concerns. ⍀ their impact on patient outcomes. The AHRQ 10 also is expected to provide grants for patient

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Advanced surgical technology experience valuable to the basic education of general surgery residents

by Charles T. Klodell, MD, Gainesville, FL Robert C. G. Martin II, MD, New York, NY Jeff W. Allen, MD, Louisville, KY, and Hiram C. Polk, Jr., MD, FACS, Louisville, KY

11

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he recent visible increase in surgical innovations Table 1. began ostensibly in 1989 Laparoscopic reports in the literature (1990-2000) T with the introduction of laparoscopic cholecystectomy. Identified no. Since then, the variety of tech- of publications nology-driven procedures has Early since increased steadily (see Table 1, Procedure report early report right).1-6 In many cases, the minimal access approach has Laparoscopic inguinal hernia 19901 704 become the “standard of care.” Laparoscopic colectomy 19912 746 Furthermore, there has been Laparoscopic fundoplication 19913 337 substantial broadening of in- Laparoscopic nephrectomy 19914 411 novation in many areas.7-9 Laparoscopic splenectomy 19915 433 Given the rapid acceptance Laparoscopic adrenalectomy 19926 330 of these techniques, the need to train general surgery residents in these areas is paramount. It is also imperative that these minimal access and technology-driven proce- job experience after starting a surgical practice dures not be exclusively limited to fellowship in fields such as advanced laparoscopy and sen- training but, instead, be kept in the basic cur- tinel lymph node biopsy. riculum for general surgery residents. Effective training in these techniques is maximized by The need for advanced training frequent exposure over a short period of time; thus, the “learning curve” is mastered more Many surgeons consider minimal access abdomi- promptly.10 nal surgery, or laparoscopy, the focal point of tech- In light of the evolving surgical environment, nological surgical advances that have occurred this training in advanced technology is a neces- within the past decade or so. In fact, it is only the sity and no longer a luxury for the practicing tip of the iceberg, because other conceptual and surgeon. Patient demand and referring physi- technical changes of equal significance have cians substantially influence the current need emerged in parallel. Surgeons safely and effica- for persistent refinement and evolution of new ciously provide imaging and image-directed biopsy procedures and methods. In fact, the breadth of of breast lesions. Surgeons perform endovascular public demand has led to a diversification of the placement of prosthetic grafts in the arterial tree. forum in which these procedures are performed. Surgeons regularly perform diagnostic and They are no longer performed solely in special- interventional endoscopic retrograde cholangio- ized or tertiary centers but, rather, in commu- pancreatography (ERCP) and have taken the lead nity and rural hospitals as well. These events in many other diagnostic and therapeutic proce- have created a major demand for surgeons dures as exemplified by ethical group trials of sen- trained in the entire spectrum of new surgical tinel lymph node biopsy, a technique that has technologies. moved from melanoma to breast cancer to other Obtaining this type of advanced technical ex- forms of neoplastic disease. perience is difficult because of the other require- Hence, rather than focus an educational program ments placed on residency directors and resi- purely on minimal access abdominal surgery, the dents. With the demand to meet the required surgical faculty of the University of Louisville number of mainstream surgical cases, the ten- School of Medicine decided to create a program that dency is to encourage post-residency fellowships is broad-based and depends on our unusual insti- in many advanced surgical techniques. In some tutional collaboration and liaison with other spe- 12 instances, a resident may need to obtain on-the- cialists in diagnostic and interventional radiology,

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 2. Table 4. Examples of advanced laparoscopic surgery Average monthly CAST experience for general surgery resident Adhesiolysis (PG4 and PG5 levels) Adrenalectomy Cholecystectomy with common bile duct Average exploration per Donor nephrectomy Experience month Fundoplication Advanced laparoscopy 14 Gastric bypass Advanced breast imaging with or Inguinal hernia repair without biopsy, including Laparoscopic-assisted aortobifemoral bypass stereotactic mammatone 7 Large and small bowel resection Noninvasive vascular lab Ostomy creation and reversal procedures 6 Pancreatic resection Interventional endoscopy, with Partial colectomy emphasis on therapeutic ERCPs 5 Pediatric procedures for Hirschsprung’s disease Endoscopic and endorectal Splenectomy ultrasounds 5 Ventral hernia repair Radioguided parathyroidectomy 4 Sentinel lymph node biopsy 3 Photodynamic therapy and YAG laser 3 Advanced laparoscopy (pig laboratory) 2 Table 3. Liver tumor radiofrequency ablation 1 Examples of advanced endoscopy Endovascular procedures 1 Total 51 Cyst duodenostomy Cyst gastrostomy Evaluation during Heller myotomy Pancreatic or common bile duct stent placement population is high. Second, it creates a “finish- Percutaneous endoscopic jejunostomy ing school” type of attitude for the senior resi- Sphincterotomy dent with a vital and focused opportunity to re- Therapeutic ERCP fine advanced skills, especially in laparoscopy. A consistent mechanism to test, implement, as- sess, and refine new technologies is required, with the goal of keeping only the best procedures as well as emergency medicine, gastroenterology, and discarding those that represent “fool’s and cardiology. gold.” Initially funded through a grant from Alliant Center established Community Trust, Norton Healthcare, Louis- ville, KY, the training program benefits enor- The formation of the Center for Advanced Sur- mously from the resources and financial support gical Technologies (CAST) at Norton Hospital of two private hospitals in addition to our uni- and Norton Healthcare has become an invalu- versity and veterans’ hospitals. Fortunately, one able resource and has spawned a new resident of our private hospitals sponsors CAST and has rotation with a dual role for upper-level resi- provided enough financial support to make the dents in our training program. First, it provides center the focal point for perfecting advanced a “break” in the intensity of the senior resident techniques. CAST allows the resident to master years (PGY4 and PGY5) when the volume of these skills before entering the competitive job work and the severity of illness in the patient or academic market. Recent graduates of our 13

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS program who have gone through the CAST ro- opened the door to combined laparoscopic and tation have noted an increase in their market- endoscopic procedures. Procedures such as the ability as potential recruits to established prac- laparoscopic Heller myotomy and laparoscopic tices as a direct result of this working knowl- transgastric cyst-gastrostomy are performed edge of emerging technology and procedures. with the combination of endoscopy and laparoscopy. Residents who are involved in the Exposure to a range of techniques CAST rotation have significant interaction with the surgical ERCP fellows,11 allowing an in- The breadth of exposure to new techniques in crease in the scope of advanced endoscopic ex- the CAST rotation cannot be overstated. It in- perience for both. We believe it is our commit- cludes an extensive experience in advanced ment to both endoscopy and laparoscopy that laparoscopy (see Table 2, p. 13), in addition to permits the evolution of these truly minimally other advanced technologies such as advanced invasive techniques. During this rotation, sur- interventional endoscopy (see Table 3, p. 13), gical residents also participate in advanced en- sentinel lymph node biopsy, photodynamic doscopic ultrasound procedures, an opportunity therapy, image-guided breast biopsy, and provided to them by our gastroenterology fac- radioguided surgery. Additionally, while our resi- ulty. dency maintains a high level of emphasis on Extensive opportunities are also presented for endoscopy, it is the CAST rotation that has resident involvement with sentinel node biopsy for melanoma, breast cancer, and other sites, as well as radioguided minimal access parathy- Dr. Klodell is a fellow roidectomy. Concentrated experience in stereo- in cardiothoracic tactic and ultrasound-guided breast biopsy, in- surgery, University of struction in the interpretation of noninvasive Florida, Gainesville, FL. vascular testing, and exposure to advanced tech- niques using photodynamic therapy and yttrium- aluminum-ganet (YAG) laser are obtained. The endovascular graft effort was suspended tempo- rarily when CAST was initiated because of tech- nical problems with a specific brand of graft being used, but this training has since resumed. Endorectal ultrasound for both prostate and rectal disorders occurs during this rotation, but supplements a vast experience with ultrasound for trauma and emergency surgery at our level I trauma center. Dr. Martin is a fellow This broader view of new technologies has in surgical oncology, Memorial Sloan- been extremely attractive to trainees and offers Kettering Cancer them an understanding of surgical advances in Center, New York, NY. the broadest possible perspective. It also pro- vides them with an initiation in new concepts as well as new techniques across the whole do- main of surgery. For example, CAST includes thoracoscopy as a substantial improvement in the management of blunt chest trauma and sur- geon-performed and formally interpreted ultra- sound examination in the management of the trauma victim. Experiences with these diverse procedures are accomplished as a separate ro- 14 tation in the fourth and/or fifth clinical year of

