JULY 2020 | VOLUME 105 NUMBER 5 | AMERICAN COLLEGE of SURGEONS Bulletin

JULY 2020 | VOLUME 105 NUMBER 5 | AMERICAN COLLEGE OF SURGEONS Bulletin

Surgeon leadership in the time of COVID-19

20MAYBULL cover 1.indd 1 6/17/2020 10:02:24 AM VIRTUAL

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#acsqsc facs.org/QualitySafetyConference Contents

FEATURES 16 The role of the site reviewer: Ensuring patient- centered standards for optimal patient outcomes Tony Peregrin

25 The Surgical Metrics Project: What was achieved, and where is it headed? Carla Pugh, MD, PhD, FACS; Cassidi Goll; Anna Witt; Hossien Mohamadipanah, PhD; and Brett Wise

31 Surgeons appointed by Spanish royalty contributed to 16 development of oldest U.S. city: St. Augustine, FL John D. Ehrhardt, Jr., MD, and J. Patrick O’Leary, MD, FACS

40 2019 ACS Governors Survey: Surgeons wanted: Workforce challenges in health care David J. Welsh, MD, FACS; Hiba Abdel Aziz, MBBCH, FACS; Juan C. Paramo, MD, FACS; John Kirby, MD, FACS; Dhiresh Rohan Jeyarajah, MD, FACS; David W. Butsch, MD, FACS; Christopher DuCoin, MD, MPH, FACS; Joann Lohr, MD, FACS; and Shilpa Shree Murthy, MD, MPH

25 46 2019 ACS Governors Survey: ACS Governors: Bidirectional communication ambassadors David W. Butsch, MD, FACS; David J. Welsh, MD, FACS; Hiba Abdel Aziz, MBBCH, FACS; Juan C. Paramo, MD, FACS; John Kirby, MD, FACS; Dhiresh Rohan Jeyarajah, MD, FACS; Christopher DuCoin, MD, MPH, FACS; Shilpa Shree Murthy, MD, MPH; Julian A. Smith, MB BS, FACS; and Joann Lohr, MD, FACS

51 2019 ACS-COSECSA Women Scholars describe how they and their patients benefit from the scholarships: Part I Natalie Bell and Girma Tefera, MD, FACS

40 continued on next page

JUL 2020 BULLETIN American College of Surgeons | 1 Contents continued

FEATURES, continued 55 A call into the distance: How quality review can change a rural cancer patient’s outcome Mary O. Aaland, MD, FACS, and Karen W. Luk, MD

58 Surprise billing, trauma, and cancer top state legislative agendas in 2020 Christopher Johnson, MPP 55 64 Filling the gap: Using 3-D printing to overcome critical equipment shortages during the COVID-19 crisis Daniel T. Lammers, MD; Matthew J. Eckert, MD, FACS; and Jason R. Bingham, MD

67 Community hospital’s losing battle with COVID-19: A surgery resident’s account Justin Gauthier, MD

DEPARTMENTS 64  COMMENTARY 76 ACS Clinical Research Program: 11 COVER STORY: Looking forward Ga-68 imaging changes David B. Hoyt, MD, FACS clinical management of GI and pancreatic neuroendocrine 14 Letters to the Editor tumors Clancy J. Clark, MD; J. Bart Rose,  FOR YOUR PATIENTS MD; Judy C. Boughey, MD, FACS; 71 ACS quality and safety case and Flavio G. Rocha, MD, FACS studies: Virtual acute care for 79 NCDB cancer bytes: older patients reduces hospital Neoadjuvant and perioperative length of stay chemotherapy for localized Melanie Morris, MD, FACS; pancreatic cancer: Leveraging 67 Lauren Wood, MPH;Emily small and large databases in the Simmons, MSN, RN, CNL, FGNLA; absence of Level 1 evidence Shari Biswal, MSN, RN, PCCN, Timothy L. Fitzgerald, MD, FACS CNL; David James, DNP, RN-BC, CCNS, LSSGB; Jasmine Vickers, continued on next page MPH, CHES; John Russell, MBA, CPA; Katrina Booth, MD; and Kellie Flood, MD

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DEPARTMENTS, contd. NEWS

 FOR YOUR PRACTICE 91 Letter from the Editor 83 A look at The Joint Diane Schneidman, Editor-in- Commission: Recommendations Chief pour in as surgeons navigate COVID-19 pandemic 92 Announcing the new Cancer Surgery Standards Program Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon) Matthew H.G. Katz, MD, FACS; Kelly K. Hunt, MD, FACS; 87 Heidi Nelson, MD, FACS; and  FOR YOUR PROFESSION Amanda Francescatti, MS 87 From residency to retirement: 94 ACS remembers Howard M. ACS offers opportunities for Snyder III, MD, FACS, trailblazer increased specialty resident in pediatric urology participation in the College 96 ACS mourns the passing of Sonia Bhandari Randhawa, MD, Francis Robicsek, MD, and Enrique Hernandez, MD, PhD, FACS, a dedicated FACS, FACOG humanitarian surgeon 89 From the Archives: German 98 ACS issues call to action on influences on U.S. surgery and racism as a public health crisis: the founding of the ACS An ethical imperative David E. Clark, MD, FACS 99 Memoir recounts “golden 94 age” of surgical innovation Dr. Wangensteen led at University of Minnesota 102 Report on ACSPA/ACS activities, February 2020 Ronald J. Weigel, MD, PhD, FACS 108 Lessons from a virtual chapter annual meeting John H. Armstrong, MD, FACS; Jay Redan, MD, FACS; and Brian Hart, JD 112 Chapter news 98 Luke Moreau and Brian Frankel MEETINGS CALENDAR 116 Calendar of events

JUL 2020 BULLETIN American College of Surgeons | 3 The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an VIRTUAL OCTOBER 4–7 optimal and ethical practice environment. facs.org/clincon2020 EDITOR-IN-CHIEF Letters to the Editor Diane Schneidman should be sent with the writer’s SENIOR GRAPHIC DESIGNER/ name, address, PRODUCTION MANAGER e-mail address, and Tina Woelke daytime telephone SENIOR EDITOR number via e-mail to Tony Peregrin dschneidman@facs. org, or via mail to NEWS EDITOR Diane S. Schneidman, Matthew Fox Editor-in-Chief, Bulletin, American EDITORIAL AND PRODUCTION ASSISTANT College of Surgeons, Kira Plotts 633 N. Saint Clair St., ACS Chicago, IL 60611. EDITORIAL ADVISORS Letters may be edited Danielle A. Katz, MD, FACS for length or clarity. CLINICAL Dhiresh Rohan Jeyarajah, MD, FACS Permission to publish Crystal N. Johnson-Mann, MD letters is assumed Mark W. Puls, MD, FACS unless the author CONGRESS Bryan K. Richmond, MD, FACS indicates otherwise. Marshall Z. Schwartz, MD, FACS 2020 Anton N. Sidawy, MD, FACS Gary L. Timmerman, MD, FACS The Best Surgical Education. Douglas E. Wood, MD, FACS All in One Place. FRONT COVER DESIGN Tina Woelke

Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, and Affiliate Members. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295; tel. 312- 202‑5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2020 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. 4 | Officers and Staff of the American College of Surgeons* *Titles and locations current at press time.

Henri R. Ford, MD, FACS Christian Shalgian Officers Miami, FL Advisory Council Director Gerald M. Fried, MD, FACS, FRCSC AMERICAN COLLEGE OF Valerie W. Rusch, MD, FACS Montreal, QC to the Board SURGEONS FOUNDATION New York, NY James W. Gigantelli, MD, FACS of Regents Shane Hollett PRESIDENT Executive Director Ronald V. Maier, MD, FACS Omaha, NE (Past-Presidents) ALLIANCE/AMERICAN Seattle, WA B.J. Hancock, MD, FACS, FRCSC Kathryn D. Anderson, MD, FACS IMMEDIATE PAST-PRESIDENT COLLEGE OF SURGEONS Winnipeg, MB Eastvale, CA CLINICAL RESEARCH PROGRAM John A. Weigelt, MD, FACS Enrique Hernandez, MD, FACS W. Gerald Austen, MD, FACS Kelly K. Hunt, MD, FACS Sioux Falls, SD Philadelphia, PA Boston, MA Chair FIRST VICE-PRESIDENT Lenworth M. Jacobs, Jr., MD, FACS Barbara Lee Bass, MD, FACS CONVENTION AND MEETINGS F. Dean Griffen, MD, FACS Hartford, CT Houston, TX Robert Hope Shreveport, LA Director SECOND VICE-PRESIDENT Fabrizio Michelassi, MD, FACS L. D. Britt, MD, MPH, FACS, FCCM New York, NY Norfolk, VA DIVISION OF EDUCATION Tyler G. Hughes, MD, FACS, Ajit K. Sachdeva, MD, Salina, KS Lena M. Napolitano, MD, FACS John L. Cameron, MD, FACS SECRETARY Ann Arbor, MI Baltimore, MD FACS, FRCSC Director Don K. Nakayama, MD, MBA, FACS Linda G. Phillips, MD, FACS Edward M. Copeland III, MD, FACS Chapel Hill, NC Galveston, TX Gainesville, FL EXECUTIVE SERVICES TREASURER Kenneth W. Sharp, MD, FACS Lynese Kelley A. Brent Eastman, MD, FACS Director, Leadership Operations David B. Hoyt, MD, FACS Nashville, TN Rancho Santa Fe, CA Chicago, IL Anton N. Sidawy, MD, FACS FINANCE AND FACILITIES EXECUTIVE DIRECTOR Gerald B. Healy, MD, FACS Gay L. Vincent, CPA Washington, DC Wellesley, MA Gay L. Vincent, CPA Director Steven C. Stain, MD, FACS R. Scott Jones, MD, FACS Chicago, IL Albany, NY HUMAN RESOURCES CHIEF FINANCIAL OFFICER Charlottesville, VA AND OPERATIONS Gary L. Timmerman, MD, FACS Edward R. Laws, MD, FACS Michelle McGovern, Sioux Falls, SD Boston, MA MSHRIR, CPSP Officers-Elect Steven D. Wexner, MD, FACS LaMar S. McGinnis, Jr., MD, FACS Director Weston, FL (take office October 2020) Atlanta, GA INFORMATION TECHNOLOGY Douglas E. Wood, MD, FACS David G. Murray, MD, FACS Brian Harper J. Wayne Meredith, MD, FACS Seattle, WA Syracuse, NY Director Winston-Salem, NC DIVISION OF INTEGRATED PRESIDENT-ELECT Patricia J. Numann, MD, FACS Syracuse, NY COMMUNICATIONS H. Randolph Bailey, MD, FACS Board of Cori McKeever Ashford Houston, TX Carlos A. Pellegrini, MD, FACS Director FIRST VICE-PRESIDENT-ELECT Governors/ Seattle, WA JOURNAL OF THE AMERICAN Lisa Ann Newman, MD, MPH, FACS Executive J. David Richardson, MD, FACS COLLEGE OF SURGEONS New York, NY Committee Louisville, KY Timothy J. Eberlein, MD, FACS SECOND VICE-PRESIDENT-ELECT Richard R. Sabo, MD, FACS Editor-in-Chief Ronald J. Weigel, MD, PhD, FACS Bozeman, MT DIVISION OF MEMBER SERVICES Iowa City, IA Patricia L. Turner, MD, FACS CHAIR Seymour I. Schwartz, MD, FACS Board of Regents Rochester, NY Director Taylor Riall, MD, PhD, FACS M. Margaret Knudson, MD, FACS Beth H. Sutton, MD, FACS Tucson, AZ Courtney M. Townsend, Jr., Wichita Falls, TX VICE-CHAIR MD, FACS Medical Director, Military Health CHAIR Galveston, TX Systems Strategic Partnership Mika Sinanan, MD, PhD, FACS L. Scott Levin, MD, FACS Seattle, WA Andrew L. Warshaw, MD, FACS Girma Tefera, MD, FACS Philadelphia, PA SECRETARY Boston, MA Director, Operation Giving Back VICE-CHAIR Andre R. Campbell, MD, FACS PERFORMANCE IMPROVEMENT Anthony Atala, MD, FACS San Francisco, CA Will Chapleau, RN, EMT-P Winston-Salem, NC Executive Staff Director Mark Alan Dobbertien, DO, FACS John L. D. Atkinson, MD, FACS Orange Park, FL EXECUTIVE DIRECTOR DIVISION OF RESEARCH AND Rochester, MN David B. Hoyt, MD, FACS OPTIMAL PATIENT CARE Nancy Lynn Gantt, MD, FACS Clifford Y. Ko, MD, James C. Denneny III, MD, FACS Youngstown, OH DIVISION OF ADVOCACY Alexandria, VA MS, MSHS, FACS Dhiresh Rohan Jeyarajah, AND HEALTH POLICY Timothy J. Eberlein, MD, FACS Frank G. Opelka, MD, FACS Director MD, FACS Heidi Nelson, MD, FACS Saint Louis, MO Richardson, TX Medical Director, Quality and Health Policy Medical Director, Cancer James K. Elsey, MD, FACS Martin A. Schreiber, MD, FACS Atlanta, GA Portland, OR Patrick V. Bailey, MD, MLS, Ronald M. Stewart, MD, FACS Diana Lee Farmer, MD, FACS, FRCS FACS Medical Director, Trauma Sacramento, CA Medical Director, Advocacy

JUL 2020 BULLETIN American College of Surgeons | 5 Author bios*

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

a b c

d e f g

h i j

DR. AALAND (a) is associate professor MS. BELL (d) is Program Manager, DR. BOUGHEY (h) is W.H. Odell Professor of surgery, University of North Dakota Operation Giving Back (OGB), ACS Division of Individualized Medicine, professor of School of Medicine and Health Sciences of Member Services, Chicago, IL. surgery, and vice-chair, research, department (UND SMHS), Grand Forks, and director, of surgery, Mayo Clinic, Rochester, MN. DR. BINGHAM (e) is a general and bariatric UND Rural Surgery Support Program. She is Chair, ACS Clinical Research surgeon, director of medical student Program (CRP) Education Committee. DR. ABDEL AZIZ (b) is an acute care education, and co-director, surgical research, surgeon, Hamad General Hospital, Doha, Madigan Army Medical Center, Tacoma, WA. DR. BUTSCH (i) is a volunteer clinical Qatar, and member, American College of He is a Major in the U.S. Army Medical Corps. associate professor of surgery, Robert Larner, Surgeons (ACS) Board of Governors (B/G) MD, College of Medicine, University of MS. BISWAL (f) is nursing professional Survey Workgroup. She is the founding Vermont, Burlington. He is Chair, ACS B/G development specialist/nurses Governor of the ACS Qatar Chapter. Survey Workgroup, and Past-President, ACS improving care for healthsystem elders Vermont Chapter and Vermont Medical Society. DR. ARMSTRONG (c) is associate professor coordinator, University of Alabama of surgery, University of South Florida at Birmingham (UAB) Hospital. DR. CLANCY CLARK (j) is assistant Morsani College of Medicine, Tampa; adjunct professor of surgery and associate program DR. BOOTH (g) is regional medical director, professor of surgery, Uniformed Services director for general surgery, department Landmark Health, Ohio/Kentucky. University of the Health Sciences, Bethesda, of surgery, Wake Forest Baptist Health, MD; and Immediate Past-President and Winston-Salem, NC. He is a member, former Governor, ACS Florida Chapter. ACS CRP Education Committee and the Alliance Cancer in the Elderly Committee. continued on next page

6 | V105 No 5 BULLETIN American College of Surgeons Author bios continued

k l m n

o p q r

s t u v

DR. DAVID CLARK (k) is faculty scientist, MR. EHRHARDT (n) is a first-year DR. GAUTHIER (s) is chief surgery department of surgery, Maine Medical general surgery resident, Kendall resident, postgraduate year 5 (PGY-5), Center, Portland. He was the recipient of Regional Medical Center, Miami, FL. Mount Sinai-South Nassau, Oceanside, the 2018–2019 ACS History and Archives NY, and Lieutenant, U.S. Navy. DR. FITZGERALD (o) is director, division of Committee Archives Fellowship. surgical oncology, Tufts University School of MS. GOLL (t) is marketing and administrative DR. DuCOIN (l) is associate professor of Medicine–Maine Medical Center, Portland. coordinator, Technology Enabled Clinical surgery, chief of minimally invasive and Improvement (T.E.C.I.) Center, Stanford DR. FLOOD (p) is associate professor, bariatric surgery, and fellowship director, University School of Medicine, CA. division of gerontology, geriatrics, University of South Florida Morsani College and palliative care, University of MR. HART (u) is Executive of Medicine, Tampa. He is a member, ACS Alabama at Birmingham. Director, ACS Florida Chapter. Young Fellows Association Governing Council and ACS B/G Survey Workgroup. MS. FRANCESCATTI (q) is Senior DR. HERNANDEZ (v) is a gynecologic Manager, ACS CRP and Cancer oncologist, and professor and DR. ECKERT (m) is trauma medical Surgery Standards Program, Cancer chairman, department of obstetrics director, chief of general surgery clinics, Programs, ACS Division of Research and and gynecology, Lewis Katz School and co-director, surgical research, Optimal Patient Care, Chicago, IL. of Medicine, Temple University, Madigan Army Medical Center. He Philadelphia, PA. He is an ACS Regent. is an active-duty Lieutenant Colonel MR. FRANKEL (r) is Manager, International in the U.S. Army Medical Corps. Chapter Services and Special Initiatives, continued on next page ACS Division of Member Services.

JUL 2020 BULLETIN American College of Surgeons | 7 Author bios continued

w x y z

aa bb cc dd

ee ff gg hh

DR. HUNT (w) is Hamill Foundation MR. JOHNSON (z) is State Affairs DR. LOHR (dd) is a staff member, Distinguished Professor of Surgery in Associate, ACS Division of Advocacy William Jennings Bryan Dorn VA honor of Dr. Richard G. Martin, Sr., and Health Policy, Washington, DC. Medical Center, Columbia, SC. She is a and chair, department of breast surgical DR. KATZ member, ACS B/G Survey Workgroup. oncology, University of Texas MD Anderson (aa) is associate professor of DR. LUK (ee) is chief surgery Cancer Center, Houston. She is Program surgical oncology, University of Texas resident, UND SMHS. Director, ACS CRP, and Vice-Chair, MD Anderson Cancer Center, Houston; Cancer Surgery Standards Program. Chair, Cancer Surgery Standards Program; DR. MOHAMADIPANAH (ff) is senior and Chair, ACS CRP Cancer Care research engineer, T.E.C.I. Center, MR. JAMES (x) is nursing professional Standards Development Committee. Stanford University School of Medicine. development specialist, UAB. DR. KIRBY (bb) is director, wound MR. MOREAU (gg) is Manager, DR. JEYARAJAH (y) is assistant chair, clinical healing programs, and associate Domestic Chapter Services, ACS sciences, and head of surgery, Texas Christian professor of surgery, department of Division of Member Services. University and University of North Texas surgery, Washington University St. Louis Health Science Center School of Medicine, School of Medicine, MO. He is Vice- DR. MORRIS (hh) is associate Fort Worth; and director of gastrointestinal Chair, ACS B/G Survey Workgroup. professor of surgery, UAB. (GI) surgical services, and director, DR. LAMMERS hepatopancreatobiliary/advanced GI fellowship (cc) is a PGY-4 continued on next page program. He is a member and Communications general surgery resident, Madigan Pillar Lead, ACS B/G Executive Committee. Army Medical Center, and active-duty Captain, U.S. Army Medical Corps.

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ii jj kk

ll mm nn oo

pp qq rr

DR. MURTHY (ii) is a general surgeon DR. PARAMO (ll) is a surgical oncologist, DR. PUGH (oo) is professor of surgery and recent graduate of Indiana Mount Sinai Medical Center Comprehensive and director, T.E.C.I. Center, Stanford University, Indianapolis, general surgery Cancer Center, Miami Beach; associate University School of Medicine. residency program. She is a member, professor of surgery, Florida International DR. RANDHAWA (pp) is a third-year ACS B/G Survey Workgroup. University Werbert Wertheim College of obstetrics-gynecology resident, Reading Medicine, Miami; and clinical professor DR. NELSON (jj) is emeritus chair, Hospital, PA, and a member, Resident of surgery, Nova Southeastern University department of surgery, and past-chair, and Associate Society of the ACS. Dr. Kiran C. Patel College of Osteopathic division of colon & rectal surgery, Mayo Medicine, Ft. Lauderdale. He is a DR. REDAN (qq) is chief of surgery, Advent Clinic, Rochester, MN. She is Medical member, ACS B/G Survey Workgroup. Health-Celebration, FL; professor of surgery, Director, Cancer Programs, ACS Division University of Central Florida, Orlando; and of Research and Optimal Patient Care. DR. PELLEGRINI (mm) is professor and President and Governor, ACS Florida Chapter. chair emeritus, department of surgery, DR. O’LEARY (kk) is founding executive University of Washington, Seattle. He DR. ROCHA (rr) is a staff surgeon, surgical associate dean of clinical affairs and assistant is Past-President, ACS, and member, oncology and hepatopancreatobiliary vice-president for strategic planning, Board of The Joint Commission. surgery, Virginia Mason Medical Center, Florida International University Herbert and associate medical director, the Floyd and Wertheim College of Medicine, Miami. MR. PEREGRIN (nn) is Senior Editor, Delores Jones Cancer Institute, Seattle, WA. Bulletin of the American College of Surgeons, ACS Division of Integrated continued on next page Communications, Chicago, IL.

JUL 2020 BULLETIN American College of Surgeons | 9 Author bios continued

ss tt uu vv

ww xx yy zz

aaa bbb ccc ddd

DR. ROSE (ss) is assistant professor DR. TEFERA (xx) is professor of surgery, DR. WELSH (aaa) is a general surgeon, of surgery, UAB, division of department of surgery, University of Batesville, IN. He is a member, American surgical oncology, and director, UA Wisconsin, Madison; and vice-chair, division Medical Association (AMA) Council Pancreatobiliary Disease Center. of vascular surgery, and chief of vascular on Science and Public Health, and surgery, Middleton Veteran Affairs Hospital chair, Organized Medical Staff Section MR. RUSSELL (tt) is associate vice- in Madison. He is Medical Director, OGB. Governing Council, AMA. He is a president, business analytics and consultant, ACS B/G Survey Workgroup. decision support, UAB Hospital. MS. VICKERS (yy) is research technician, department of health behavior, UAB. MR. WISE (bbb) is researcher, MS. SCHNEIDMAN (uu) is Editor-in-Chief, T.E.C.I. Center, Stanford University Bulletin of the American College of Surgeons, ACS DR. WEIGEL (zz) is the E.A. Crowell, Jr. School of Medicine. Division of Integrated Communications. Professor and chair of surgery, professor of surgical oncology and endocrine MS. WITT (ccc) is lab manager, MS. SIMMONS (vv) is a nursing professional surgery, professor of biochemistry, T.E.C.I. Center, Stanford University development specialist, UAB Hospital. professor of anatomy and cell biology, School of Medicine. DR. SMITH (ww) is head, department and professor of molecular physiology MS. WOOD (ddd) is researcher, division of surgery, and head, department of and biophysics, University of Iowa, of gastrointestinal surgery, UAB. cardiothoracic surgery, School of Clinical Iowa City. He is Chair, ACS B/G. Sciences, Monash Health, Monash University, Clayton, Victoria, Australia. He is President and Governor, ACS Australia and New Zealand Chapter.

10 | V105 No 5 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

imes of crisis call for leadership. During the coronavirus disease 2019 (COVID-19) pan- Tdemic, surgeons and other health care pro- Sensing the direct involvement of the fessionals have demonstrated their extraordinary leader is reassuring. Being visible is dedication to maintaining quality care. More recently, we have witnessed and responded to tur- possibly the most important thing moil in the nation after the tragic death of an a leader can do in a time of crisis. unarmed black man, George Floyd, while in the custody of Minneapolis, MN, police officers. The American College of Surgeons (ACS) has provided resources and guidance to its members who have been battling COVID-19 on the front- lines. Much of this information was reported through a twice-weekly e-newsletter, Bulletin: ACS COVID-19 Updates. As the curve flattened in many areas of the nation in the middle of May, we moved to weekly publication of Bulletin Brief, an e-newsletter that highlights not only the Col- lege’s leadership in caring for patients who have been affected in some way by the pandemic, but also patients who had to reschedule a nonemergent operation. The College also issued comments condemn- ing racism and police brutality after the deaths of Mr. Floyd and Breonna Taylor, a 26-year-old African-American emergency medical technician in Louisville, KY. We stated:

The ACS stands in solidarity against racism, violence, and intolerance. Our mission is to serve all with skill and fidelity, and that extends beyond the operating room. Racism, brutal attacks, and subsequent violence must end. We will help any injured, and we will use our voice in support of the health and safety of every person.

Furthermore, the ACS Committee on Ethics and the Board of Regents issued a call to action June 9, stating that racism is a public health crisis, resulting in health care inequities and asking

JUL 2020 BULLETIN American College of Surgeons | 11 EXECUTIVE DIRECTOR’S REPORT

all members of the organization to treat all patients, and will have a pretty good idea of where the situation regardless of race, ethnicity, religion, or sexual pref- stands. Being truthful, even if that means providing erence with compassion, skill, and fidelity. information that may not be desired, is important. In as much as the leader remains credible, followers will respect him/her as a leader and do what they are asked How to lead during a crisis to do. Err on the side of overinforming, recognizing that Early on in the COVID-19 crisis in the U.S., I was sometimes truly confidential information may need to in contact with Carlos A. Pellegrini, MD, FACS, be kept private. Because most people are terrible at keep- FRCSEd(Hon), FRCS(Hon), FRCSI(Hon), Past- ing a secret, a leader should be the first one to provide President of the ACS. He noted, “This is not leader- the news. By being the first to communicate good and ship as usual—this is leadership on the edge,” and bad news, a leader ensures that accurate information is offered the following tenets for leaders in the diffi- shared and is seen as the trusted source. cult days ahead: • Exercise pragmatic optimism. Remain true to the facts • Be present. Crises engender anxiety and fear among and anchor the message in reality, but sound a note of all those affected. Sensing the direct involvement of optimism. Remind people that there is a “way out of the the leader (by written communications, personal out- crisis,” and describe a future worth pursuing. reach to the members of the organization known to be more vulnerable, visibility through social networks, • Delegate and empower. Exercising authority at a time and so on) is reassuring. Being visible is possibly the of crisis may help ensure that decisions contribute to most important thing a leader can do in a time of crisis. solving problems, but it also can become obstructive, creating a bottleneck when all decisions and responsibili- • Communicate frequently. The best way to avoid panic ties go through one person. A good leader has chosen his among those who are fearful and anxious is to hear or her associates well and must empower them. Trusted from the leader frequently with updates on what is hap- allies will support their leader and enable that individ- pening and what actions are being taken/considered to ual to achieve much more than one can achieve alone. ameliorate the crisis. Of course, delegation and empowerment of other team members can have a downside. If other members • Communicate thoroughly. Share with the group more of the team develop solutions and move ahead with a rather than less. This situation calls for more talk, for plan that is not aligned with the leader’s vision, the rest storytelling, rather than “cold instructions.” Connecting of the workforce will have unclear direction and receive with the constituency is more important than issuing mixed messages about their responsibilities and roles. dictates. Communications should explain clearly and Thus, constant communication with allies and the team concisely what is expected. The challenge for the leader is necessary and should emphasize gratitude for what is to strike the right balance, bearing in mind that con- they are doing and the need, while in crisis mode, to stituents will remember when they heard their leader communicate their actions and intentions to the leader. speak from the heart. This type of connection is how In moments of crisis, most leaders want to be completely people build relationships. informed and to have a chance either to be the official conduit for communication or to have the opportunity • Communicate truthfully. Most members of a team will to modulate the discussion, so the message matches have collected information from a range of sources their vision.

12 | V105 No 5 BULLETIN American College of Surgeons . EXECUTIVE DIRECTOR’S REPORT

Leaders and their constituents feel comfortable following strategies that they have crafted. Crisis management, particularly in severe crisis, may require that we ignore elements of a strategic plan that up to that time have been guiding our actions.

• Generate support from the constituency. Buy-in from • Be resilient (and patient). The anxiety and the fears all individuals affected will hasten achievement of that followers feel as a result of the crisis will fre- the goal. Consultation and engagement to the extent quently manifest as criticism of the actions the leader possible will contribute to feelings of ownership. A key takes. The leader’s authority, judgment, and style may element will be appealing to constituents’ shared values, be questioned. Leaders must muster all the resilience the sense that they are involved in a worthy and just possible to maintain inner calm, confidence, and the cause, and that the cause is aligned with the mission/ ability to take the high road. This is not a time to feel vision of the organization. Crisis management requires hurt, victimized, or to seek justice. This is a time to identifying the “north star” and following it. stand tall, acknowledge the criticism, and move forward without thoughts of retaliation. Taking the high • Manage the relationship with superiors and constit- road will inspire followers and provide support and uents. In times of crisis, a leader must show support for an example to all. the decisions of the leadership of the entire organization and simultaneously listen to constituents and decide I want to commend the College’s officials, mem- when and how to communicate upward their feelings. bers, and staff for taking the high road throughout the The more intense the crisis, the more difficult it will be COVID-19 outbreak and the mostly peaceful protests to question the top officials’ decisions, and the leader this summer. You have repeatedly shown a commit- may have to “sell” them to his or her constituency. ment to doing what is best for the surgical patient. The long-term effects of these crises may linger for some • Define the magnitude of the crisis. Leaders and their time. I have every confidence that we will get through constituents feel comfortable following strategies that this period together because of your leadership. ♦ they have helped to craft. Crisis management, particularly in severe crisis, may require that we ignore elements of a strategic plan that until that time have been guiding our actions (key performance indica- tors, finances, volume of patients seen, and so on). One should be very careful about declaring a “crisis” as such, but COVID-19 is unprecedented and will require that we concentrate on “navigating through these difficult storms” rather than following the path decided upon. During the management of a crisis, leaders must strike the balance between two different activities: those related to the management of the crisis and those associated with more routine business. It must be clear to the followers whether the leader’s actions are related to management of the crisis or conduct of business. The former will be associated with a more authoritarian style, whereas the latter lends itself to a more democratic style. Clarity regarding management mode will allow everyone to If you have comments or suggestions about this or other issues, please function effectively. send them to Dr. Hoyt at [email protected].

JUL 2020 BULLETIN American College of Surgeons | 13 COMMENTARY Dear sir or madam, @   Letters to the Editor  @ To whom it may concern,

Editor’s note: The following A recent survey of practicing comments were received The future of surgery is female women surgeons in the U.S. regarding recent articles Over the last decade, the number showed that nearly 60 percent published in the Bulletin. of women entering surgical reported having experienced training has increased. In the U.S., sexual harassment, versus Letters should be sent with the number of women in general 25 percent of men.3 Another study the writer’s name, address, surgery residency programs revealed gender bias in evaluations e-mail address, and daytime has doubled from 20 years ago.1 of women residents in surgical telephone number via e-mail On the other side of the globe, training programs.4 Beyond to [email protected], or the College of Surgeons of East, gender-based discrimination and via mail to Diane Schneidman, Central and Southern Africa saw a aggression at the micro-level, Editor-in-Chief, Bulletin, American drastic increase in women trainees systemic inequities and structural College of Surgeons, 633 N. Saint from 8 percent to 23 percent sexism persist in surgery. Clair St., Chicago, IL 60611. just in the last three years (see Women are still paid related story, page 51).2 Moreover, significantly less than men. In Letters may be edited for length aspiring and new surgical Canada, women surgeons were or clarity. Permission to publish trainees are emerging leaders, found to be paid 24 percent less per letters is assumed unless the as shown in the student session hour spent operating than men.5 author indicates otherwise. on trainee involvement in Itum and colleagues also found global surgery at the American that only half of U.S. residency College of Surgeons Clinical programs offer paid parental Congress 2019, which was leave.6 These disparities create a entirely organized by women toxic working environment that medical students and residents. makes balancing surgical training Thanks to many trailblazing with family life more difficult for women, progress is clearly being women. It is no surprise that the made toward parity. With women attrition rate for women surgical often outnumbering men in trainees is higher than for men.7 medical schools, the future is The further we look on promising for gender balance in the hierarchical ladder, the surgery. However, has the surgical fewer women we find. In the training environment and culture U.K., the percentage of women kept pace with this change? Can consultant surgeons in 2019 was these women climb the ladder 12.9 percent.8 In 2017, Epstein from trainee, to consultant, to analyzed the literature on professor in the same way as full professorships in surgery their male counterparts do? and found that the number of

14 | V105 No 5 BULLETIN American College of Surgeons COMMENTARY Dear sir or madam, @     @ To whom it may concern,

women was so low, and the increase so slow, that REFERENCES it would take 120 years to reach gender parity.9 1. Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. It is important to celebrate the increase in the The climb to break the glass ceiling in surgery: Trends number of women entering surgery. However, we in women progressing from medical school to surgical need to do more to retain, nurture, and maximize training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-572. their potential. Women trainees and surgeons must 2. Odera A, Tierney S, Mangaoang D, Mugwe R, be treated better. Accountability measures for sexual Sanfey H. Women in Surgery Africa and research. Lancet. harassment, microaggressions, and all forms of 2019;393(10186):2120. gender-based discrimination must be implemented. 3. Nayyar A, Scarlet S, Strassle PD, et al. A national survey Policy changes should be made to accommodate of sexual harassment among surgeons. American Surgical Congress 2019. Abstract 85.06. Available at: www.asc- family planning and to prevent the penalization abstracts.org/abs2019/85-06-a-national-survey-of-sexual- of childbearing. This step will not only encourage harassment-among-surgeons/. Accessed June 5, 2020. more women to climb the career ladder, but also 4. Gerull KM, Loe M, Seiler K, McAllister J, Salles A. may improve their male colleagues’ quality of Assessing gender bias in qualitative evaluations of surgical life because men also benefit from parental leave. residents. Am J Surg. 2019;217(2):306-313. 5. Dossa F, Simpson AN, Sutradhar R, et al. Sex-based The relationship between physician wellness and disparities in the hourly earnings of surgeons in the 10 patient outcomes is clear. Thus, surgical training fee-for-service system in Ontario, Canada. JAMA Surg. programs owe it to patients to make surgical 2019;154(12):1134-1142. training a period when trainees can thrive both 6. Itum DS, Oltmann SC, Choti MA, Piper HG. Access to professionally and personally, regardless of gender. paid parental leave for academic surgeons. J Surg Res. 2019;233(1):144-148. As we start a new decade, we should acknowledge 7. Liang R, Dornan T, Nestel D. Why do women leave that the future of surgery is female. It is time for surgical training? A qualitative and feminist study. Lancet. surgery to shift away from its patriarchal norms and 2019;393(10171):541-549. better accommodate the new, eager female workforce. 8. The Royal College of Surgeons of England. Statistics. Bringing gender parity to the surgical workforce Women in surgery. Available at: www.rcseng.ac.uk/careers- in-surgery/women-in-surgery/statistics/. Accessed June 5, is an opportunity to increase the attractiveness 2020. of surgical training and improve patient care. 9. Epstein NE. Discrimination against female surgeons is Zineb Bentounsi, MD still alive: Where are the full professorships and chairs of Oxford, U.K. departments? Surg Neurol Int. 2017;8:93. Eliana E. Kim 10. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A systematic review of the impact of San Francisco, CA physicians’ occupational well-being on the quality of patient Xiya Ma, MSc care. Int J Behav Med. 2015;22(6):683-698. Montréal, QC

JUL 2020 BULLETIN American College of Surgeons | 15 THE ROLE OF THE SITE REVIEWER

The role of the site reviewer:

Ensuring patient-centered standards for optimal patient outcomes

by Tony Peregrin

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(CoC), the Metabolic and Bariatric Surgery Accredita- HIGHLIGHTS tion and Quality Improvement Program (MBSAQIP), • Identifies how accreditation standards the National Accreditation Program for Breast Cen- enhance quality of care ters (NAPBC), the National Accreditation Program for • Describes the qualities of effective site reviewers Rectal Cancer (NAPRC), and Trauma Verification and Review Committee (VRC) (see Figure 1, page 20). Pro- • Provides examples of process improvements gram standards criteria range from 20 to 200 standards developed from reviewer feedback or more depending on the specialty (CSV and Trauma • Summarizes the College’s initiative to align ACS have the highest number of standards because of the Quality Programs to enhance client experience complex nature of those specialties). According to the Optimal Resources for Surgical Qual- ity and Safety manual (also known as the Red Book), Editor’s note: Because of the coronavirus disease 2019 “In high reliability organizations (HROs), the focus is (COVID-19) pandemic, the American College of Surgeons on development and implementation of effective sys- (ACS) Quality Programs are exploring innovative virtual tems, transparency, and teamwork. The intent is to options for the traditional in-person site visit. Each ACS bring process failures and systemic issues to light and Quality Program suspended on-site visits during the pan- to solve them in a nonpunitive way. Lessons learned demic and has developed a proposed plan and agenda from analysis of errors are shared as best practices in for conducting these reviews in the future. Pilot sites for order to mitigate future errors.”1 alternative approaches are being identified this summer. The Red Book also identifies specific concepts that The ACS will provide updates on these programs as they reinforce the principles of high reliability, including become available. standardization of best practices that reduce unwar- ranted variation and optimizes reproducible outcomes.1 ach of the ACS quality improvement (QI) accred- “When care is standardized, variation arises only itation and verification programs is a singular because of differences in patient needs or resources,” Eentity tasked with the responsibility of verifying according to the manual. “Standardization accentuates compliance with the standards established for that deviations from best practices, making them easier to particular specialty. All of the programs feature the spot than if every health care provider used a different same general structure: application, pre-review ques- approach to deliver care.”1 tionnaire (PRQ), site visit, assessment, and facility Site reviewers, previously referred to as “surveyors,” report. are trained members of the health care team that assist This article focuses on requirements for the site facilities in identifying gaps in their adherence to stan- reviewer role, characteristics shared by productive dards, enabling HROs to continue to provide consistent, reviewers, and real-world examples of process improve- high-quality care to the surgical patient. ments tied to reviewer assessment. At present, 388 surgeons serve as site reviewers for the following ACS accreditation and verification Accreditation standards programs, collectively known as the ACS Qual- enhance quality of care ity Programs: the Accredited Education Institutes, The ACS Quality Programs collectively accredit and/ the Children’s Surgery Verification (CSV) Quality or verify more than 3,000 hospitals. Studies examining Improvement Program, the Commission on Cancer the effectiveness of these programs suggest that the

JUL 2020 BULLETIN American College of Surgeons | 17 THE ROLE OF THE SITE REVIEWER

Dr. Margulies

levels of care necessary to meet accreditation standards Requirements to serve as a reviewer lead to improved quality of care. The minimum qualifications for the site reviewer role For example, a study published in the Journal vary by program, but generally the requirements are of Trauma examined the effect of preparing for and organized into three main components: credentials/ achieving ACS Level I trauma verification on patient affiliations and skills and knowledge.5-8 A site reviewer outcomes and hospital performance. After evaluating must be in active practice in a clinical, academic, or 1,098 trauma patients admitted to a facility in 1994, administrative role and employed or affiliated with the and 1,658 patients admitted in 1998, the authors con- corresponding ACS-accredited program. As for the skills cluded, “Trauma system improvement as related to and knowledge component, reviewers should have an achieving ACS Level I verification appeared to have extensive and demonstrable knowledge of the current a positive impact on survival and patient care,” with standards, significant knowledge of specialty registries a notable decrease in mortality for severely injured where applicable, and strong verbal and written com- patients, a marked decrease in average length of stay, munication skills.5-8 The site visit team typically includes and an estimated cost savings for 1998 of more than one to five members, depending on the program and $4,000 per patient.2 site request (the average is a three-person team), with Another study published in the Journal of the Amer- one individual designated as the lead reviewer. ican College of Surgeons compared bariatric surgery “Certain requirements are in place that are outcomes in U.S. accredited versus nonaccredited unchangeable,” including that the reviewer is active centers based on a review of 13 studies that covered in the specialty, according to Daniel Margulies, MD, more than 1.5 million patients. Researchers found that FACS, professor of surgery, Cedars-Sinai Medical “10 of the 13 studies identified a substantial benefit of Center; chief section of trauma, emergency surgery Center of Excellence accreditation for risk-adjusted and surgical intensive care, University of California- outcomes, and six of the eight studies reported a con- Los Angeles, David Geffen School of Medicine; and siderable reduction in mortality in patients operated Chair, ACS VRC Program Committee. “An older sur- on in Centers of Excellence.”3 geon who is no longer active will not be allowed to ACS CoC accreditation programs also have been continue to do reviews. We actually remove them as linked to improved outcomes. A survey of the CoC reviewers within one year of retirement. In terms of and NAPBC program participants revealed more than the young reviewers, there’s a requirement that they 90 percent of respondents displayed a “high level of have to have been a trauma director or director of a agreement that accreditation is regarded as important service like the surgical intensive care unit, and gener- in improving oncologic outcomes through compli- ally a very young, inexperienced person is not going ance with standards that include continuous quality to be in that role,” said Dr. Margulies, who became a improvement.”4 VRC reviewer in October 2011. Although the literature suggests that accreditation Teresa LaMasters, MD, FACS, FASMBS, DABOM, standards are linked to improved quality of care, the medical director, bariatric surgery, UnityPoint Clinic Red Book notes a “paucity of research that evaluates Weight Loss Specialists, Des Moines, IA, and a reviewer accreditation status and surgical quality” and states, for MBSAQIP since September 2014, noted that capable “...further research to specifically address outcomes reviewers generally have been in practice seven to 15 at accredited institutions will better illuminate the years. specific structural components of care that may be Someone who has been in practice for five to associated with improved outcomes.”1 seven years and is invested in learning about quality

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Dr. LaMasters could definitely be a good site reviewer, Dr. LaMas- for me,” said Dr. LaMasters. “The previous system ters added. “But a lot of surgeons early in their would isolate each member of the team in something careers are focused on practice building. And some like an interrogation room in an effort to identify of them have not really learned the principles behind problems rather than work with the whole team quality improvement. I think that seven-year mark together to talk through processes and understand is ideal because these physicians have some experi- the reasoning behind the processes. When I came ence, they’re excited to learn, and they have some in as a site reviewer, I felt like that approach should time to commit to doing this.” be completely flipped on its head. The team should Site reviewers must be willing to commit six be kept together. The physician leadership should be to 12 hours per site visit, with an additional two there, and it should be an open, collaborative pro- to four hours for preparation and final review. cess for learning rather than an isolating process.” Depending on the program, each reviewer should Peter Hopewood, MD, FACS, a site reviewer for plan on participating in four to eight site visits a both the CoC and NAPBC, and a surgeon with Cape year as specified in the individual specialty site Cod Healthcare Cancer Programs, Falmouth, MA, reviewer agreement. said he became a reviewer to gain exposure to inno- Linda Farkas, MD, FACS, a site reviewer for vative quality improvement practices. NAPRC, and professor of surgery with University of “I’m in Cape Cod, so I’m a little out of the main- Texas-Southwestern, Dallas, noted that time-related stream,” Dr. Hopewood said. “I’m not in an academic barriers are a significant challenge in recruiting hospital, I’m in a community hospital, and the initia- new reviewers. “There are a lot of surgeons whose tives (clinical trials, community outreach activities) salaries are based on revenue, or they’re in a busy that are happening in the academic teaching centers practice where they’re just not afforded the time to can take years to filter down into the community take off to be on a site visit,” explained Dr. Farkas. hospitals. However, as a reviewer, I’m visiting these “In those instances, surgeons would have to use centers and I’m observing cancer conferences as part their vacation time, or the revenue’s going to be of the site visit, and I’m talking to all the specialists. down. If we had more reviewers, especially if we I learn a lot. So, it’s helping my practice and improv- could get more surveyors distributed across the ing the care I give to my patients.” country, then maybe the time commitment wouldn’t be so bad—so the reviewer in Florida doesn’t have to fly to Washington if we can have a reviewer who Qualities of effective reviewers lives in Oregon.” Effective site reviewers share specific personality and Site reviewers are compensated for their time and leadership traits, including a collaborative approach to effort. The College provides an honorarium to each and an innate interest in quality improvement starting reviewer, which generally is used to cover the cost of at the local level. For example, site reviewers often are travel expenses. Although the honorarium is a prac- involved in their hospital’s QI committee or are peer tical benefit, reviewers are motivated to take on this reviewers or case reviewers for a medical board or jour- role for a variety of reasons—from an interest in refin- nal before taking on the site reviewer role. ing the accreditation/verification process to learning “When selecting a reviewer, we look for some- best practices employed at other institutions. one who is actively doing this in their own center,” “I had undergone a site review in a previous said Douglas C. Barnhart, MD, MSPH, FACS, FAAP, system, and that site review was really unsatisfying continued on page 21

JUL 2020 BULLETIN American College of Surgeons | 19 THE ROLE OF THE SITE REVIEWER

FIGURE 1. ACS QUALITY PROGRAMS

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Dr. Farkas who started his role as a CSV reviewer in January paying for, more than data registries or anything else— 2017. Dr. Barnhart is a professor, division of pediat- the education, the consultation, the mentoring, and the ric surgery, University of Utah School of Medicine, sharing of best practices that our reviewers offer them.” and medical director for surgical patient safety and quality, Primary Children’s Hospital, Salt Lake City, UT. “Reviewers should know from their own experi- Preparing for a site visit ence which standards are hard and which ones are ACS accreditation/verification programs share some aspirational. Effective reviewers will recognize the similar practices based on compliance with patient- struggles involved in solving some of these problems centered standards. For example, each program has and will appreciate the work that’s been done, rather a manual that outlines the optimal resources for care than focusing only on the gap. I always introduce the of the patient served in each program.9-11 fact that I come from a center that’s been through Each program also employs varying business pro- the verification part, and that we appreciate all the cesses for verifying and accrediting participating work that they’ve gone through. Reviewers should facilities. For example, during the verification review also be actively practicing clinicians. Our foremost process, a trauma center is assessed on criteria out- goal is improving patient care, and in order to do that, lined in the ACS Trauma Programs’ standards manual, reviewers should have ongoing, direct experience in including volumes of severely injured patients, 24-hour caring for patients.” availability of trauma surgeons and other specialists, “As a site reviewer, you have to be patient and a surgical capabilities, and availability of specialized little charismatic,” said Dr. Farkas. “Team members equipment. Based on the review, the trauma center is at the site may be a little nervous when you come in categorized as Level I, II, or III.12 because you’re a surgeon and a site reviewer, and they The site review process generally occurs in four may be program nurse coordinators, for example, and phases: reviewer selection, pre-site visit preparation, feel like their job is on the line with this survey.” She site visit, and report generation. added, “The purpose of the survey is not to be puni- A notable component of the pre-site verification tive; it is to give hospitals feedback so that they can get process is the completion of a pre-review document. over any impediments necessary for accreditation.” For most programs, such as trauma and CSV, this According to Dr. LaMasters, “You have to be able document is the PRQ. These questionnaires inform to articulate the entire vision of the accreditation pro- reviewers of the existing care capabilities of the hos- cess and goals and spirit on the positive side, not just pital or center before the on-site review.13 the negative side, and to do it in a way that I think “These site visits aren’t intended to be a surprise really inspires them to want to continue to improve inspection with some element for which people aren’t their quality, to see where they can go next, to not be prepared,” said Dr. Barnhart. “For example, when we complacent or content simply because they passed.” had our site visit here, I knew we had some areas of “It’s just not about checking a box, indicating the weakness, having read the criteria and having been hospital was compliant or not compliant, and that’s on some of these site visits. I knew we had some prob- why it’s so critical for us, across all of our programs, lem areas that we were in the process of solving but that we pick the right people to do these site visits, be had not completely solved. And in my introductory they surgeons, nurses, other physician specialists, or comments to our site visit, I said, ‘Look, I want to others,” said Teresa Fraker, MS, RN, Program Admin- tell you about our place. I want to tell you about our istrator, MBSAQIP. “Because that’s what our sites are strengths, and I want to show you two things that

JUL 2020 BULLETIN American College of Surgeons | 21 THE ROLE OF THE SITE REVIEWER

Dr. Hopewood

we’ve struggled with. I’m going to show you our audit kept at a specified temperature, rather than in a cooler data.’ That’s really what we’re looking for places to do. where the blood warms up and is basically wasted if it If you know your weaknesses, and you’re committed is not used,” Dr. Margulies said. to performance improvement, you’ll solve your weak- Dr. Hopewood said a process improvement his insti- nesses,” Dr. Barnhart said. tution is adopting—based on what he encountered as “We’re not saying that you have to be perfect, but a site reviewer—involves decreasing emergency room we are saying you should have a process in place to (ER) visits and unexpected admission for chemotherapy look at your mistakes, think critically about them, and patients. “Some programs preemptively call patients work to make a sustainable change in your program early in the morning to ascertain how they are feel- that addresses problems more generally than just looking. Certain chemotherapy regimens result in potential ing at outcomes,” added Dr. Margulies. diarrhea or neutropenia, and targeting those patient “I tell the team that throughout the day I’m going populations and leaving room for empty appointments to look for things that they can do better, and that later in the day can reduce visits to the ER, resulting in doesn’t mean that they’re not doing a great job. We better quality of care,” Dr. Hopewood said. all can learn to do things better,” said Dr. LaMasters. Dr. LaMasters said process improvements often “I try to engage each person in the team around the entail understanding why the standard was created standards and how they apply to this part of the site and realizing the difference between “the letter of the visit. It’s not just about the case that we’re auditing, it’s law and the spirt of the law.” really about how you develop the team culture to get “The letter of the law might state that you have to everybody behind a process improvement that came have equipment that is weight-based appropriate for from this adverse event.” our patients, but the spirit of the law means understanding that you can’t have only one chair in your waiting room that is appropriate for a person of size Process improvements because often family members may also be of size,” Site reviewers identify patient care challenges across a explained Dr. LaMasters. “Understanding that the con- spectrum of clinical topic areas and offer suggestions cept of this standard is to help the entire institution for improvements in administrative processes related recognize and be sensitive to patients of size and to to equipment needs, scheduling and job sharing, and be prepared to care for those patients wherever they time management. occur in the institution—even though I’m specifically “One program was able to arrange one-stop shop- reviewing the sites where bariatric surgery patients ping for its patients so that they can get their CEA will go,” she said. [carcinoembryonic antigen], their CAT [computerized axial tomography] scan, and their MRI [magnetic resonance imaging] in one day,” said Dr. Farkas, noting Aligning ACS Quality Programs that such strengths are institution-specific and may be To unify ACS quality programs, the College launched difficult to achieve at every site. a project in July 2017 to enhance both the site reviewer Dr. Margulies offered another example of a process and the client experience. Although each program was improvement, one that a site reviewer to his institu- originated with the similar aim of improving surgical tion sought to replicate at his center. “The use of whole care, the models to achieve that goal varied by specialty. blood is new in trauma. We developed a mobile refrig- The ACS alignment team identified three goals to erator so that the blood that is sent out to trauma is unify ACS Quality Programs, including the development

22 | V105 No 5 BULLETIN American College of Surgeons THE ROLE OF THE SITE REVIEWER

Dr. Barnhart of a shared information technology platform, similar site visit REFERENCES and performance reports, and a common standards framework 1. Hoyt DB, Ko C (eds). Optimal Resources for and template, including both the formatting and branding of the Surgical Quality and Safety. Chicago, IL: standards manuals. This updated standards framework com- American College of Surgeons; 2017. prises nine standard domains: 2. DiRusso S, Holly C, Kamath R, et al. Preparation and achievement of American College of Surgeons level I trauma verification • Institutional administrative commitment raises hospital performance and improves patient outcome. J Trauma. 2001;51(2):294-299. • Program scope and governance 3. Azagury D, Morton JM. Bariatric surgery outcomes in U.S. accredited vs non-accredited centers: A systematic review. J Am Coll Surg. • Facilities and equipment resources 2016;223(3):469-477. 4. Knutson AC, McNamara EJ, McKeller DP, • Personnel and services resources Kaufman CS, Winchester DP. The role of the American College of Surgeons’ cancer • Patient care: Expectations and protocols program accreditation in influencing oncologic outcomes. J Surg Oncol. 2014;110(5):611-615. 5. American College of Surgeons. Quality • Data surveillance and systems Programs. National Accreditation Program for Rectal Cancer. Become an NAPRC site • Quality improvement reviewer. Available at: facs.org/quality- programs/cancer/naprc/site-reviewer. Accessed March 17, 2020. • Education: Professional and community outreach 6. American College of Surgeons. Quality Programs. Commission on Cancer. Become a • Research site visit reviewer. Available at: facs.org/quality- programs/cancer/coc/become-site-reviewer. In 2019, the MBSAQIP was the first program to translate its Accessed March 17, 2020. 7. American College of Surgeons. Quality standards into the new framework, successfully meeting one Programs. National Accreditation Program of three goals the ACS established to unify these programs. for Breast Centers. Become a site reviewer. Other programs migrating to the new standards format this Available at: facs.org/quality-programs/napbc/ year include: become-reviewer. Accessed March 17, 2020. continued on next page • GSV: July 2019

• CoC: October 2019

• NAPRC: May 2020

• Trauma: 2021 (Q1)

• CSV: 2021 (Q1)

• NAPBC: late 2021

JUL 2020 BULLETIN American College of Surgeons | 23 THE ROLE OF THE SITE REVIEWER

In March 2019, the ACS Quality Portal (QPort) was com- REFERENCES, CONTINUED pleted, successfully meeting another goal in the alignment 8. American College of Surgeons. Quality Programs. process. The MBSAQIP was the first to migrate to QPort, Verification, Review, and Consultation Program. and other quality programs will be migrating to the portal VRC site reviewer criteria and application. Available at: facs.org/quality-programs/trauma/ in the near future. tqp/center-programs/vrc/reviewer. Accessed Alignment efforts are intended to provide consistent, high- March 17, 2020. quality experiences to all our hospitals participating in ACS 9. American College of Surgeons. Quality Programs. Quality Programs. By providing a consistent framework for Verification, Review, and Consultation Program. the standards manuals, portal, and reports for all ACS verifica- The VRC consultation process. Available at: facs.org/quality-programs/trauma/tqp/center- tion programs, the ACS aims to bring QI and leadership teams programs/vrc/process. Accessed March 17, 2020. at participating hospitals together to work toward surgical 10. American College of Surgeons. Quality Programs. quality within their institutions. The objective is to provide Children’s Surgery. Children’s Surgery Verification. a road map of strengths and opportunities for improvement. Available at: facs.org/quality-programs/childrens- surgery/childrens-surgery-verification. Accessed March 17, 2020. 11. American College of Surgeons. Quality Programs. ACS Quality Programs in the future Commission on Cancer. Apply for accreditation. With more than 105 years of experience in QI, the ACS con- Available at: facs.org/quality-programs/cancer/ tinues to define the standards necessary to provide optimal coc/apply. Accessed March 17, 2020. patient care across all surgical specialties. The College’s ongo- 12. Bost SJ, Ball JN, Sanddal ND, et al. ACS COT leads study to develop comparative data on trauma care ing commitment to this goal continues with the development organization. Bull Am Coll Surg. 2020;105(4):43-48. of a new standards-based program—a verification program Available at: bulletin.facs.org/2020/04/acs-cot- based on the Optimal Resources for Surgical Quality and Safety, participates-in-study-to-develop-comparative-data- with pilot visits occurring over the last year.14,15 on-trauma-care-organization/. Accessed June 19, Site visits are an essential component of achieving qual- 2020. 13. American College of Surgeons. Quality Programs. ity in all phases of surgical care. Standardizing the College’s Commission on Cancer. Site visit preparation. approach to verification and accreditation processes for both Pre-Review Questionnaire. Available at: facs.org/ established and new Quality Programs will likely enhance quality-programs/cancer/coc/accreditation/site- the effectiveness of site reviews. visit-prep. Accessed March 17, 2020. “Participation in accreditation programs does not guar- 14. Hoyt DB. Executive Director’s annual report. Bull Am Coll Surg. 2019;104(12):37-53. Available at: antee high-quality care,” note the authors of the Red Book, bulletin.facs.org/2019/12/2019-executive-directors- 1 “but it does demonstrate a commitment to such aims.” The annual-report/. Accessed April 1, 2020. authors assert that “clearly defined roles and responsibili- 15. Puls MW, Hughes TG, Sarap MD, Caropreso ties, coupled with appropriate resources and support” can PR, Nakayama DK, Welsh DJ. New ACS-led lead to improved patient outcomes, shorter lengths of stay, verification program aims to improve care for rural surgical patients. Bull Am Coll Surg. and a reduction in costs. ♦ 2020;105(4):24-28.

24 | V105 No 5 BULLETIN American College of Surgeons THE SURGICAL METRICS PROJECT

The Surgical Metrics Project: What was achieved, and where is it headed?

by Carla Pugh, MD, PhD, FACS; Cassidi Goll; Anna Witt; Hossien Mohamadipanah, PhD; and Brett Wise

JUL 2020 BULLETIN American College of Surgeons | 25 THE SURGICAL METRICS PROJECT

linical Congress 2019 provided the opportunity for surgeons to participate in The Surgical CMetrics Project. A total of 255 attendees visited The Surgical Metrics Project booth to explore the use of wearable technologies as a means of measur- ing surgical decision making and surgical technique. Spearheading the effort is Carla M. Pugh, MD, PhD, THE SURGICAL METRICS PROJECT FACS, coauthor of this article and professor of surgery, RESEARCH ADVISORY BOARD MEMBERS and her research team at the Technology Enabled • Peter Angelos, MD, PhD, FACS Clinical Improvement (T.E.C.I.) Center, Stanford • Megan Applewhite, MD, FACS University, CA. The initial goal of The Surgical Met- rics Project is to enable information exchange and • Jo Buyske, MD, FACS facilitate data sharing. It is imperative that surgeons • E. Patchen Dellinger, MD, FACS lead the discussion about how their data should be • David Hoyt, MD, FACS managed and applied. The Surgical Metrics Project exhibit contained 10 • Carlos Pellegrini, MD, FACS, FRCSI(Hon), surgical simulation stations where participants were FRCS(Hon), FRCSEd(Hon) equipped with wearable technologies and asked to “run • Steven Stain, MD, FACS the bowel” and perform an open repair of any small • Patricia Turner, MD, FACS bowel enterotomies identified in a segment of porcine intestines. COMMITTEE ON SURGICAL SKILLS TRAINING FOR PRACTICING SURGEONS Participation in The Surgical Metrics Project • Barbara Bass, MD, FACS, FRCS(Hon), Upon entering The Surgical Metrics Project exhibit, FRCSI(Hon), FCOSECSA(Hon) participants completed a one-page demographic survey. • Ajit Sachdeva, MD, FACS, FRCSC, FSACME A summary of the survey results are shown in Figure 1, page 27. After providing their demographic information, participants were fitted with a wearable electroenceph- alography (EEG) sensor to record and measure brain activity (see Figures 2a–2c, page 28). The sensors were attached to their foreheads, at which point participants were led to the cognitive testing area to undergo a baseline assessment of their cognitive skills. Participants were then outfitted with magnetic motion-tracking sensors on their hands and an audio recorder on their lab coat. Once participants were fully instrumented with the wearable technologies (see Figure 2d, page 28), they stepped into one of the

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FIGURE 1. SURVEY RESPONDENT DEMOGRAPHICS (N = 255)

10 simulated surgical environments equipped with decisions using magnetic motion-tracking sensors, two video cameras, a stopwatch, one surgical assis- audio recorders, video cameras, and EEG sensors. tant, and all of the surgical tools necessary to operate Upon completion of the simulated surgical pro- on their “patient.” cedure, researchers documented the surgeon’s The research team used a template and surgi- procedure time and performed a leak test to deter- cal tools to pre-injure the porcine tissue in the lab mine the quality of the repair (see Figure 2e, page 28). such that each surgeon was presented with the same The standardized operative surgical task and case. Surgeons had varying completion times and wearable technologies allowed the team to collect approaches to the procedure. The team was able baseline data to better understand how surgeons’ to capture all of these preferences and individual continued on page 29

JUL 2020 BULLETIN American College of Surgeons | 27 THE SURGICAL METRICS PROJECT

FIGURE 2. THE SURGICAL METRICS PROJECT IN ACTION

2a The Surgical Metrics Project exhibit featured 10 surgical simulation stations

2b Above and right: Participant engaging in the baseline cognitive assessment with the EEG on his forehead 2c

2e After each participant indicated they had completed the procedure (or their allotted time of 15 minutes ran out), researchers clamped one end of the bowel and inserted a motorized pump into the other end to perfuse liquid through the bowel to determine the integrity of the repair

Four wearable technologies were used to capture video, audio, motion, and EEG data 2d from participants

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Tweet by Andrew S. Wright, MD, FACS, Seattle, WA, describing his experience with The Surgical Metrics Project As The Surgical Metrics Project database grows, Stanford researchers anticipate that they will gain a clearer understanding of the variance in surgical decision making and technical approaches

decision making, technical skill, and communication strat- ADDITIONAL INFORMATION egies contribute to procedural outcomes. Additional information and videos about The Surgical Metrics Project Reactions to The Surgical Metrics Project are available at the following links: The Clinical Congress News, the daily paper published • Surgeons test new wearable tech that helps during the conference, queried participants for their ini- measure operating skills: tial reactions to The Surgical Metrics Project. “It’s really CBS SF Bay Area KPIX: important to get baseline data in terms of where surgeons https://sanfrancisco.cbslocal.com/2019/11/14/ in practice are—in both their cognitive and technical abili- surgeons-test-new-wearable-tech-that- ties,” said Sabha Ganai, MD, PhD, FACS, Springfield, IL. helps-measure-operating-skills/ Arthur Berg, DO, Hackensack, NJ, said, “This is an interesting way to see and quantify variations of sur- • Stanford Medicine: geon techniques in terms of different movements and The metrics of surgery: https://youtu.be/GUQzBW7WfTc different decisions. It’s really great that they’re actually using objective data—EEG monitoring—to see the different variations in technique, and it will be cool to see the differences between beginners and more highly trained, experienced surgeons.” “This can help us to understand what the differences are between novices and experienced surgeons. Once we understand the differences, we’ll be able to get novice surgeons looking more like experienced surgeons in a shorter period of time. The value is getting lots of people to do it, so having it here at Clinical Congress is a great chance to get real data that will yield real results,” said David M. Notrica, MD, FACS, FAAP, Phoenix, AZ. In addition to the anecdotes shared with the Clinical Congress News, several participants engaged in The Surgi- cal Metrics Project conversation on Twitter. A tweet by Andrew S. Wright, MD, FACS, Seattle, WA, described

JUL 2020 BULLETIN American College of Surgeons | 29 THE SURGICAL METRICS PROJECT

FIGURE 3. ATTITUDES REGARDING DATA AND ASSESSMENT (N = 255)

his experience with The Surgical Metrics Project and “The Surgical Metrics Project is the foundation of encouraged others to participate (see photo, page 29). assessing surgical technique,” according to American Paving the way for a new frontier of data-driven College of Surgeons Executive Director David B. Hoyt, metrics to advance quality, The Surgical Metrics MD, FACS. “Once validated it can define how we might Project aims to include all members of the surgical measure skills acquisition, obtain mastery, and even community in the conversation regarding data use demonstrate deterioration of skills over time.” and data sharing. As part of The Surgical Metrics Proj- The College is proud to announce the continuation ect data collection, Dr. Pugh and her research team of its strategic partnership with the T.E.C.I. Center and had the opportunity to gauge participants’ attitudes plans to continue offering The Surgical Metrics Project regarding data and assessment. For the responses, see at Clinical Congress. ♦ Figure 3, this page. Authors’ note Looking forward The T.E.C.I. Center is a research group directed by Dr. Pugh Ongoing data analysis is now taking place and with that aims to transform human health and welfare through guidance from The Surgical Metrics Project Advi- advances in data science and personalized, data-driven sory Board (see sidebar, page 26), Dr. Pugh and her performance metrics for health care providers. More infor- research team will determine how to distribute feed- mation about the T.E.C.I. Center is available at h t t p ://m e d . back to participants. The overall goal is to develop an stanford.edu/tecicenter.html. anonymous database of video, motion, and audio data to facilitate surgical planning, training, and review.

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Surgeons appointed by Spanish royalty contributed to development of oldest U.S. city: St. Augustine, FL

by John D. Ehrhardt, Jr., MD, and J. Patrick O’Leary, MD, FACS

JUL 2020 BULLETIN American College of Surgeons | 31 EARLY SURGEONS IN ST. AUGUSTINE

Spanish colony. His first Florida voyage landed along HIGHLIGHTS the northeast peninsular coast near modern-day • Identifies surgeons’ roles during 16th century St. Augustine in 1513. That expedition explored Flor- conquistador expeditions to Florida ida’s east coast, the Florida Keys, the Dry Tortugas, and parts of southwest Florida until a tropical squall • Summarizes how surgeon leaders were integrated 1 into the colonial community of St. Augustine, FL sent their ships back to Puerto Rico. The entourage returned to Florida’s Gulf Coast in 1521, the region • Describes how Spanish, French, and where foul weather had abruptly halted their first English surgeons practiced at the Spanish voyage.2 During that mission, Ponce de León unwit- Royal Hospital in St. Augustine tingly became the first documented surgical patient in the continental U.S.2 As soldiers unloaded supplies onto a remote Editor’s note: The American College of Surgeons History and island near what is now Fort Myers, they were Archives Committee (formerly the Surgical History Group) ambushed by Calusa natives, a then-dominant hosts an annual poster session at Clinical Congress. The tribe in Southwest Florida. Ponce de León suffered following article is based on the second-place winner of a penetrating arrow shot in a vulnerable area of the poster competition at Clinical Congress 2019 in San the groin caught between two plates of armor. His Francisco, CA. An article based on the first-place poster mariners bolstered a respectable defense against was published in the April issue of the Bulletin. Calusa archers and carried their commander to safety. The ship surgeon removed the arrow and urgeons played an active role during 16th controlled hemorrhage, but Ponce de León soon century conquistador explorations of Flor- developed shock. Although unnamed in expedi- Sida and the later development of a Spanish tion documents, historians believe Gaspar López colony at St. Augustine, settled in 1565 and recog- de Villalobos, a personal physician to Ponce de León nized today as the oldest continuously occupied on previous voyages, performed the procedure.3 European-established settlement in the continental Ponce de León’s condition worsened, and he U.S. However, limited access to health care was ordered the fleet to retreat to Cuba. At the time, a significant barrier to cultivating the colony. Havana was the nearest Spanish settlement where Surgeons, both free and imprisoned, faced adversity they could access medical supplies and possibly and treated early settlers and soldiers using scarce locate another surgeon. Ponce de León ultimately supplies. As the colony grew, surgeons became died from shock three days after arriving in Havana. community leaders, often enjoying royally appointed Hemorrhagic shock is a possible cause of death, but positions and open lines of communication with the he survived the initial procedure and retreat to Cuba. Spanish crown. Some historians have suggested his gradual deterioration may have been caused by a poison Calusa natives routinely applied to their arrow tips.4 They Surgeons during conquistador expeditions derived a toxic substance from the sap of the Manchi- Juan Ponce de León (see Figure 1, page 33) is regarded neel tree, indigenous to the subtropical Everglades as the first documented conquistador to explore and the Caribbean.5 Cardiovascular, pulmonary, the Florida coast in anticipation of establishing a and neurologic sequelae from the toxin may have

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FIGURE 1.

Juan Ponce de León, Florida conquistador and first documented surgical patient for an operation to remove a lodged arrow from his groin (public domain image)

influenced his clinical course.6 It also is possible that part of established law on the Iberian Peninsula, Ponce de León developed bacteremia and died from held little weight in the untamed frontier of Florida.9 septic shock, an all-too-common scenario more than De Soto narratives later described another scene 400 years before the discovery of antibiotics. in which a Spanish settler distrusted the expedition Ponce de León’s death in 1522 highlighted surgeon. The patient doubted the surgeon’s ability, the challenges of New World conquest. Trauma, noting his lack of dexterity and haphazard treat- infectious disease, and a limited surgical workforce ment for a penetrating knee injury. Displeased by in the New World all plagued missions aimed at the clinical services rendered, the patient remarked establishing a Florida colony. The remote peninsula that he would never seek the surgeon’s expertise remained wild, elusive, and unsettled for another 40 again, even if on his deathbed. Angry with the accu- years, during which five more Spanish conquistadors sations, the unnamed surgeon replied that he would attempted to settle in Florida. Hernando de Soto led refuse treatment if the patient returned, even under the largest expedition from 1538 to 1542. The fleet life-threatening circumstances.8 It remains unclear landed near Tampa Bay and explored the Gulf Coast whether both mentions of surgeons referenced the and southeast U.S. Many surgeons who arrived same person. These isolated journal entries likely with the fleet likely disbanded along the harsh were dramatized to some extent but provide insight trek, setting up camp with native tribes, a common into daily struggles conquistadors faced on a Florida practice among those disaffected by conquistador expedition. brutality. Sixty years after Columbus’s first voyage in 1492, Surgeons are mentioned only a couple of times in health care delivery in the New World still had its more than 1,000 pages of narrative documents from challenges across the Caribbean, especially outside the de Soto expedition;7 nonetheless, these few pas- of royal colonies like Santo Domingo, Dominican sages are telling. Soldiers disliked one ship surgeon Republic; San Juan, Puerto Rico; and Havana. First- who had falsely advertised his medical and surgi- hand accounts of mass trauma, endemic disease, cal expertise; he later unravelled under pressure as starvation, and lackluster medical care trickled back a clinically incompetent imposter. The narrative to the Spanish crown. In 1561, King Philip II decided elaborated: “There was not in the whole army more that settling Florida was no longer worthwhile than one doctor, and he was not so skillful and dili- and suspended all plans for future conquistador gent as was needed; on the contrary, he was stupid expeditions.10 and practically useless.”8 The clinician described Without Spanish occupation, other European was little more than a Good Samaritan who had an imperials began to express interest in colonizing the interest in medicine, and may have spent some time Florida peninsula. In June 1564, French fleets made lending a hand to an empiric practitioner. Spanish remarkable progress along the unsettled northeast- regulations on medical and surgical practice, though ern coast of Florida under the leadership of René

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FIGURE 2.