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the residency. The greatest advantage of this forefront of advanced training and not at the program is an opportunity to sample these and back. The painful lessons learned from laparo- many other new concepts as part of the regular scopic cholecystectomy a decade ago should not trainee program, providing a basis for further be repeated with each new surgical advance. skills if a surgical resident chooses to pursue any Specialized rotations in advanced surgical tech- of them in-depth. niques during residency are needed and can be formulated even in the busiest of surgical resi- Ensuring competitiveness dencies. If not, training programs will fail in their ultimate goal of training residents com- These experiences in advanced surgical tech- pletely. ⍀ niques (see Table 4, p. 13) have allowed residents at the University of Louisville to offer estab- References lished practices the knowledge of new and ef- fective procedures that are in high demand. The 1. Ger R, Monroe K, Duvivier R, et al: Management combination of broad-based surgical training of indirect inguinal hernias by laparoscopic clo- sure of the neck of the sac. Am J Surg,159:370- and advanced skills in minimal access surgery 373, 1990. and sentinel node biopsy allows these emerging 2. Redwine DB, Sharpe DR: Laparoscopic segmen- surgeons to compete at the highest level and, at tal resection of the sigmoid colon for endometrio- the same time, enhance the currency of ideas and sis. J Laparoendosc Surg, 1:217-220, 1991. forward thinking of the practice group that they continued on page 31 join. Certain technologies have led to an occasional Dr. Allen is assis- blurring of margins between the disciplines.7 tant professor, depart- This can pose a significant obstacle and, in some ment of surgery, University of Louisville institutions, has led to such contention and dis- School of Medicine, agreement that there is outright civil war. We Louisville, KY. have been fortunate because the departments of radiology and surgery and the gastrointestinal division in internal medicine have been willing to cooperate and foster the immense success of this budding joint venture. The CAST rotation is unique to general surgery training programs, and we believe it is among the first of its kind to emphasize exposure to the new techniques that are now permeating the surgical field.* Surgical educators are faced with a vast array of new surgical techniques that are in demand. Dr. Polk is Ben A. Reid, Sr., Professor and Relying on laparoscopic fellowships and other chair, department of post-residency training is not the answer for the surgery, University of next generation of surgeons. Exposing surgical Louisville School of residents to advanced minimal access and new Medicine, Louisville, techniques during their residencies will allow KY. them to master these skills while they complete their surgical training. Surgical training programs need to be at the

*We have recently become aware of a similar highly fo- cused program at Indiana University in nearby Indianapo- lis, IN, directed by Jay Grosfeld, MD, FACS, and David A. Canal, MD, FACS. 15

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS environment. The result, as Charles T. Klodell, MD, and his col- leagues note in this issue (p. 11-15), has been to accelerate the tendency New technology for specialization and to encourage post-residency fellowships. In considering these authors’ ap- and new approaches proach, it is important to reflect on the fact that there have been rela- tively few efforts to re-examine the to surgical education “efficiency” of current residency education. Indeed, there appears to be an increasing sense that the problems facing our health care system and the traditional resi- dency model are sufficiently severe to warrant exploratory alternative approaches. This lack of educa- tional innovation seems overdue since the current Halstedian-based model has been extant for roughly 100 years and was developed in a very different era of medical prac- tice. Concentrating experience is a by relevant and well-established prin- ciple of surgical experience. The Robert S. Rhodes, MD, FACS, Philadelphia, PA University of Louisville’s (KY) ef- forts (and those at Indiana Univer- sity, as well) to address teaching uring the past decade, minimally invasive tech- new technology in residency train- nologies have rapidly dispersed throughout medi- ing appear to go beyond tradition, cal practice. Unfortunately, training in these and, therefore, are very welcome. Demerging techniques has often left something to be desired. In the case of laparoscopic cholecystectomy, Important considerations for instance, there has been a relatively high incidence of operative bile duct injuries. Although for the moment Several features of the authors’ training in many of these techniques occurs primarily dur- model are particularly worthy of ing residency, it would seem only a matter of time before comment. The primary consider- a new spurt of technology renews this challenge. Thus, it ation is the value of broadening is important that we focus attention on how new tech- surgical skills within the context of nologies are evaluated, taught, and learned. current residency education in gen- Even if the learning of new technologies could be con- eral surgery. “See, do, teach” is an- fined to the residency environment, significant problems other hallmark of surgical educa- would remain. As an example, many of these new tech- tion and also remains a valid prin- nologies complement rather than replace the more tradi- ciple. Every procedure has a learn- tional “open” procedures. As a result, the time required ing curve, and the shape of this to learn the new technology often competes with that re- curve varies among individuals and quired in learning their traditional counterparts. All of by procedure. However, we lack these changes occur in an era in which restrictions on uniform criteria or reproducible time and resources further detract from the educational 16 methods by which to assess when a

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS surgeon has achieved “competence” in a given tech- program is clearly the beneficiary of the resources nique. Thus, current accreditation and certifica- to create the structure. Hopefully, this new ap- tion depend on acquiring at least a minimal de- proach will further improve the processes and the fined experience with specific procedures. Again, outcomes by improving the context within which due to difficulties in measurement, relatively little teaching occurs. emphasis has been placed on aspects of the struc- It should be noted that this is a time of signifi- ture and the context of the educational process that cant changes in some of the forces that affect sur- are critical to its outcomes. The enhanced avail- gical education. To name a few: (1) the Residency ability of supervision and feedback on performance Review Committee for Surgery, through a joint ini- implied in the Louisville model should greatly fa- tiative of the Accreditation Council for Graduate cilitate learning. Medical Education and the respective specialty Another consideration relates to the fact that our boards, has recently begun to sharpen the focus current health care system is extremely disjointed. on outcome measures for specific competencies; (2) The solution to this problem involves creating a the evolution of virtual reality also holds great system that enhances (or simplifies) communica- promise for enhancing the teaching of surgical tion and coordination. By expanding the capabili- technique and for creating objective criteria for ties of a given surgeon, the authors’ approach fa- measuring technical ability; (3) there is increas- cilitates the ability of both patients and managed ing uncertainty about the future funding of gradu- care organizations to be referred to an appropri- ate medical education; and (4) there are concerns ate surgeon in a timely fashion. Patient satisfac- about the attractiveness of the surgical lifestyle. tion as well as other outcomes are also likely to be The result of these interactions cannot be pre- improved by enhancing collegiality (and thus com- dicted, but only through continued active partici- munication) among specialists with overlapping pation in the process can we hope for the best pos- turf. The Louisville approach, by increasing the sible outcome. ⍀ collegial atmosphere of learning among relevant specialists, could address both of these issues. A related consideration is the trend toward in- creasing specialization. It is hard to argue against the idea that more training and experience is bet- ter. Specialization, per se, is not bad, and the forces driving it make it seemingly inexorable. However, we should be cautious of such specialization if it is tied to technique rather than to the fundamental knowledge of given disease systems and the prin- ciples of their treatment. Specialization related to technique alone makes one vulnerable to being outdated by the emergence of even newer technolo- Dr. Rhodes is a vascular surgeon and gies. the director of evalua- tion at the American What works? Board of Surgery, Philadelphia, PA. The key question about the Louisville approach is, of course, whether these types of experiences accomplish what they say they do. The emerging paradigm of quality assessment in health care iden- tifies three measurable elements of quality: struc- ture, process, and outcome. Regardless of the teach- ing structure that students of surgery may have at their disposal, the context of the process will al- ways be critical to the outcomes. The Louisville 17