Timucua tribe treating sick patients near Fort Caroline. Art by French Huguenot settler Jacques le Moyne de Morgues (Library of Congress)

Laudonnière. His voyage led a group of French about New World medicine—featured a 20-page Protestants known as Huguenots to construct and discussion on sassafras. One excerpt explained that populate a fort near modern-day Jacksonville. They the French showed the Spanish its medicinal prop- christened the settlement as Fort Caroline, making erties and acknowledged the French for treating ill the first fortified European settlement in the main- Spanish colonists (see Figure 3, page 35).12 Given the land U.S. a French colony.11 imperial rivalry between the Spanish and French, it was remarkable for a Spanish physician to credit the French with exchanging New World medical French surgeons in Florida wisdom during this period. A separate letter in 1565 An unnamed surgeon at Fort Caroline contributed from a Fort Caroline settler confirmed that it was to French efforts to settle Florida. He integrated the surgeon who facilitated the sassafras exchange.13 with native Timucua shamans and encouraged Spanish forces led by Admiral Menéndez de Avilés the transfer of medical knowledge and technique massacred the French at Fort Caroline in August (see Figure 2, this page). One notable product of 1565. They spared some women, children, and the this exchange was the European acquisition of surgeon, who conveyed local medical knowledge the medicinal sassafras plant. After the surgeon at as recognized by Monardes’s 1565 text. French sur- Fort Caroline sent samples back to France, sassa- geons, in more ways than one, proved their worth fras became popularized across Europe as a wonder over the next 50 years in St. Augustine. Spanish drug. Spanish physician Nicolás Monardes’ 1565 ship surgeons passed through St. Augustine, but monograph Historia Medicinal de las Cosas que se their presence was often transient and short-lived. Traen de Nuestras Indias Occidentales (Medical Study No salary or benefits package was large enough to of the Products Imported from our West Indian Posses- keep a Spanish physician stationed in the rural, dirt- sions)—the first comprehensive European book road, tidal marshland of St. Augustine. Spaniards

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FIGURE 3.

Folio from an English translation of Nicolás Monardes’ 1565 monograph, regarding French acquisition of medicinal plants at Fort Caroline, Joyfull newes out of the new found world: wherein are declared the rare and singular vertues of divers and sundrie herbs, trees, oyles, plants & stones, with their applications as well to the use of phisicke, as chirurgery...Also the portrature of the sayde herbes, very aptly described (Courtesy of the Florida State University Libraries, Special Collections and Archives)

addressed their physician shortage in part by cap- with piracy in Florida waters and proceeded to exe- turing French ship surgeons and holding them cute most of them. Governor Menéndez Marqués prisoners. commanded they spare only a handful of French A severe storm in the winter of 1576 blew a prisoners—one surgeon and three boys who could French ship, Le Prince, ashore near Santa Elena, a interpret native languages.14 Spanish post in South Carolina. Natives killed most The French surgeon was Jean de Le Compte (iden- of the crew and enslaved Frenchmen who remained. tified in Spanish letters as Juan de LeConte). Spanish A total of 40 prisoners from the shipwreck lived and authorities soon realized Le Compte possessed med- worked for the local tribe. In August 1579, Florida ical knowledge and sent him to St. Augustine. Upon Gov. Pedro Menéndez Marqués issued a command his arrival in late 1579, Le Compte continued his that an army raid their village. Spanish forces kid- prison sentence for a grueling seven years, in which napped the native chieftain’s mother, wife, and he met the medical needs of Spanish and Timucua sister, later releasing them in exchange for 16 French throughout the community. His good deeds led to prisoners. Spanish authorities charged the French a promotion to chief surgeon at the military fort

JUL 2020 BULLETIN American College of Surgeons | 35 EARLY SURGEONS IN ST. AUGUSTINE

in 1586, a position that came with a modest salary. for trial, but Governor Menéndez Marqués refused Because St. Augustine began as a military town, to relinquish Florida’s only surgeon. He believed most of his patients were soldiers at the fort. Over that if Le Compte left St. Augustine, “he would be the course of his tenure as their surgeon leader, the very much missed, and so I determined this time colony grew and expanded his clinical responsibili- to leave him here.”17 ties to a larger breadth of patients.15 Three unnamed French surgeons were dis- Le Compte was the only permanent medical figure cussed in letters during the latter half of the 16th in Florida for more than two decades. After 23 years century. The St. Augustine community relied on of service, he declared that he was “old and tired and their training to meet the town’s health care needs cannot support himself.”16 He requested a return trip as well as the demands of Spanish medical regula- to Europe if the royal authorities were unwilling to tions, calling for a surgeon to be stationed at each negotiate for higher pay. Spanish authorities declined Spanish military fort. On one later occasion in 1668, his highball request for a tenfold salary increase. Flor- conflict between Gov. Francisco de la Guerra y de ida Gov. Gonzalo Méndez de Canço urged him to Vega and French surgeon Pedro Pique ultimately draft a formal address to the King of Spain regarding led to a pirate raid on St. Augustine. Pique fled on his salary and benefits as the only resident physician a ship sailing toward Havana that English pirates of the colony. As a testament of his faith and reliance captured. Florida medical historian William Straight upon his colony’s only permanent surgeon, Governor later wrote about the incident,16 in which the cap- Méndez de Canço affixed a letter of recommenda- tured surgeon reportedly led the pirates back to St. tion to the surgeon’s appeal for a higher salary. The Augustine and helped them gain entrance to the monarch acknowledged the appeal and returned an Matanzas River Inlet with confidential port code offer for two-and-a-half times Le Compte’s origi- signals, thus facilitating a British raid on the Spanish nal salary.16 town. Eighty civilians were killed, and the wood- Le Compte’s service in St. Augustine was para- frame hospital was burned to the ground. doxical. The Spanish were not French allies, but they needed to recruit a physician to their new colony. It speaks volumes that Spanish authorities needed Surgeons at the growing Florida colony to capture a surgeon and hold him as prisoner to Clinical practice represented only one aspect of sur- keep a resident physician in St. Augustine. He ran geon life in colonial Florida. Surgeons stationed in his clinical practice with the support of assistant St. Augustine served primarily as general practitio- surgeons and apothecaries who were less skilled. ners, but there were scattered reports of surgical In an August 1583 letter, Governor Menéndez procedures throughout the first Spanish period Marqués wrote to the Spanish crown, mentioning (1565–1763). Most surgical procedures on civilians Le Compte as the Frenchman who is “a surgeon” were undocumented or only mentioned briefly on and noting the lack of Spaniards of equal skill.17 bills and receipts. Le Compte’s service at St. Augus- Not only was their medical competence question- tine showed that he often reduced and immobilized able, but they arrived and departed with each new fractures of the upper and lower limbs in addition breeze that brought ships through the mouth of to treating skull fractures. He also handled pen- the Matanzas River. The king wanted French pris- etrating trauma from arrows, swords, and musket oners like Le Compte sent to Spain, presumably balls with some regularity.

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FIGURE 4.

Letters from the Second Spanish Period (1784–1821) related to surgeons in St. Augustine (East Florida Papers, Library of Congress)

Most detailed evidence for the scope of clinical sur- On rare occasions, surgeons attracted negative gery came through letters with Spanish authorities, in attention to St. Augustine. As the colony grew, the which surgeons at the royal hospital in St. Augustine problem became not the supply of surgeons but reported their expert opinion to the crown on con- the need for well-trained surgeons who practiced ditions of Spanish statesmen. Natives shot military responsibly. One chief garrison surgeon, Carlos leader Don Francisco Ponce de León during an upris- Robson, was embroiled in a scandal during the ing in 1705. Musket balls shattered his humerus and 1680s. In a letter to royal authorities, colonial Gov. the standard of care warranted an amputation for the Juan Márquez Cabrera wrote, “Not only is he not comminuted fracture. He died of hemorrhagic shock a physician or a qualified surgeon, but also he is during the procedure, making it unclear whether deprived of consciousness most of the time by being traumatic axillobrachial arterial injury or uncon- drunk.”18 Years later, concerns arose about another trolled surgical bleeding led to his death. In 1727, surgeon, and the governor wrote, “Although we chief surgeon Juan Frisonou documented that his have a great need for a physician, if there is not a patient, Gov. Antonio de Benavides, developed an competent one to be found, we will manage with abscess that required an operation. Frisonou located the surgeon of the garrison who, were he not so the painful pocket of pus between his buttocks, near taken by rum, is not bad, but everybody refrains the lower level of the coccyx, and commented that it from calling him.”16 Royal officials responded to the impaired the governor’s ability to urinate and empty negligence by calling on the Hospitalliers de San his bowels. Frustrated by the lack of surgical instru- Juan de Dios, a Catholic fraternal order devoted to mentation in St. Augustine, Frisonou recommended providing health care in underserved areas that still transporting the governor to Cuba. In Havana, chief exists today.19 Florida officials requested that three physician and surgeon Carlos Del Ray drained the men come from Havana to staff the St. Augustine governor’s 7 cm perirectal abscess.16 hospital, creating tension among local priests in

JUL 2020 BULLETIN American College of Surgeons | 37 EARLY SURGEONS IN ST. AUGUSTINE

REFERENCES St. Augustine who held privileges at the hospi- 1. Kelley J. Juan Ponce de León’s discovery of Florida: tal as medico-friars. They protested the arrival Herrera’s narrative revisited. Revista De Historia De América. of medical support from Cuba, but the crown 1991;111(1):31-65. ultimately overrode their petition and wrote an 2. Synder C. Don Juan Ponce de León and the first operation in order for new hospital administrators. Florida. J Fla Med Assoc. 1965;52(7):488-493. The surgeon’s role in colonial Florida soci- 3. Picaza JA. European medicine in America before ety has been best captured by the East Florida Florida’s discovery: The fleet physician. J Fla Med Assoc. 20 1990;77(11):971-975. Papers, a vast repository of colonial documents 4. Grunwald M. The Swamp: The Everglades, Florida, and the from the Second Spanish Period (1784–1821) com- Politics of Paradise. New York, NY: Simon & Schuster; 2006: piled by the U.S. Library of Congress. Surgeons 24-39. exchanged more than 100 letters with other 5. Cheney R. Geographic and taxonomic distribution of American plant arrow poisons. Am J Bot. 1931;18(2):136-145. surgeons, colonial Florida governors, and the 6. Duke JA. Duke’s Handbook of Medicinal Plants of Latin America. Spanish crown. This correspondence speaks vol- Boca Raton, FL: CRC Press; 2008: 548-553. umes, especially when considering the position 7. Clayton L, Moore E, Knight V, et al. The de Soto Chronicles of surgeons in Europe, who had less social status (Vols. 1–2). Tuscaloosa, FL: University of Alabama Press; 1995. than physicians, training as apprentices and 8. Irving T. The Conquest of Florida by Hernando de Soto. New practicing their craft without a formal medical York, NY: George P. Putnam & Sons; 1869: 279, 300. 21 9. Lanning JT, TePaske JJ. The Royal Protomedicato: The education. Another noteworthy characteristic Regulation of the Medical Professions in the Spanish Empire. was communication between French, Spanish, Durham, NC: Duke University Press; 1985. British, and American surgeons, many of whom 10. Bolton HE. The Spanish Borderlands. New Haven: Yale practiced at the same St. Augustine Royal Hospi- University Press; 1921:134. 11. Laudonnière R. A Notable History Containing Four Voyages tal at one time or another. As a dominant Spanish Made by Certain French Captains unto Florida. Martin Basanier colony, they communicated almost uniformly in (ed). Larchmont, NY: Henry Stevens, Son & Stiles; 1964. Español Castellano—the King’s Spanish—despite 12. Monardes N. Joyfull Newes Out of the Newfounde Worlde, their multinational heritage as a collective group. Englished by John Frampton. London: B. Norton; 1596: 46- The East Florida Papers, portions of which 64. 13. Covington JW. La Floride: 1565. Fla Hist Q. 1963;41(3):274-281. are still undergoing English translation and tran- 14. Carvajal AM. Chief Pilot Antonio Martínez Carvajal of Florida scription, add clarity to Florida medical history to the Crown, Havana. Microfilm. November 3, 1579. Archivo and paint surgeons’ lives on a more personal General de Indias, William Straight Collection, Florida level (see Figure 4, page 37). These documents International University, Reel 54: 3. Accessed September 28, show surgeons appointed and vetted by the Span- 2019. 15. Webster M. Medical men and medical events in early ish monarchy, demonstrating the formality and St. Augustine. J Fla Med Assoc. 1965;52(7):494-497. permanence intended by granting privileges to 16. Straight WM. Medicine in St. Augustine during the Spanish practice at the Royal Hospital. Even into the early period. J Fla Med Assoc. 1968;55(8):731-741. 19th century, royally appointed surgeons were continued on next page required to petition the crown if they intended to resign from their position.22 They most commonly requested transfer to Havana, at that time a bustling port with more resources than St. Augustine. As government employees, they

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periodically wrote local governors to ask for REFERENCES, CONTINUED house repairs. 17. Marques PM. Governor Pedro Menéndez Marqués of Florida to Surgeons testified in court for their clinical the Crown, St. Augustine. Microfilm. August 1, 1583. Archivo expertise and as respected leaders in the commu- General de Indias, William Straight Collection, Florida nity. One documented hearing in 1791 focused on International University, Reel 54: 3. Accessed September 28, banishing a patient with leprosy from St. Augus- 2019. 23 18. Cabera JM. Governor Juan Márquez Cabrera of Florida to the tine. Other ill patients periodically were sent to Crown, St. Augustine. Microfilm. April 30, 1685. The Stetson Havana, in anticipation that the sea breezes and Collection, Reel 86: 1. Accessed September 28, 2019. higher elevation in Cuba would offer cleaner air, 19. McMahon BN. The Story of the Hospitallers of St. John of God. believed to be more suitable for recovery. Other Westminster, MD: Newman Press; 1958. 20. The East Florida Papers. U.S. Library of Congress Manuscript letters described surgeons who were called on Division. Microfilm. Available at: https://lccn.loc.gov/ horseback to remote parts of Florida and coastal mm80019398. Accessed March 12, 2020. Georgia where they operated in the field.24 21. Risse GB. Medicine in New Spain. In: Medicine in the New Although surgeons were respected as a whole, World, New Spain, New France, New England (Numbers RL, some documents commented on the arrest and ed). University of Tennessee Press; 1987:12-63. 22. Coppinger J. Jose Coppinger to Jose Cienfuegos, Florida. imprisonment of individual surgeons, one of Microfilm. September 1, 1816. The East Florida Papers. whom needed to be extradited from “America” Accessed September 28, 2019. in 1818,25 likely because he fled across the border 23. Detailed proceedings concerning disposition of Minorcan Agueda to Georgia, then part of the newly formed U.S. Villalonga living in St. Augustine with leprosy, St. Augustine. Altogether, the history of surgery in Microfilm. July 19, 1791. The East Florida Papers, Miami- Dade Public Library. Reel 173: 6. Accessed September 28, St. Augustine is rich and contrasts with exist- 2019. ing papers that focus on medical developments 24. Governor of Florida to Josef Taso, St. Augustine. Microfilm. in the British colonies, including Jamestown and April 27, 1788. The East Florida Papers, Miami-Dade Public Plymouth in 1607 and 1620, respectively. The roy- Library. Reel 45: 1. Accessed September 28, 2019. ally appointed surgeons of St. Augustine made 25. Cienfugos J. Jose Cienfuegos to Governor of Florida, Havana. Microfilm. July 31, 1818. The East Florida Papers, Miami- significant contributions to the establishment Dade Public Library. Reel 6: 1. Accessed September 28, 2019. of clinical practice in the New World, and their impact is more than a footnote in this nation’s medical history. ♦

JUL 2020 BULLETIN American College of Surgeons | 39 2019 ACS GOVERNORS SURVEY

2019 ACS Governors Survey: Surgeons wanted: Workforce challenges in health care

by Editor’s note: The American College of Surgeons (ACS) Board of David J. Welsh, MD, FACS; Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means Hiba Abdel Aziz, MBBCH, FACS; of communicating the concerns of the Governors to the College lead- Juan C. Paramo, MD, FACS; ership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate. John Kirby, MD, FACS; One of the survey’s topics was surgeon workforce. This article Dhiresh Rohan Jeyarajah, MD, FACS; outlines the Governors’ feedback on this issue. David W. Butsch, MD, FACS; ecent literature reveals a growing need for more infor- Christopher DuCoin, MD, MPH, FACS; mation on, and awareness of, the surgeon workforce shortage. For example, the Bulletin published an arti- Joann Lohr, MD, FACS; R cle by Mark W. Puls, MD, FACS, a general surgeon and an and ACS Governor in Alpena, MI, on the increasing shortage of surgeons in rural settings, a trend that has been attributed Shilpa Shree Murthy, MD, MPH to an aging workforce and other factors. This shortage has left many rural U.S. counties without any surgeons, even though more than half of the counties have a local hospital. Another study by E. Christopher Ellison, MD, FACS, chief, division of general surgery and the Robert M. Zollinger Pro- fessor, The Ohio State University, Columbus, and colleagues showed that although the number of general surgery resident positions and graduating surgical residents has been rising in the U.S. for more than 10 years, these increases have been insufficient to maintain the ideal number of surgeons for the population. Several surgical specialties also face workforce challenges. A 2019 Association of American Medical Colleges (AAMC) report predicted a U.S. surgeon shortage of 23,000 surgeons in 2032. (Note: At press time, the AAMC has just released a report estimating that the surgeon shortage could be as high as 28,700 by 2033.) The AAMC projects that clinical demand

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will continue to outpace the supply of surgeons with in rural settings. Rural general surgeons continue a projected total shortfall of 46,900−121,900 by 2032. to face an increasing workload demand, but with a This projected shortfall range is based on a model median age in the late 50s, they also are aging out that accounts for population projections, demand and of practice. supply projections, estimates of physician specialty choice, recently revised federal health professional shortage area designations for primary care and Specialty variations mental health, and lower projections of future insur- Most Governors (65 percent) indicated they did not ance coverage expansion. A shortage of physicians in perceive workforce shortages in their geographic area. surgical specialties is estimated to be between 14,300 Although 55 percent indicated that their specialty was and 23,400. experiencing no shortages, further analysis revealed In 2016, the U.S. Department of Health and Human that while obstetrician-gynecologist Governors did Services issued a report on national and regional pro- not see shortages in their respective geographical jections of supply and demand for surgical specialty areas, they did recognize overall specialty shortages. practitioners from 2013 to 2025. The study projected Governors from other specialties reported similar that a shortage of surgical specialists would rise to observations, with more global shortages in the fol- 24,330 by 2025, with wide geographic variation: 1,750 lowing specialties: vascular (60 percent), wound care in the Northeast, 7,040 in the Midwest, 10,210 in the (58 percent), cardiothoracic (57 percent), colorectal South, and 5,330 in the West. (52 percent), and pediatric surgery (50 percent).

Practice settings and geography Quality of care Because surgeon workforce needs can differ based on The survey also sought to determine if workforce practice settings and geographic location, a closer look shortages led to treatment delays and reduced quality at the practice settings of the survey’s respondents of care. Most Governors (75 percent) indicated they did was warranted: 75 percent were in full-time academic not perceive significant delays in the delivery of patient practice or hospital employment (see Figure 1, page care, and 74 percent noted they had not seen a nega- 42), and only 24 percent of respondents practice in tive effect on the quality of care rendered because of a settings with a population of less than 250,000 (see perceived shortage of surgeons. Although 34 percent Figure 2, page 42). In addition, 74 percent of ACS of international Governors indicated they experienced Governors indicated they worked in groups of five shortages of surgeons in their geographic area and spe- or more surgeons. This finding is important in light cialty, this shortage was reported to be the cause of of an article by Jonathan Ford Hughes that examined less than 20 percent of the signiﬁcant delays in elective physician shortages by U.S. regions. He predicted surgical procedures and adversely affected the quality greater shortages in the South and Midwest, as well of care in less than 20 percent of the cases. as higher shortages in rural settings—geographic areas and practice types less commonly represented in the Governors’ sample. Recruitment Research findings on physician shortages may vary Most Governors (78 percent) said it takes at least six depending on the specialty and the location under months to replace a partner or add a new surgeon to analysis. For example, surgeons in academia or hos- their practice (see Figure 3, page 42), but variances were pital employment may be less affected than surgeons continued on page 44

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FIGURE 1. Type of surgical practice

FIGURE 2. Population of practice location

FIGURE 3. Estimated time to replace and/or add a surgeon

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FIGURE 4. Is locum tenens used for unfilled positions?

FIGURE 5. Where workforce needs and deficiencies, such as rural surgery shortages, are discussed

FIGURE 6. How important is it for the College to continue addressing surgical workforce issues?

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BIBLIOGRAPHY seen among practice settings. Many solo private prac- American Medical Association. U.S. Physician Shortage tice surgeons (47 percent) indicated they needed more H-200.954. Available at: https://policysearch. than a year to add a partner. More than six months was ama-assn.org/policyfinder/detail/workforce%20 needed for new surgeon recruitment for a variety of shortages?uri=%2FAMADoc%2FHOD.xml-0-1344. practice settings: private practice multispecialty (67 per- xml. Accessed February 20, 2020. Association of American Medical Colleges. 2019 update: cent), hospital employment (65 percent), government The complexities of physician supply and demand: (60 percent), and military service (60 percent). Governors Projections from 2017 to 2032. Available at: https:// in solo private practice (57 percent) needed more than aamc-black.global.ssl.fastly.net/production/ six months to recruit another surgeon. Forty percent media/filer_public/31/13/3113ee5c-a038-4c16-89af- of private practice single-specialty groups with more 294a69826650/2019_update_-_the_complexities_ of_physician_supply_and_demand_-_projections_ than five members indicated they needed more than a from_2017-2032.pdf. Accessed February 20, 2020. year for recruitment. Interestingly, 33 percent of Gover- Bailey P. Surgical workforce shortages in rural nors in government practices were able to successfully areas. Available at: www.mdedge.com/surgery/ recruit in less than six months. article/109133/practice-management/surgical- Overall, Governors in private practice multispecialty workforce-shortages-rural-areas. Accessed February 18, 2020. groups with primary care and surgical care settings were Darves B. Physician shortage spikes demand in several the most successful: 25 percent fulfilled positions in less specialties, 2017. Available at: www.nejmcareercenter. than six months, 50 percent within six months to a year, org/article/physician-shortage-spikes-demand-in- and 25 percent needed more than a year to recruit. Inter- several-specialties-/. Accessed February 18, 2020. nationally, 40 percent of Governors were able to replace Ellison EC, Pawlik TM, Way DP, Satiani B, Williams TE. Ten-year reassessment of the shortage of general surgeons in fewer than six months, but one-third needed surgeons: Increases in graduation numbers of more than a year. Interestingly, only 11 percent of all general surgery residents are insufficient to meet Governors used locum tenens for unfilled positions (see the future demand for general surgeons. Surgery. Figure 4, page 43). 2018;164(4):726-732. Available at: www.ncbi.nlm.nih. gov/pubmed/30098811. Accessed February 20, 2020. G4 Alliance. The surgical workforce shortage—A global crisis. Available at: https://static1.squarespace.com/ Addressing workforce needs static/5435b2b9e4b0e1fd29fa9d26/t/5a67ac0a652de Most Governors (73 percent) said they believe ACS a5f53dd05ca/1516743691252/Surgery+Workforce+- chapter and specialty society meetings provide the best +G4+Briefing_Final1-1.pdf. Accessed February 20, platform for addressing workforce needs and deficien- 2020. Haskins J. Desperately seeking surgeons. Available at: cies (see Figure 5, page 43). Discussions about workforce www.aamc.org/news-insights/desperately-seeking- needs also occurred at residency programs (55 percent) surgeons. Accessed February 20, 2020. and local medical schools (43 percent). Most Governors Hughes JF. Physician shortage: Which U.S. regions did not appear to seek out the ACS as a national orga- affected the most? MDLinx.com. July 17, 2019. nization for solutions to surgeon practice recruitment Available at: www.mdlinx.com/internal-medicine/ article/3888. Accessed March 10, 2020. or more global workforce issues, suggesting an opportunity for ACS action. continued on next page Despite most Governors not recognizing a workforce shortage in their practice geographic area, 94 percent (see Figure 6, page 43) believed it was an important issue for the ACS to continue addressing in the future, especially by creating more

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surgical residency programs and training positions BIBLIOGRAPHY, CONTINUED (60 percent). Kenning TJ. Neurosurgical workforce shortage: The effect of subspecialization and a case for shortening residency training. Available at: https://aansneurosurgeon.org/ Governor recommendations departments/neurosurgical-workforce-shortage-effect- Although most Governors report that they have yet subspecialization-cast-shortening-residency-training/. Accessed February 18, 2020. to personally experience a workforce hardship that Lynge DC, Larson EH, Thompson MJ, et al. A longitudinal impedes access or the provision of quality care in analysis of the general surgery workforce in the United their practice area, they do recognize that a more States, 1981–2005. Arch Surg. 2008;143(4):345–350. global problem exists and encourage the College to Available at: https://jamanetwork.com/journals/ keep this issue a high priority. Many Governors (142) jamasurgery/fullarticle/599060. Accessed February 20, 2020. offered recommendations on how the ACS could better Ohio State University Wexner Medical Center. Study address surgical workforce issues. For example, inter- suggests part-time solution to surgeon shortage. national Governors suggested enhancing collaboration Available at: https://wexnermedical.osu.edu/ between the international chapters and the ACS, as mediaroom/pressreleaselisting/study-suggests-part- well as among international surgeon groups. Interna- time-solution-to-surgeon-shortage. Accessed February 20, 2020. tional Governors also asked for additional statistics Palikuca P. A surgeon shortage is mounting, recent and resources to better understand surgeon workforce report finds. Available at: https://thedo.osteopathic. needs through both dedicated meetings and presenta- org/2019/05/a-surgeon-shortage-is-mounting-recent- tions at the Clinical Congress. report-finds/. Accessed February 18, 2020. Within the U.S., rural communities seem to be Puls MW. Dispatches from rural surgeons: Shortage of rural surgeons: How bad is it? Bull Am Coll experiencing the greatest surgeon workforce chal- Surg. 2018;103(4):52-55. Available at: bulletin.facs. lenges. Many Governors called for additional funding org/2018/04/shortage-of-rural-surgeons-how-bad-is-it/. for rural surgery and targeted rural residency training Accessed February 18, 2020. positions and programs. Governors also recommended Rapaport L. General surgeon shortage growing in U.S. increasing advocacy focused on federal legislative Available at: www.reuters.com/article/us-health- shortages-surgeons/general-surgeon-shortage- efforts, such as the Ensuring Access to General Surgery growing-in-u-s-idUSKCN1L920O. Accessed February Act (H.R. 1841) and Keep Physicians Serving Patients 18, 2020. Act of 2019 (H.R. 3302). The College supports both Thompson MJ, Lynge DC, Larson EH, et al. bills. Additional outreach to state and local government Characterizing the general surgery workforce in leaders, ACS chapters, medical schools, and residency rural America. Arch Surg. 2005;140(1):74-79. Available at: https://jamanetwork.com/journals/jamasurgery/ programs is encouraged as well. fullarticle/508241. Accessed February 18, 2020. The surgeon workforce shortfall is a multifac- U.S. Department of Health and Human Services eted issue that requires both national and regional, Health Resources and Services Administration. practice-specific solutions. An additional in-depth Bureau of Health Workforce National Center for study and analysis of surgeon workforce shortages Health Workforce Analysis. National and regional projections of supply and demand for surgical specialty is warranted to better understand its complexities practitioners: 2013–2025. Available at: https://bhw.hrsa. and refine long-term solutions. Governors strongly gov/sites/default/files/bhw/health-workforce-analysis/ encourage the College to continue focusing on sur- research/projections/surgical-specialty-report.pdf. geon workforce concerns to ensure access to optimal Accessed February 20, 2020. surgical care for all patients and the future success of the profession. ♦

JUL 2020 BULLETIN American College of Surgeons | 45 2019 ACS GOVERNORS SURVEY

2019 ACS Governors Survey: ACS Governors: Bidirectional communication ambassadors

by Editor’s note: The American College of Surgeons (ACS) Board of David W. Butsch, MD, FACS; Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means David J. Welsh, MD, FACS; of communicating the concerns of the Governors to the College lead- Hiba Abdel Aziz, MBBCH, FACS; ership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate. Juan C. Paramo, MD, FACS; One of the survey’s topics was ACS communication and repre- John Kirby, MD, FACS; sentation efforts. This article outlines the Governors’ feedback on this issue. Dhiresh Rohan Jeyarajah, MD, FACS; Christopher DuCoin, MD, MPH, FACS; embers of the ACS B/G serve as an official, direct communications link between the Board of Regents and Shilpa Shree Murthy, MD, MPH; Mthe Fellows. Governors have the responsibility to com- Julian A. Smith, MB BS, FACS; municate across all strata of the College in the following ways:

and • Provide bidirectional communication between the B/G and Joann Lohr, MD, FACS constituents

• Provide reports to their chapter or specialty society

• Welcome Initiates/Fellows from the ACS chapter or surgical specialty society that the Governor represents into the College

• Promote ACS Fellowship in state and specialty societies

The ability to effectively communicate and promptly respond to members on everyday concerns and urgent issues is critical to the ACS’ continued growth and evolution. The continued relevancy of the College depends on how appropriately it addresses and represents the views of its members. To better understand the effectiveness of the College’s communication efforts, Governors responded to survey questions regarding

46 | V105 No 5 BULLETIN American College of Surgeons 2019 ACS GOVERNORS SURVEY

FIGURE 1. During your time as a Governor, how often did Fellows bring specific concerns to you that they would like the ACS to address?

preferred communication methods, the effectiveness at least in part, to a lack of clarity by Fellows regarding of addressing membership concerns, and how repre- the process for addressing concerns. Lack of interest sentative the College is on key issues. The survey also by Fellows accounted for 54 percent, and for 15 per- explored whether improvements to communication cent, there were no needs that members felt had to initiatives were necessary. be brought forward as a concern because the issue was already being addressed (see Figure 2, page 48). Similarly, international Governors cited lack of inter- Bringing concerns forward est as the leading factor at 66 percent, followed by While serving as a Governor, respondents indicated lack of knowledge among Fellows on how to address how often a Fellow brought a specific concern to concerns at 40 percent. them to either address directly or bring forward to Several Governors noted that they did not know ACS leadership (see Figure 1, this page). Only 8 per- what the ACS could do or its level of effectiveness in cent of all domestic Governors had a concern brought addressing any forwarded concerns. These results to them monthly, whereas 31 percent had a concern reveal an opportunity to better educate Governors brought to them once a quarter, 30 percent only once on how to solicit and address the concerns of their a year, and 30 percent have not received a concern to constituents, an opportunity to inform Fellows address. (The percentages in this article are rounded about how and when to contact Governors when figures.) International Governors reported a simi- an issue arises, and information on how issues are lar experience, with 11 percent indicating monthly, considered and handled when brought to the ACS 27 percent quarterly, and 27 percent once-a-year leadership. requests for advice or concerns. Interestingly, 30 percent of all Governors had never received a concern to address; International Governors tracked similarly Resolving concerns with 34 percent. Governors who were contacted by Fellows with Over a 12-month period, most Governors reported concerns primarily resolved their issues by con- they had received more than two concerns (47 percent) tacting their local chapter (57 percent), contacting or three to five concerns (42 percent). Only 11 per- their respective specialty societies (32 percent), and a cent of Governors indicated they received six or more minority (28 percent) contacted the College’s Chicago, concerns. In contrast, most international Governors IL, and/or Washington, DC, offices (see Figure 3, page (59 percent) reported three to five concerns, 10 per- 48). For international Governors, a similar pattern cent reported more than 10 concerns, and 31 percent was revealed, with 66 percent resolving their issues reported more than two concerns. via their local chapter, 28 percent contacting the Chi- For those Governors who never had a concern cago and/or Washington, DC, offices, and 17 percent brought to their attention, 70 percent attributed this, contacting their respective specialty societies.

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FIGURE 2. What factors do you believe contribute to the lack of concerns from Fellows? Select all that apply.

FIGURE 3. How have you advanced any specific concerns that you and/or a constituent wanted the ACS to address? Select all that apply.

Most Governors (69 percent) who advanced a con- Effectiveness cern ranked their efforts as extremely or moderately When evaluating the effectiveness of the communica- effective. Only 26 percent ranked their efforts as slightly tion method used in contacting the ACS, 71 percent effective and 5 percent believed the process was inef- believed e-mail was very or moderately effective, fective. Several Governors who found the process to be 56 percent believed in-person contact was very or ineffective noted that in many cases the concern was moderately effective, and 44 percent found phone already being addressed by the College and, therefore, calls to be very or moderately effective (see Table 1, they chose not to advance it further. page 49). Regarding instances when urgent feedback on topical issues is needed, the survey also queried Communication methods respondents on their communication preferences. The survey also queried respondents on the commu- Most Governors (80 percent) ranked e-mail as their nication methods they have used to contact the ACS preferred choice, followed by text messaging (46 per- regarding a specific issue. Most Governors (85 percent) cent), and 44 percent ranked the ACS Communities as used e-mail, 67 percent communicated in person, and their third choice (see Table 2, page 50). International 46 percent used the phone (see Figure 4, page 49). Governors similarly ranked e-mail as their top choice

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FIGURE 4. In general, what communication methods have you used to contact the ACS about an issue?

TABLE 1. How effective was your communication method?

Very Moderately Slightly Not at all N/A Total effective effective effective effective Phone 26.09% 17.75% 4.35% 1.45% 50.36% 276 E-mail 42.39 28.26 11.59 1.81 15.94 276 In-person 37.32 18.84 8.70 2.54 32.61 276

(91 percent), followed by text messaging (52 percent), in a timely fashion by the respective Governor remains and ACS Communities (36 percent). a challenge, according to the survey findings. Preferred communication methods did not vary by age group. Across all ages, most Governors wanted the flexibility to communicate via a variety of meth- Conclusions and improvements ods. This preferred flexibility is aligned with the Communication preferences are rapidly changing. It is College’s ability to tailor messages to different audi- critical that the College keep abreast of new technol- ences via multiple communication channels. ogy and preferences among its membership, especially as they may differ by age, practice type, and specialty. Although the survey revealed that most Governors Responding to Fellows’ concerns are satisfied with how the ACS communicates and Governors also were queried on the way the ACS responds to urgent issues, the College must continue typically responds to Fellows’ concerns. Although to disseminate information via a variety of communica- most Governors (69 percent) found the College to be tion channels to accommodate all member preferences. approachable and appreciative of concerns raised by It also is important that the College ensure all members Fellows, 25 percent believed the ACS response was are aware of the variety of communication vehicles the bureaucratic and procedural, and 6 percent found the College uses to disseminate information. College to be distant and nonrepresentative. Interna- There is clearly an opportunity for better engage- tional Governors reported a similar experience, with ment with the ACS. For example, members can seek 73 percent indicating the ACS was approachable and assistance from ACS through the following channels: representative, 20 percent saying the ACS was bureaucratic and procedural, and 7 percent viewing the College • Contact a Governor as distant and nonrepresentative. Acknowledging a Fel- low’s concern and providing feedback and/or a response • Contact a member of the Board of Regents

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TABLE 2. When urgent feedback on topical issues is needed, how would you prefer the ACS contact you?

First Second Third Fourth Score* choice choice choice choice ACS Communities 3.62% 31.88% 43.84% 20.65% 2.18

E-mail 80.07 15.94 2.90 1.09 3.75

Social media 1.81 6.16 29.71 62.32 1.47

Text 14.49 46.01 23.55 15.94 2.59 *A higher score is preferable.

• Contact a College Official BIBLIOGRAPHY Belonwu V. 20 ways to communicate effectively • Contact the ACS via phone: 800-621-4111 or 312-202-5000; with your team. Small Business Trends. April fax: 312-202-5001 (general) or 312-202-5007 (Member 30, 2020. Available at: https://smallbiztrends. Services); or e-mail: [email protected] (general) or com/2013/11/20-ways-to-communicate-effectively- in-the-workplace.html#comments. Accessed [email protected] (Member Services) March 17, 2020. Keates C. The five C’s of effective • Post a message in an ACS Community communication. Forbes. September 2018. Available at: www.forbes.com/sites/ • Use the Find a Surgeon tool on facs.org to connect with forbescoachescouncil/2018/09/10/the-five-cs- of-effective-communication/#60d62d2f20c8. other members Accessed March 16, 2020. Makoul G. Essential elements of communication in Informing members of all the available channels for com- medical encounters. Acad Med. 2001;76(4):390-393. municating and raising concerns with the ACS will remain Richards L. How effective communication will help a key focus of the B/G Communications Pillar today and in an organization. Houston Chronicle. March 2019. Available at: https://smallbusiness.chron.com/ the future. effective-communication-organization-1400.html. Governors also will be key to educating Fellows on how to Accessed March 17, 2020. bring concerns forward. Annually, all Fellows receive a “You Robinson L, Segal J, Smith M. Effective Have a Voice” e-mail/letter in January or February that lists communication. HelpGuideOrg International. the contact information for their respective chapter Gover- Available at: www.helpguide.org/articles/ relationships-communication/effective- nors and the chair of their specialty-specific Advisory Council. communication.htm. Accessed March 16, 2020. This important document will need to be expanded with Skills You Need. What is communication? Available additional information on how to bring forward concerns to at: https://skillsyouneed.com/ips/what-is- the ACS, as well as the key role Governors play in champion- communication.html. Accessed March 17, 2020. ing Fellows’ concerns. Touro University Worldwide. Five ways to define good communication. Available at: www.tuw. Effective communication is essential to the success of edu/program-resources/good-communication/. any organization. The survey results reveal that although Accessed March 16, 2020. strong and effective communication exists between the Col- lege administrative leadership, the Board of Regents, the B/G, and the Fellows, the College must continue to adapt to the communication preferences of its membership, adopting new technology as needed. A focus on the importance of effective communication and actively working to improve and expand the available opportunities for outreach, dialogue, and feedback will support and empower members. Future ACS communication efforts must continue to fulfill the five C’s of effective communication: clarity, consistency, creativ- ity, content, and connections. ♦

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2019 ACS-COSECSA Women Scholars describe how they and their patients benefit from the scholarships: Part I

by Natalie Bell and Girma Tefera, MD, FACS

Editor’s note: The following is the first of two articles pro- COSECSA is the leading surgical organiza- filing the 2019 American College of Surgeons-College of tion in the sub-Saharan region and is dedicated Surgeons of East, Central and Southern Africa Women Schol- to improving surgical education standards and ars. Part II will be published in the October issue of the strengthening overall quality of surgical care. To Bulletin. become COSECSA Fellows, candidates must successfully pass both a written and a clinical exam. ub-Saharan Africa suffers from a severe short- Candidates who successfully complete the written age of surgeons. The data indicate that there exam are invited to the clinical exam, which usually Sare only 0.5 surgeons for every 100,000 people, takes place in December during the annual general and though women comprise more than 50 percent COSECSA meeting. The ACS-COSECSA Women of the population, they represent only 7 percent of Scholars Program provides women residents with the surgical workforce.* the opportunity to sit for the final oral examination. To address this challenge, the American College of Surgeons (ACS) and the College of Surgeons of East, Central and Southern Africa (COSECSA) developed a Process for selecting scholars scholarship program to support women in their final Once the trainees successfully complete the written year of surgical residency to help them complete their exam, they become eligible for the scholarship. Subse- training and to encourage other women in medicine quently, members of the COSECSA Examination and to consider surgery as a profession. This scholarship is Credentialing Committee and Operation Giving Back financially supported jointly by the ACS Foundation (OGB) Educational Subcommittee finalize the selec- and the Association of Women Surgeons. Each schol- tion. In December 2019, several ACS Fellows traveled arship is worth $2,500 and is administered through to Kampala, Uganda, for the 20th Annual General COSECSA. Since its inception in 2017, 30 scholarships Meeting and Graduation Ceremony of COSECSA. At have been awarded. the meeting, ACS Fellows assisted in administering the clinical examinations on site and participated in *O’Flynn E, Andrew J, Hutch A, et al. The specialist surgeon workforce in East, Central and Southern Africa: A situation analysis. World J Surg. the annual meeting. ACS-COSECSA Women Schol- 2016;40(11):2620-2627. ars had the opportunity to connect and interact

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The 2019 ACS-COSECSA Women Scholars and members of the ACS at a post-exam celebratory dinner, where they networked and shared experiences

with ACS Fellows, including Past-First Vice-Presi- designation: ACS-COSECSA Women Scholars dent Hilary Sanfey, MD, BCh, FACS; Sherry Wren, Program. MD, FACS, member, ACS Committee on Global Engagement through OGB; ACS Past-President Patricia Numann, MD, FACS; Sharon Stein, MD, Dr. Kibansha faithfully pursues FACS, member, ACS Women in Surgery Commit- career in urology tee (WiSC); Past-ACS Governor Kristin Long, MD, Matumaini Hope Kibansha, MD, received her FACS; Celeste Hollands, MD, FACS, member, WiSC; bachelor’s degree in medicine and surgery from and Girma Tefera, MD, FACS, Medical Director, Makerere University Medical School, Kampala, in ACS OGB, and coauthor of this article. 2009. She then joined a district general hospital in According to Abebe Bekele, MD, FCS, FACS, southwestern Uganda, where she initially practiced chair, examinations and credentials committee, as a medical officer for two years, later becoming COSECSA, the program has contributed to an abun- the head of the same hospital. In 2014, Dr. Kiban- dance of opportunities for women in the region. sha received her master’s degree in surgery from “The scholarship is instrumental in supporting her alma mater, and in 2019, completed her master women scholars to sit for their fellowship exami- of science in urology from Kilimanjaro Christian nation and, most recently, allows our young women Medical College, Moshi, Tanzania. Dr. Kiban- to register for training under COSECSA. This sha completed her fellowship in urology through undoubtedly contributes to increasing the surgical COSECSA. Dr. Kibansha’s career interest is in recon- workforce in the region, and to the progress women structive urology. She is a Rotarian, enjoys nature surgeons have made in the field,” Dr. Bekele said. walks, loves dancing, and takes pleasure in mentor- In this article, we introduce six of our 12 women ing young physicians. scholars from 2019. The other six will be featured “It was a great favor from God to be a beneficiary in the October issue of the Bulletin. If you are inter- of the ACS-COSECSA Women’s Scholarship. This ested in financially supporting the scholarships, [opportunity] came at a time when I was financially visit the ACS Foundation web page (facs.org/donate) unstable since I had just completed my training in and designate your support toward OGB, program urology. I didn’t have to feel the [financial] pain

52 | V105 No 5 BULLETIN American College of Surgeons 2019 ACS-COSECSA WOMEN SCHOLARS

Dr. Kibansha Dr. Yimam Dr. Shinondo

because of this award. I am forever grateful, and as a woman student far from home. This experience may God strengthen our society,” Dr. Kibansha said. helped Dr. Shinondo during her surgical training in the male-dominated field of pediatric surgery at the University of Zambia, leading to her graduation as Inspired by parents’ experiences, the first Zambian woman pediatric surgeon in 2019. Dr. Yimam pursues MIS oncology Dr. Shinondo is pursuing a fellowship with COSECSA Hanan Alebachew Yimam, MD, completed her under- and has a keen interest in research, surgical education, graduate studies in 2013 at the University of Gondar and global surgery. She is part of the global pediat- College of Medicine and Health Sciences School ric surgery community seeking to improve access to of Medicine, Ethiopia. She then went on to com- children’s surgical care and to provide safe surgery for plete her postgraduate training in general surgery children in low- and middle-income countries. at St. Paul’s Hospital Millennium Medical College, “The ACS-COSECSA Women Scholars Program Addis Ababa, Ethiopia, in 2019 and recently began scholarship was not only the financial ticket and working at St. Paul’s. means to get me through the pediatric surgical fel- Dr. Yimam was inspired to help others who need lowship and examination, but also an opportunity medical care after witnessing her mother’s experi- for continued surgical and professional development ence with Ethiopian surgeons during her battle with thanks to the ACS five-year membership and the breast cancer, as well as her father’s experience with COSECSA annual fellowship fee coverage,” Dr. Shi- Ethiopian surgeons during treatment for renal cell nondo said. “Being the first female Zambian pediatric carcinoma. Dr. Yimam intends to study minimally surgeon, I inevitably have to continue proving myself invasive surgery (MIS) in the future. against my male peers, but with this award I can stay Dr. Yimam said she would have been unable to abreast of current surgical trends and practice and cover the fee and expenses of Fellowship in COSECSA be a step ahead.” without the scholarship. “The scholarship helped me on so many levels. It inspired me and female residents and colleagues around me. It gave me courage Dr. Munanzvi pays it forward always to do more as a human being for the nation, Kudzayi Sarah Munanzvi, MD, is an aspiring pediat- for the world,” she said. “Thank you for giving me ric surgeon who completed her undergraduate degree this opportunity.” in 2017 at the University of Zimbabwe College of Health Sciences, and practices at Harare Central Chil- dren’s Hospital, Zimbabwe. Dr. Munanzvi has been Dr. Shinondo overcomes challenges involved in establishing a short course in pediatric in pediatric surgery surgery for junior physicians, and in developing a Patricia Shinondo, MD, is a pediatric surgeon who com- new protocol for the management of patients with pleted her undergraduate training in 2009 at the Kuban gastroschisis. She also is proud to have provided medi- State Medical University, Krasnodar, Russia, where she cal services for sex workers at the Centre for Sexual quickly learned to adapt to challenging circumstances Health and HIV/AIDS (human immunodeficiency

JUL 2020 BULLETIN American College of Surgeons | 53 2019 ACS-COSECSA WOMEN SCHOLARS

Dr. Munanzvi Dr. Odhiambo Dr. Ahmed

virus/acquired immunodeficiency syndrome) Research “I am excited and honored,” Dr. Odhiambo said. Zimbabwe. “I look forward to numerous networks on the path Dr. Munanzvi is passionate about surgical educa- to surgical excellence.” tion and laparoscopy and aspires to merge these two disciplines and share them with upcoming surgeons. Having been mentored by the eminent pediatric sur- Dr. Ahmed strives to improve geon Bothwell Mbuwayesango, MD, Dr. Munanzvi has the surgical community not only gleaned meticulous surgical skills, but also Marta S. Ahmed, MD, is assistant professor of general adopted Dr. Mbuwayesango’s mantra that surgeons surgery, Debre Berhan University, Ethiopia. She com- can improve patient outcomes by learning how to do pleted her undergraduate degree in 2014 at Mekelle simple things well. University School of Medicine, Tigray, Ethiopia, and “The ACS-COSECSA Women Scholars Program then pursued general surgery training at St. Paul’s has provided a platform for me to interact with emi- Hospital Millennium Medical College, Addis Ababa, nent women surgeons—pioneers in their fields who Ethiopia. Dr. Ahmed’s parents inspired her to develop are willing to give me a ‘hand up.’ Spending time with an interest in medicine, which led to her lifelong dream these women and getting to learn from them has been of becoming a surgeon. She intends to continue prac- a phenomenal opportunity,” Dr. Munanzvi said. “With- ticing surgery, while encouraging women to join the out the financial assistance from this program, I would profession and engage in surgical innovation and not be where I am today. I am grateful to have been research. awarded the opportunity to benefit from the program.” “This scholarship was very important to me for many reasons. First, it provided me the opportunity to take the COSECSA Fellowship of the College of Dr. Odhiambo looks forward to Surgeons general surgery examination by covering expanding professional network all the expenses of travel, accommodations, and the Clara A. Odhiambo, MD, is a general surgeon and examination fee. Now because of this scholarship, I am endoscopist at St. Francis Hospital Nsambya, a a Fellow of COSECSA. Second, this scholarship gave COSECSA-accredited hospital in Kampala, Uganda. me the chance to join the ACS as an Associate Fellow, Dr. Odhiambo also is an honorary lecturer for the as well as obtain membership with COSECSA, which Mother Kevin Postgraduate Medical School, St. Fran- helps me to get additional benefits,” Dr. Ahmed said. cis Hospital Nsambya. She attained her undergraduate “I am so grateful for being one of the awardees of this degree from Gulu University in northern Uganda and scholarship because this journey would not have been completed her postgraduate studies in 2017 at Uganda possible without the dedicated support I received from Martyrs’ University Nkozi. Dr. Odhiambo is a proud the scholarship. I would like to thank the ACS and I member of COSECSA. look forward to working with the ACS and COSECSA Apart from surgery, she is a dedicated wife and to help my community in the surgical practice.” ♦ mother of two beautiful daughters. She enjoys sing- ing and cooking for her family.

54 | V105 No 5 BULLETIN American College of Surgeons QUALITY REVIEW FOR CANCER PATIENTS

A call into the distance: How quality review can change a rural cancer patient’s outcome

by Mary O. Aaland, MD, FACS, and Karen W. Luk, MD

HIGHLIGHTS mucosa-associated lymphoid tissue (MALT) lymphoma after diagnostic upper endoscopy in a critical access • Describes a case history in which a nonsurgical hospital (CAH). Three weeks after initial treatment department quality review led to a better outcome decisions were made, an internal quality review— • Identifies cancer care challenges for performed by the referring tertiary center’s pathology providing timely diagnosis and treatment department—uncovered a discrepancy that drastically • Discusses the importance of continuity altered this patient’s clinical outcome. of care and effective communication strategies for rural cancer patients Case history In a town of approximately 1,000 people, an 81-year-old male presented to the local monthly general surgery or more than 100 years, the American College clinic with complaints of a one-year history of vague of Surgeons (ACS) has led national and interna- epigastric pain and sore throat without weight loss, Ftional initiatives to improve quality in hospitals, appetite change, fever, or chills. He was otherwise in specifically in the fields of trauma, cancer, and surgi- good physical health, working full time in his weld- cal care. The ACS was the forebear of what is now ing shop, which involved lifting up to 80 pounds and The Joint Commission and continues to develop pushing objects greater than 130 pounds. quality standards for cancer, trauma, metabolic and According to his surgical and medical history, the bariatric, and geriatric patient care. patient had been treated for colon cancer requiring The ACS soon will launch a standards program to surgical resection and chemoradiation therapy, pros- ensure surgical care facilities are in compliance with tate cancer requiring prostatectomy, and bradycardia the guidelines outlined in Optimal Resources for Surgi- requiring placement of a cardiac pacemaker. His only cal Quality and Safety (also known as the Red Book) medications were benazepril, hydrochlorothiazide, and for rural hospitals, as noted in an article in the aspirin, omeprazole, and multivitamins. He quit smok- April issue of the Bulletin.* The execution of these pro- ing more than 50 years ago and consumed one or two grams and their impact on surgical patients often is alcoholic beverages a week. He had a sister who had underappreciated. The following case history features Lynch syndrome with colon and uterine cancer. a nonsurgical department quality review and its effect Following the initial surgery consultation, the on a rural surgical patient. patient underwent a diagnostic upper endoscopy at the A patient in rural North Dakota was diagnosed CAH, which demonstrated diffuse gross flattening of with diffuse helicobacter (H.) pylori-negative gastric the gastric mucosa with hyperemia without ulceration within the body of the stomach. Distal to this abnor- *Puls MW, Hughes TG, Sarap M, Caropreso P, Nakayama DK, Welsh DJ. mality was a pale, flattened area without ulceration, New ACS-led verification program aims to improve care for rural sur- less than 1 cm in size. Multiple biopsies were taken of gical patients. Bull Am Coll Surg. 2020;105(4):24-28. Available at: https:// bulletin.facs.org/2020/04/new-acs-led-verification-program-aims-to- these areas, in addition to a sample for H. pylori eval- improve-care-for-rural-surgical-patients/. Accessed June 22, 2020. uation. Specimens were reviewed by the consulting

JUL 2020 BULLETIN American College of Surgeons | 55 QUALITY REVIEW FOR CANCER PATIENTS

The first challenge is maintenance of quality in diagnostic techniques for accurate disease identification.... The second challenge is communication.

pathology department at the regional medical center 65 postoperative course and recovery were uneventful. miles away. The pathology report returned as mucosal Today, the patient continues to work in his welding involvement of extranodal marginal zone lymphoma shop. of MALT lymphoma; H. pylori was negative. Two weeks after the endoscopy, medical oncology staff at the regional medical center referred and Challenges in cancer care evaluated the patient for the H. pylori-negative MALT Optimal care for any cancer patient demands timely lymphoma. However, the following week, the patholo- diagnosis and treatment. The diagnostic process gist updated the surgeon on the patient’s biopsy results involves a series of professionals—from the surgeon in accordance with the pathology department’s internal performing the procedure and obtaining the appropri- quality review, a process performed once a month in ate biopsy, to the procedure room team organizing and which a randomly selected group of specimens are re- identifying each specimen, to the lab technicians pre- examined for accuracy and consistency. According to paring the tissue samples, to the pathologist making the updated evaluation, the patient not only had MALT the final interpretation. Each member of the team is lymphoma, but also may have had adenocarcinoma. directly responsible for the patient and can contribute More information was needed to officially make to diagnostic progress or delay. the diagnosis. Thus, a second endoscopist performed Once patients are diagnosed with a malignancy another upper endoscopy at the regional center. The and referred to a tertiary care center, they become original lesions were again encountered, biopsied, and part of multidisciplinary tumor board conferences and found positive for adenocarcinoma. The specimens are assigned care coordinators to manage appoint- were sent to the region’s largest academic center for ments and therapy schedules. Unfortunately, this level additional review, which confirmed the presence of a of organization does not exist for patients during the small focus of poorly differentiated adenocarcinoma. diagnostic period, and ownership of the patient’s care The patient was then referred to the same academic is less well-defined, especially in rural America. This center for the remainder of his work-up and treatment. case demonstrates challenges within the diagnostic Staging computed tomography (CT) and positron phase that influence cancer care for patients in rural emission tomography (PET)/CT imaging, repeat communities. endoscopy with endoscopic ultrasound, and diagnos- The first challenge is maintenance of quality in tic laparoscopy with peritoneal washings identified no diagnostic techniques for accurate disease identifica- signs of metastatic disease, and the patient ultimately tion. A critical component of the diagnosis in this case underwent definitive resection by total gastrectomy was the second review of the initial biopsy as part of four months after his original endoscopic evalua- the pathology department’s routine quality review tion. Final diagnosis based on his surgical pathology process. Had it not been for this quality review, this was multifocal involvement of MALT lymphoma patient would have received inappropriate treatment with 1.8 x 1.5 x 0.5 cm of invasive poorly differenti- and later developed advanced disease. ated intramucosal adenocarcinoma with signet cell The second challenge is communication. Equally component. All lymph nodes were negative, making important to the pathologist’s addendum was the direct the final stage pT1a, pN0. The diagnosis, determined phone call from the pathologist to the patient’s care preoperatively, was consistent with a gastric collision team at the community hospital, including the initial tumor; a rare pathology more often seen incidentally endoscopist who promptly redirected the patient’s care. within surgically resected specimens.† The patient’s Efficient and effective communication is fundamental to convey changes in diagnosis and treatment. To suc- †Schizas D, Katsaros I, Michalinos A, et al. Collision tumors of the gastrointestinal tract: A systematic review of the literature. Anticancer Res. cessfully contact rural providers, it also is important 2018;38(11):6047-6057. to consider the communication method.

56 | V105 No 5 BULLETIN American College of Surgeons QUALITY REVIEW FOR CANCER PATIENTS

Challenges in rural health care a rural surgery support program in July 2014 to The electronic health record (EHR) has become a promote quality surgical care for vulnerable com- convenient way for providers to exchange patient infor- munities that previously lacked access to consistent mation with each other, but it can be an unreliable surgical care. Part of the program’s commitment communication modality for some regions because of was to employ a single surgeon in the same commu- a lack of integration between referring and referral sys- nities to facilitate familiarity and continuity through tems. This patient’s case involved three different EHRs, regular general surgery call schedules, as well as which is typical for individuals whose care begins at 24-hour/seven-days-a-week direct phone availabil- a CAH and ends hundreds of miles away at a tertiary ity. This surgeon serves as an immediate surgical academic center. Therefore, information that may be resource for the local primary care providers regard- updated within the tertiary center may not be updated ing patients such as this 81-year-old patient, whose at the other institutions where a rural patient seeks care. outcome was dependent on timely direct commu- The surgeons and clinicians caring for rural patients nication; this patient’s case was a success in part also may practice in multiple facilities, transitioning because of this program. days to weeks between separate computer communi- No single program is applicable for all health care cation systems. For this reason, message receipt and systems. Each quality improvement program should response times can be prolonged. For these providers, be tailored to its respective community. This case no e-mail, secure chat, or instant message can replace demonstrates the need to consider the needs of rural the more traditional provider-to-provider phone call communities where the diagnostic evaluation begins. to relay time-sensitive information. When it comes to The referral and referring centers must connect at all keeping in touch with patients—an equally important phases of care—patient consultation, preoperative, task—a phone call might be the only way to reach indi- intraoperative, postoperative, and after discharge— viduals without reliable Internet access. Although many otherwise, quality surgical care will be lost. potential barriers to adequate communication can be found in rural health care, in this case, the barriers were avoided because the pathologist placed a simple The right provider at the right time phone call to personally discuss new concerns with the No physician is further from direct contact with the initial endoscopist, resulting in little to no delay for an patient than the pathologist, yet his or her findings accurate cancer diagnosis. direct treatment plans every day. At the same time, A third factor that influences prediagnosis care in the pathologist’s information is only meaningful when rural centers is continuity. In tertiary medical centers, it is communicated in a timely manner to the other the pre- and postdiagnosis phases are well guided members of the patient’s care team. In this case, a within a confined network of specialists and through pathology quality improvement program prevented multidisciplinary meetings, but for rural America, the the pathologist from making an incomplete diagnosis, diagnosis of surgical disease may be more disjointed. but the pathologist’s phone call to the right provider Rural hospitals often are supported by providers at the right time was the primary reason the patient with limited surgical background. Locum tenens are is alive and cancer-free today. This patient’s success common in these hospitals, not only among the phy- validates the need for multidisciplinary quality review, sicians, but also for nursing and other ancillary staff. communication, and continuity between tertiary Diagnostic procedures are offered on a limited basis, and rural centers. The emphasis of these principles and imaging and pathology require interpretation at through programs such as the Red Book and the Col- a remote facility. lege’s new rural verification programs will facilitate To mitigate some of this fragmentation, the Uni- recognition of community-specific needs to improve versity of North Dakota, Grand Forks, established the health and safety of patients nationwide. ♦

JUL 2020 BULLETIN American College of Surgeons | 57 STATE LEGISLATIVE WRAP-UPACTIVITY SHUTTERSTOCK.COM THIS PAGE: NAGELTHIS PAGE: PHOTOGRAPHY/

Surprise billing, trauma, and cancer top state legislative agendas in 2020

by Christopher Johnson, MPP

Editor’s note: The information in this article was current Out-of-network surprise billing before the coronavirus disease 2019 (COVID-19) pandemic State legislation to address out-of-network surprise led to state legislature shutdowns. For the latest informa- medical bills continues to be a priority issue before tion on state legislative activity, read the weekly Bulletin state legislatures. At press time, 30 states had intro- Brief and Bulletin Advocacy Brief, which is published every duced at least one bill that would create a new law or other week. amend existing state law to address out-of-network surprise billing. Legislation in Georgia, Indiana, and ore than half of the state legislatures have Virginia had advanced out of their legislature’s cham- picked up where they left off in 2019, carry- bers, sending bills to the governor, whereas bills in Ming over priority legislative issues into 2020, Hawaii, Kentucky, and Nebraska had passed out of whereas those states that do not carry over legis- the originating chamber. lation (a term for bills that span two years) from The Georgia Senate passed S.B. 359 on February 24, the previous year have quickly introduced their 2020, while the House passed H.B. 888 on March 3, own legislative solutions to the major issues facing 2020. The bills would take patients out of the middle surgeons and patients. These bills concern issues of pricing issues, leaving negotiations on cost of care such as out-of-network surprise billing, STOP between the physician and insurer for emergency care THE BLEED®, trauma prevention and readiness, and nonemergency care provided by an out-of-network nonphysician scope of practice, and cancer physician at an in-network facility. For payment, the prevention and screening. The state legislatures bill would treat out-of-network physicians providing of Montana, Nevada, North Dakota, and Texas emergency services the same as in-network physicians comprise the small group that does not meet in with regard to the patient’s health insurance plan, 2020. The American College of Surgeons (ACS) while an out-of-network physician providing services is tracking more than 1,400 bills in the 46 states in an in-network facility would be reimbursed the in session in 2020. The following is a summary of greater of the following: the median in-network rate the advocacy efforts and legislation that the ACS of all insurers for the same or similar service, the most is tracking. recent amount paid to the physician for the same

58 | V105 No 5 BULLETIN American College of Surgeons Market value is based on the weighted average of the of the average weighted on the based is value Market service. of the value” “market-based for the facilities at in-network or services services emergency vide pro who physicians out-of-network reimburse would that language insurance-friendly with amended was 1251when H.B. faded support That (MSV). of Virginia Society Medical of the bill preferred the originally was of 1251 H.B. sage S.B. 172, 1251 and H.B. respectively. the process. resolution dispute independent an as such insurers, with for negotiation avenues ACS-supported additional with physicians vide do not pro bills The of charges. estimate a good-faith request can also provider insurance health their with contracted is that aphysician seeing apatient that lates stipu bill The estimate. on agood-faith based amount charge ahigher to paying writing in consented has patient the unless price in-network at the physician out-of-network by an for care would set reimbursement Holcomb now Eric tois headed Governor (R), which approved bill of version The the Senate. by the passed bill to the made amendments rejected House the when committee out of aconference came 1004H.B. that for 2020. priority akey is issue the to address legislation passing that stated publicly The few sessions. past the legislature the in bills surprise of out-of-network issue on the engaged actively has TheGSACS bill. afinal in more favorable language to negotiate of surgeons to advocate on behalf groups physician other with of acoalition part as working prohibition. billing surprise the from out-of-network an to see physician agree that patients exempts bill the Additionally, insurer. by the paid amount the with who do not agree physicians for process arbitration an provides bill The insurer. the by determined amount or an out-of-network services, Two distinct legislative proposals moved through moved through proposals legislative Two distinct The The ACS of the (GSACS) been Society has Georgia The Virginia Georgia Georgia Indiana House and Senate, culminating in the pas the in culminating Senate, and House governor and legislative leadership have leadership legislative and governor legislature passed a version of aversion passed legislature STATE LEGISLATIVE ACTIVITY - - - - • • mission’s Bureau of Insurance. The MSV ultimately ultimately MSV The mission’s of Insurance. Bureau Com Corporation State Virginia tothe reimbursement the Under 1251, H.B. may dispute insurer. physicians by acommercial paid amount average unweighted the and Medicare from to aphysician paid amount • follows: as are billing out-of-network surprise of arbitration. inclusion and charges, of billed average median the as well as claims, of-network paid out- and of average in-network median on the based payments reasonable of commercially establishment the billing, on balance a ban includes signature his (D) for Northam to Governor headed bill agreed That 2019. in of Washington state by the passed legislation on the based was that favor of in legislation amended were bills of the versions both Senate, and House payment. one) the chooses to dispute arbitrator an and amount final their present sides (both system arbitration abaseball-style includes and rate, payment commercial customary and at payment usual initial the sets by out-of-network physicians, facilities in-network at provided care and care emergency toboth applies billing, balance prohibits 172, S.B. which preferred physicians to bill for charges if the charges are based based are charges the if for charges to bill physicians Nebraska physician. out-of-network the from costs for uncovered of pocket pay to out writing in agrees patient the when amount ahigher bill may out-of-network physicians ations, situ nonemergency in amount; allowed the to care nonemergency or emergency for physicians network Idaho Medicare. bill to allowed are they what more than amount payor or other an plan, care managed apatient, billing from physician participating Hawaii Other notable state legislative efforts to address to address efforts legislative notable state Other the between However, deal due to alast-minute (H.B. 506) would limit payment rates to out-of- to rates payment limit 506) would (H.B. (S.B. 2423 and H.B. 1881) H.B. (S.B. and 2423 anon prohibit would (L.B. 997) states that it is permissible for permissible it is that 997) states (L.B. JUL 2020 BULLETIN 2020 JUL American College of Surgeons of College American - - -

| THIS PAGE: NAGEL PHOTOGRAPHY/ 59 SHUTTERSTOCK.COM STATE LEGISLATIVE ACTIVITY CS FOTO IVAN VIEITO TRAVELER1116 POWEROFFOREVER

on the higher of the health carrier’s contracted rate or Indiana, Mississippi, Missouri, South Dakota, Vir- 125 percent of Medicare and would establish a media- ginia, and West Virginia. The College sent a letter to tion process. the Idaho Board of Nursing opposing a board statement recommending that CRNAs call themselves • Kentucky (S.B. 150) would establish a database of billed nurse anesthesiologists. charges for use to determine “usual and customary” The College sent a letter to Idaho legislators rates and includes an independent dispute resolution opposing legislation that would expand the scope of process. practice for optometrists to include certain surgical procedures, such as laser surgery. Other optometrist • Maine (L.D. 2105) would enable uninsured patients and scope bills have been introduced in Mississippi, individuals covered by a self-insured plan to initiate an Nebraska, and Wyoming. independent dispute resolution process to challenge The ACS has been supporting the Florida Chap- physicians’ bills and to resolve disputes between physi- ter’s efforts to oppose legislation, H.B. 607 and cians and insurers for billed charges. S.B. 1676, which would create a new specialized practice license for autonomous practice advance • Arizona (S.B. 1602) already has a law partially address- practice registered nurse (APRNs) and autonomous ing out-of-network surprise bills that would repeal the physician assistants (PAs) to practice without phy- arbitration option; however, it would set up a database to sician supervision as well as APRN-Independent determine usual and customary rates at the 80th percen- Practioners. The Florida Speaker of the House Jose tile of all charges for a given service in a geographic area. Oliva (R) has publicly stated that passing legislation to author independent practice for APRNs and PAs is one of his legislative priorities for the year. Scope of practice expansion An amended version of H.B. 607 that only granted Nonphysician health care practitioners continue independent practice to APRNs passed out of the their efforts to expand their legal scope of practice legislature and was quickly signed by Governor to include procedures beyond their education and DeSantis (R) on March 11. training and to gain independent practice authority by removing supervision and collaboration requirements. Consequently, the ACS continues to advocate Trauma legislation for state legislation to maintain high standards for The College continues to advocate for the safety of education and training of all health care practitioners individuals and access to care in the event of a trau- to perform surgical procedures and to support other matic injury, working with the ACS Committee on physician specialties that have concerns about legis- Trauma (COT) and state chapters on issues related lative encroachment. To date this year, the ACS has to state trauma systems, advancing the STOP THE sent letters to legislators in Missouri, South Dakota, BLEED campaign, and supporting laws that would and West Virginia opposing legislation to grant result in a reduction of injuries. independent practice to certified registered nurse anesthetists (CRNAs). Despite opposition, the bill Trauma systems and funding in South Dakota passed and was signed by the gov- Kansas Gov. Laura Kelly (D) included a recommen- ernor. Bills on CRNA scope have been introduced in dation in her fiscal year 2021 budget proposal to

60 | V105 No 5 BULLETIN American College of Surgeons STATE LEGISLATIVE ACTIVITY SHUTTERSTOCK.COM JAMES KIRKIKIS PHOTOGRAPHY/ KIRKIKIS JAMES GJGK PHOTOGRAPHY/SHUTTERSTOCK.COMGJGK

provide funding directly from the state general fund Violence prevention to the Kansas Trauma Program to avoid a revenue The Connecticut Chapter of the ACS submit- shortfall, as well as increase funding to the Divi- ted testimony at a public hearing March 16 on sion of Public Health to support the trauma system. H.B. 5448, which would expand the state risk pro- A bill in New Jersey, A.B. 2050, would deny a tection order law. Under the expansion, family certificate of need to a health care facility seeking members and physicians could apply for a protec- to designate itself as a trauma center if the facility tive order requiring individuals to surrender their is within 15 miles of an existing trauma center. In firearms, as well as prohibit them from purchasing addition, the Commissioner of Health could not new firearms during the extent of the order. issue a request for certificate of need without the The Washington state legislature passed favorable approval of the New Jersey State Trauma S.B. 6288 to “establish the Washington office of System Advisory Committee. firearm safety and violence prevention to provide statewide leadership, coordination, and techni- STOP THE BLEED cal assistance to promote effective state and local STOP THE BLEED legislation continues to gain efforts to reduce preventable injuries and deaths support among state lawmakers, who are reaching from firearm violence.” out to the ACS for model legislation and for support of their own STOP THE BLEED legislation. Motorcycle helmets Bills to advance STOP THE BLEED training and The Connecticut Chapter of the ACS submit- access to bleeding control kits are under consid- ted testimony at a February 28 public hearing eration in 12 states: California, Florida, Illinois, on S.B. 148, which would require all individuals Iowa, Massachusetts, Michigan, Missouri, North younger than 21 years old to wear a helmet while Carolina, New York, Pennsylvania, Tennessee, operating a motorcycle. and Washington. The Iowa legislation, H.F. 2169, The Missouri COT testified against S.B. 590, was amended to add STOP THE BLEED training to which would roll back the state’s universal motor- Iowa secondary school health education programs. cycle helmet law to require only riders younger The Iowa Chapter of the ACS and State COT sent than 18 years old to wear a helmet or all riders letters of support for legislation that advanced out operating the vehicle with a learner’s permit. How- of the House Committee on Education February ever, the bill would prohibit law enforcement from 18. The Tennessee House passed H.B. 1587 on stopping riders solely on the basis of not wearing February 27 to require STOP THE BLEED train- a helmet. ing for school personnel and permit the installation Bills in Maryland, Massachusetts, Nebraska, of bleeding control kits. New York, Vermont, Washington, and West Vir- A bill in Washington, S.B. 6157, that would ginia would eliminate requirements for adults to require STOP THE BLEED training for school wear a helmet. Bills in Hawaii, Iowa, New Hamp- personnel and make available bleeding control shire, and Oklahoma would require adults to wear kits in school buildings passed out of the Senate a helmet. New York has legislation to study the effi- Committee on Early Learning and K–12 Educa- cacy of wearing a helmet while riding a motorcycle, tion January 31 but was subsequently moved to the and West Virginia has a bill to allow out-of-state Rules Committee. residents to ride without a helmet.