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Save the charts:

For whom and for what?

by Robert Kerin, MD, FACS, Milford, CT

he “Socioeconomic tips of the month” column to resolve. The following are suggestions to the solo regarding retirement (Bulletin, February surgeon contemplating retirement. Each of the is- 2001, p. 31-32) provides an opportunity for sues raised in the column is discussed, but not in Tcomment from a recent retiree. Actually, several equal amounts, nor to the same degree. Particular of the author’s comments call for a response. emphasis is placed on what to do with patient One comment in the column pertains to the fate charts. of the charts still in the hands of the retiring sur- It is for the solo surgeon about to retire that these geon. As the article states, it is true that “simply words are primarily intended, if any remain in this by getting another surgeon to take custody of these era of managed care. Those surgeons who are in charts. . .” costs inherent in storing them could be group practice or who are planning to leave sur- avoided. It is equally true that an old maid simply gery but have replacements on hand may find these needs to get married to change her status. And if words superfluous. she is out of work and driving an old jalopy, she simply needs to get a job and buy a new car. Real- Space and staff ity has a way of interfering with all of these recom- The space problem evaporates if the retirement mendations. It is prudent to bear in mind that dovetails with a lease termination. This is a ten- one’s traverse in life may collide with a wish rather ant-landlord issue and, once resolved, is behind the than coincide with it. retiree. Owning your building helps considerably. The article also points out that in the retirement With regard to employees, the longer the lead process, patients, their records, the employees, the time prior to closure of the office, the easier the space, and the equipment all need to be addressed. transference for the office staff. My entire team was There is a crucial sentence tucked away in this aware that the office would be closing for one year article that lends itself to amplification, and that before the event. It proved to be an easy transition is, “In a solo practice. . .all of these issues must be for them. A certified public accountant hired one handled independently.” of the staff, another staff member went back to My personal experience as a solo orthopaedic sur- school, and the third retired. Meanwhile, the physi- geon who retired almost three years ago indicates cal therapist, after several decades of service, de- 18 that some of these issues may not be that difficult cided to spend more time with me, her husband.

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Weeding out equipment cians who would just listen to the patient. That is The pieces of equipment faced one of three fates: a luxury most patients don’t have even though long some of it we sold, some we donated, and the rest ago Sir William Osler drew attention to the im- we carted to the dump. One of our sons was open- portance of listening to patients to reach a diag- ing a law practice, so old tables, chairs, and sofas nosis. A family practitioner in town listens well, readily found a new home. The old X-ray unit re- but he is booked to near capacity. Over the past quired more time to reach its destination. Tried, half-century, the referral pattern in my office took true, and dependable day in and day out, it was by a 180-degree turn. Back when I first opened my far the most valuable of the capital goods. Internet practice, family practitioners were sending their inquiries yielded a clinic in Katmandu, Nepal, that patients to me, but toward the end of my career I needed an X-ray machine, but the reality of ship- found myself referring patients to them because ping so much weight and so many components ar- they would listen to my patients. I also have re- gued against that prospect. In the end, the unit ferred patients to a naturopathic physician who found a home in a nearby college that was offering impressed me both with her speech to our local X-ray technician training, and I was able to use medical society and the subsequent care of my wife. this donation advantageously at tax time. Indeed, my experience has been that patients’ overwhelming concern is not their charts but them- Patients and their charts selves. In the epilogue to my retirement, I have According to the column to which this article found that old charts have not been critical in responds, “Surgical practices must maintain pa- making suggestions to those patients asking for tient records and have them available to patients them. Often I only have needed to discern whether and physicians who need them. This could mean the patient has experienced a new problem or an- storing them for years....” The author then projects other chapter in an ongoing condition. The pa- the cost of storage over the first five years to be tients themselves have been quite adept at provid- $10,000 or more. ing information in that vein. In the first several weeks after closing the office doors, I received many cards, notes, and letters Learning the legal standards thanking me and wishing me well. Within the first While only a handful of patients requested their six months, no more than three dozen patients re- charts and no physicians did, requests did come quested their charts. Since then, there have been from attorneys who were interested in chart con- no more requests from patients and none from tent only. These requests were predominantly from physicians. attorneys representing insurance companies seek- While few patients requested their charts, many ing information on previous patients of mine who sought my advice as to whom they should consult might be under the care of another physician. My to manage their conditions. With advances made care now constituted a “past history.” Any infor- in orthopaedics over the last several decades, my mation in that category becomes excellent grounds options for referral had enlarged. While still in for an attorney on a “fishing expedition.” The re- practice, I could make appropriate referrals to a quests typically would call for the entire record and myriad of physicians with expertise in the area the attorney would reference a Connecticut Stat- matching a patient’s need—joint replacement, spi- ute allowing 45 cents per page for each page of the nal stenosis, and sports medicine, to name a few. chart copied plus first-class postage. While the re- Though no longer in practice, former patients quests were certainly legitimate, I had little desire would seek me out by phone or personally to ob- or interest in funding fishing trips, especially those tain my ongoing recommendations. While no one not my own. ever has asked me to personally provide a service It became apparent to me that I needed some since I retired, I continue to encounter former pa- definition of how long to store the charts. It also tients who ask to be pointed in the right direction was important to differentiate between what was for treatment of their current problems, ortho- desired and what was required and by whom. paedic or otherwise. Each state has laws and regulations defining how One big problem that I faced was finding physi- long charts should be retained and the statute of 19

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS limitations for bringing a malpractice action. In formation. And the patient who serves as the Connecticut, where I practiced, there are multiple genesis of each chart has every right to expect that regulations addressing medical records. Section the confidentiality of the information in the records 19A, 14-42, provides that all parts of a medical be respected. If, for whatever reason, a chart falls record must be retained for seven years from the into unauthorized hands, the physician may be last date of treatment. The same section of the rule vulnerable to legal action from the patient. states that a record must be retained for three years It is painful to destroy the charts amassed over after the patient’s death. X rays also must be kept an entire career—to dispose of thousands (yes, for three years. thousands) of records. Yet, if the physician does not Section 19A, 14-44, addresses the discontinuance dispose of charts sooner, then his estate will be ob- of practice in the event of a practitioner’s death or ligated to do it later. And with disposal goes the retirement. The last sentence in this section states, priceless follow-up on every patient. “Medical records of all patients must be retained for at least 60 days following both the public and Conclusion the private notice to patients.” Our focus is on what It is sad enough that all of us in medicine have is required upon retirement; the requirement in become captives of mundane requirements, such Connecticut is clearly 60 days. as paperwork and precertification mandated by This knowledge paved the way to another con- managed care plans and other insurers. We should clusion. Simple mathematics would argue against do nothing that allows or encourages further in- the wisdom of maintaining a record library at an trusion into our activities. estimated cost of $10,000 over five years at a reim- Retirement is a time to relieve oneself of outside bursement rate of 45 cents per page. demands and not to become encumbered with fixed Section 52-584 defines malpractice vulnerabil- obligations or expenses. Maintaining an obsolete ity. An action must be brought within two years of chart library is a shining example of the latter. The the date that injury is first sustained or discovered. retiring solo surgeon should not believe that records In cases in which there is a delay in recognizing must be stored for “many years.” Indeed, in Con- the problem, the plaintiff has up to three years to necticut all that’s required is 60 days. ⍀ file a claim. Additionally, children’s charts should be preserved for one year after they turn 18. Editor’s note: This month’s “Socioeconomic tips This information about state mandates provided of the month” column (p. 23) gives additional informa- some parameters as to what was required of me as tion on the subject of record retention. a retiring solo surgeons.

When to dispose of the chart All of us in medicine have been inculcated with the inviolate chart doctrine. It is the repository of what was ordered for and done to each patient. Dr. Kerin has served Every chart is at least a short story; some are sa- as assistant professor gas. There is dual authorship—the patient and phy- of orthopaedic surgery, Yale School of Medi- sician each contributing respective parts. Each cine, New Haven, CT, chart contributes to a rich source of medical data and chief of ortho- and is a literary treasure of human experience. But paedic surgery, Milford in the world of the solo retiree, as jolting and dis- (CT) Hospital. He is quieting as it sounds, and in spite of all the time, currently on the effort, and cost deployed in their assemblage, the executive committee of vast majority of records stored in the chart library Yale Alumni in have little value beyond perhaps a trip down Medicine. memory lane. In retirement, these charts actually constitute a 20 liability inasmuch as each contains privileged in-

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Keeping current

Using ACS Surgery: Online tips and tools by Adrienne M. Stoller, New York, NY

n collaboration with the American College of ® Surgeons, WebMD is pleased to announce a Need to register? You can easily register online Inew title for Scientific American® Surgery: by clicking on the blue “Not Yet Registered?” ban- ACS Surgery: Principles and Practice. ner on WebMD’s physician portal, or contact cus- ACS Surgery, the first Web-based surgical ref- tomer service at 1-877-GO-WEBMD. erence for practicing surgeons, allows immedi- ate access to updated procedures, recommenda- tions, and developments important to your daily practice. As WebMD® subscribers, ACS members have the benefit of exploring ACS Surgery while 3. Browsing the Table of Contents located in also obtaining the latest surgery updates and the left-hand column of the screen. features on WebMD’s physician site (www. • Keyword Search and Advanced Search. If webmd.com). you’re searching for a topic of interest in ACS Surgery online, the fastest route is through Key- Navigating ACS Surgery on WebMD* word Search and Advanced Search. After entering WebMD’s physician portal at Keyword Search is a straightforward and user- www.webmd.com by clicking on “Physician” and friendly search tool. Just type in your search term using your password and ID, you can reach ACS and click GO! Instantly, a complete list of all ar- Surgery online by: ticles, references, tables, and figures containing 1. Clicking on the Library channel located on your search term will appear in the “search re- the top navigation bar, then clicking on ACS Sur- sults” panel located on the right of your computer gery; or, screen, beginning with the content that best 2. Clicking on the underlined title of ACS Sur- matches your search criteria. gery wherever you see it listed on WebMD’s phy- Advanced Search is a valuable option if you’re sician site, including the Medical Library section seeking more focused Search Results. Unlike the and the “Surgery” specialty channel. Keyword Search, which reveals all chapters, ref- Once you enter ACS Surgery online, you will erences, tables, and figures that contain your immediately come to the main page, the starting search term, Advanced Search allows you to re- point from which you can find the information strict or limit your search by selecting specific you’re looking for in the following ways: types of information. You can also limit the num- 1. Using the Keyword Search that appears in ber of search results (or “hits per page”) you the upper left hand portion of the screen, above want to display. the Table of Contents; • Table of Contents. Using the Table of Con- 2. Using the Advanced Search function by click- tents in ACS Surgery online, you can go directly ing on the “Adv Search” button located at the top to a section or chapter with the simple click of the screen; and, of your mouse. The Table of Contents consists of three levels of content including sections, * You must use 4.x generation browser or newer to access chapters, and chapter subsections. By clicking ACS Surgery online. the section title, the section “opens” or expands to reveal a list of chapters within that section. Scientific American® and Scientific American® Surgery are trademarks of Scientific American, Inc., and are used by WebMD Similarly, each chapter expands to reveal Corporation under license from Scientific American, Inc. chapter subsections, as well as interactive treat- 21

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ment algorithms. A click of the mouse will make ACS Web site can be found on the main page of the related content immediately appear to the ACS Surgery online. right. • Specialty news on WebMD. Finally, if you’re seeking more topics in surgery, you will find con- Exploring Tools and Features tinuously updated News and Clinical Perspectives, WebMD invites you to explore the many including CME activities, on WebMD’s “Surgery” unique tools and features available within ACS specialty page. Surgery online. These include the following: Look for updates on ACS Surgery online con- • Treatment algorithms. Several chapters in tent and features in upcoming issues of the Bulle- ACS Surgery online include “treatment algo- tin. For more information, log onto WebMD at rithms,” which provide a step-by-step approach www.webmd.com. for evaluating a clinical situation and managing ACS Surgery is sponsored by the American Col- decision making. The treatment algorithms are lege of Surgeons. ⍀ interactive, giving you the ability to scroll up and down or left and right to bring various parts of the image into view. Clicking onto an algorithm box also reveals further explanations that will appear in the bottom portion of the algorithm window. Use the algorithm toolbar to move, resize, print, and exit the algorithm. • Tables and figures. ACS Surgery online con- tains more than 1,300 detailed tables and figures, including diagrams, photographs, and full-color il- lustrations. Not only are the table and figures eas- ily accessible, but also you can print and down- load the images for lecture or presentation use, or simply add them to favorites on your browser. Tables and figure citations can be accessed from within the chapter text, and are indicated as ac- tive text links surrounded by brackets (for example, [see Table 1]). Figures can also be retrieved from a small version of the image, or “thumbnail,” within the chapter text. • Reference links. To refer to the sources cited within the chapter text, simply click onto the small red superscript numbers that appear in the text to reveal citation information and a link to PubMed to obtain the complete abstract. Links to abstracts also appear at the end of the chapter, where refer- ences are cited in full. PubMed is a search engine for the National Library of Medicine’s database, MEDLINE. • Continuing medical education (CME). Begin- ning this fall, you can earn 120 hours of Category 1 credit online. • American College of Surgeons Web site. ACS Surgery online also connects you to the official Web site of the ACS, so that you have immedi- ate access to membership updates, publications, Ms. Stoller is editor/writer, division of physician com- 22 and advances in surgical practice. A link to the munications, WebMD, New York, NY.

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Socioeconomic tips of the month

Record retention

s a practicing surgeon, you understand the fore, it is helpful to become familiar with the importance of maintaining a patient’s medi- agencies that provide retention criteria. There A cal record. However, if you decide to close are federal retention requirements, state laws your surgical practice, are you aware of the proper or regulations, accreditation agency retention retention and storage requirements for the standards (for example, the Joint Commission patient’s health information? on Accreditation of Healthcare Organizations) This is an important consideration, as the sur- and the American Health Information Manage- geon needs to ensure that patients, health care pro- ment Association’s (AHIMA) recommendations. viders, and other legitimate users have access to As retention standards vary by state, it is too health information, while maintaining patient con- difficult to list each state retention requirement fidentiality. individually. It is advisable to first check your state’s current laws regarding record retention. Recommendations Individual state regulations can be obtained by First, the surgeon should complete the pa- accessing the Web site: www.alllaw.com/ tients’ medical records in order to maintain fu- state_resources/. For additional retention advice, ture continuity of care. The surgeon should en- the Journal of AHIMA published an article list- sure that all dictated operative notes, laboratory ing the various guidelines and individual state and pathology results, referrals, radiology re- laws for patient health information retention. sults, and so on are filed within the patient’s This article, “Practice Brief: Protecting Patient medical record. The surgeon should accomplish Information after a Facility Closure,” published this task before transferring or storing the medi- March 1999, may be obtained by contacting cal records. AHIMA at www.ahima.org/journal/pb/99.03. Second, the surgeon should notify patients of html.1 Also available from AHIMA is “Practice the decision to close the practice. This can be brief: Retention of health information,” at accomplished through a simple letter or by plac- www.ahima.org/journal/pb/99.06.html.2 ing an announcement in the local newspaper in- forming patients of the decision to close. This Retention schedule provides patients with the opportunity to obtain The majority of states have specific record re- copies of their medical record before the surgeon tention requirements; however, in the absence transfers records to a storage facility or, if fea- of state retention requirements, patient health sible, to another surgeon. When a surgeon closes information should be retained for at least the a practice, he or she does not have to retain period specified by a state’s statute of limita- medical records outside of the parameters speci- tions, if not longer, for both minors and adults. fied by law. Therefore, it is important to first In the absence of specific state retention require- review current state retention requirements. ments, AHIMA created recommendations re- Other retention requirement articles may be garding established minimum time periods for referenced; however, keep in mind that some of retaining patient health information (see table, the data may be outdated. It is advisable that next page). the surgeon become familiar with state reten- tion requirements. Closure of a practice with a sale As a surgeon remains liable for disclosure of If the decision is made to sell the practice to health information, whether the disclosure is ac- another surgeon, then the medical records may cidental or not, during or after closure of a prac- be considered assets. In this instance, the medi- tice, medical records should be transferred or cal records can be included in the practice valu- stored by knowledgeable and reputable re- ation. As part of the agreement to sell, the sur- sources for the required retention time. There- geon should include the right to access the 23