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Vehicle passenger safety for funding from the Substance Abuse and Mental The New York Chapter of the ACS has actively sup- Health Services Administration. ported S. 4336/A. 6163, which would require all At press time, 27 states were considering Tobacco passengers ages 16 and older to wear a seat belt when 21 legislation: Alabama, Alaska, Arizona, Colo- riding in the rear seat of a vehicle. The chapter issued rado, Florida, Georgia, Idaho, Indiana, Iowa, a memorandum of support for the legislation in addi- Kansas, Kentucky, Michigan, Minnesota, Mis- tion to activating a grassroots call to action. The New sissippi, Missouri, Nebraska, New Hampshire, York Assembly passed the bill February 12 followed by New Mexico, Oklahoma, Pennsylvania, Rhode the Senate passing the bill on March 3. The legislation Island, South Carolina, Tennessee, Washington, is in the State Assembly pending final action before West Virginia, Wisconsin, and Wyoming. The heading to Gov. Andrew Cuomo (D). The Connecti- bill in Wyoming was signed by Governor Gordon cut Chapter of the ACS is part of an AAA (formerly (R) while the Indiana legislature sent their bill to the American Automobile Association)-led coalition Governor Holcomb (R) for his signature. Tobacco to support legislation, S.B. 151. 21 bills in Kentucky, New Hampshire, and Wis- consin also had passed out of at least one legislative chamber. Cancer-related legislation In addition to raising the age for the purchase of The ACS Commission on Cancer and other stake- tobacco products, state legislators have emphasized holder organizations continue to monitor and engage including electronic cigarette and vapor products as on cancer-related state legislation, such as raising the part of the Tobacco 21 bills and have introduced leg- age for the purchase of tobacco and vapor products to islation to curb vapor product use, such as banning age 21 from 18 years old; expanding health insurance flavored nicotine products. The New York Chapter coverage expansion for breast, cervical, colorectal, of the ACS is supporting a proposal in Governor and prostate cancer; and protecting minors from the Cuomo’s budget to ban the sale of flavored nico- harmful effects of tanning beds, as well as permit- tine products. In 2019, the New York State Supreme ting students to use sunscreen products at school and Court struck down an executive order from Gover- school events. nor Cuomo to achieve the same result. The states of Massachusetts and New Jersey have enacted Tobacco 21 and vapor bans, whereas Arizona, Colorado, Connecticut, The federal government passed and enacted legisla- Florida, Hawaii, Kentucky, Maryland, Michigan, tion to raise the age to purchase tobacco products Missouri, Nebraska, Oklahoma, Oregon, South nationally to age 21 from 18 years old, but the Dakota, Vermont, Virginia, and Washington State groundswell of support for enacting state legislation have introduced bills to regulate the ingredients in to follow suit, referred to as Tobacco 21, remains electronic cigarette vapor products in addition to a strong in 2020. States that had not passed their own ban on the use of nontobacco flavors. laws raising the age before passage of the federal law are still advancing legislation to address issues Skin protection specific to state regulations on the sale of tobacco The College continues to support legislative efforts products, such as retail licensing and identification, to protect children and minors from dangerous as well as aligning state law with the federal law exposure to ultraviolet light through the passage

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of laws allowing primary, middle, and secondary Get engaged school students to possess and use sunscreen prod- Engagement of ACS Fellows is critical in ensuring ucts on school premises and at school-sponsored that surgeons continue to be leaders in patient safety events, as well as establishing minimum age require- and health care quality. Fellows are encouraged to ments to use tanning beds. Three states have active support ACS advocacy efforts by participating in bills related to sunscreen in schools: Massachusetts, state chapter meetings and lobby days, building rela- Rhode Island, and Virginia. The Virginia Senate tionships with elected officials (critical to effective passed S.B. 44 January 14. grassroots advocacy), speaking about public policy Legislation in 14 states restricts a minor under issues with colleagues, responding to grassroots the age of 18 from using a tanning bed: Arizona, Action Alerts from the College, and attending the Iowa, Michigan, Mississippi, Missouri, Nebraska, annual ACS Leadership & Advocacy Summit. New Jersey, New York, Ohio, Oklahoma, Penn- The ACS State Affairs team is available to answer sylvania, South Carolina, Utah, and Virginia. The questions and provide background information Utah House passed H.B. 34 February 20, and the regarding state issues and policy programs. Numer- Virginia House passed H.B. 38 February 7, moving ous state advocacy resources are available on the both bills to their state’s respective Senates. Bills in College’s website at facs.org/advocacy/state, and Fel- Iowa, H.F. 283; Oklahoma, H.B. 3506; and Penn- lows may contact us any time at state_affairs@facs. sylvania, S.B. 909, do not align with the College’s org or at 202-337-2701. ♦ position in that they provide too many exemptions, such as allowing a parental waiver for a minor under 18 years old age to use a tanning bed.

Bariatric surgery coverage The Connecticut Chapter of the ACS is continuing its efforts to enact legislation to expand essential health care insurance benefits to include coverage for bariatric surgery. The Connecticut Chapter submitted testimony in support of S.B. 204 for a February 26 Joint Committee on Insurance and Real Estate hearing. The legislation is similar to a 2019 bill that the Connecticut Chapter also supported.

COVID-19 States have issued coronavirus disease 2019 (COVID-19)-related Executive Orders regarding dental, medical, and surgical procedures. For more information on state-level legislation, visit www.facs.org/ covid-19/legislative-regulatory/executive-orders.

JUL 2020 BULLETIN American College of Surgeons | 63 3-D PRINTING FOR CRITCAL EQUIPMENT SHORTAGES Example of 3-D printed respirator mask

Filling the gap: Using 3-D printing to overcome critical equipment shortages during the COVID-19 crisis

by Daniel T. Lammers, MD; Matthew J. Eckert, MD, FACS; and Jason R. Bingham, MD

he ongoing coronavirus disease 2019 (COVID-19) crisis has uncovered numerous deficiencies in the health care HIGHLIGHTS system and its capability to respond to a global pandemic. T • Describes 3-D-printing Although as of press time the spread of the disease appears to have slowed in select countries, parts of the U.S. continue to products, including ventilator experience growth in the number of cases. The influx of crit- parts, respirator masks, face ically ill patients had overwhelmed the capacity of an already shields, and nasopharyngeal taxed health care system in many regions, and providers had rap- swabs, that can close the gaps in equipment shortages idly exhausted critical supplies needed to protect themselves and provide optimal care for their patients. Notably, critical short- • Identifies early adopters ages in essential personal protective equipment (PPE), along of this technology with a previous reliance on foreign supply chains, had left health • Summarizes areas for further care personnel, as well as patients, in a particularly vulnerable investigation, including the state. As a result, providers were understandably frustrated and evaluation of the safety and often resorted to bringing their own supplies, as well as cleaning efficacy of these solutions and reusing items normally recommended for single use.1 This critical shortage, however, spurred innovation and brought forth novel approaches to overcoming the supply gaps. Of these, additive manufacturing and three-dimensional (3-D) printing emerged as promising solutions to this and future medical supply dilemmas.

How it works The techniques associated with 3-D printing use a multitude of materials to create on-demand, user-defined objects that can be produced on site and are rapidly adaptable to the current needs.

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Additive manufacturing techniques have been used in respirator masks, which led to significant demand for the medical field for years; however, they have been a 3-D-printed reusable personal mask.4 The “Montana confined largely to anatomic modeling, custom-fit sur- Mask” has the capability to change filter materials gical implants, and tissue engineering. based on supply availability and situational risk pro- In response to the COVID-19 pandemic, numer- file. Numerous private and academic entities have ous grassroots movements surfaced to help combat also recently described similar successes, ranging the ongoing logistical shortages facing the health care from small- to large-scale production of 3-D-printed community. To date, items such as ventilator parts, face shields for health care workers. One example of respirator masks, face shields, and nasopharyngeal institutional production of 3-D face shields is the Uni- swabs have all been designed by numerous multidis- versity of California-San Francisco clinical technologies ciplinary members of the 3-D-printing community, program.5 ranging from physicians and engineers to high school students. 3-D printing offers the ability to create customized, reusable parts that can be produced at a rate Pros and cons that is scalable to fill supply gaps in resource-stressed Hesitancy and skepticism regarding these new manu- health care systems. facturing techniques, however, continue to surround Early adoption of these techniques has not been the multiple PPE prototypes recently developed, widely accepted in the medical community. Concerns resulting in mixed feelings within the health care com- surrounding the safety, performance, and efficacy of munity. With recent Centers for Disease Control and 3-D-printed PPE, medical devices, and equipment have Prevention (CDC) recommendations supporting the been raised because of the untested nature of these nationwide use of masks in public places, at press time products. the critical shortage of PPE was projected to worsen. Despite these concerns, numerous Italian hospitals Researchers at the National Institutes of Health (NIH), incorporated these techniques to create 3-D-printed Veterans Affairs, and Food and Drug Administra- mechanical ventilator valves following the depletion of tion (FDA) recognized these issues and implemented their supply and cite their use as a critical component of programs, such as the NIH 3D Print Exchange—an patient care during the peak of their crisis.2 Although open-sourced, online file-sharing community dedi- the demand for mechanical ventilators continues to cated to the safe development of 3-D-printed medical rise in the U.S., the use of these 3-D-printed mechani- devices, to help overcome the critical supply defi- cal ventilator parts has not been reported. ciencies.6 The Joint Commission issued a statement Nevertheless, some U.S. hospitals have turned to authorizing the use of PPE brought from home, but 3-D printing to address the critical shortages of naso- consensus statements from the U.S. medical associa- pharyngeal swabs for patient testing, as well as PPE tions supporting the use of 3-D-printed materials are for both health care personnel and patients. North- lacking.7 well Health, the largest health care system in New Despite being an exciting and promising solution York State, recently announced it was able to produce for the critical supply shortage the health care system thousands of nasopharyngeal swabs per day using 3-D is facing, the rapid creation of 3-D-printed materials printing to help avoid supply shortages as widespread remains an ongoing source of debate. Proponents testing is implemented.3 argue that Internet-based, open-source file-sharing net- In March, physicians at Billings Clinic, MT, works, along with the global armamentarium of 3-D announced production of 3-D-printed personal printers, act as a major strength and force multiplier

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for this movement, contending that decentralization improves REFERENCES overall access to these resources. 1. Thielking M. Frustrated and afraid about Opponents and skeptics fear that the lack of a centralized protective gear shortages, health workers repository places end users at risk of using potentially inferior are scouring for masks on their own. Stat products. Many questions regarding the safety of the materials News. March 18, 2020. Available at: www. statnews.com/2020/03/18/ppe-shortages- used in these approaches, as well as their efficacy, have yet to be health-workers-afraid-scouring/. Accessed answered within the scientific community. Many of these designs April 4, 2020. have yet to meet or be subjected to the rigorous quality assurance 2. Feldman A. Meet the Italian engineers 3-D testing processes that define industry standards. Programs such printing respirator parts for free to help as the NIH 3D Print Exchange should help to address these con- keep coronavirus patients alive. Forbes. March 19, 2020. Available at: www.forbes. cerns; however, objective data within the literature surrounding com/sites/amyfeldman/2020/03/19/ these products is sparse. Recognizing these concerns, supporters talking-with-the-italian-engineers- of this movement argue that 3-D-printed products should not who-3d-printed-respirator-parts-for- replace standard equipment, but rather serve as an alternative hospitals-with-coronavirus-patients-for- option should the need arise. free/#5bdb5b1778f1. Accessed April 3, 2020. 3. Carroll L. New York’s Northwell Health begins 3-D printing nasal swabs for coronavirus testing. Reuters. March 31, 2020. COVID-19 reveals deficiencies Available at: www.reuters.com/article/ The ongoing COVID-19 crisis has uncovered a multitude of limita- us-health-coronavirus-usa-swabs/new- tions within our health care system. At press time, social distancing yorks-northwell-health-begins-3d-printing- nasal-swabs-for-coronavirus-testing- efforts suggested promising confinement of disease spread, but idUSKBN21I2Y2. Accessed April 3, 2020. these efforts had fallen short in terms of addressing the needs of 4. Make the Masks. The Montana Mask. the thousands of afflicted patients and the health care personnel Available at: www.makethemasks.com/. striving to care for them. Prospective planning and the develop- Accessed April 3, 2020. ment of novel solutions need to be actively pursued to ensure the 5. University of California-San Francisco. Face Shield Project. Available at: www.library. U.S. health care system is designed to proactively respond to such ucsf.edu/news/ucsf-3d-printed-face-shield- enormous challenges now and in the future. project/. Accessed April 3, 2020. As technology-based fields continue to become more prominent 6. National Institutes of Health. COVID-19 components of our society, adaptations of their state-of-the-art supply chain response. National Institutes processes, specifically additive manufacturing and 3-D printing, of Health 3D Print Exchange. Available at: https://3dprint.nih.gov/collections/covid- within the health care system may prove to be the missing link in 19-response. Accessed April 1, 2020. overcoming the logistical and supply gap shortages. Nonetheless, 7. The Joint Commission. Statement on Use of the concerns regarding the safety and efficacy of these innova- Face Masks Brought From Home. March 31, tive solutions is valid and more research should be rapidly sought 2020. Available at: www.jointcommission. before widespread adoption can be recommended. ♦ org/-/media/tjc/documents/resources/ patient-safety-topics/infection-prevention- and-hai/covid19/public_statement_on_ masks_from_home.pdf. Accessed April 4, Editor’s note 2020. The views addressed in this article represent the opinions of the authors and do not reflect the views of the U.S. Army, the Department of Defense, or the U.S. government.

66 | V105 No 5 BULLETIN American College of Surgeons COMMUNITY HOSPITAL BATTLES COVID-19

Community hospital’s losing battle with COVID-19: A surgery resident’s account

by Justin Gauthier, MD

HIGHLIGHTS tarting this past winter, the coronavirus disease 2019 (COVID-19) pandemic has swept across the world, with the • Describes the experiences U.S. reporting the highest number of cases globally. New of a chief surgical resident S York, NY, and surrounding areas experienced a disproportion- treating COVID-19 patients ately higher number of cases, with their death toll at more than • Summarizes the trend of 24,000 at press time, owning 8 percent of the entire world’s car- COVID-19 leading to AKI nage. Nassau County specifically had seen nearly 40,000 cases, a • Outlines one community hospital’s rate of nearly 1,861 cases per 100,000 people, one of the highest investigation of increased in the greater New York region.1 pneumothorax rates and COVID-19 Our 450-bed community hospital—Mount Sinai–South Nassau—is located in the heart of that suburban county and thus within the regional epicenter of this deadly virus. Our institution transformed from a primarily suburban center to a Photo: The author outside his hospital, global COVID-19 hotbed. We augmented our staff with physi- taking a break from treating COVID-19 patients (photo by Jason D’Cruz, surgery cians from across the country, admitted thousands of cases (2,300 intern, Mount Sinai-South Nassau) as of the publication of this article), and upgraded our critical

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As residents, we found ourselves powerlessly fighting an invisible enemy and witnessing scenes of fatality that are unlikely to leave our nightmares anytime soon.

care unit to five times its pre-COVID-19 capacity. by using HD, we could filter the cytokine and other Although we optimistically focused on the more than immune factors from the blood, thereby preventing 60 patients successfully extubated and the nearly 1,000 the virus’ deadly effects. Historically, HD has been COVID-19-recovered discharges, sadly we also have the most widely used tool in our armamentarium for lost more than 400 lives to this horrific pandemic. correcting rising creatinine levels.2 As I approached the end of my final year of train- HD, however, is a very expensive, physically ing, I had envisioned this period as a time to prepare taxing, and time-consuming process for patients.3 It for private practice and study for boards. Instead, as requires the placement of a temporary dialysis cathe- the chief surgical resident at a facility in the heart of ter, which is an invasive procedure that leads to many this war, I was on the front lines battling its unpre- potential complications (infection being the most dictable sequelae. Our training program was halted, pertinent, pneumothorax being the most detrimen- roles were changed, and positions were reassigned, tal).4 Placement of these dual-lumen catheters has as we were all enlisted to this army of physicians. become the responsibility of surgical residents, as, As residents, we found ourselves powerlessly fight- historically, vascular surgeons have been tasked with ing an invisible enemy and witnessing scenes of inserting large-bore central venous devices. Until the fatality that are unlikely to leave our nightmares COVID-19 pandemic, our team placed roughly one anytime soon. The following describes some of our HD catheter per week. Since the onset of this kidney- experiences. killing virus, our team places an average of three to five urgent HD catheters per day. Though not yet exclusively studied, anecdotal evi- Acute kidney injury and failed hemodialysis dence has shown that HD has no significant positive Our institution recently submitted for publication an effect on the COVID-19 patient’s clinical course or article identifying the trend between COVID-19 and AKI progression. This statement is not to fault the the onset of acute kidney injury (AKI). We found that nephrologists nor the intensivists; it is just all we AKI developed in 81 percent (n = 142) of intubated know. patients, with a greater percentage of patients devel- Though peritoneal dialysis (PD) has started to be oping AKI in the expired group when compared with used instead, the shift occurred more out of neces- the group of living patients (92 percent versus 72 per- sity (limited hemodialysis machines) than improved cent). We further calculated the odds ratio for death efficacy. PD also is unstudied in COVID-19-related after the diagnosis of AKI as 4.5 and thus concluded AKI. Some have theorized it is more cogent to employ that intubation was a harbinger to AKI, as well as to continuous renal replacement therapy in the man- eventual expiration. agement of COVID-19-induced AKI,5 but no reports Our study shows that intubated COVID-19 patients on the efficacy of this approach have been published are at risk of developing AKI and that their chance at press time. Highly educated medical profession- of survival diminishes significantly after its onset. In als are relying on what they have previously seen to an attempt to counteract this deleterious sequelae, work in medicine, rather than any evidence base, nephrologists have been recommending hemodial- because the facts pertaining to this evasive enemy ysis (HD). These specialists have extrapolated that are not yet available.

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A formal study is under way, but preliminary results show nearly half of the intubated COVID-19 patients required pigtails for clinically significant pneumothorax.

Pneumothorax, pneumomediastinum, Despite this effort, we found very little change in and plenty of pigtails the pneumothorax rate. We thus reconsidered its In the first five weeks since the outbreak of this deadly etiology as potentially secondary to the fragility of virus, I placed more pigtail catheters in hypoxic patients’ lungs. Treated similarly to patients with patients than in my previous five years of surgical acute respiratory distress syndrome, the brittle lung training. Now, when our thoracic surgery service parenchyma of COVID-19 is failing with only the is called for urgent placement, after a large pneu- smallest amount of positive pressure, even with mothorax is noted on a recent chest X ray, the story noninvasive methods. Our surgical team, again, sounds rehearsed: “COVID-positive, PEEP [positive performed the most appropriate intervention to end-expiratory pressure] above 10 cm H2O and PaO2 treat the patients’ symptoms, seemingly without less than 50 mm Hg.” On further examination, respi- altering the clinical course. ratory rates are universally in the 30s, presumably in an attempt to blow off the severe hypercapnia, typically above 50 mm Hg. As the textbook teaches, the Many silver bullets, no cure…yet 14Fr Wayne pigtail catheters are placed in the second University Hospitals Birmingham, U.K., published intercostal space, midclavicular line, without even a research briefing in April that highlighted all the contacting our attendings. active COVID-19 trials internationally.6 The brief- This drastically increased rate of pneumotho- ing, though primitive, was intriguing—ivermectin rax has again led our institution to investigate the removed the in-vitro viral load in 48 hours; siltux- causative connection with the COVID-19 virus. A imab and other immunotherapies touted significantly formal study is under way, but preliminary results reduced c-reactive protein levels, but some patients show nearly half of the intubated COVID-19 patients actually worsened; angiotensin-converting enzyme required pigtails for clinically significant pneumo- inhibitors were reducing mortality and intensive care thorax. Furthermore, our thoracic surgeons were unit admission rates with an odds ratio of 0.29. These consulted, and have been subsequently following studies, like many regarding COVID-19, have small with serial chest X rays in an overwhelming major- sample sizes but stimulate significant hope that a cure ity of the 80-patient critical care units. In specific will emerge. cases, we were occasionally required to place surgical Our hospital, like most affected around the chest tubes (30–34Fr in the traditional 5th intercostal world, are attempting most of these potential ther- space, midaxillary line) and even twice resorted to apies. COVID-19-positive patients are universally venting skin incisions to relieve extensive, clinically receiving ritonavir, tocilizumab, full-dose lovenox, diminutive, subcutaneous emphysema. intravenous famotidine, and even the controversial We first postulated that this procedure was a hydroxychloroquine. We also initiated a protocol response to the high levels of PEEP the critical trial for convalescent plasma exchange. Some col- intensivists were using to adequately oxygenate the leagues claimed that this therapy was the new silver patients’ COVID-19-infected lungs. After several bullet and would be the long-awaited cure. Recov- multidisciplinary meetings, the team universally low- ered COVID-19 victims eagerly donated their plasma ered the PEEP levels, capping them at 10 cm H2O. which, containing IgG and IgM antibodies, would

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potentially cure well-selected patients. However, without ran- REFERENCES domized control trials, it is impossible to prove the efficacy of 1. Statista. COVID-19 death rates by age these treatments compared with a placebo. Overall, what I can group in New York City 2020. Available state anecdotally, and based on lengthy discussions with my at: www.statista.com/statistics/1109867/ colleagues, is that no therapy yet initiated in our hospital has coronavirus-death-rates-by-age-new-york- had any obvious meaningful effect on our patients’ prognoses. city/. Accessed May 1, 2020. 2. Friedrich JO, Wald R, Bagshaw SM, Burns It is with great reluctance that we take on this next revolution- K, Adhikari N. Hemofiltration compared ary endeavor. In Israel, a minute group of qualified COVID-19 to hemodialysis for acute kidney injury: patients were given pluripotent stem cells with incredible results. Systematic review and meta-analysis. Crit The theory is that these placenta-derived mesenchymal cells, Care. 2012;16(4):R146. because of their unique limitless capabilities, can mitigate the 3. Loubeau PR, Loubeau JM, Jantzen R. The economics of kidney transplantation tissue-damaging effects of the virus, particularly in the pulmo- versus hemodialysis. Prog Transplant. nary and renal systems. Though inclusive of only a small subset 2001;11(4):291‐297. of qualified patients, and therefore, again, a minimally powered 4. Bevc S, Pecovnik-Balon B, Ekart R, Hojs study, the results appear very promising. After anxiously awaiting R. Non-insertion-related complications of its transatlantic arrival, we gave these 15 intramuscular injec- central venous catheterization—temporary vascular access for hemodialysis. Ren Fail. tions to several specifically selected patients in our critical care 2007;29(1):91-95. unit. The improvement in chest X rays and arterial blood gases 5. Tolwani A. Continuous renal-replacement have been astounding; in only three days, it looked as if we had therapy for acute kidney injury. N Engl J tested a different patient. Though we are hesitant to declare vic- Med. 2012;367(26):2505-2514. tory, with much larger trials to be conducted, this therapy does 6. University of Birmingham. COVID-19 research briefing. Available at: www. give hope for the positive outcome of this battle. birmingham.ac.uk/university/colleges/ Throughout this pandemic, our program’s surgical residents mds/Coronavirus/COVID-19-research- have successfully placed hundreds of HD catheters and pigtails, briefing.aspx. Accessed May 1, 2020. administered every potentially curative therapy mentioned, and yet our mortality rate in the critical care unit has remained dauntingly high. Again, specialty-trained physicians are treating the symptoms of COVID-19, but apparently not affecting its prognosis. We have spent hundreds of thousands of dollars, countless numbers of hours, and irreplaceable years of our lives training to fight illness. On a scale unlike ever before, all this education, all this research, all this dedication to our trade, is simply not enough. When these patients become critically ill, regardless of our best lifesaving measures, this deadly virus has consistently proven victorious. Though a vaccine, or even our novel stem cell study, may prove to be a successful remedy, the toll this pandemic has taken on health care professionals is one that will not soon be forgotten. ♦

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ACS quality and safety case studies: Virtual acute care for older patients reduces hospital length of stay

by Melanie Morris, MD; Lauren Wood, MPH; Emily Simmons, MSN, RN, CNL, FGNLA; Shari Biswal, MSN, RN, PCCN, CNL; David James, DNP, RN-BC, CCNS, LSSGB; Jasmine Vickers, MPH, CHES; John Russell, MBA, CPA; Katrina Booth, MD; and Kellie Flood, MD

he U.S. surgical patient focus was on reducing delirium, based geriatric care processes population is aging, with improving patient mobility, with subsequent reductions in T38 percent of operations decreasing hospital length of cost and 30-day readmissions.1 performed on older adults. stay (LOS), and improving This model was used to design Traditionally, postoperative rates of discharge to home. the Virtual ACE intervention patients have received care in a with the goal of delivering the surgical ward. Nurses and other core ACE care processes to members of the multidisciplinary Putting the quality surgical patients admitted to a health care team are trained improvement (QI) surgical ward without the daily to provide postoperative care activity in place presence of a geriatric provider to surgical patients but may UAB Hospital is a large public (physician or nurse practitioner). not receive special training to health care and tertiary referral Based on well-established, prevent or manage preexisting center with approximately 1,200 improved outcomes from geriatric syndromes, such beds. More than 36,000 operations the ACE unit care and the as cognitive impairment, are performed annually at the growing geriatric surgery delirium, and functional decline. facility. It is the only Level I literature, including best Furthermore, even if trained, trauma center in Alabama. The practice guidelines for optimal these health care professionals hospital is continually full, with perioperative management must work in microsystems that a 95–98 percent occupancy of geriatric surgical patients,2 support the delivery of evidence- most days. We have embarked the team recognized the need based geriatric care processes on a throughput initiative to to disseminate ACE-like care to achieve quality outcomes. decrease LOS to create more bed (Virtual ACE) to surgical patients The University of Alabama availability to serve more patients admitted to surgical wards. at Birmingham (UAB) in the large catchment area. To prepare the hospital system recognized an opportunity to UAB Hospital has an acute care for this care delivery redesign, redesign geriatric care delivery for elders (ACE) unit designed a core team of geriatricians, at the microsystem level (a to care for older adults admitted geriatric nurse practitioners, surgical ward), with the goal to the hospitalist service. Health and geriatric-trained nurses of providing care that is safe, care personnel in the unit have used the Institute of Healthcare timely, effective, efficient, daily team meetings guided by Improvement model for equitable, and patient-centered a geriatric physician or nurse improvement with iterative Plan, for an older surgical patient practitioner. The UAB ACE unit Do, Study, Act (PDSA) cycles to population. For this initial has demonstrated that this model implement standardized geriatric project implementation, the increases the delivery of evidence- screens into the electronic

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For this initial project implementation, the focus was on reducing delirium, improving patient mobility, decreasing hospital LOS, and improving rates of discharge to home.

health record (EHR) for use by interprofessional team approach nurses on our ACE and other for care transitions planning. Description of the QI activity pilot units. More specifically, Finally, the developed and vetted After securing key stakeholder patients were screened for care algorithms for each of these support in individual meetings, cognitive impairment, functional domains were packaged into a Virtual ACE kick-off meeting impairment, and mobility. Each the Virtual ACE intervention. took place in March 2016, PDSA cycle worked to ensure Next, implementing the with the entire unit-based the new screens fit into the Virtual ACE intervention was interprofessional team leadership nursing workflow. The geriatric pilot tested on orthopaedic4 in attendance. One role of team also joined a collaborative and then trauma surgery this team was to review and with Aurora Health System, units to learn and refine the provide feedback and advice on headquartered in Milwaukee, implementation process, the roles and responsibilities WI, and embedded the ACE which resulted in a revised of each discipline and key Tracker report into the hospital implementation strategy components and goals of Virtual EHR. The ACE Tracker is an that was then brought ACE, and help develop the electronic report that displays the to the gastrointestinal project educational plan for the results of geriatric assessments, (GI) surgery units. leadership and frontline staff. including screens for function Stakeholder engagement The Virtual ACE intervention and delirium; process and meetings with members of the implementation included outcome metrics, such as LOS; GI surgery unit began in January interprofessional team training use of tethers, such as Foleys, 2016. These initial meetings and up to six months of intensive restraints, and oxygen; and centered on attaining guidance, coaching, followed by three administration of medications for feedback, interest, and support to six months of surveillance all patients on a specific unit.3 from the surgical medical and retraining/coaching as With this infrastructure in director, followed by engaging needed to ensure the new care place, the geriatric team then frontline staff and leadership of processes are hardwired into engaged stakeholders from other the unit interprofessional health the teams’ approach. Team interprofessional disciplines care team members. Members of training was delivered to (rehabilitation therapists, the unit interprofessional team groups of the varied disciplines, pharmacists, dietitians, care also served as the liaisons for further enforcing the role of coordinators, social workers, their disciplines throughout the working as a team to address nurses, nurse practitioners, education and implementation geriatric syndromes. The core and physicians) and family phases of Virtual ACE. We curriculum included cases and caregivers in an iterative process framed the Virtual ACE care data designed to create a sense to inform and pilot test the processes as a model of care for of urgency for change, followed development of the Virtual ACE all vulnerable patients—making by knowledge and skills intervention care processes, geriatric care just routine care. In required to implement the care workflows, and nurse-driven addition, Virtual ACE is designed processes and algorithms for the care algorithms. These care to align with hospital and health targeted geriatric syndromes. pathways targeted four geriatric care professional priorities, Three nurse-driven domains: function/mobility, including reduced LOS, less use care algorithms included pain management, delirium of restraints, early mobility, and in the intervention target prevention and management, and so on. Buy-in was immediate. were as follows:

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One goal was to equip and empower the team to provide evidence- based geriatric care as much as possible without daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service for the most complex or vulnerable patients.

• Nonpharmacological pain Trainees included all staff from obtaining gait belts and items for management. the core disciplines on these two a delirium prevention toolbox. In GI surgical units (nurses, patient June 2017, these GI surgical units • Early safe mobility. care technicians, unit secretaries, implemented the final unit-based rehabilitation therapists, change in structure to further • Delirium prevention and pharmacists, dietitians, chaplains, enhance use of the ACE Tracker management, including care coordinators/managers, and geriatric interprofessional avoidance of potentially and social workers). Virtual team care, conducting daily inappropriate medications for ACE training for physicians interprofessional team rounds older adults (Beers Criteria was delivered in two one-hour every weekday morning. medications). These pathways didactic sessions in April and These transition of care rounds include geriatric screens for May 2016. The education was were implemented across all function (Katz Index of basic provided by the core Virtual medical-surgical units at UAB activities of daily living), ACE team. One goal was to Hospital in 2016–2017 and serve mobility (Johns Hopkins equip and empower the team to as the foundational structure Highest Level Mobility Scale), provide evidence-based geriatric for interprofessional team cognition (Six Item Screen), and care as much as possible without coordination of Virtual ACE care. delirium (Nursing Delirium daily oversight by a geriatrician, The GI surgical units’ staff receive Screening Scale).5-9 thereby expanding the capacity booster coaching in use of these of the formal geriatric consult daily team meetings to identify Based on screen results, service for the most complex patient care issues, especially the care algorithms include or vulnerable patients. those related to pain, mobility, steps to guide nurses and other Following the training, the and delirium in geriatric patients. disciplines toward preventing units received support from the and addressing any identified risk Virtual ACE coach. The coach is factors or existing syndromes. For a master’s prepared nurse who Resources used and example, the early safe mobility has training in geriatrics and QI, skills needed algorithm includes setting goals is a member of the core geriatric The time and effort to develop for patient mobility, optimizing team, and has responsibilities and implement the Virtual pain management, verifying for the day-to-day management ACE intervention was part mobility orders, and educating of the Virtual ACE initiative. of the routine leadership and patients and families about the Coaching sessions included QI responsibilities of the core benefits of mobilization while in rounds with staff and one-on- geriatric team charged with the hospital. The ACE Tracker one consultation on using the operationalizing multiple report provided the most up- ACE Tracker report to identify hospital-based geriatric to-date results of these screens at-risk patients and activate the programs, including Virtual and other care processes for the clinical algorithms to prevent ACE. This core team includes a interprofessional team, especially and manage geriatric syndromes. 0.3 full-time equivalent (FTE) nurse leaders of the unit, to The Virtual ACE coach also geriatrician and three FTE coordinate the daily plan of care. worked with unit leadership to geriatric-trained clinical nurse The Virtual ACE curriculum remove barriers to implementing leaders, with approximately was delivered in three one-hour the Virtual ACE model, such 0.5 FTE nurse time dedicated sessions April 10 to May 15, 2016. as hardwiring the process for to Virtual ACE teaching and

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Allow frontline staff to participate in developing the plan to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.

coaching. Additional project- Overall hospital LOS (median pragmatic QI studies, is the specific costs included staff time seven days [5–10 interquartile challenge in accounting for all for the education sessions, food range [IQR] versus five days [3–8 possible confounding variables provided during training, and IQR] p < 0.001) and postoperative from other hospital or unit supplies. The hospital provided LOS (median seven days [5–10 interventions that also may funding for all these costs. IQR] versus four days [3–7 IQR]) have affected LOS. Of note, were significantly shorter in enhanced recovery after surgery patients admitted post-Virtual (ERAS) is known to reduce Results ACE intervention. Readmission LOS, and the GI surgical service The primary outcome measure rates were similar (11 percent implemented ERAS for colorectal for this case study is hospital versus 12 percent, p = 0.1), surgery patients in 2015, and postoperative LOS, and the signaling that reducing LOS prior to launch of the Virtual balancing measure was 30-day did not adversely affect 30-day ACE intervention. Whereas readmissions. To determine these readmissions. The LOS model Virtual ACE also includes care outcome measures, we examined showed that Virtual ACE care processes addressing mobility, institutional American College decreased both hospital LOS it supports and complements of Surgeons National Surgical (incident rate ratio [IRR] 0.74 ERAS with training, Quality Improvement Program [0.66–0.83], p < 0.0001) and screening, and care algorithms data for patients ages 70 and postoperative LOS (IRR 0.69 that address the unique older who underwent colectomy, [0.61–0.71], p < 0.0001). vulnerability of older adults. proctectomy, esophagectomy, Barriers encountered during The Virtual ACE hepatectomy, or pancreatectomy Virtual ACE implementation initiative approximate costs from January 1, 2013, to included the challenge of finding related to training staff and October 23, 2018, and stratified the ideal times to train health care supplies were $6,000. information into standard care or providers from all disciplines To estimate potential cost Virtual ACE care. Demographics, on two busy acute care units. savings for reduction in LOS, we hospital LOS, postoperative Another initial challenge was used our cost accounting system LOS, and readmission rates resupplying tools in a timely to identify patients from fiscal were recorded and compared. manner. This latter challenge year 2018 who were 70 years of Binomial regression models were has led to new and sustainable age or older and underwent a performed for LOS. The overall processes for securing these GI operation, yielding a sample cohort included 676 patients—318 items through hospital central of 221 patient encounters. The standard care and 358 Virtual supply. These units, as is typical average direct cost for the ACE care, with a 3 percent overall for hospital units, continue last full day of each patient’s mortality rate. The two cohorts to undergo staff turnover, hospitalization was $1,053. So, were similar in age (74.9 versus prompting the need to develop each hospital day of shortened 75.1 years, p = 0.83), gender a process for introducing new hospital stay saves $1,053. (57 percent versus 56 percent staff to Virtual ACE initiatives, as male, p = 0.79), and comorbidities. well as providing at least annual More patients had independent booster training for existing staff. Tips for others functional status in the standard Both processes are now in place. We have learned several lessons care cohort (99 percent versus A limitation to the case that we have used in each iterative 97 percent, p = 0.015). study, which is common to PDSA cycle. They are as follows:

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Provide frequent measures of progress, celebrate successes, and actively partner to overcome barriers to keep stakeholders and staff engaged.

• Stakeholder engagement from the beginning and throughout REFERENCES is critical for success. 1. Flood KL, MacLennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care Ȗ Speak the language that is important to your institutional for elders unit on costs and 30-day readmissions. leaders. Although delirium reduction is a key quality JAMA Intern Med. 2013;173(11):981-987. 2. Mohanty S, Rosenthal RA, Russell MM, outcome for patients, it also leads to significant reductions Neuman MD, Ko CY, Esnaola NF. Optimal in LOS, which is a strategic priority for our senior leaders. Perioperative Management of the Geriatric Surgical So, communicating the benefits of Virtual ACE with a Patient: A best practices guideline from the focus on LOS impact is important to hospital leadership American College of Surgeons NSQIP and the stakeholders. American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947. 3. Malone ML, Vollbrecht M, Stephenson J, Ȗ Speak the language that is important to your frontline care Burke L, Pagel P, Goodwin JS. Acute care for providers. The challenge of managing delirious patients is a elders (ACE) tracker and e-geriatrician: Methods chief concern of frontline nurses. Thus, communicating the to disseminate ACE concepts to hospitals benefits of Virtual ACE on delirium reduction is important with no geriatricians on staff. J Am Geriatr Soc. 2010;58(1):161-167. to achieve buy-in from this group of stakeholders. 4. Booth KA, Simmons EE, Viles AF, et al. Improving geriatric care processes on two Ȗ Allow frontline staff to participate in developing the plan medical-surgical acute care units: A pilot study. to implement Virtual ACE care into the workflows and J Healthcare Qual. 2019;41(1):23-31. patient populations that are unique to each hospital unit 5. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics microsystem. Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in • Sustainment older adults. J Am Geriatr Soc. 2019;67(4):674-694. 6. Katz S, Ford AB, Moskowitz RW, Jackson BA, Ȗ Provide frequent measures of progress, celebrate successes, Jaffe MW. Studies of illness in the aged. The Index of ADL: A standardized measure of and actively partner to overcome barriers to keep biological and psychological function. JAMA. stakeholders and staff engaged. 1963;185:914-919. 7. Hoyer EH, Friedman M, Lavezza A, et al. Ȗ Manage-up the unit leaders and staff to their supervisors Promoting mobility and reducing length of and senior leaders so they are the recipients of system-wide stay in hospitalized general medical patients: A quality-improvement project. J Hosp Med. recognition they deserve for leading change. 2016;11(5):314-317. 8. Carpenter CR, DesPain B, Keeling TN, Shah M, Ȗ Create a process to onboard new staff and provide booster Rothenberger M. The Six-Item Screener and training at least annually and as needed regarding the AD8 for the detection of cognitive impairment Virtual ACE care processes. in geriatric emergency department patients. Ann Emerg Med. 2011;57(6):653-661. 9. Gaudreau JD, Gagnon P, Harel F, Tremblay A, Ȗ Create a unit-based accountable care team structure and Roy MA. Fast, systematic, and continuous culture, including providing process and outcome measures delirium assessment in hospitalized patients: in accessible data reports or dashboards, so the unit-based The nursing delirium screening scale. J Pain interprofessional team leaders transition from dependency Symptom Manage. 2005;29(4):368-375. on the Virtual ACE coach to truly owning and driving the ongoing improvements. This transition moves the team from buy-in to ownership. ♦

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ACS Clinical Research Program: Ga-68 imaging changes clinical management of GI and pancreatic neuroendocrine tumors

by Clancy J. Clark, MD; J. Bart Rose, MD; Judy C. Boughey, MD, FACS; and Flavio G. Rocha, MD, FACS

tandard management increased from approximately as octreotide, lanreotide, and of gastrointestinal and one per 100,000 persons in pasireotide) can inhibit tumor Spancreatic neuroendocrine 1973, to seven per 100,000 growth and improve progression- tumors (GEP-NETs) is surgical in 2012.1 In 2017, the World free survival as demonstrated resection. However, identifying Health Organization (WHO) in the PROMID (Placebo- the primary tumor and burden recategorized neuroendocrine Controlled, Double-Blind, of disease can be problematic, neoplasms into low proliferative Prospective, Randomized Study leading to challenges in surgical index neuroendocrine tumors on the Effect of Octreotide LAR planning, optimal chemotherapy and high proliferative index in the Control of Tumor Growth selection, and surveillance. neuroendocrine carcinomas in Patients with Metastatic Since the Food and Drug deemphasizing anatomic Neuroendocrine Midgut Tumors) Administration approved gallium location.2 Proliferative indices and CLARINET (Placebo- 68 dotatate (Ga-68) positron are determined by Ki-67 levels Controlled Study of Lanreotide emission tomography (PET) on (a nuclear protein associated Antiproliferative Response in June 1, 2016, clinical management with cellular division) with a Patients with Enteropancreatic of GEP-NETs has rapidly evolved, high-grade (G3) tumor defined Neuroendocrine Tumors) trials.4-6 and this new imaging modality as more than 20 percent has opened the field to new staining positive (see Table 1, surveillance schema, as well as page 77). While some anatomic Progress to date targeted interventions, such as locations can be associated with Taking advantage of somatostatin lutetium 177 dotatate (Lutathera). improved outcomes, high Ki- receptor overexpression, GEP- GEP-NETs are rare tumors 67 percentages found in poorly NETs can be localized using of the pancreas and the tubular differentiated and undifferentiated somatostatin receptor-targeted gastrointestinal (GI) tract neuroendocrine carcinomas can imaging modalities.7 Imaging (stomach, duodenum, small predict worse overall survival.3 of somatostatin receptors in a bowel, pancreas, appendix, Well-differentiated GEP- tumor was first described in 1984 colon, and rectum). These NETs typically overexpress and more specifically for NETs tumors can secrete bioactive somatostatin receptors, in 1993.7,8 Gamma radiation- substances (functional tumors), specifically somatostatin receptor based octreotide scan, which leading to constellations of subtype 2. In both functional has been in use for more than clinical syndromes. Overall, and nonfunctional GEP-NETs, 20 years, uses an indium 111 incidence of GEP-NETs somatostatin analogs (such isotope with known poor image

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TABLE 1. WHO CLASSIFICATION 2017 FOR GASTROENTEROPANCREATIC NEOPLASMS

Grade Description Ki-67, % Mitotic index (HPF)

G1 Well-differentiated NET < 2 < 2/10

G2 Well-differentiated NET 3–20 2–20/10

G3a Poorly differentiated NECb > 20 > 20/10

a Pancreatic NENs further subdivided into well-differentiated G3 NETs and poorly differentiated G3 NECs b Differentiated into small and large cell

New category: mixed NEN/non-NEN (MiNEN) hyperplastic and preneoplastic lesions NET = Neuroendocrine neoplasm tumor NEC = Neuroendocrine carcinoma NEN =Neuroendocrine neoplasm (includes NETs and NECs) HPF = High power field

quality, has a high radiation GEP-NET imaging can assist multiple studies are ongoing to dose requirement, and requires with locating the primary define its optimal role in clinical prolonged scintigraphy for tumor, preoperative planning, practice. Retrospective studies imaging (typically more than quantification of disease burden, have suggested that Ga-68 one day). Radiolabeled meta- and surveillance monitoring. imaging altered diagnosis and iodobenzylguanidine (MIBG) For example, in a 51-year- management in up to one-third with iodide 123 or 131 also has old man who presented with of NET patients and 50 percent been used for neuroendocrine shock from upper GI bleeding of those referred for surgical cancers but similarly struggles from presumed peptic ulcer resection. Most changes in with spatial resolution. disease, gastroduodenal artery surgical management were Ga-68 PET combined with coils placed by interventional found in small bowel NETs computed tomography (CT) or radiology obscured visualization (6/7) and consisted of additional magnetic resonance imaging of a duodenal NET on CT but lesions that precluded curative substantially improves spatial was readily visible on Ga-68 therapy in four patients. In 77 differentiation and detection of PET/CT (see Figure 1, page 78). patients with known metastatic NETs with sensitivity ranging Reflecting improvements disease, additional sites of from 80 percent to 100 percent in image quality, guidelines by metastases were seen in 37 and specificity ranging from the National Comprehensive and consisted of distant lymph 82 percent to 90 percent. The Cancer Network and the North nodes (18), bone (15), and liver patient experience is much better American Neuroendocrine (9). Occult primary tumors than in previous studies because Tumor Society have now were seen in 3/13 (28 percent) of imaging takes two hours rather recommended Ga-68 imaging patients who presented with M1 than two days. Ga-68 imaging over somatostatin receptor (metastatic spread) disease.12 has a significantly improved scintigraphy (octreotide Based on a recent review of detection rate for primary tumor scan) for the detection and clinicaltrials.gov, 51 studies are compared with octreotide surveillance of GEP-NETs.9-11 evaluating Ga-68 PET with 23 scan. Importantly, studies have recruiting participants, 7 closed demonstrated that Ga-68 imaging to enrollment, and 12 sponsored provides additional information Ongoing study by the National Institutes of resulting in change in clinical While Ga-68 PET has become Health. We eagerly look forward management for more than the standard imaging study to the results of these studies, 70 percent of patients.3 Improved for evaluation of GEP-NETs, particularly as a means of clearly

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FIGURE 1. CORONAL Ga-68 VS. CORONAL CT IMAGING

A. Coronal Ga-68 PET/CT demonstrated high standardized uptake value associated with the primary duodenal NET not visible in normal CT B. Coronal CT image demonstrating artifact created by gastroduodenal artery coils placed during acute GI bleeding thought to be secondary to peptic ulcer disease

identifying which patients would REFERENCES benefit most from liver-directed 1. Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and therapy, cytotoxic systemic survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol. 2017;3(10):1335-1342. chemotherapy, or other novel 2. Lloyd R, Osamura R, Klöppelm G, Rosai J, eds. WHO Classification of Tumours of targeted treatment options, Endocrine Organs, 4th edition. World Health Organization, Geneva; 2017. including Lutathera. In the 3. Wang R, Zheng-Pywell R, Chen HA, Bibb JA, Chen H, Rose JB. Management of gastrointestinal neuroendocrine tumors. Clin Med Insights Endocrinol Diabetes. Neuroendocrine Tumor Therapy October 24, 2019 [Epub ahead of print]. (NETTER-1) phase 3 trial, the 4. Caplin ME, Pavel M, Cwikła JB, et al. Lanreotide in metastatic enteropancreatic peptide receptor radionucleotide neuroendocrine tumors. N Engl J Med. 2014;371(3):224-233. 5. Rinke A, Wittenberg M, Schade-Brittinger C, et al. Placebo-Controlled, Double- therapy Lutathera resulted Blind, Prospective, Randomized Study on the Effect of Octreotide LAR in in an improved 20-month the Control of Tumor Growth in Patients with Metastatic Neuroendocrine progression-free survival of Midgut Tumors (PROMID): Results of long-term survival. Neuroendocrinology. 2017;104(1):26-32. 65.2 percent over the 10.8 percent 6. Rinke A, Müller H-H, Schade-Brittinger C, et al. Placebo-Controlled, Double- demonstrated in the octreotide Blind, Prospective, Randomized Study on the Effect of Octreotide LAR in the long-acting repeatable group.13 Control of Tumor Growth in Patients with Metastatic Neuroendocrine Midgut Tumors: A report from the PROMID study group. J Clin Oncol. 2009;27(28):4656- Additionally, targeted molecules 4663. for imaging and treatment for 7. Krenning EP, Kwekkeboom DJ, Bakker WH, et al. Somatostatin receptor non-somatostatin expressing scintigraphy with [111In-DTPA-D-Phe1]- and [123I-Tyr3]-octreotide: The Rotterdam experience with more than 1000 patients. Eur J Nucl Med. 1993;20(8):716-731. GEP-NETs are still lacking 8. Reubi JC, Landolt AM. High density of somatostatin receptors in pituitary tumors and critically needed in these from acromegalic patients. J Clin Endocrinol Metab. 1984;59(6):1148-1151. patients with a traditionally 9. Shah MH, Burns J, Zuccarino-Catania G. Neuroendocrine and adrenal tumors. NCCN Guidelines Version 1.2019. Available at: www.nccn.org/professionals/ more aggressive disease. ♦ physician_gls/pdf/neuroendocrine.pdf. June 2019. Accessed March 3, 2020. 10. Strosberg JR, Halfdanarson TR, Bellizzi AM, et al. The North American Neuroendocrine Tumor Society consensus guidelines for surveillance and medical management of midgut neuroendocrine tumors. Pancreas. 2017;46(6):707-714. 11. Howe JR, Merchant NB, Conrad C, et al. The North American Neuroendocrine Tumor Society consensus paper on the surgical management of pancreatic neuroendocrine tumors. Vol 49. 2020. Available at: https://nanets.net/images/ guidelines/NANETS_2020_Surgical_Management_of_PNETS.pdf. Accessed June 8, 2020. 12. Crown A, Rocha FG, Raghu P, et al. Impact of initial imaging with gallium-68 dotatate PET/CT on diagnosis and management of patients with neuroendocrine tumors. J Surg Oncol. 2020;121(3):480-485. 13. Strosberg J, El-Haddad G, Wolin E, et al. Phase 3 trial of 177 Lu-Dotatate for midgut neuroendocrine tumors. N Engl J Med. 2017;376(2):125-135.

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NCDB cancer bytes: Neoadjuvant and perioperative chemotherapy for localized pancreatic cancer: Leveraging small and large databases in the absence of Level 1 evidence

by Timothy L. Fitzgerald, MD, FACS

evel 1 evidence often cancer is divided into four is lacking secondary Evolving treatment paradigms subgroups: locally advanced, Lto ongoing trials, new for localized pancreatic cancer borderline resectable, high-risk, treatment paradigms, or lack Effective multiagent chemotherapy and imminently resectable. of feasibility. For example, has revolutionized the treatment small, retrospective, single of metastatic and localized institutional series suggested pancreatic cancer. FOLFIRINOX Locally advanced no benefit to completion lymph and nab-paclitaxel/gemcitabine pancreatic cancer node dissection with sentinel improve survival for patients with Effective chemotherapy node metastases for melanoma.1 metastatic pancreatic cancer.3 As has improved survival and A large surveillance, a result, the use of neoadjuvant resectability for locally epidemiology, and end results and adjuvant multiagent advanced pancreatic cancer. (SEER) tumor registry study chemotherapy for localized With traditional neoadjuvant also demonstrated no survival pancreatic cancer has increased. chemoradiation, such patients are advantage.1 These data Prospective randomized data rarely converted to resectable. guided clinical practice before and retrospective studies Multiple centers have reported publication of the Multicenter demonstrate profound outcomes with neoadjuvant Selective Lymphadenectomy improvement in survival for therapy for locally advanced Trial (MSLT)-II prospective resected localized pancreatic pancreatic cancer and note randomized trial that cancer with the addition of increased conversion rates with confirmed the nonrandomized multiagent chemotherapy, multiagent chemotherapy. studies. For Merkel cell cancer, 45–60-month median survival.4-6 Investigators at the Medical a rare neuroendocrine tumor Multiple clinical trials are College of Wisconsin, of the skin, a randomized investigating the timing and Milwaukee, reported outcomes trial regarding sentinel node content of adjuvant therapy in 108 consecutive patients biopsy is infeasible. However, for localized pancreatic cancer. with locally advanced pancreas SEER registry data comparing However, there is a dearth of cancer treated in 2009−2017.7 sentinel lymph node biopsy Level 1 data to guide therapeutic The most common and nodal observation paradigms. Small and large definition for locally advanced demonstrated a prognostic database studies can bridge pancreatic cancer is greater and therapeutic advantage these knowledge gaps. In this than 180° encasement of the to sentinel node biopsy.2 column, localized pancreatic superior mesenteric artery

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Effective multiagent chemotherapy has revolutionized the treatment of metastatic and localized pancreatic cancer. FOLFIRINOX and nab-paclitaxel/gemcitabine improve survival for patients with metastatic pancreatic cancer.

(SMA), celiac, hepatic artery, carbohydrate antigen (CA)-19-9, The role of radiotherapy for or unreconstructable occlusion and pathologic response. borderline resectable pancreatic of the portal vein. The group Survival was not associated cancer is unclear. Results from from Wisconsin further with anatomic classification or a prospective randomized trial subdivides these patients into change in chemotherapy. Overall by the Alliance comparing Type A and Type B.7 Evans survival was almost 60 months. neoadjuvant FOLFIRINOX with/ Type A has more than 180° without radiation are pending. involvement of the SMA/ Unfortunately, much of the hepatic artery but less than 270, Borderline resectable retrospective data regarding greater than 180° involvement In the absence of Level 1 neoadjuvant radiation therapy of the celiac not involving the data, neoadjuvant multiagent combines locally advanced aorta. Evans Type B patients chemotherapy has become the and borderline resectable. have more extensive vascular standard of care for borderline Our group, using National involvement. Most patients resectable pancreatic cancer.3 Cancer Database (NCDB) received FOLFIRINOX or nab- The Alliance for Clinical data, investigated the role of paclitaxel/gemcitabine, with Trials in Oncology defines radiation therapy in addition to radiation. A total of 50 percent borderline resectable as more multiagent chemotherapy for of patients went to the operating than 180-degree involvement locally advanced and borderline room, and successful outcomes of the superior mesenteric resectable disease. The NCDB is were reported in 42 percent, vein (SMV)/portal vein a joint project of the Commission 62 percent for Type A, and that is reconstructable, the on Cancer (CoC) of the American 24 percent for Type B. Median involvement of the SMA/ College of Surgeons (ACS) and overall survival after resection celiac axis of more than 180 the American Cancer Society. was approximately 40 months. degrees, or short segment The reader should be mindful The Mayo Clinic, Rochester, hepatic artery involvement. The that the data used in the study MN, reported outcomes for Japanese Society of Pancreatic are derived from a deidentified 123 patients receiving total Surgery reported outcomes in NCDB file. The ACS and the neoadjuvant therapy from 2010 to 884 patients with borderline CoC have not verified and are 2017.4 The neoadjuvant regimen resectable pancreatic cancer not responsible for the analytic was most often FOLFIRINOX treated in 2011−2013, the or statistical methodology or nab-paclitaxel/gemcitabine, largest series to date. In this employed or the conclusions followed by radiation therapy. manuscript, upfront surgery drawn from these data. Chemotherapy regimens were is compared with neoadjuvant A total of 2,703 patients changed for nonresponders. chemotherapy +/- radiation. diagnosed in 2006−2014 were Only 37 percent had locally In the upfront surgery group, included in the study. Radiation advanced disease; the remainder 93 percent of the patients were therapy was associated with were borderline resectable. The resected versus 75 percent increased complete pathological investigators reported significant in the neoadjuvant group. response rates, R0 resection downstaging, even with little Despite the lower resection rates, and downstaging with radiographic response. Three rates, neoadjuvant therapy no improvement in survival. factors were associated with was associated with improved The Japanese Society of survival: more than six cycles survival, 25.7 versus 19.0 months, Pancreatic Surgery also failed of chemotherapy, decreased and increased R0 resection rates.8 to demonstrate improved

80 | V105 No 5 BULLETIN American College of Surgeons FOR YOUR PATIENTS

Although prospective randomized trials remain the gold standard, large and small data sets can inform clinical practice.

survival with neoadjuvant loss.10 The American Society Four groups were defined: radiation in borderline resectable of Clinical Oncology (ASCO) chemotherapy-only, surgery-only, patients.8 Conversely, a multi- guideline also includes reversible neoadjuvant, and postoperative institutional French study medical conditions and large adjuvant. Chemotherapy-only noted improved survival size.5 In the absence of clear-cut patients have the worst survival with radiation therapy after data, expert opinion from both rate, followed by surgery-only. neoadjuvant chemotherapy.6 ASCO and NCCN recommends Outcomes are improved with the consideration of neoadjuvant addition of adjuvant therapy. therapy for high-risk patients. Neoadjuvant and High-risk pancreatic cancer postoperative adjuvant Many patients are high risk, even chemotherapy had similar when not locally advanced or Imminently resectable survival rates. Only one-quarter borderline resectable. NCDB Surgeons should be mindful of patients who start with data can classify patients that at least 20 to 30 percent of curative intent chemotherapy into high and low risk for patients treated with neoadjuvant underwent resection. A mortality.9 This study included therapy will never undergo series from the University of 25,897 patients diagnosed in surgical resection. The recently Pittsburgh, PA, reported similar 2004−2013 with stage I, II, or published PRODIGE 24/CCTG findings.12 In this series, 552 III pancreatic cancer. Factors PA.6 trial is a prospective patients with resected pancreatic associated with mortality randomized trial comparing adenocarcinoma treated in include size ( 2 cm), grade, postoperative FOLFIRINOX 2008−2015 were included, and lymph node metastasis, adjuvant to gemcitabine in 493 patients the authors noted improved therapy, and surgical margins. enrolled in 2012−2016.11 The survival with at least six cycles For example, a patient survival in the FOLFIRINOX of perioperative chemotherapy. younger than 65 years of age group was 54.4 months versus Similar to our findings, the with a small, low-grade tumor, 35.0 with gemcitabine. Given the authors noted no effect on who undergoes an R0 pancreatic excellent outcomes with upfront survival if therapy was delivered resection and is treated with resection with postoperative preoperatively, perioperatively, adjuvant therapy, has an expected multiagent chemotherapy and or postoperatively. One could five-year survival of 51 percent. high dropout rates, the question define a group of patients as In contrast, a 70-year-old patient remains, which patients should imminently resectable if they with a larger, high-grade tumor undergo upfront surgery? do not have high-risk features resected with positive margins Although the cancer care and can be resected with an treated with adjuvant therapy has community has achieved broad anticipated negative margin. In an expected five-year survival consensus regarding neoadjuvant this group, upfront resection rate of 5 percent. Unfortunately, therapy for advanced tumors, should be considered. many of these factors are questions remain about how unknown preoperatively. to manage patients who fit The National Comprehensive into none of these categories. Conclusion Cancer Network (NCCN) To answer this question, our Although prospective defines preoperative high-risk group examined 13,412 NCDB randomized trials remain the features as high CA-19-9, lymph patients with T1 and T2 tumors gold standard, large and small node disease, pain, and weight diagnosed in 2006−2014.13 data sets can inform clinical

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In the rapidly evolving clinical paradigms for localized pancreatic cancer, a combination of Level 1 data and database studies inform management.

practice. Large national registries REFERENCES such as the NCDB can be leveraged to 1. Kachare SD, Brinkley J, Wong JH, Vohra NA, Zervos EE, answer important clinical questions. Fitzgerald TL. The influence of sentinel lymph node biopsy on survival When using such databases, it is for intermediate-thickness melanoma. Ann Surg Oncol. 2014;21(11):3377- important that investigators understand 3385. 2. Kachare SD, Wong JH, Vohra NA, Zervos EE, Fitzgerald TL. Sentinel the limitations of the data, study lymph node biopsy is associated with improved survival in Merkel cell clinically meaningful hypothesis- carcinoma. Ann Surg Oncol. 2014;21(5):1624-1630. driven questions, apply appropriate 3. Vidri RJ, Vogt AO, Macgillivray DC, Bristol IJ, Fitzgerald TL. Better controls, and account for imbalance in defining the role of total neoadjuvant radiation: Changing paradigms study arms with appropriate techniques in locally advanced pancreatic cancer. Ann Surg Oncol. 2019;26(11):3701- 3708. such as propensity matching. 4. Truty MJ, Kendrick ML, Nagorney DM, et al. Factors predicting In the rapidly evolving clinical response, perioperative outcomes, and survival following total paradigms for localized pancreatic neoadjuvant therapy for borderline/locally advanced pancreatic cancer. cancer, a combination of Level 1 data and Ann Surg. April 5, 2019 [Epub ahead of print]. database studies inform management. 5. Khorana AA, McKernin SE, Katz MHG. Potentially curable pancreatic adenocarcinoma: ASCO clinical practice guideline update summary. Clearly, multiagent chemotherapy has J Onc Practice. 2019;15(8):454-457. improved survival for localized pancreatic 6. Pietrasz D, Turrini O, Vendrely V, et al. How does chemoradiotherapy cancer. For locally advanced pancreatic following induction FOLFIRINOX improve the results in resected cancers, neoadjuvant treatment should borderline or locally advanced pancreatic adenocarcinoma? An AGEO- be given. By dividing patients into FRENCH Multicentric Cohort. Ann Surg Oncol. 2019;26(1):109-117. 7. Chatzizacharias NA, Tsai S, Griffin M, et al. Locally advanced pancreas Evans Type A and B, we can better cancer: Staging and goals of therapy. Surgery. 2018;163(5):1053-1062. educate patients about the likelihood of 8. Nagakawa Y, Sahara Y, Hosokawa Y, et al. Clinical impact of a successful operation. In this setting, neoadjuvant chemotherapy and chemoradiotherapy in borderline with a high risk of R1 resection, it is resectable pancreatic cancer: Analysis of 884 patients at facilities reasonable to consider the addition specializing in pancreatic surgery. Ann Surg Oncol. 2019;26(6):1629-1636. 9. Fitzgerald TL, Hunter L, Mosquera C, et al. A simple matrix to predict of radiation therapy to preoperative treatment success and long-term survival among patients undergoing multiagent chemotherapy. For patients pancreatectomy. HPB (Oxford). 2019;21(2):204-211. with borderline resectable tumors four 10. Tempero MA. NCCN guidelines updates: Pancreatic cancer. J Natl months of neoadjuvant therapy, ideally Compr Can Netw. 2019;17(5.5):603-605. FOLFIRINOX, and selective use of 11. Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med. radiation therapy should be considered. 2018;379(25):2395-2406. High-risk disease can be defined as 12. Epelboym I, Zenati MS, Hamad A, et al. Analysis of perioperative the abutment/involvement of major chemotherapy in resected pancreatic cancer: Identifying the number vasculature structures, high cancer and sequence of chemotherapy cycles needed to optimize survival. antigen 19-9, pain, weight loss, reversible Ann Surg Oncol. 2017;24(9):2744-2751. 13. Vidri RJ, Olsen WT, DE Clark DE, Fitzgerald TL. No advantage of medical comorbidities, and tumor size neoadjuvant therapy for clearly resectable pancreatic cancer. Ann Surg greater than 2 cm. In such patients, Onc. 2019;26(2):S33-S33. neoadjuvant or perioperative multiagent chemotherapy should be considered. In a select group of patients with imminently resectable tumors, upfront surgery with postoperative adjuvant FOLFIRINOX could be considered. ♦

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A look at The Joint Commission: Recommendations pour in as surgeons navigate COVID-19 pandemic

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

hen the number of resources and other supplies, My take on the ACS confirmed cases of and ensure that hospitals could coronavirus disease keep up with the anticipated recommendations is that W 1 2019 (COVID-19) began rising demands in capacity. we all must rise to the local across the U.S. in March, The U.S. Surgeon General regulators and administrators also recommended canceling all challenges this pandemic called for hospitals, surgeons, nonemergent operations. Then, poses and preserve the and other providers to take on March 13, the American several measures to combat the College of Surgeons (ACS) “three S’s” (space, staff, and disease and its spread, including released recommendations stuff) to serve the anticipated delaying or postponing elective for hospitals and surgeons needs of our patients. surgical and procedural cases. on delaying or postponing As the immediate threats nonemergent procedures, waned, public health authorities followed by “COVID-19: called on the public and the Guidance for triage of non- health care community to emergent surgical procedures” respond in other ways. on March 17, 2020.2-3 As the number of COVID-19 cases began to level off, Immediate response hospitals and surgeons sought to the crisis to provide opportunities The Centers for Disease to patients who needed Control and Prevention (CDC) nonemergency operations. recommendations to health In response, the ACS issued care organizations included “Local resumption of elective delaying both inpatient and surgery guidance” April 17.4 outpatient nonemergent My take on the ACS surgical and procedural cases, recommendations is that as well as prioritizing urgent we all must rise to the local and emergency visits and challenges this pandemic procedures to keep staff and poses and preserve the “three patients safe, preserve personal S’s” (space, staff, and stuff) to protective equipment (PPE) serve the anticipated needs

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People wearing cloth face coverings or face masks over their mouths and noses to contain their respiratory secretions helps to reduce the dispersion of droplets from an infected individual.

of our patients. I also believe hospitals and ambulatory secretions helps to reduce the that the principle of having surgery centers (ASCs) around dispersion of droplets from the medical need for a given the country began requiring an infected individual.1 Face procedure determined by that everyone who entered the coverings will decrease the the surgeon is paramount to facility—including staff, patients, possibility that anyone with protect the patients at large and visitors—wear a mask. As unrecognized COVID-19 and surgeon-patient trust. surgeons resume nonemergent infection will expose others And although the logistical procedures, this policy will be to the disease.1 However, for feasibility is determined by critical in curbing the spread of source control to be effective, administrative personnel, the COVID-19 to patients and staff. everyone in the hospital or principle that the surgeon The CDC added this advice ASC must wear a mask while determines the need puts to their late-April infection inside to prevent droplet and— the health care professional prevention and control to a lesser extent—aerosol at the center of the decision- recommendations related spread of COVID-19 and making process. This is good to COVID-19, and The Joint other respiratory viruses.2 for medicine and for patients. Commission supports this The Joint Commission has At a time when surgical policy. The CDC guidance— issued a statement that universal procedures were postponed “Interim infection prevention masking within health care and nonemergent visits to and control recommendations settings is a vital tool to protect the clinic also were being for patients with suspected or staff and patients from being rescheduled, many surgeons confirmed Coronavirus Disease infected by asymptomatic and turned their attention to the 2019 (COVID-19) in healthcare presymptomatic individuals service they could provide in settings”—states that health care and should be implemented the intensive care unit (ICU), facilities should “implement anywhere coronavirus is demonstrating their leadership source control for everyone occurring. Even one case of and commitment to patient care. entering a healthcare facility community spread means that (e.g., health care personnel, the facilities and staff are at patients, visitors), regardless risk because asymptomatic Staying safe in a post- of symptoms.” This process is and presymptomatic patients pandemic world critical to address asymptomatic may come in for care and As surgical professionals and presymptomatic inadvertently infect staff. returned to the operating room transmission of COVID-19.5 The Joint Commission’s and clinic, concerns about the People wearing cloth statement also summarizes risk of transmitting COVID-19 face coverings or face masks key steps for implementing virus continued to surface. To over their mouths and noses the CDC’s recommendation, help alleviate these concerns, to contain their respiratory as follows.5

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If there are actual or anticipated shortages of face masks, they should be prioritized for health care personnel and for patients with symptoms of COVID-19.

For patients and visitors • Anyone who has trouble breathing is possible (such as after entering a private office). To ensure staff can • All patients and visitors should be • Anyone who is unconscious, remove their masks for meals and instructed to wear a cloth mask incapacitated, or otherwise unable breaks, scheduling and location for when entering any health care to remove the mask without meals and breaks should ensure building. assistance that at least a six-foot distance can be maintained between staff. • If they arrive without a cloth For health care personnel mask, one should be provided. • It is important for hospitals and • Facility staff should wear at least ASCs to emphasize that hand • If there is a sufficient supply of a cloth mask when leaving their hygiene is essential to maintaining medical-grade face masks, one may home employee safety, even if staff be provided instead of a cloth mask. are wearing masks. If the face • When providing direct patient mask is touched, adjusted, or • Patients may remove the cloth care to any patient, health care removed, hand hygiene should be face covering while in their own personnel should don a medical- performed. rooms, but they should put the face grade, official PPE face mask covering back on when leaving their or respirator, depending on the The CDC guidance room or when others who are not care provided. According to the recommends that “as part of wearing a mask enter the room. CDC, “Cloth face coverings are source control efforts, [health not considered PPE because their care personnel] should wear a • If available, hospitals and ASCs capability to protect health care facemask at all times while they should consider switching personnel...is unknown.” are in the health care facility.”4 patients who have tested positive If there are actual or anticipated for COVID-19 or who have • Health care personnel who shortages of face masks, they respiratory symptoms—such as provide support services but do should be prioritized for health a cough or sneeze—to a medical- not provide direct patient care care personnel and for patients grade face mask. should also wear a face mask. with symptoms of COVID-19. However, to conserve supplies, the Health care personnel may wear Per the CDC recommendations, face mask may be cloth. Outbreaks cloth face coverings when not face masks and cloth face of COVID-19 have occurred engaged in direct patient care.5 coverings should not be among health care personnel who “To avoid risking self- placed on the following: provide support services. contamination, [health care personnel] should consider • Infants and toddlers younger than • Masks may be removed when continuing to wear their age two social distancing of at least six feet respirator or facemask (extended

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Resources and the full statement on universal masking can be found at www. jointcommission.org/-/media/tjc/documents/ covid19/universal-masking-statement-04232020.pdf.

use) instead of intermittently switching back to their cloth face REFERENCES covering,” the guidance recommends. “Of note, N95s with an 1. Centers for Disease Control and Prevention. exhaust valve might not provide source control. [Health care Resources for clinics and healthcare facilities. personnel] should remove their respirator or facemask and put March 16, 2020. Available at: www.cdc.gov/ on their cloth face covering when leaving the facility at the end coronavirus/2019-ncov/healthcare-facilities/ index.html. Accessed May 31, 2020. of their shift. They should also be instructed that if they must 2. American College of Surgeons. COVID-19: touch or adjust their facemask or cloth face covering, they Recommendations for management of elective should perform hand hygiene immediately before and after.”5 surgical procedures. March 13, 2020. Available The Joint Commission encourages health care facilities at: facs.org/about-acs/covid-19/information- to remind patients and visitors that they should be wearing a for-surgeons/elective-surgery. Accessed May 31, 2020. face mask when they arrive for care. Hospitals and ASCs also 3. American College of Surgeons. COVID-19: can provide links to CDC resources, such as how patients can Guidance for triage of non-emergent surgical make their own masks with commonly available materials.6 procedures. March 17, 2020. Available at: facs. To assist with rapid implementation of the org/about-acs/covid-19/information-for- CDC recommendations, The Joint Commission surgeons/triage. Accessed May 31, 2020. 4. American College of Surgeons. Local developed the following resources:6 resumption of elective surgery guidance. April 17, 2020. Available at: facs.org/covid-19/clinical- • Signage that can be posted at entrances in black and white and guidance/resuming-elective-surgery. Accessed in color May 31, 2020. 5. Centers for Disease Control and Prevention. Interim infection prevention and control • An infographic on the do’s and don’ts for wearing face masks recommendations for patients with suspected during the COVID-19 pandemic that can be used to educate or confirmed Coronavirus Disease 2019 staff and patients (COVID-19) in healthcare settings. Available at: www.cdc.gov/coronavirus/2019-ncov/hcp/ These resources—as well as the full statement infection-control-recommendations.html. Accessed May 31, 2020. on universal masking—can be found at www. 6. The Joint Commission. Statement on jointcommission.org/-/media/tjc/documents/covid19/ Universal Masking of Staff, Patients, and universal-masking-statement-04232020.pdf. ♦ Visitors in Health Care Settings. Available at: www.jointcommission.org/-/media/tjc/ documents/covid19/universal-masking- Disclaimer statement-04232020.pdf. Accessed May 31, 2020. The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the ACS.

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From residency to retirement: ACS offers opportunities for increased specialty resident participation in the College

by Sonia Bhandari Randhawa, MD, and Enrique Hernandez, MD, FACS, FACOG

pecialty societies provide surgeons PENNSYLVANIA OB-GYN RESIDENCY in training with opportunities PROGRAMS AND REPRESENTATIVES Sto expand their knowledge and clinical expertise through their Abington Memorial Hospital, Penn State Medical Center, training. Residency programs have Abington Hershey a long checklist of knowledge and Dr. Perrin Downing Dr. Alexa Swailes skills training they must provide to Dr. Tanvi Joshi their trainees, yet somewhere along Pennsylvania Hospital, Allegheny Health, Pittsburgh Philadelphia the way, the enrichment related to networking and career building gets Dr. Mary Sims Dr. Jordann Mishael-Duncan lost. The Resident and Associate Crozer-Chester Medical Center, Reading Hospital (Tower Society of the American College of Upland Health), West Reading Surgeons (RAS-ACS) is a specialty Brett Smith-Hams Dr. Sonia Bhandari Randhawa organization for residents and recent graduates that connects them to Albert Einstein Medical Center, St. Luke’s University Hospital– Philadelphia Bethlehem people and projects specifically for young surgeons. These opportunities Dr. Katelyn Brendel Dr. Julia Ritchie help residents develop professionally Geisinger Medical Center, Temple University Hospital, as they progress through their Danville Philadelphia training and early years in practice. Dr. Luke King Dr. Miriam Aioub The RAS-ACS assists residents Dr. Julia Middleton Dr. Olga Mutter who want to attain skills pertaining Jefferson University Hospital, University of Pennsylvania, to advocacy, health policy, leadership, Philadelphia Philadelphia global health, and career planning. It allows for networking and Dr. Nimali Weerasooriya Dr. Leigh Ann Humphries camaraderie, both of which are Lankenau Medical Center (Main University of Pittsburgh Magee essential for professional development. Line Health), Wynnewood Women’s Hospital, Pittsburgh This camaraderie fosters a kinship Dr. Sumin Park Dr. Alison Zeccola among residents whose common goal Lehigh Valley Health Network, of surgical excellence attracts them Allentown to this profession. The challenge lies in attracting residents in the Dr. Jose Lazaro surgical specialties, such as residents in obstetrics and gynecology, otolaryngology−head and neck

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The RAS-ACS is a specialty organization for residents and recent graduates that connects them to people and projects specifically for young surgeons.

surgery, urology, and so on. ACS. In the past, the program Regent who knows the leaders of These residents likely find their directors had been contacted the programs. Our persistence own specialty organizations through mail with little to no eventually led to 15 of the 16 provide much of the support response. This year, the Resident programs expressing interest in they need, but they also would Liaison on the advisory council the project and nominating one benefit from the extensive and co-author of this article, to two residents per program. resources offered by the College. Sonia Bhandari Randhawa, Once we had representatives Obstetricians-gynecologists MD, paired with ACS Regent from most OB-GYN residency (OB-GYNs) have been an Enrique Hernandez, MD, programs across the state, we integral part of the ACS since FACS, FACOG, a member of the hosted a welcome dinner for its founding more than 105 advisory council and a coauthor the selected residents where years ago. In fact, the College’s of this article, in an effort to they learned about the ACS founder, Franklin H. Martin, significantly increase OB-GYN and the resources it has to MD, FACS, chose the name resident involvement in the ACS. offer them and about the goals Surgery, Gynecology & Obstetrics The goal was to form a of our committee. We had (now known as the Journal of Pennsylvania OB-GYN Resident a significant turnout at the the American College of Surgeons) Committee under the ACS to dinner and positive responses for the organization’s clinical help residents learn about and from the residents nominated publication. OB-GYN residents take advantage of the resources to become ACS members. are an important part of the ACS that the ACS has to offer, We asked these residents to legacy and should be encouraged including leadership, advocacy, take back to their programs what to be active participants in the and surgical skills training, as they learned about the College largest and preeminent surgical well as networking opportunities. and to encourage their fellow association in the world. The authors started by reaching residents to join the organization; out to each of the 16 Pennsylvania to select a junior resident in their residency program directors program who would continue in Expanding involvement of and coordinators, asking each this role after the initial group OB-GYN residents in RAS program to nominate a resident graduated; and to participate The ACS Advisory Council for to the committee. The purpose in a statewide service project Obstetrics and Gynecology noted of the request was to give the for residents to lead a sanitary the void in OB-GYN resident program directors a chance to supply drive for a women’s involvement in RAS, and despite select a resident who was most shelter in their community. multiple efforts in the past, was interested in the surgical aspects We are looking forward to unable to increase membership. of OB-GYN and, in turn, will this group of residents becoming At the 2019 Leadership & carry their ACS membership actively involved in the RAS- Advocacy Summit, the OB- throughout their career. Some ACS and in the Pennsylvania GYN advisory council proposed programs were eager early on, ACS chapters’ (Keystone, a systematic effort to increase whereas others needed to be Metropolitan, Northwestern, OB-GYN residents’ interest in contacted directly by an ACS and Southwestern) activities. ♦

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From the Archives: German influences on U.S. surgery and the founding of the ACS

Franklin Martin, MD, FACS, Founder of the American College of Surgeons

by David E. Clark, MD, FACS

hen the American Conversely, German surgeons leaders Dr. Murphy; George College of Surgeons who visited the U.S. during Crile, MD, FACS; Harvey W(ACS) was founded in the early 20th century were Cushing, MD, FACS; Charles 1913, the German-speaking impressed by the practical Mayo, MD, FACS; J.M.T. Finney, countries of Europe were skills, excellent nurses, private MD, FACS, the first President the preeminent leaders in philanthropy, and respect of the ACS; and A.J. Ochsner, biomedical science. Abraham for patients they found.2 MD, FACS, all of whom had Flexner, MD, and other Meanwhile, millions of studied in Germany. Following U.S. physicians admired people dissatisfied with life in the German “wanderlust” the principles of German central Europe were migrating tradition, members of the medical education, including to the U.S. Among these SCS traveled from place to national standards for students European immigrants were place to observe surgical and universities, academic dozens of German-educated centers at home and abroad.3 freedom, the expectation of surgeons, including Christian In 1904, Dr. Halsted postgraduate training, and an Fenger, MD, and Carl Beck, described his residency program adventurous tradition in which MD, in Chicago, IL, who further at the Johns Hopkins Hospital, “the student wanders from influenced Americans unable to Baltimore, MD, as designed place to place, seeking new afford a European tour. Many “to adopt as closely as feasible teachers.”1 World War I would of these immigrants remained the German plan.”4 He also have a devastating impact on members of the German criticized the exclusive surgical Germany’s reputation following Surgical Society (also known societies in America and the war, but we should as DGCH), which William S. advocated for a broad-based acknowledge its influences on Halsted, MD, FACS; Roswell organization like the DGCH, the genesis of our College. Park, MD, FACS; and John B. which “admits to its fellowship During the latter 19th Murphy, MD, FACS, also joined. any reputable surgeon of any century, more than 15,000 U.S. Admission to the American country of the world, and physicians traveled to Germany, Surgical Association (ASA), its halls at each Congress Austria, and Switzerland for founded by German-American are filled and overflowing.”4 postgraduate education.2 Samuel Gross, MD, in 1880, was Dr. Park had made a similar Visiting physicians and scholars limited to 125 members. In 1903, recommendation in his role praised German dedication younger American academic as ASA President in 1901.5 to research, innovation, and surgeons founded the Society In 1905, ACS founder teaching, but disliked how for Clinical Surgery (SCS), Franklin H. Martin, MD, FACS, European professors treated whose even smaller membership established Surgery, Gynecology patients as social inferiors.2 included ACS founders and & Obstetrics (SG&O, now the

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Dr. Crile Dr. Cushing Dr. Finney

Dr. Halsted Dr. Martin Dr. Mayo Dr. Murphy NATIONAL CANCER INSTITUTE NATIONAL

Dr. Ochsner Dr. Park Dr. Senn

Photos courtesy of the American College of Surgeons Archives, except where indicated

Journal of the American College of Within a few years, the REFERENCES Surgeons), with Swiss-American Clinical Congresses were “filled 1. Flexner A. The German side of Nicholas Senn, MD, FACS, as and overflowing” and evolved medical education. Atlantic Monthly. Editor-in-Chief. During its first into the ACS. Other than 1913;112:654-662. decade, more than 40 percent Dr. Martin, most of the initial 2. Bonner TN. American Doctors and of the literature cited in SG&O ACS Regents and Presidents German Universities. Lincoln, NB: University of Nebraska Press; 1963. was in German. After the SCS were SCS and ASA members. 3. Cushing H. The Society of Clinical proposed a translated abstract The new organization adopted Surgery in retrospect. Ann Surg. publication like the Zentralblatt the name and some traditions 1969;169(1):1-9. für Chirurgie,3 Dr. Martin of the British Royal Colleges, 4. Halsted WS. The training of the expanded SG&O to include the ties that would be strengthened surgeon. Bull Johns Hopkins Hosp. 1904;15:267-275. International Abstract of Surgery. by wartime alliance, but in 5. Sparkman RS, Shires GT, eds. Dr. Martin explicitly intended 1913, it owed at least as much to Minutes of the American Surgical the initial Clinical Congresses Germany as to Great Britain. ♦ Association. Dallas TX: Taylor as a way to make the SCS Publishing Co; 1972. model more widely available.

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Bulletin Bulletin Bulletin Bulletin Read Bulletin: ACS COVID-19 Updates at facs.org/about-acs/covid-19/newsletter

Olga M. Jonasson, MD, Lecture: Robert N. McClelland, MD, FACS, founder of SRGS

Recapturing the joy of surgery

The ISCR expands scope to include emergency general surgery

Death of Dr. Isaac Burrell inspired black hospital movement

Letter from the Editor

by Diane Schneidman, Editor-in-Chief

This year has been one of ACS business and activities in a trusted and valued resource unprecedented change in most weekly newsletter called Bulletin for all members of the College. of our lifetimes as a result of Brief, which you should receive As always, please provide any the coronavirus disease 2019 every Tuesday and replaces ACS comments or suggestions (COVID-19) pandemic and NewsScope. The new Bulletin on how we can best serve the outcry against systemic Advocacy Brief e-newsletter will be you at [email protected]. racism. The monthly Bulletin released every other Thursday. Thank you for your of the American College of With this issue of the continued efforts “to serve Surgeons (ACS) went on pause magazine, we resume a all with skill and fidelity” for three months so we could more regular publication and for your continued devote resources to publishing schedule for the traditional support of the Bulletin. ♦ Bulletin: ACS COVID-19 Updates Bulletin. One more issue of as the pandemic spread rapidly the Bulletin will be published across the nation. After 15 this year in October. The issues of the newsletter and as Bulletin will resume monthly the curve began to flatten in publication in January 2020. early hotspots, we switched Throughout all the upheaval to a weekly format focused and uncertainty, we hope that not only on COVID-19-related the Bulletin in its various forms developments, but also other has continued to serve as a

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Announcing the new Cancer Surgery Standards Program

by Matthew H.G. Katz, MD, FACS; Kelly K. Hunt, MD, FACS; Heidi Nelson, MD, FACS; and Amanda Francescatti, MS

The American College of Surgeons (ACS) Cancer Programs Background and origins of CSSP is proud to announce the launch The CSSP has its origin in of the Cancer Surgery Standards the Cancer Care Standards Program (CSSP). Led by Chair Development Committee of Matthew H.G. Katz, MD, FACS, the ACS Clinical Research and Vice-Chair Kelly K. Hunt, Program (ACS CRP), which MD, FACS, the CSSP seeks to was established to evaluate the improve the quality of surgical level of evidence that exists to care provided to persons with support the development of cancer through the development standardized surgical approaches of technical standards and and to develop standards based quality measures; the creation on this evidence. The committee and dissemination of electronic also was tasked with improving tools to support implementation the quality of surgical data and adherence to these captured during the conduct of standards; and the education of clinical trials. The collaboration surgeons, trainees, and staff. between the ACS and the The ACS has been committed Alliance for Clinical Trials in to setting standards for more Oncology, created in 2012 by than 100 years and sponsors a Heidi Nelson, MD, FACS, past- multitude of initiatives focused Program Director of the ACS on improving the quality of care. CRP, current Medical Director Surgical clinical research trials, of ACS Cancer Programs, including many conducted by and co-author of this article, the ACS through the American has produced two volumes of College of Surgeons Oncology Operative Standards for Cancer Group, have generated data that Surgery, each of which describes demonstrate that the specific evidence-based standards for the methods by which certain technical conduct of oncologic technical aspects of surgery are surgery. Two additional volumes conducted have a direct impact currently are in production. on patient outcomes. In some These technical standards Current volumes I, II, and III of cases, the results from these trials are now being implemented Operative Standards for Cancer Surgery led to the widespread adoption of into surgical practice through standardized surgical approaches collaboration with other and evidence-based best practices. ACS Cancer Programs.

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The CSSP builds upon this history with a view toward standardizing operative documentation such that it accurately reflects oncologically critical standard components.

1953 CoC Manual for Cancer Programs

For nearly 100 years, the accurately reflects oncologically Association, the Resident and Commission on Cancer (CoC) has critical standard components. Associate Society of the ACS, set standards to ensure patients Increased collaboration across and surgical societies such as the received the best care possible surgical teams using the common American Society of Colon and through accreditation of cancer language of these standardized Rectal Surgeons, the American practices. Over the last decade, operative reports is an important Society of Breast Surgeons, and the CoC standards have shifted goal for this new program. the Society of Surgical Oncology. from facilities and equipment In order to facilitate Additionally, the CSSP will to processes, and now toward implementation of the operative benefit from broad representation outcomes-based standards. In standards in CoC-accredited from, and coordination between, 2020, the CoC included six of the sites, to improve the quality of the other ACS Cancer Programs, operative standards—two for surgical documentation, and to including the CoC, ACS CRP, breast cancer surgery, two for educate surgeons and surgical National Accreditation Program colorectal cancer surgery, and trainees, the CSSP is developing for Breast Centers, National one each for lung cancer surgery synoptic operative reporting Accreditation Program for and melanoma surgery—in the templates and point-of-care Rectal Cancer, and American Optimal Resources for Cancer Care electronic documentation tools. Joint Committee on Cancer. (2020 Standards). The evidence Furthermore, the program will Leaders of the ACS Cancer from the Operative Standards for create cancer surgery protocols Programs have been gratified Cancer Surgery manuals formed to provide guidance on the to have the approval of David B. the basis for the six CoC operative collection of essential data Hoyt, MD, FACS, ACS Executive standards, and adherence to elements for cancer surgery. Director, and the Board of these standards will be required Educational content will be Regents to launch the CSSP. for maintenance of CoC created and disseminated to We look forward to providing accreditation. Download the 2020 assist with implementation our members with tools and Standards at facs.org/2020standards. of these standards and tools resources to help improve the at each accredited center. quality of surgical care for Disease site-specific all persons with cancer. ♦ Goals of the program workgroups within the CSSP The CSSP builds upon this include a diverse group of history with a view toward experts in the surgical oncology standardizing operative community and representatives documentation such that it from the ACS Young Fellows

JUL 2020 BULLETIN American College of Surgeons | 93 NEWS

ACS remembers Howard M. Snyder III, MD, FACS, trailblazer in pediatric urology

Dr. Snyder

Howard M. Snyder III, MD, FACS, Koop, MD, FACS, then-surgeon- Many of his treatments remain a pioneer in pediatric urology in-chief of the hospital and the standard of care to this day. and a former American College future Surgeon General of the Dr. Snyder was actively of Surgeons (ACS) Regent and U.S., and John W. Duckett, involved as a member and leader Governor, passed away June 4 MD, FACS, a renowned of many medical societies. at age 76 from complications urologist. He remained there An ACS Fellow since 1984, he of Parkinson’s disease and until his retirement in 2015. served as a Governor (2002– the coronavirus disease 2019 In addition to his practice 2008) and a Regent (2007–2016), (COVID-19). Prior to his in Philadelphia, Dr. Snyder chaired the Advisory Council retirement in 2015, Dr. Snyder was proud to follow in his for Urology (2003–2007), and was a pediatric urologist in the grandfather’s and father’s served on several committees. division of urology at Children’s footsteps by serving in the Dr. Snyder also was a member Hospital of Philadelphia U.S. armed forces. Dr. Snyder and leader of the American (CHOP), PA, and professor of served for more than 20 years Association of Genitourinary surgery in urology, Perelman in the U.S. Army Medical Corps Surgeons; the American School of Medicine at the and was deployed to active Surgical Association; the University of Pennsylvania. duty in 2003 in Operation American Board of Urology, on His contributions to the field Iraqi Freedom. He also served which he served as a member shaped modern understanding as a professor of surgery and examiner; among others. In and treatment of many urologic at the Uniformed Services 2013, he received the American conditions in young patients. University of the Health Urological Association’s Sciences, Bethesda, MD. Urology Medal for contributions to pediatric urology. Service to patients and country Dr. Snyder earned his Innovator and leader undergraduate degree from in pediatric urology Comments from friends Princeton University, NJ; Dr. Snyder’s research and and colleagues at the ACS received his medical education innovation in pediatric urology Dr. Snyder’s undeniable at Harvard Medical School, led to advancements in diverse skill as a surgeon and Boston, MA; and then spent a areas of care, including compassionate demeanor found year in the U.K. learning from posterior, prune belly syndrome, him many friends among experts in pediatric urology. He ureteroceles, hypospadias, his surgical colleagues. returned to the U.S. in 1980 and cryptorchidism, management of Marshall Z. Schwartz, MD, began to practice at CHOP at the neuropathic bladder, andrology, FACS, FRCSEng(Hon), Past-Vice- recommendation of C. Everett and pediatric urologic oncology. Chair, ACS Board of Regents,

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Dr. Snyder’s research and innovation in pediatric urology led to advancements in diverse areas of care, including posterior, prune belly syndrome, ureteroceles, hypospadias, cryptorchidism, management of neuropathic bladder, andrology, and pediatric urologic oncology. Many of his treatments remain the standard of care to this day.

said, “How do you summarize within our federal government. I was elected to the Board of a 47-year wonderful friendship We wanted to emphasize the Regents, he called me at my with someone who was so College’s mission of quality home. He wanted to introduce giving of himself? Howard surgical care and patient safety himself as a seasoned member was a multidimensional person and the accomplishments of of the Board. He offered to be who loved to learn and teach. the College in fulfilling these my mentor in the room to help We first met in 1973, when goals. I will miss him dearly.” me get a good start and navigate we were general surgery “Howard and I shared an the complexities of the job. I residents rotating to Boston apartment when we were have never forgotten that act of Children’s Hospital, MA. Our residents at the Brigham kindness. What I came to find close friendship developed even [Boston] in the early 1970s,” out during the several years of though we pursued different said Lenworth M. Jacobs, Jr., MD, working with him was that this surgical fields within the MPH, FACS, ACS Regent. “It was was his way with everyone, and pediatric age group—Howard a pleasure to learn from his his avuncular nature permeated in pediatric urology (he became wise counsel and thoughtful all the actions of his life. I will an international icon) and me comments about pretty nearly miss him, and I am sure he is in pediatric general surgery. any subject. We all had a getting his just reward.” ♦ Ironically, in 1996 we ended wonderful time with friends up in Philadelphia together from across the entire spectrum. living less than one mile apart. He also was always open to Howard was already established helping others and to lending a in Philadelphia, and he and hand to those who needed it. He his wife Mimi took us under was an excellent surgeon and their wings and exposed us was superbly trained. He really to the arts, local and regional made a positive impression surgical associations, and so on. on the world. I will miss him He had many diverse interests terribly. Rest in peace.” including art, music, old pocket James K. Elsey, MD, FACS, ACS watch collecting, and gourmet Regent, described Dr. Snyder cooking, to name a few. We as “a brilliant man, a superb were both excited when we surgeon, and an ACS servant, became Regents of the College. but, most importantly, he was We shared a common passion as a warm, caring, compassionate Regents, which was to improve man and my friend. I’ll never the visibility of the College forget one night, shortly after

JUL 2020 BULLETIN American College of Surgeons | 95 NEWS

ACS mourns the passing of Francis Robicsek, MD, PhD, FACS, a dedicated humanitarian surgeon

Dr. Robicsek

Francis Robicsek, MD, PhD, where he worked alongside Paul found one of the first integrated FACS, a cardiothoracic surgeon Sanger, MD, and Fred Taylor, patient practices in the area. from Charlotte, NC, whose MD, to perform Charlotte’s In 1959, Dr. Robicsek innovations in surgery and first open-heart operations, and cofounded Heineman Medical consummate humanitarianism coordinated with an engineer Outreach, Inc., a one-time brought profound health to construct the heart-lung research organization in improvements around world, machine needed to keep a Charlotte, NC. As president passed away peacefully patient’s heart beating during of the organization for nearly April 3. He was 94 years old. surgery. In 1986, Dr. Robicsek 50 years, Dr. Robicsek guided Dr. Robicsek’s commitment and Harry Daugherty, MD, its evolution to a local and to his patients, domestic and performed the city’s first humanitarian aid program international, made a lasting heart transplant. Dr. Robicsek in partnership with the impact and was recognized continued to perform surgery Carolinas HealthCare System. by the American College at Carolinas Medical Center of Surgeons (ACS) in 2017 until his retirement from with the ACS/Pfizer Surgical active practice in 1998, but A lifetime of international Humanitarian Award. he continued teaching and humanitarianism mentoring well after that. The breadth of Dr. Robicsek’s Dr. Robicsek’s passion for humanitarian spirit became Early dedication to humanitarian aid was apparent clear through his work on domestic patient care from his early days in the the global stage. Dr. Robicsek Born and educated in Hungary, U.S. He chose to operate on began his international Dr. Robicsek came to the U.S. to African-American patients who, humanitarian work in the escape the Hungarian revolution in the segregation era, were early 1960s in Honduras, in the 1950s, after becoming denied treatment at the former treating surgical tuberculosis the chief of the University of Charlotte Memorial Hospital. patients and then expanding Budapest department of cardiac Dr. Robicsek worked around his surgical services to other surgery at just 29 years old. He this limitation by admitting countries, providing direct began practicing at Charlotte black patients to a tuberculosis surgical care to patients in Memorial Hospital, NC, now hospital nearby and performing Belize, Guatemala, Nicaragua, the Carolinas Medical Center, operations there. He went on to and Eastern Europe. His

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Dr. Robicsek (left) at the bedside of a young patient who underwent open- heart surgery at UNICAR.

contributions to cardiothoracic the region each year. UNICAR La Orden del Quetzal, in the surgery in Central America now serves patients from rank of Grand Commander, by are particularly noteworthy. neighboring countries, as well. the President of the Republic Dr. Robicsek performed the The facilities of Carolinas during the founding of the first open-heart operations Medical Center were provided Cardiovascular Surgery Unit in Honduras and Guatemala for the training and education of Guatemala in 1976. and initiated and assisted the of Guatemalan surgeons, For his dedicated patient first open-heart surgery by technicians, and nurses who care in Charlotte and a native surgeon in Belize. specialized in different areas lifelong commitment to In the 1970s, he arranged to related to cardiovascular providing cardiothoracic have patients from Guatemala surgery. For many years, he surgery and health services flown into Charlotte for maintained a guest house at in Guatemala and around the operations, and he accepted the hospital for these health world, Dr. Robicsek will be Guatemalan surgeons for care workers to train at no remembered as a surgeon and training fellowships. His cost. Dr. Robicsek’s efforts person of rare caliber. ♦ ties with the Guatemalan also led to the establishment government and health care of burn units, mammography, system eventually led to echocardiogram networks, the founding of Unidad de catheter labs, and more across Cirugía Cardiovascular de Central America. Since 2010, Guatemala—or UNICAR—the when Heineman and the Guatemalan Heart Institute, Carolinas HealthCare System where more than 700 heart established the International operations are performed Medical Outreach Program, annually. These and other these humanitarian efforts operations in Central America have continued to grow. are made possible in part by Dr. Robicsek was recognized the more than $1.5 million in with high honors from the new and refurbished hospital Guatemalan government supplies that Dr. Robicsek for his efforts, including the arranged to have delivered to highest Guatemalan award,

JUL 2020 BULLETIN American College of Surgeons | 97 NEWS

ACS issues call to action on racism as a public health crisis:

An ethical imperative

In light of the disproportionate Floyd sparked nationwide protests effects of the coronavirus disease that demanded justice against the These unprecedented 2019 (COVID-19) on African- deep racial inequities in the U.S. crises call for enlightened American and other minority According to the ACS Board communities, as well as the of Regents and the Committee and innovative leadership, continued police violence against on Ethics, which developed the inspired intervention, and black people in the U.S., the comments, “These unprecedented compassionate service from American College of Surgeons crises call for enlightened and (ACS) in early June issued a innovative leadership, inspired all members of the ACS. call to action declaring racism intervention, and compassionate as a public health crisis. service from all members of the “At a time when people ACS.” Specifically, the College are desperately seeking a calls upon its members to work vaccine to allow them to shed toward eliminating health their ‘protective face masks’ care disparities, identifying the and return to a semblance structural racism that leads to of normalcy, unfortunately, a greater prevalence of chronic African Americans continue illness, and recognizing that racial to confront, all too frequently, injustice exacerbates existing mistreatment or brutality by health care disparities. College some law enforcement officers, leadership said, “Correcting these which has given rise to more injustices now, by denouncing than an aspirational slogan, but racism and its deleterious effects rather an urgent cry: ‘Black Lives on the health of Black and Brown Matter,’” the call to action reads. people, is among the most The compounding effects of important missions of the ACS.” systemic racism that led to the Read the full call to action recent killing of Ahmaud Arbery, at facs.org/about-acs/responses/ Breonna Taylor, and George racism-as-a-public-health-crisis. ♦

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Memoir recounts “golden age” of surgical innovation Dr. Wangensteen led at University of Minnesota

Owen H. Wangensteen, MD, FACS, who chaired the department of surgery, University of Minnesota, Minneapolis, for several decades and established the American College of Surgeons (ACS) Surgical Forum—now the Owen H. Wangensteen, MD, FACS, Scientific Forum—presented annually at Clinical Congress, remains a surgeon of great renown. Another highly esteemed surgeon and a champion of bariatric and metabolic surgery who trained under Dr. Wangensteen, Henry Buchwald, MD, PhD, FACS, has recently published a recollection of the heady days at the University of Minnesota and the important contributions Dr. Wangensteen and his attendings and residents have made to surgical care. Surgical Renaissance in the Heartland: A Memoir of the Wangensteen Era chronicles Dr. Buchwald’s personal journey from Nazi-occupied Austria to New York, NY, and ultimately to Minneapolis and his professional career at the University of Minnesota— both forever changed under the guidance and tutelage of Dr. Wangensteen and the surgeons he recruited. Dr. Buchwald chronicles the culture of innovation that Dr. Wangensteen cultivated and how it led the scientific and clinical discoveries associated with the latter half of the 20th century. Dr. Buchwald is professor of surgery and biomedical engineering and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery Emeritus, University of Minnesota. He is the recipient of the 2019 ACS Jacobson Innovation in Surgery Award, presented by the College in recognition of his pioneering work and innovative research in metabolic and bariatric surgery.