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Retention schedule

Health information Recommended retention period

Diagnostic images (e.g., X rays) Five years Disease index 10 years Fetal heart monitor records 10 years after the infant reaches age of majority Master patient/person index Permanently Operative index 10 years Patient health/medical records (adults) 10 years after most recent encounter Patient health/medical records (minors) Age of majority plus statute of limitations Physician index 10 years Register of births Permanently Register of deaths Permanently Register of surgical procedures Permanently

records and retrieve copies, if needed, for any state archives or health departments, as some reasonable purpose. If a surgeon requests cop- may store medical records from a dissolved prac- ies of medical records, a fee for retrieval and tice. A directory of state health officials in state copying of records may be charged. health departments may be obtained by refer- ring to the Web site www.health.gov/hpcomments/ Closure of a practice without a sale Guide/state_PH.htm. If this option is unavail- If the decision is made to dissolve the practice able, then records should be stored with a repu- without selling to another surgeon, then either table storage firm if a surgeon has not agreed to the medical records can be transferred to an- maintain the records. Before placing records other surgeon who has agreed to maintain re- with a storage firm, the surgeon should verify sponsibility for the records, or they can be the firm’s experience in maintaining patient archived. If the decision is made to transfer the confidentiality and the ability of legitimate us- medical records to another surgeon, a written ers to access the information. Prior to archiving agreement should specifically outline terms and or storing records, the surgeon should create a obligations. The new surgeon should agree to written contract specifically outlining the terms maintain the medical records according to spe- and obligations of using a storage facility. The cific retention requirements and permit access surgeon should be aware that there will be fees by authorized persons. It is recommended that, for copying or reproducing the records. This if another surgeon can maintain the records, amount should be specified in the contract. this method be used, as the expense of storage and retrieval of records can be costly. Helpful tips If the decision is made to archive or store the Before closing a practice, the surgeon may wish records, the surgeon should remember the need to contact professional organizations such as the to maintain patient confidentiality and the need state licensure board for guidelines and recom- to assure future access of a patient’s health in- mendations. Also, it is advisable to obtain legal formation by patients, health care providers, counsel to help assure compliance with state laws. physicians, and other legitimate users. In larger practices and managed care systems, it 24 Additionally, a surgeon may wish to check with continued on page 33

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Philip Sandblom, MD, PhD, FACS, dies by C. Rollins Hanlon, MD, FACS, ACS Executive Consultant

On Ash Wednesday, a phenom- his activities in surgery and ad- enal career ended when Philip ministration he was skilled in Sandblom was fatally stricken the sports of skiing and sailing in the Lausanne airport as he and had a life-long interest in prepared to travel to Lund, Swe- modern Swedish and French den. Dr. Sandblom had been pro- art. During 70 years of mar- fessor of surgery and depart- riage, he and his charming wife mental chief at Lund Hospital Grace formed a remarkable col- from 1950 to 1970. From 1957 lection of masterpieces of paint- to 1968, he had also served in ing and sculpture. When he “re- challenging times as president tired” to an active visiting pro- of Lund University, where he fessorship in the department of brilliantly accomplished both a surgery at Lausanne, Switzer- radical democratization of land, the Sandbloms donated to higher education and a restora- the National Museum in tion of ancient academic tradi- Stockholm works by Cezanne, tions. Courbet, Delacroix, Picasso, and To his remarkable adminis- Seurat. trative accomplishments and his As tangible evidence of his in- significant contributions to pe- terest in the humanities, in diatric and biliary surgery, he Dr. Sandblom, pictured in 1952 1982, he published Creativity upon receiving Honorary Fellow- added an unassuming but el- ship in the American College of and Disease: How Illness Affects egant collegiality with his Surgeons. Literature, Art and Music. Of younger associates and a deep this gem-like book Carl concern for patients and stu- Nordenfalk, PhD, director dents. emeritus of the Swedish Na- Born in Chicago, IL, and edu- tional Museum, has written that cated in Sweden, Dr. Sandblom it provides “...a deeper insight spent an early postgraduate year largely unknown syndrome, into many of art history’s most with the great physiologist, An- which he clarified and developed poignant life-stories” as set out drew Ivy, at Northwestern Uni- as his special province. Thou- by “...the foremost Swedish art versity; this experience underlay sands of surgeons worldwide as- collector of his generation.” his pioneering introduction of sociated him with this landmark With its incisive characteriza- experimental surgery into Scan- entity and with his other contri- tions and its splendid color re- dinavia. Extensive research on butions to the treatment of por- productions, the book has been wound healing taught him the tal hypertension. widely acclaimed and has now importance of a rigorous scien- As the doyen of Honorary Fel- passed through a dozen English tific methodology and contrib- lows in the American College of and four Swedish editions to uted to his gentle, meticulous Surgeons (1952), Dr. Sandblom become an enduring classic. surgical technique. was also an honorary fellow of Two days before his 97th Facile in many languages, he three other surgical colleges and birthday in October 2000, he lectured widely on traumatic an honorary member of more lectured at the Clinical Congress biliary tract hemorrhage or than a dozen surgical organiza- of the American College of Sur- hemobilia, an ancient but tions here and abroad. Besides geons on his signature topic of 25

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS disease and creativity as the lead ductive career and the buoyant come to the U.S. for all impor- speaker for the final program of spirit of this magnificent hu- tant events in my life: to be the Seminar on Science and Hu- manist and world citizen. But a born, to get married, to have my manism, a series that endured quote from some “Reflections” eldest son, to get my master’s for 15 years. As a birthday ges- in his 75th year* may provide degree, and to receive many ture to a large, appreciative au- some hint of the good humor so honorary awards. As, by now, I dience, he bestowed on his lis- treasured by friends and associ- have only one important event teners the gift of several hun- ates. Speaking of Chicago as his left in my life, you may appreci- dred copies of “the Book” for birthplace, as well as that of his ate why I hesitate to return to those who would go to a desig- eldest son and grandson, he the U.S.” nated booth in the exhibition wrote: “Though none of us lives Despite this whimsically ap- hall. When a negligent hotel em- there, it has become a family tra- prehensive comment, he and ployee failed to deliver the books dition always to have a son born Grace made what I would esti- promptly, he and his cheerful, in Chicago. In fact, although my mate as some 50 subsequent resolute consort personally whole education and career have trips to the U.S. for active par- transported them by taxi to the taken place in Sweden, I have ticipation in surgical meetings. designated point of distribution. The surgical world is enor- This brief note makes no pre- * Sandblom P: Reflections, Contem- mously poorer by Philip’s ab- tense of capturing the long, pro- porary Surgery, Vol. 11, 1977. sence.

Fellows and facts

Haile T. Debas, MD, orary member of the European Royal College of Surgeons FRCS(C), FACS, has been Association of Endoscopic Sur- (Eng).This lectureship is one of elected to serve as the new Presi- gery. Dr. Marks is a colon-rectal medicine’s oldest and most dis- dent of the American Surgical surgeon in Wynnewood, PA. tinguished. Dr. Sheldon’s pre- Association. Dr. Debas is a gen- sentation was titled “John eral surgeon in San Francisco, James O. Menzonian, MD, Hunter and the American CA. FACS, professor of surgery at School of Surgery.” Addition- Boston University School of ally, Dr. Sheldon, a Past-Presi- The Queen of England re- Medicine, recently received the dent of the College, was admit- cently knighted Barry T. Jack- Association of American Medi- ted as an honorary fellow of son, MS, PRCS, FACS (Hon), cal Colleges (AAMC) Human- the Hunterian Society, founded for his contributions to the pro- ism in Medicine Award for in 1819. fession of surgery. Sir Barry, 2000. Honorees are nominated President of the Royal College by the AAMC Organization of The National Academy of of Surgeons (Eng), was the guest Student Representatives. Medicine of Argentina recently speaker during the Opening presented its highest distinc- Ceremony of the 2000 Clinical George F. Sheldon, MD, tion, the title of Honorary Congress. His presentation fo- FACS, Zack D. Owens Distin- President, to Julio Vicente cused on the 200-year history of guished Professor of Surgery Uriburu, MD, FACS, a gen- the RCS(Eng), as well as its re- and chairman of the depart- eral surgeon in Buenos Aires, lationship with the ACS. ment of surgery at the Univer- Argentina. This distinction has sity of North Carolina-Chapel been awarded only six times Gerald Marks, MD, FACS, Hill, recently delivered the since the academy’s founding 26 was recently inducted as an hon- 17th Hunterian Oration at the in 1822.

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Biography of Richard J. Field, Jr., MD, FACS, published

A biography of Richard J. Richard Jennings Field III. Field, Jr., MD, FACS, former Another “large component of ACS Governer and Regent, this story is Dick Field’s rela- was released this spring. Dr. tionship with the American Dick—The Hands and Heart of College of Surgeons,” Dr. a Rural Surgeon follows Dr. Hanlon notes. He has served as Field’s life throughout his a College Governor and Re- training, his military duty, his gent, positions to which he efforts to uphold his father’s brought the unique perspec- legacy in Centreville, MS, and tives of a rural surgeon. Dr. his dedication to the College. Field also served as the Second Dr. Field trained at Tulane Vice-President of the College University in New Orleans, (1994-1995). LA, and the Lahey Clinic in Dr. Field continues to prac- Boston, MA. After completing tice at the Field Clinic and his surgical training, Dr. Field Field Memorial Community served as a military surgeon at Hospital in Centreville. He the close of the Korean War. He also serves on the clinical fac- then returned to Centreville to ulties of the University of Mis- work at the Field Clinic and sissippi School of Medicine in Field Hospital, both founded Jackson, MS, the Tulane Uni- by his father and his uncle, versity School of Medicine, and Samuel Field, MD, FACS. the Louisiana State University The book describes the frus- School of Medicine in Baton tration Dr. Field felt in trying Rouge, LA. to bring modern surgical tech- Dr. Dick—The Hands and niques to an antiquated facil- Heart of a Rural Surgeon was ity when he went back to his written by Bob Pittman and is home town. Nonetheless, Dr. available for $26.70, including Field stayed true to his dream tax, through the Field Memo- of carrying on the work his fa- rial Community Hospital. To ther had begun in rural Missis- waves that have swamped hun- order the book, contact Leanne sippi, and the biography de- dreds of similar institutions. Jenkins, director of marketing tails how he resolved conflicts And, it is more than the story and public relations, Field Me- relating to his father, his faith, of one young couple who put morial Community Hospital, and his profession. aside personal preferences to P.O. Box 639, Centreville, MS In the foreword of the biog- establish a center for modern 39631-0639; tel. 601/645-5221; raphy, C. Rollins Hanlon, MD, medical care and teaching in a fax 601/645-5842. FACS, ACS Executive Consult- most unlikely location. ant and a former Director of “A great faith is depicted here, the College, states, “This book joined with steely determination is more than an account of a over three generations,” Dr. small hospital’s survival in the Hanlon writes. The third gen- face of socioeconomic tidal eration is left in the hands of 27

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 28

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Letters...

The following comments were dict the men and women that we it is my view that the issue was received via e-mail regarding would wish for our own sur- handled in a highly political “From my perspective” columns geons, as well illustrated by Dr. manner, to the detriment of good written by ACS Executive Direc- Ritchie’s article in the April Bul- surgical training. tor Thomas R. Russell, MD, letin. Continued success from a George Lim, MD, FACS FACS. The columns were pub- once-busy surgeon who has now lished in: (1) the December 2000 become a potential (shivers...) I have continued to enjoy your issue of the Bulletin and focused surgical patient. “perspectives” on important is- on the current debate regarding John N. Baldwin, sues for a number of months. residency work hours (see MD, FACS You give an excellent overview www.facs.org/fellows_info/bulle- of a subject and sound reasons tin/dec00bullet.html), and (2) Letters in response to “From why you have your own personal the March 2001 issue and fo- my perspective” were a bit sur- viewpoint. I read with great in- cused on the residency review prising to me in that they com- terest in the March 2001 issue committee for dermatology seek- mented very little on the issue of the Bulletin your perspective ing to establish a subspecialty in of the value of residency work on the value of four years of dermatological surgery (see hours to future performance as training in surgery to achieve a www.facs.org/fellows_info/bulle- a practicing surgeon. No doubt broad experience in performing tin/mar01bullet.html). a less demanding residency surgery rather than just becom- schedule may seem to enhance ing a “technician.” I agree that Thank you for adding “Let- the performance of the surgical many people can learn to per- ters” to the Bulletin. It is a much resident. As one from the old form a certain type of surgery appreciated and needed forum. days of 33 hours on call, l5 hours but have little training or appre- I particularly enjoyed hearing off, then repeat, for all of intern- ciation for the larger picture, from a recent chief resident ship and residency, I thought it where mature surgical judgment about his hours and from my was excellent training in com- occurs while dealing with the own mentor, Dr. Blaisdell, on his mitment for future actual prac- patient as a whole entity. Thank concept of responsibility. It was tice, which may be even more you for dealing with these diffi- over 30 years ago, while inter- demanding. cult socioeconomic issues and viewing a candidate for Fellow- It is no excuse before a peer re- putting them into proper “per- ship, that I said, “Tell me about view body (or malpractice de- spective.” this death following a porta- fense) to argue fatigue as a miti- Jack Bruner, MD, FACS caval shunt.” The individual re- gating circumstance. Many pri- plied, “Oh, I don’t know how vate practitioners in all fields that happened. I was the sur- must respond with accurate geon, but became ‘off duty’ and judgment and commitment, had left the hospital before the whether for the single case in the case was over.” ER or for the community medi- I believe that this is what we cal catastrophe. One of the key are talking about and agree com- lessons learned from a stressful pletely that the term “responsi- residency’s demands is to condi- bility” goes hand-in-hand with tion the mentality of the 25- to the privilege of operating on a 30-year-old surgical resident so living human being. Unfortu- that his or her decision making nately, the responsibility concept and performance as an older starts in kindergarten and re- practitioner will stand up under quires parenting, personal dedi- scrutiny and the demands of ac- cation, honesty, and stamina. countability. As a New York phy- SATs, MCATs, and recertifica- sician who testified at the hear- tion programs do not always pre- ing on limiting house staff hours, 29

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 30

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College launches CME Joint Sponsorship Program

The Office of Continuing tion under the Accreditation programs that are scheduled to Medical Education of the Council for Continuing Medi- be held after July 1, 2001. American College of Surgeons cal Education and will offer Further information and ap- has announced the launch of a cost-effective joint sponsorship plications materials are avail- CME Joint Sponsorship Pro- to not-for-profit surgical orga- able on the ACS Web site (www. gram. Approved by the Board nizations nationwide for their facs.org) or may be obtained by of Regents at its February 2001 CME programs and meetings. contacting the program’s ad- meeting, the program will be In the initial phase of the pro- ministrator, Kathleen Gold- conducted by the College as a gram, CME accreditation is smith, at e-mail [email protected], national accrediting organiza- being offered for educational or tel. 312/202-5212.