Surgical innovation Among his own innovations, Dr. Wangensteen proved that simple gaseous bowel distention, primarily from swallowed air, was the responsible

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Dr. Wangensteen circa 1935 Dr. Wangensteen circa 1961

agent for intestinal PRAISE FOR SURGICAL RENAISSANCE IN THE HEARTLAND obstruction. Dr. Buchwald writes, “Most important, “The significance and origin of the values behind the Wangensteen he invented nasogastric and legacy are brought to life in Surgical Renaissance in the Heartland. nasointestinal suction, later This is a must read for everyone involved in surgery and will referred to as ‘Wangensteen help us remember the origin of our wonderful profession.” suction,’ performed by the ‘Wangensteen tube.’” This —David B. Hoyt, MD, FACS, ACS Executive Director device evacuated intestinal “Who would have guessed that a Minnesota farm boy would gas and fluid, relieving the found one of the greatest research surgical centers in the abdominal distention of a bowel obstruction, allowing patients world? In this remarkable book, Henry Buchwald, one of today’s to recover spontaneously or great surgeon-leaders, reveals not only how it happened, but be adequately prepared free also how we can and must learn from that experience.” of sepsis for interventional —Walter J. Pories, MD, FACS, director, Metabolic Surgery surgery. “This innovation Research Group, East Carolina University, Greenville, NC alone saved millions of lives” and “reduced the mortality of “Initially as surgery resident, then as a faculty member, acute intestinal obstruction and subsequently as one of the giants in his field, Henry to below 3 percent” down Buchwald has expertly captured this vibrant atmosphere of from 40 percent in the 1930s, medical discovery. His very personal and beautifully written according to Dr. Buchwald. account of this unique period is well worth the read.” The son of Midwestern farmers, Dr. Wangensteen —Marshall Z. Schwartz, MD, FACS, transformed surgical Past-Vice-Chair, ACS Board of Regents education for aspiring surgical investigators, establishing a surgical residency with a mandatory seven-plus years— five years of clinical training, supplemented by two or more

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Among his other accomplishments, Dr. Wangensteen founded the journal Surgery in 1937; established the Society of University Surgeons in 1939; and originated the ACS Surgical Forum in 1940.

years in a basic science research consulted on how to develop, it impossible for him to operate. laboratory coincident with the reflect upon, and improve He pleaded with Dr. Buchwald return to the classroom for a their concepts,” according to in 1966 to perform a jejunoileal PhD in surgery and, whenever Dr. Buchwald. In many ways, bypass. Dr. Buchwald initially possible, an advanced degree in Dr. Varco was the progenitor hesitated because of his focus on a basic science. By the end of his of Dr. Buchwald’s specialty. In perfecting partial ileal bypass more than three-decade tenure 1953, Dr. Varco performed the and his other research interests. as department of surgery chair in first intestinal bypass operation Seeing a friend and mentor in 1967, the graduates of his program to incite massive weight loss. need, Dr. Buchwald reluctantly included 38 department heads, Dr. Buchwald describes yielded, and since 1966 his 31 division heads, 72 program Dr. Varco as an “insightful and name has been associated directors, and 110 full professors. complex technical marvel,” as with bariatric surgery. Among his other well as a scholar, innovator, “However, I have no regrets,” accomplishments, innovative thinker, teacher, Dr. Buchwald writes. “Indeed, Dr. Wangensteen founded and curmudgeon. While as I became more and more the journal Surgery in 1937; Dr. Buchwald was pursuing his acquainted with the problem established the Society of research interests in cholesterol of morbid obesity and the University Surgeons in 1939; and, control to prevent cardiothoracic unfortunate individuals suffering as noted previously, originated and vascular disease, Dr. Varco from this disease, the more the ACS Surgical Forum in 1940. was developing the jejunoileal grateful I was to Richard for bypass operation for morbid forcing me to become involved, obesity, taking more than 90 and very rapidly I became University of Minnesota percent of the small intestine out dedicated to the discipline.” and advances in surgery of contact with food to reduce Dr. Buchwald also recounts Much of the memoir focuses caloric consumption. Dr. Varco his longstanding friendship on three of Dr. Wangensteen’s repeatedly asked Dr. Buchwald with Ward O. Griffen, MD, most influential mentees and to start performing the FACS, past-chair, department of their impact on Dr. Buchwald’s procedure, but Dr. Buchwald surgery, University of Kentucky, professional development. These refused. He wanted his name Lexington, and a leader of the individuals included C. Walton to be associated with his work ACS; both the Lillehei brothers; Lillehei, MD, FACS, known as in lipid and atherosclerosis Jack Bloch, MD, FACS; and the father of open-heart surgery; management—not bariatric John P. Delaney, MD, PhD— Richard C. Lillehei, MD, FACS, surgery. Furthermore, all residents who trained a transplant surgeon; and, most Dr. Buchwald had developed the under Dr. Wangensteen. significantly for Dr. Buchwald, partial ileal bypass for cholesterol Surgical Renaissance in the Richard L. Varco, MD, FACS. control and was gaining Heartland: A Memoir of the Dr. Varco was known recognition for that procedure. Wangensteen Era is published by as “the surgeon who other At one point, Dr. Varco the University of Minnesota surgeons at Minnesota developed a condition that made Press, Minneapolis. ♦

JUL 2020 BULLETIN American College of Surgeons | 101 NEWS

Report on ACSPA/ACS activities, February 2020

by Ronald J. Weigel, MD, PhD, FACS

The Board of Directors of the The Regents also approved cutting-edge science. The position American College of Surgeons the formation of the Ontario of Director of the Division of Professional Association Chapter in Canada. Integrated Communications (ACSPA) and the Board of was filled when Cori McKeever Regents (B/R) of the American Ashford officially joined the College of Surgeons (ACS) Division of Education College in December 2019. met February 6–8, 2020, at The Committee on Ethics, housed the College’s headquarters in in the Division of Education, STOP THE BLEED® Chicago, IL. The following is held several programs at Clinical In October 2019, bleedingcontrol.org a summary of key activities Congress 2019 in San Francisco, became StoptheBleed.org as the discussed. The information CA, including the John J. Conley next step in raising the public provided was current as of Ethics and Philosophy Lecture, profile of this internationally the date of the meeting. What We Talk About When renowned public safety program. We Talk About Surgery, by StoptheBleed.org is the College’s Gretchen M. Schwarze, MD, first entirely public-facing website. ACSPA FACS. Additional events included The content reflects a new In 2019, the ACS Political the 2019 Ethics Colloquium, approach to informing, educating, Action Committee, ACSPA- The Ethics of Extraordinary and empowering the general SurgeonsPAC, supported more Care; a Panel Session, Should public to learn more about the than 120 candidates, political Surgeons Care for their Family STOP THE BLEED program. campaign committees, and Members?; a Meet-the-Expert Since its launch and through other PACs. Nearly $400,000 session, Dealing with Death and January 20, StoptheBleed.org was raised for key congressional Dying: How to Conduct Goals page views were up 46 percent champions. Commensurate of Care Discussions, Provide and sessions were up 55 percent with congressional party Quality Care to Dying Patients, compared to bleedingcontrol.org. ratios, 50 percent of the and Cope After a Difficult Death; New social media handles were amount given went to and a Postgraduate Course, launched alongside the new Republican and 50 percent Ethical Issues in Geriatric STOP THE BLEED website to Democratic campaigns. Surgical Care. Plans are under to help spread information way to develop programs for about the program. Twitter (@ Clinical Congress 2020. StopTheBleedACS) and Facebook ACS accounts provide STOP THE In addition to reviewing BLEED-related updates and reports from the ACS division Division of Integrated showcase the efforts of school directors, the B/R approved the Communications and community groups that are following policy statement: In 2019, the Division of Integrated training the public in their areas. Communications developed and • Statement on Suicide Prevention supported initiatives to enhance Clinical Congress 2019 the College’s external reputation, Eleven studies from the Clinical The B/R also accepted increase engagement among Congress Educational Forum resignations from 12 Fellows and members, boost awareness of were promoted through changed the status from Active or and interest in industry-leading press releases. These studies, Senior to Retired for 74 Fellows. programs, and drive awareness of selected for the impact and

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newsworthiness of their Resources to Increase Value NewsScope findings, addressed topics and Efficiency), an ambitious In 2019, ACS launched a new including the recurrence of new program to measure and artificial intelligence (AI)-driven traumatic injuries in children, improve the value of surgical care. version of ACS NewsScope to all the impact of surgeon shift Leveraging the College’s expertise members of the College—My length on patient outcomes, the in quality measurement and HBS’ ACS NewsScope—which was ability of artificial intelligence to expertise in activity-based cost distributed twice a week and triage postoperative patients, and accounting, the program will help used AI to deliver customized use of the ACS National Surgical hospitals accurately measure their content to each recipient. The AI Quality Improvement Program costs, tie those costs more closely database collected articles from (ACS NSQIP®) Surgical Risk to robust outcome measures, nearly 80 sources of both clinical Calculator to predict quality- and take steps to improve the and nonclinical information of-life outcomes for geriatric value of care. Presentations were on topics that are relevant to surgical patients. Scientific created for use on Capitol Hill surgeons. Each issue included a presentations and activities and at a preconference session “News Brief” on an important during Clinical Congress 2019 with industry thought leaders ACS program and occasional captured 286 media mentions, for the 2019 Quality and Safety updates from the ACS Division of with an overall potential Conference. Nearly 100 Capitol Advocacy and Health Policy. In reach of 466.8 million. Hill staff members attended the response to the demand for more briefing, and multiple media clinical information, abstracts GSV interviews were facilitated. from the top 50 journals in surgery The College’s Geriatric Surgery were added. The traditional ACS Verification (GSV) Program— ACS website (facs.org) NewsScope (now ACS Bulletin Brief) introduced at the July 2019 ACS In a continuing effort to provide continues to be disseminated to Quality and Safety Conference a comprehensive resource for more than 55,000 recipients. in Washington, DC—captured those who visit facs.org, multiple national media attention this past content updates and overall Bulletin summer with several news articles improvements were made to A strategic plan was developed on the need for the program and the website last year. In 2019, in 2019 to help freshen the how it will improve outcomes the College’s website logged print and online editions for older surgical patients. Stories 11,264,958 page views from of the Bulletin. The Bulletin were published online and in nearly 2.1 million visitors in implemented content and print by the New York Times, 3.4 million sessions. Overall design changes in both versions, Associated Press, Kaiser Health website traffic was up from 2018, including adding highlights and News, AARP.com, Reuter’s with 11.6 percent more users, pull quotes to online feature Health, Becker’s Healthcare, 9 percent more sessions, and stories, redoing the headers and Fierce Healthcare. 5.5 percent more page views. and table of contents in the In 2019, returning visitors print edition, and making other ACS THRIVE represented 17 percent of website tweaks that improved readers’ In 2019, the College partnered traffic, and the remaining experiences. A new navigational with Harvard Business School 83 percent were new visitors. structure has been implemented (HBS) to create ACS THRIVE Planning is under way for an in the online version to (Transforming Health care updated facs.org in 2020. match the print version.

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Clinical Congress Daily Highlights Science Direct and Clinical General Surgery, Breast Surgery, Clinical Congress Daily Highlights Key platforms. In the same Colon and Rectal Surgery, Rural supplements the on-site period, journalacs.org received Surgery, and Women Surgeons. newspaper, Clinical Congress nearly 799,000 page views. News, and is distributed to all Fellows, including those unable to Social media Division of Research and attend. The 2019 edition included Upward trajectories continue Optimal Patient Care coverage of 40 sessions and more for engagement with the ACS The Division of Research and than 27 video interviews with Facebook, Twitter, and LinkedIn Optimal Patient Care (DROPC) investigators. Stories included sites. By January 13, 2020, 34,639 encompasses the areas of Late-Breaking Clinical Trials, people had “Liked” the ACS Continuous Quality Improvement liquid biopsy, robotic surgery, Facebook page, and 36,308 were (CQI), including ACS research machine learning, personalized following ACS. The College and the accreditation programs. medicine, resident duty hours, has 55,295 Twitter followers, appendicitis, bariatric surgery representing a nearly 5 percent Quality and Safety Conference outcomes, diverticulitis, and growth since October 2019. The 2020 ACS Quality and others. The newsletter was The College now has 25,801 Safety Conference (QSC) will distributed twice daily over LinkedIn followers, an 8 percent focus on the theme, Achieving three days, and stories were increase since October 2019. Surgical Quality: HOW? and shared on social media using the will provide attendees with #ACSCC19 and #ACSHighlights ACS Communities practical and actionable steps hashtags. Plans for 2020 included Since its launch in 2014, ACS to improve surgical quality extending the reach of selected Communities continue to be a and safety at their institutions. stories through a targeted post popular member benefit. The Sessions will highlight “the how” campaign on LinkedIn. platform has received 4.5 million of achieving surgical quality, page views, and 36,749 members applying evidence-based best JACS of the College have agreed to practices to improve quality, and In 2019, the Journal of the the site’s terms of use. The 127 how principles of value-based American College of Surgeons ACS Communities have become surgery can be better understood (JACS) successfully achieved the go-to place for members of and ultimately achieved. a subscription benchmark of the College to collaborate with converting 40 percent of College their peers. Popular discussion Optimal Resources for Surgical members to an electronic-only topics last year included gender Quality and Safety format. The January 2020 issue equity, family members in The development of adjunctive featured 17 selected papers the hospital, surprise billing and integrated resources/ presented at the Clinical Congress legislation, health care access, standards based on Optimal 2019 Scientific Forum—an gender reassignment surgery, Resources for Surgical Quality and increase from 13 papers published and surgeon replacements. Safety is near completion. These in the 2018 inaugural issue. In the Overall, site visitors have posted standards will be used to launch first three quarters of 2019, JACS 102,455 discussion group posts a Surgical Quality Verification full-text articles were downloaded and viewed library items more Program. Pilot visits began with approximately 375,000 times than 168,000 times. The five a group of targeted hospitals in across journalacs.org and the most active communities are 2018 and have continued into

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2020 as the verification elements phase of the project started, with began enrollment at Clinical of the program are further hospitals collecting data after Congress 2019. An education refined. The goal is to refine and implementation of an evidence- curriculum is being developed revise the standards based on the based protocol designed to track for sites to help them prepare findings from the site visits and use of multi-modal pain strategies. for the verification process. to launch the program in 2020. Data will be collected until the project concludes in 2021. ISCR Program ACS NSQIP Preliminary hospital engagement The Agency for Healthcare A total of 853 hospitals participate with BSTOP has been positive. Research and Quality in ACS NSQIP—712 in the adult Improving Surgical Care and option. The pediatric option CSV Program Recovery (ISCR) Program, represents 17 percent of overall The Children’s Surgery a collaborative effort participation. Another 26 hospitals Verification (CSV) Quality between the ACS and the are in various stages of the Improvement Program launched Johns Hopkins Armstrong onboarding process. At present, in 2017 with the goal of ensuring Institute for Patient Safety 130 hospitals outside of the U.S. that pediatric surgical patients and Quality, Baltimore, MD, participate in ACS NSQIP— have access to quality care. In all, continues to attract hospitals approximately 15 percent of 141 centers participate in CSV. interested in implementing all participating hospitals. All 141 centers also participate enhanced recovery practices. in ACS NSQIP Pediatric, an Approximately 60 percent MBSAQIP increase of 12 sites since January of enrolled hospitals also A total of 936 facilities participate 2019. Approximately 45 of these participate in ACS NSQIP. The in the Metabolic and Bariatric centers are in the various stages final cohort launched earlier this Surgery Accreditation and of verification. A total of 21 year with a concentration on Quality Improvement Program active sites are fully verified emergency general surgery— (MBSAQIP), and 60 surgeon as Level I children’s surgery specifically, appendectomy, surveyors are expected to centers. Approximately 15 site cholecystectomy, and laparotomy. complete 275 site visits in visits are projected for 2020. Hospitals participating in 2020. Between October 2014 ISCR receive a ready-to-use and January 2020, 1,573 site GSV Quality Improvement Program pathway, access to educational visits were completed. The GSV Quality Improvement materials on how to implement In 2019, MBSAQIP launched Program launched in 2019 and the pathway, access to experts its third national collaborative is composed of 30 required in performance improvement project, Bariatric Surgery and two optional patient- and education who will help Targeting Opioid Prescriptions centered standards designed to them troubleshoot problems as (BSTOP), focused on opioid systematically improve surgical they implement new practices, reduction in bariatric surgery. care and outcomes for the and inclusion in a community The project’s primary objective aging adult population. The of surgeons and clinicians is to reduce provider prescription program defines the resources rolling out the same pathway. of opioids and patient use during required to achieve optimal the perioperative period in more patient outcomes for older adults Strong for Surgery than 300 participating hospitals. receiving surgical care at verified Strong for Surgery (S4S), a In January 2020, the second health care facilities. Hospitals joint program of the ACS and

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the University of Washington, facilities and issued accreditation The American Joint Seattle, is a quality initiative decisions and performance Committee on Cancer (AJCC) aimed at identifying and reports. The new 2020 CoC is a multidisciplinary team of evaluating evidence-based standards have been released and professionals who are responsible practices to optimize the health will be implemented this year. for developing and publishing of patients before surgery. The The National Accreditation staging standards. The AJCC program empowers hospitals Program for Breast Cancer recently published the eighth and clinics to integrate (NAPBC) is a multidisciplinary edition AJCC Cancer Staging checklists into the preoperative accrediting body that sets Manual, complete with 80 chapters phase of clinical practice for standards, conducts surveys, and 100 staging systems, which elective operations. Released and accredits 674 U.S. and three has sold more than 41,000 copies. in 2017, S4S has more than international centers. In 2019, In 2020, the AJCC is expected 700 participating sites. Newly NAPBC scheduled and surveyed to complete Phase 1 of the added topics include chronic 185 breast care centers and structured authoring (EasyDITA) disease management, mental issued accreditation decisions implementation. health, and substance abuse. and performance reports. The ACS Clinical Research Launched in 2017, the Program (CRP) is strategically SSR National Accreditation Program aligned with the Alliance National The Surgeon Specific Registry for Rectal Cancer (NAPRC) sets Cancer Institute (NCI)-sponsored (SSR) allows surgeons to track evidence-based standards and clinical trials cooperative group their cases, measure outcomes, conducts surveys. NAPRC has and is supported by the Patient- and comply with changing 15 newly accredited centers, Centered Outcomes Research regulatory requirements. The with 42 in the pipeline. Sites Institute and NCI to conduct SSR can be used to meet the must be CoC-accredited to join health sciences research and requirements of Centers for NAPRC to ensure harmony clinical trials. In 2019, the CRP Medicare & Medicaid Services between both programs. integrated six operative standards (CMS) Quality Payment Program The National Cancer into CoC accreditation standards Merit-based Incentive Payment Database (NCDB) has curated and sponsored the Designing and System (MIPS), as well as the more than 39 million cancer Running a Prospective Surgical American Board of Surgery records since inception and is Clinical Trial Didactic Course Continuous Certification Program the largest database of its kind at Clinical Congress 2019. requirements. The SSR has an in the U.S. The NCDB, through active user base of approximately its 1,533 CoC-accredited sites, Trauma Programs 5,600 surgeons, and more than continues to collect roughly 1.5 Launched at Clinical Congress 2 million case records have been million cancer cases annually, 2019, the FTL 100 Fundraising entered into the SSR system which represents 72 percent Campaign was established to since its release in 2017. of all newly diagnosed cancer generate financial support for cases in the U.S. In 2019, the 100 Future Trauma Leaders Cancer Programs NCDB initiated the new Rapid (FTL) to coincide with the The Commission on Cancer Cancer Reporting System 100th anniversary of the (CoC) accredits more than 1,500 data processing infrastructure Committee on Trauma (COT) U.S. hospitals. In 2019, the CoC and rolled out the Participant in 2022. FTL’s mission is to scheduled and surveyed 405 User File program. foster the advancement of

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future leaders in trauma. The responders in the event of a are working to increase individual FTL aims to recruit, mentor, bleeding emergency. A redesigned and corporate support. Through provide program support, and public-facing website debuted in December 31, 2019, philanthropic reimburse travel to various 2019 to better focus on the general support totaled $578,801. trauma meetings for eight populace. The STOP THE BLEED The Foundation’s portfolio participants annually. The COT instructor portal launched January of new projects and programs is seeking funding from previous 2020 to provide more automation continues to expand. donors and targeted individuals, for potential instructors. The STOP Philanthropic gifts from independent corporations, not- THE BLEED State Champions Fellows continue to support for-profit organizations, and convened for the first time at Operation Giving Back, individual trauma leader groups, Clinical Congress 2019 to discuss international scholarship travel with a target goal of $1 million roles and responsibilities for awards, fellowship research to support the program and states to foster growth, provide awards, STOP THE BLEED make it self-sustaining. necessary resources, and grow training materials, and the The 2019 TQIP Annual public interest and training Support A Student program. Scientific Meeting and Training for STOP THE BLEED. Corporate grants provided took place November 16–18 The COT continues to support for the following: in Dallas, TX, and focused review and revise standards in on error management and the Resources for Optimal Care of • 13 Skills Courses at high-functioning teams. the Injured Patient and expects Clinical Congress The inaugural Advancing to complete all standards Leadership in Trauma Center revisions in 2020. Next steps • The third annual Residents Management Course was held will include transitioning the Surgical Skills Competition at TQIP and received positive new standards into a new featuring eight teams from feedback. TQIP also is piloting format, updating the pre-review across the country a new peer coaching program. questionnaire, and developing This initiative will link high- and rolling out training for • Educational materials to educate performing centers, evaluated reviewers and trauma centers. patients and medical staff on via TQIP benchmark report The COT also is in the process proper pain management, wound results, with centers requesting of implementing its inaugural care, and ostomy maintenance ♦ assistance, and will help to Firearm Injury Prevention provide a framework to facilitate Clinical Scholar in Residence a peer coaching relationship. Fellowship later this year. TQIP will celebrate its 10th anniversary in Phoenix, AZ, on December 6–8, 2020. ACS Foundation The STOP THE BLEED The ACS Foundation remains program’s primary focus is to focused on securing and growing provide training in the techniques financial support for the College’s of basic bleeding control and charitable, educational, and to impress upon the public of patient-focused initiatives. The the importance of learning the development team and the skills in becoming immediate Foundation Board of Directors

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Lessons from a virtual chapter annual meeting

by John H. Armstrong, MD, FACS; Jay Redan, MD, FACS; and Brian Hart, JD

Screenshot of virtual presentation by Dr. Weigelt

“Life is what happens to a positive contribution margin halted elective surgery through you while you are busy from the annual meeting is May 8 (subsequently changed making other plans.” essential to fund other chapter to May 3) and reinforced the —John Lennon activities throughout the year. need for surgical readiness. On Factors that shaped the March 23, the chapter’s Executive With practice, business, and decision were the resolution of Committee decided to go virtual travel collapsing in mid-March financial repercussions from with the annual meeting May 2. as the coronavirus disease 2019 canceling hotel and venue (COVID-19) unfolded in the U.S., contracts, bylaws requirements the leadership of the Florida for the annual governance Going virtual Chapter of the American College transition, and the necessity of The theme of this year’s program of Surgeons (ACS) faced a difficult supporting chapter entries into was “Predicting the Surgeon decision. We could cancel the ACS competitions. Importantly, of 2030.” The program was in-person Chapter Annual leadership anticipated the reshaped from 8.25 Continuing Meeting, May 1–3; postpone the need for surgical community Medical Education (CME) meeting until later in 2020; or in a time of lingering crisis hours in-person to three hours conduct the meeting virtually. in a way that would support virtually (see Table 1, page 95). Changing the annual meeting workforce readiness. The Edward M. Copeland III, was no small matter: The chapter On March 20, Florida MD, FACS, Resident Abstract year ends and begins anew Gov. Ron DeSantis (R) issued Competition was condensed with the annual meeting, and Executive Order 20–72, which into two presentations, the

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TABLE 1. MOVING FROM AN IN-PERSON TO VIRTUAL MEETING FORMAT— DIFFERENCES In-person Virtual 8.25 CME hours 3.0 CME hours Six lectures Two 30-minute prerecorded lectures Six resident abstract competition presentations Two resident abstract competition presentations One panel No panel Three CoC competition presentations Same Five Spectacular Case presentations Same 15-minute annual business meeting 10-minute annual business meeting Medical student and resident poster session Website exhibition and showcase Surgical Jeopardy Deferred; 2019 team resubmitted Surgical Olympics Deferred; 2019 team resubmitted 18 exhibitors Same

top-scoring basic and clinical tested with two moderator science abstracts, and inclusive and three full-scale presenter Virtual becomes reality of the Florida Commission on drills. Program flow was A total of 118 ACS members Cancer (CoC) Competition. adjusted to accommodate registered for the 195-minute Other high-scoring abstracts the online platform. Because meeting; 113 participated in were presented on the chapter moderator and presenter video some portion of the program, website as a Resident Research challenged system performance, with an average time of 163 Abstract Showcase (available audio accompanied slides in minutes, and 93 remained for the at floridafacs.org/2020- unrecorded presentations. business meeting. Domestic out- abstracts). Medical student Costs for the virtual of-state participants connected poster submissions also were meeting were anticipated to be from Georgia, Massachusetts, posted as a Medical Student significantly less than the in- North Carolina, South Dakota, Research Abstract Exhibition. person meeting, yet still required Texas, and Virginia; there were Presenting speakers were funding through two sources— international participants from accepting of the necessity participant registration and Kuwait. The range of ACS of the virtual format, and exhibitor fees. Participants paid member registration for the postponed speakers were by category as follows: Fellow/ last three in-person Chapter gracious in deferring Associate Fellow, $20; Resident, annual meetings (2017−2019) presentations to the future. $10; and Medical Student, $5. was 122−138, with an average The in-person Exhibit Registration also helped to 130. The Virtual Solutions Hall for industry sponsors solidify participant intention Center hosted 18 exhibitors. was converted into a Virtual to attend the virtual meeting. The program opened with Solutions Center on the chapter Given the novelty of a virtual brief leadership remarks and website, available at floridafacs. meeting and general uncertainty, moved quickly to the first of two org/annual. Exhibitors had we set a goal of 100 ACS member 30-minute recorded lectures, “space” to demonstrate their participants. The meeting was Surgical CME by 2030, given products and technology, marketed to members of all three by John A. Weigelt, DVM, MD, and some provided videos. Florida Chapters and the College FACS, ACS First Vice-President. The chapter’s online as a whole through e-mails and Next was the one-hour Edward platform was assessed for the ACS Communities. The M. Copeland III, MD, FACS, compatibility with virtual exhibitor fee for the Virtual Resident Abstract Competition, program expectations and then Solutions Center was $250. with a single moderator and

JUL 2020 BULLETIN American College of Surgeons | 109 NEWS

A virtual format for chapter meetings is a good option for staying connected when in-person meetings are infeasible. For chapters representing a large geographic area and who have interest in connecting with other chapters, the virtual option might substitute for in-person meetings.

five abstracts. Questions were with 30-minute lectures on hot easily sent via chat and Q&A Keys to successful topics that add variety and pique rooms. The Florida CoC Abstract virtual meetings interest.1 Opportunities for Competition was scored online. A virtual format for chapter engagement between presenters The one-hour Spectacularly meetings is a good option for and participants should be Challenging Case Competition staying connected when in- defined for each session— followed with five cases. Again, person meetings are infeasible. not all sessions need Q&A. chat and Q&A rooms ensured For chapters representing a engagement between participants large geographic area and who • Identify the technology platform. and presenters. The winning have interest in connecting Operating characteristics and case was determined with a live with other chapters, the virtual engagement possibilities vary poll, with results rapidly visible option might substitute for in- across platforms. In the emerging to all participants and the winner person meetings. We identified remote meeting industry, the announced moments later. seven key considerations tendency is to overpromise and The second recorded for success, as follows: underperform. The technology lecture, The Past, Present, and creates a temporary network with Future of Women in Surgery, • Establish meeting expectations. a dependency on the quality of by V. Suzanne Klimberg, The virtual format cannot Internet connectivity, including MD, PhD, FACS, followed. replicate all of the dimensions service providers and browsers. The business meeting of an in-person meeting, Maximum participant load, concluded the event and included including length. Three hours ease of connection (initial and election of officers and councilors, for a meeting is consistent sustained), audiovisual quality, as well as the annual leadership with a baseball game or movie and simplicity of use should be transition. The meeting started and makes the meeting more defined.2 Chat rooms, text Q&A, and ended on time, with 93 accessible. Thoughtful selection and polls promote interactivity participants still online at the of content and presentations and real-time feedback. conclusion. Importantly, there promotes meeting coherence. was a high level of engagement A place to start in program • Define the budget. Though throughout the meeting with 255 development is determination expenses are significantly lower chat comments and questions. of the essential meeting with virtual compared to in- Meeting expenses were requirements, such as chapter person meetings, they still $2,300, inclusive of technology, resident paper and case exist. Costs for the technology marketing, and competition presentations for time-sensitive platform may vary by participant awards. Registration fees did College competitions, and core number. Setting a reasoned not cover these expenses, with governance functions with assumption for the number the difference made up by elections and transitions. The of participants is necessary to Virtual Solutions Center fees. meeting can then be built out determine registration fees,

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Screenshot of overview of the Edward M. Copeland, III, MD, Screenshot of Virtual Business Meeting FACS, Resident Abstract Competition. Note the side panel for free-text of questions and comments by participants.

which should be much lower only to moderators and presenters REFERENCES than for live conferences. with no video. Group audiovisual 1. Frisch B, Greene C. What it takes to Exhibitors are receptive to modest restriction is more reliable than run a great virtual meeting. Harvard fees for a virtual presence. individual participant muting Business Review. Available at: https:// (left uncontrolled, the “airwaves” hbr.org/2020/03/what-it-takes-to-run- a-great-virtual-meeting. Accessed May • Script the meeting. A virtual are filled with echoes from the 12, 2020. meeting requires specific presenters and background noise). 2. Harvard Business Review. Running discipline with regard to flow. We also recognized the increased Virtual Meetings (HBR 20-Minute Participants are less tolerant importance of moderators in Manager Series). Boston, MA: of glitches and gaps in virtual controlling flow by keeping Harvard Business Review Press; 2016. 3. Anderson C. TED Talks: The Official meetings and, with one click, speakers on time and guiding TED Guide to Public Speaking. can leave. Similar to TED talks, discussion between presenters New York, NY: Houghton Mifflin virtual meetings should be and text questioners. Simulation Harcourt; 2016. scripted tightly to stay on time.3 also instilled confidence in the 4. Frisch B, Greene C, Prager D. Virtual Scripting helps to sustain meeting presenters and moderators offsites that work. Harvard Business Review. Available at: https://hbr. tempo. Chat rooms make meeting using the technology. org/2020/03/virtual-offsites-that- comments visible in real time work. Accessed May 12, 2020. and capture thoughts that might • Include website content. Links 5. Reynolds G. Presentation Zen: Simple otherwise have been expressed to the chapter website enhance Ideas on Presentation on Design and in hallways and receptions at virtual meetings. Links to a Delivery. Berkeley, CA: New Riders; 2008. live meetings. Q&A rooms are meeting program booklet, efficient, as typed questions virtual poster exhibit, and generally are more focused than industry virtual exhibit area verbal queries and comments. extend meeting connection beyond the assigned time. • Conduct meeting simulations. Virtual meetings do not move • Simplify. The meeting seamlessly between multiple experience is shaped by content, moderators and presenters. technology, and interaction. Practicing with the technology The virtual environment has helps organizers to define its own complexities. Keeping strengths and limitations and the instructional design of to make adjustments before the presentations and technology actual meeting.4 We discovered requirements as simple as audiovisual fidelity issues with possible reduces the risk of open virtual microphones and failures during the meeting.5 ♦ video, so we restricted open audio

JUL 2020 BULLETIN American College of Surgeons | 111 NEWS

Chapter news

by Luke Moreau and Brian Frankel

The coronavirus disease 2019 meetings and events over the chapters have started organizing (COVID-19) has forced many last several months. While a virtual meetings so members domestic and international few chapters were able to hold can continue to participate chapters of the American annual meetings and Surgical in educational offerings and College of Surgeons (ACS) to Jeopardy competitions in the network with colleagues. postpone or cancel annual early stages of COVID-19,

DOMESTIC CHAPTERS

North Texas Chapter: Annual Meeting, February 21–22, Dallas. Named lectures, scientific sessions, an abstract competition, and Surgical Jeopardy were some of the highlights from the two-day meeting. Left: Catherine Ronaghan, MD, FACS, 2019–2020 North Texas Chapter President (left), presenting the Robert S. Sparkman plaque to invited speaker O. Wayne Isom, MD, FACS, New York-Presbyterian/Weill Cornell Medical Center, New York, NY. Right: Bernhard Mittemeyer, MD, FACS, delivering the Harry M. Spence Memorial Lecture

Florida Chapter: Florida then Chapter President John H. Armstrong, MD, FACS (right), and then President-Elect Jay A. Redan, MD, FACS, proudly congratulate graduating medical students during the Resident and Associate Society of the American College of Surgeon (RAS-ACS) virtual graduation ceremony. Their message: no matter where you live and learn, make an ACS chapter part of your life. Read more about the Florida Chapter’s virtual meeting on page 108.

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Maryland Chapter (MD-ACS): Spring Meeting, March 7, Annapolis. Attendees gathered for a day of medical education and professional networking that concluded with Surgical Jeopardy, which the Anne Arundel Medical Center team won. Left: Immediate Past-President Jonathan E. Efron, MD, FACS (left), presented with the President’s Plaque by newly installed MD-ACS President Jose J. Diaz, Jr., MD, FACS Right: Winner of the MD- ACS 2020 Resident General Surgery Abstract Competition Mitchell Huang, Johns Hopkins University (right), with Dr. Diaz

Dr. Vinholo Dr. Calafiore Dr. Maniskas

Connecticut Chapter: Honoring its long-standing commitment to medical education, the Connecticut Chapter recently awarded scholarships to graduating physicians from medical schools in Connecticut. The awards were created to stimulate student interest in the surgical disciplines and to recognize outstanding achievement. Awards were presented to Thais Faggion Vinholo, MD, Yale School of Medicine, New Haven; Rebecca Lynn Calafiore, MD, University of Connecticut School of Medicine, Farmington; and Seija Maniskas, MD, Frank H. Netter MD School of Medicine at Quinnipiac University, New Haven.

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INTERNATIONAL CHAPTERS

India Chapter: The India Chapter held a May 8–10 online International Medical Student Congress with more than 800 delegates participating over three days. Interesting cases, research work, and clinical photo essays were presented, and two workshops were conducted on scientific paper writing and basic surgical skills. The chapter also held a live webinar, Surgery during COVID Times—Do’s & Don’ts, as well as an online postgraduate master class that included clinical case presentations and demonstrations of clinical examinations.

Germany Chapter: This year’s International Panel of the ACS and the German Society of Surgery, Women in Surgery, was organized by the ACS Germany Chapter and originally planned for the Annual Congress of the German Society of Surgery on April 21 in Berlin. Because of COVID-19, the session was convened as a videoconference with 220 participants. ACS President Valerie Rusch, MD, FACS, was Honorary Presenter. Pictured in the photo, from left, upper row: John H. Armstrong, MD, FACS, then Florida Chapter President; Dr. Rusch; Astrid Büren, MD; Thomas Schmitz-Rixen, MD, President, the German Society of Surgery; and Ernst Klar, MD, FACS, Germany Chapter Governor. Additional presentations included “FamSurg—A Program for Establishing Family-Friendly Structures in Surgery,” by Kim Honselmann, MD, University of Lübeck; and “The Male’s View,” by Jakob Izbicki, MD, FACS(Hon), University of Hamburg.

114 | V105 No 5 BULLETIN American College of Surgeons Your patients trust you with all aspects of their care, including pain management.

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2020_ED_Ad_OptimizingPain_Course_Update_Bulletin_7.5x10.25in_v2a_Release.indd 1 6/16/20 9:11 AM MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit facs.org/events or facs.org/member-services/chapters/meetings.

Puerto Rico Chapter Michigan Chapter APRIL April 30–May 2 May 13–15 Turkey Chapter—Turkish San Juan, PR Boyne Falls, MI National Surgery Congress Contact: Aixa Velez-Silva, Contact: Carrie Steffen, April 1–5 [email protected], [email protected], Antalya, Turkey acspuertoricochapter.org michiganacs.org Contact: Prof. Mahir Ozmen, [email protected] Australia and New MAY Zealand Chapter 120th Annual Congress of May 13 the Japan Surgical Society FloridaNote: Chapter South Wharf, Victoria April 16–18 May 1–2 Contact: Monique Whear, Yokohama, Japan Orlando, FL [email protected] Contact:Due Congress to the Secretariat, COVID-19 pandemic,Contact: Brian Hart, many ACS meetings and [email protected], [email protected], Virginia Chapter coursesjssoc.or.jp/jss120/ are being moved floridafacs.orgonline, canceled, or postponed.May 15–16 Williamsburg, VA Annual Congress of the Missouri Chapter Contact: Susan McConnell, German SocietyFor up-to-date of Surgery informationMay 2–3 on chapter meetings,[email protected], April 21–24 Lake Ozark, MO virginiaacs.org Berlin,visit Germany facs.org/member-services/chapters/meetingsContact: Denise Boland, Contact: Dr. Ernst Klar, [email protected], Metropolitan [email protected] contact Martha Zunigamoacs.org at [email protected] Chapter May 18 Indiana Chapter West Virginia Philadelphia, PA April 24–25 May 7–9 Contact: Robbi Cook, Noblesville, IN White Sulphur Springs, WV [email protected], Contact: Tom Dixon, Contact: Ashley Wiley, mp-acs.org [email protected], [email protected] infacs.org Northern California Chapter FUTURE CLINICAL South Dakota and North May 8–9 Dakota Chapters Berkeley, CA CONGRESSES April 24–25 Contact: Christina McDevitt, Sioux Falls, SD [email protected], 2020 Contact: Terry Marks, northerncalifornia45011.wildapricot.org October 4–8 [email protected] Chicago, IL Ohio Chapter Trinidad and Tobago Chapter May 8–9 2021 April 26 Toledo, OH October 24–28 Piarco Trinidad, West Indies Contact: Emily Maurer, Washington, DC Contact: Dr. Lakhan Roop, [email protected], [email protected] ohiofacs.org 2022 October 16–20 San Diego, CA

116 | V105 No 5 BULLETIN American College of Surgeons AMERICAN COLLEGE OF SURGEONS

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PROUDLY DISPLAY THAT YOU’RE A FELLOW OF THE AMERICAN COLLEGE OF SURGEONS. Log in and download FACS artwork at facs.org.

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