Disciplinary actions taken

The following disciplinary ac- reprimanded the surgeon for re- cal records and practicing medi- tions were taken by the Board of peated negligence in five surgi- cine below the standard of care. Regents at its meeting held on cal cases. The surgeon was or- The surgeon has successfully February 9, 2001: dered to submit quarterly writ- completed an evaluation pro- • The Board suspended ten reports to the Board for a gram to determine his medical Michael E. Freeburger, a general period of three years. skills, regained an unrestricted surgeon currently residing in • The Board restored the license to practice medicine, and Texas. In February 2000, he Fellowship of a plastic surgeon obtained full and unrestricted signed an Agreed Order with the from Florida who had been surgical privileges in an accred- State of Kentucky to surrender placed on probation. The sur- ited hospital. his medical license in that state geon originally was placed on In addition, the Board of Re- for an indefinite period of time. probation by the College as a gents approved the policy to • The Board censured a gen- result of action taken by the publish the names of members eral surgeon from Oregon. The Florida Board of Medicine alleg- who are expelled or suspended State Licensing Board of Oregon ing failure to keep written medi- from the College in the Bulletin.

SURGICAL TECHNOLOGY, from page 15

3. Geagea T: Laparoscopic Nissen’s fundoplication: Surg,173:2-8, 1997. preliminary report on ten cases. Surg Endosc, 8. Moore EE (ed): Horizons in general surgery. Am J 5:170-173, 1991. Surg, 173:1-69, 1997. 4. Clayman RV, Kavoussi LR, Soper NJ, et al: 9. Hunter J, Lacy A (eds): Postgraduate course: Com- Laparoscopic nephrectomy (letter). N Engl J Med, mon laparoscopic procedures from revolution to 324:1370-1371, 1991. standard of care (abstracts from the 7th World Con- 5. Delaitre B, Maignien B: Splenectomy by the gress of Endoscopic Surgery, June 1-4, 2000, laparoscopic approach: Report of a case (letter). Singapore). Dig Surg, 17:421-426, 2001. Presse Med, 20:2263, 1991. 10. Barrat C, Cueto-Rozon R, Catheline JM, et al: Im- 6. Gagner M, Lacroix A, Bolte E: Laparoscopic adrena- pact of learning and experience on the laparoscopic lectomy in Cushing’s syndrome and pheochromocy- treatment of gastroesophageal reflux. Chirurgie, toma (letter). N Engl J Med, 327:1033, 1992. 124:675-680, 1999. 7. Galandiuk S, Polk HC Jr: Dissolution of tradi- 11. Vitale GC: Advanced interventional endoscopy. Am tional surgical disciplinary boundaries. Am J J Surg, 173:21-25, 1997. 31

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Faculty career development award available

Faculty Career Development Award for Oncology of the Head and Neck, July 1, 2002-June 30, 2004

The American College of Surgeons and the notify the Scholarships Division of the College of American Head and Neck Society are offering a competing awards. two-year faculty career development award to • Supporting letters from the head of the depart- head and neck surgeons. The award is to support ment of surgery (or the surgical specialty) and from clinical, basic science, or translational research in the senior investigator (if applicable) supervising the study of neoplastic disease of the head and the applicant’s research effort should be submit- neck. The award is $40,000 per year for each of ted. This approval would involve a commitment two years to support the research and is not re- to continuance of the academic position and the newable thereafter. availability of facilities for research. General policies covering the granting of the • The applicant must submit a detailed research Faculty Career Development Award for Oncology plan and propose a budget for the two-year pe- of the Head and Neck are: riod of the research, even though renewed ap- • The award is open to surgeons who: (1) are proval by the ACS and the AHNS is required for members or candidate members in good stand- the second year. The applicant is also required to ing of both the American College of Surgeons submit a cover letter of approximately 400 words (ACS) and the American Head and Neck Soci- that describes the career objectives, how these ca- ety (AHNS); and (2) have completed specialty reer objectives will be achieved, how the research training within the preceding five years and protocol furthers the applicant’s career develop- have received a full-time faculty appointment ment, and, in particular, how this award will pro- at a medical school accredited by the Liaison vide data for subsequent major funding. Committee on Medical Education in the United • The awardee is expected to attend both the States or by the Committee for Accreditation of annual meeting of the American Head and Neck Canadian Medical Schools in Canada. Appli- Society (August 7-11 in Washington, DC) and the cants should provide evidence (by publication Clinical Congress of the American College of Sur- or otherwise) of productive initial efforts in labo- geons (October 10-15 in New Orleans, LA) in 2004 ratory research. to present reports to the ACS Scholarships Com- • The award is to be used to support the research mittee and AHNS representatives. of the recipient and is not to diminish or replace • The American College of Surgeons and the the usual, expected compensation or benefits. In- American Head and Neck Society require a re- direct costs are not paid to the recipient or to the search progress report after one year, and a sum- recipient’s institution. mary of research progress and information regard- • Applicants may not be current recipients of ing current academic rank, sources of research major research grants. Application for this award support, and future plans at the conclusion of the may be submitted even if comparable application research period. to other organizations has been made. If the re- The closing date for receipt of applications is cipient accepts a scholarship, fellowship, or career November 1, 2001. Application forms may be ob- development award from another agency or orga- tained upon request from Scholarships Division, nization, the Faculty Career Development Award American College of Surgeons, 633 N. Saint Clair for Oncology of the Head and Neck will be with- St., Chicago, IL 60611-3211, or from the College’s 32 drawn. It is the responsibility of the recipient to Web site at www.facs.org.

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Update your information online

The College has developed a Please visit the College’s Web have entered the information, program through which Fellows site at http://www.facs.org/ your Fellowship record in the can update and edit their indi- members/members.html. Fel- College membership database vidual listings (including ad- lows will need their eight-digit will automatically be updated. dresses, telephone and fax num- identification number to input There is no need to notify the bers, and e-mail addresses). the information. Once you College offices.

SOCIOECONOMIC TIPS, from page 24 is advised that the surgeon contact the director of in future columns, please contact the Health Policy health information management for advice on how and Advocacy Department, tel. 202/337-2701, fax to proceed with record retention. ⍀ 202/337-4271; or e-mail Health Policy Advocacy @facs.org.

The American College of Surgeons would like to References thank Beth Hjort, RHIA, Professional Practice Man- ager, AHIMA, for her review and comments. 1. Brandt M: Practice brief: Protecting patient information after a facility closure (up- This column responds to questions from the Fel- dated). Journal of AHIMA, March 1999. Web site: http://www.ahima.org/journal/pb/ lows and their staffs, and provides useful tips for 99.03.html. surgical practices. Developed by the College staff and 2. Fletcher D: Practice brief: Retention of health consultants, this information will be accessible on information (updated). Journal of AHIMA, our Web site for easy retrieval and future access. If June 1999. Web site: http://www.ahima.org/ there are topics that you would like to see addressed journal/pb/99.06.html.

33

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chapter news

by Rhonda Peebles, Chapter Services Manager, Organization Department

To report your chapter’s news, contact Rhonda Peebles toll-free at 888/857-7545, or via e-mail at [email protected]. Kentucky Chapter hosts annual meeting

On February 15-16, the Kentucky Chapter con- ducted its annual meeting at the Camberley Brown Hotel in Louisville, KY. In addition to the council, business, trauma, and cancer liaison meetings, the chapter also conducted a residents’ paper compe- tition. Two winners were announced: The Ohio Chapter delegation to the state Capitol in • Sandra Wong, MD,* for the paper “Sentinel Columbus included (all MD, FACS)(left to right): Robert Lymph Node (SLN) Biopsy for Breast Cancer: Im- McDevitt, Jr., Warren Muth, Sidney Miller, Michael pact of the Number of Sentinel Nodes Removed Stark, Joseph Crowe, Jr., Ali Mokhtari, Margaret Dunn, on the False-Negative Rate.” Richard Reiling, John Raaf, and David Hasl. • Andrew Barksdale, MD,* for the paper “TGF- ß and IL-13 Induce Arginase Activity in Foam Cells.” tional Relations Committee for the Argentina South Texas Chapter Chapter, have reported on their plans for 2001- recognizes basic sciences 2002 educational programming. In August, in con- junction with the Gastroenterologic Italo-Argen- At its 2001 annual meeting, March 2-3, the South tine Group, the chapter will present a course on Texas Chapter held its first named lecture, The hepatic surgery and advanced laparoscopic proce- William J. Porkorny Surgical Science Lectureship. dures. The chapter also intends to: (1) develop Stanley J. Dudrick, MD, FACS, chairman and di- mechanisms for presenting scholarships to young rector of surgical education, department of surgery, surgeons; (2) assess the development of an educa- Bridgeport Hospital-Yale New Haven Health Sys- tion center to provide programs on telementoring, tem, Bridgeport, CT, presented the first Porkorny telesurgery, and training using virtual-reality tech- lecture. He spoke on two topics: (1) the history and nology; and (3) develop an educational program clinical application of TPN, and (2) the manage- encompassing all of the College’s chapters in Latin ment of short bowel syndrome. According to Ken- America. For more information, please contact Dr. neth R. Sirinek, MD, FACS, the chapter’s Program Saad at [email protected], or Dr. Chair, the South Texas Chapter created the new Suhl at [email protected]. Porkorny lectureship to reinforce the importance of basic science research to surgical residents. Maine Chapter receives commemorative charter Argentina Chapter announces 2001-2002 plans The Maine Chapter observed its 50th anniver- sary at its annual meeting, February 16-18, at the Eduardo N. Saad, MD, FACS, President, and Grand Summit Hotel at Sugarloaf/USA. To honor Arnoldo E. Suhl, MD, FACS, Chair of the Interna- the occasion, Thomas R. Russell, MD, FACS, the College’s Executive Director, presented the 50th 34 *Denotes participant in the Candidate Group. Anniversary Commemorative Charter to the

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ing physicians and legislators. For more informa- tion, contact Jane Treiber, Executive Director of the Ohio Chapter, at [email protected], or toll-free at 877/677-FACS (3227). Lebanon Chapter presents ninth surgical congress

In conjunction with the Lebanese Society of Gen- eral Surgery, the Lebanon Chapter conducted its Ninth Surgical Congress, February 22-25, in Beirut. The educational program included presen- tations on colon-rectal surgery, laparoscopic sur- gery, liver transplantation, pain management, urology, endo-vascular surgery, and spine surgery. At a dinner, Chahine Abousleiman, MD, FRCS, FACS, presented a special medallion to His Excel- Lebanon Chapter: Dr. Abousleiman (left) presents a lency Karam Karam, MD, FACS, who serves as medallion to Dr. Karam. Lebanon’s Minister of Tourism (see photo, left). Chapter anniversaries

Month Chapter Years Maine Chapter. The meeting’s educational pro- gram featured presentations by residents and Fel- May Colorado 44 lows, and a coding and compliance seminar was Maryland 44 conducted. June Alberta, Canada 11 Arkansas 26 Connecticut 34 Ohio Chapter meets Metropolitan Washington (DC) 27 with state legislators Ecuador 34 Germany 11 On April 3, members of the Ohio Chapter par- Greece 15 ticipated in a second trip to Columbus to meet with Idaho 51 Ireland 18 state legislators (see photo, p. 34). The visits were Israel 4 arranged in conjunction with the Ohio State Medi- Maine 50 cal Society (OSMA) and several state specialty so- Mexico—Northeast 26 cieties. In all, about 150 physicians met with their Mexico—Nor-Occidental 30 elected officials to discuss legislative priorities. Minnesota 30 One priority in 2001 is SB 4, “The Prompt Pay New Mexico 16 Bill.” In a meeting with Ohio Chapter members Upstate New York 35 last year, state Sen. Larry Mumper agreed to spon- Western New York 46 sor the new prompt payment legislation. The bill North Dakota 45 would require insurers to pay claims within 30 Oregon 36 Philippines 31 days, prohibit insurers from contracting for pay- Spain 19 ment periods greater than 30 days, and prevent Wisconsin 31 insurers from conducting “take-backs” beyond one year. The day began with a briefing session and ended with a debriefing and reception for all participat- 35

JUNE 2001 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The Journal page

Message from the Editor

by Seymour I. Schwartz, MD, FACS, Rochester, NY

The July issue of the Journal of the American objects—in this case, profit and pedagogy—cannot College of Surgeons includes an article that ad- occupy the same place at the same time. Current dresses the adverse effects of diagnosis-related financial success, however, will be offset by the com- groups (DRGs) on academic health centers. The promised education of the next generation upon DRGs represent just one of many incursions that whom the future is dependent. The future is being impact negatively on the mission of these institu- disregarded. Teaching and learning, the raison tions. Academic institutions, by definition, are d’etre of a residency training program, is no longer scholastic communities with education as an inte- a priority. Medical students are merely exposed to gral component. surgery rather than being educated in the disci- What is happening in the current environment, pline. Would that our ophthalmology colleagues in which corporate medicine dominates academic could devise a keratoplastic procedure to convert health centers, brings to mind an allegoric image the myopic vision, through which our system is of St. Anthony with his body pierced by many ar- currently being viewed, to one of farsightedness. rows. The DRGS represent but one of many trau- matic events suffered by academic health centers. Dr. Schwartz is Distinguished Alumni Professor, Uni- Because a mentality focused on the bottom line has versity of Rochester (NY) School of Medicine and Den- become pervasive, academic imperatives have be- tistry. He is also Editor-in-Chief of the Journal of the come compromised. American College of Surgeons and a Past-President of Perhaps the third law of physics pertains: Two the College.

INTRODUCTORY ABSTRACT from the July lead article

How DRGs Hurt Academic Health Systems. Paul odology to estimate costs was then determined and its A Taheri, MD, MBA, FACS, David A Butz, PhD, Ron accuracy benchmarked against actual Medicare and Dechert, RRT, Lazar J Greenfield, MD, FACS. From the Blue Cross reimbursements. department of surgery, University of Michigan Health Results: Low-volume DRGs (<75 annual admissions) System (Taheri, Dechert, Greenfield) and the Univer- had the highest coefficient of variation relative to each sity of Michigan Business School (Butz), Ann Arbor, MI. of the three other DRG classifications (moderate to high Background: Academic health centers continue their volume, groups 2, 3, and 4). The regression analysis mission of clinical care, education, and research. This accurately estimated costs (within 25% of actual costs) mission predisposes them to accept patients regardless in 64.7% of the patients with a length of stay ୑4 d of their individual clinical variation and financial risk. (n=16,287). This regression fared well compared to The purpose of this study is to assess the variation in actual FY 1999 DRG-based Medicare and Blue Cross costs and the attendant financial risk associated with reimbursements (n=9,085 with length of stay ୑4 d), these patients. In addition, we propose a new reimburse- which accurately reimbursed the University of Michi- ment methodology for American health centers’ high- gan Health System in only 43.9% of cases. end DRGs that better aligns financial risks. Conclusions: American health centers receive a dis- Study design: We reviewed clinical and financial data proportionate number of admissions to low-volume, from the University of Michigan data warehouse for FY high-variation DRGs. This clinical variation translates 1999 (n=39,804). The DRGs were classified by volume into financial risk. Traditional risk management strat- (group 1, low volume to group 4, high volume). The co- egies are difficult to use in health care settings. The efficient of variation for total cost per admission was application of our proposed reimbursement methodol- then calculated for each DRG classification. A regres- ogy better distributes risk between payers and provid- sion analysis was also performed to assess how costs in ers, and reduces adverse selection and incentive prob- 36 the first three days estimated total costs. A hybrid meth- lems (“moral hazard”).

VOLUME 86, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS