NOVEMBER 2005 Volume 90, Number 11

FEATURES Stephen J. Regnier Editor Paying for quality: Making policy and practice work for patients 8 Shawn Friesen Linn Meyer Director of Surgical lifestyles: Communications Surgeon chronicles Native American history 14 Karen Sandrick Karen Stein Associate Editor Medical liability reform and state law: West Virginia 20 Daniel Foster, MD, FACS Diane S. Schneidman Statement on blunt suture needles 24 Contributing Editor

Tina Woelke Graphic Design Specialist DEPARTMENTS Alden H. Harken, MD, FACS From my perspective 4 Charles D. Mabry, Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director MD, FACS Dateline: Washington 6 Jack W. McAninch, MD, Division of Advocacy and Health Policy FACS Editorial Advisors In compliance... 25 with HIPAA’s NPI provisions—Part II Tina Woelke Division of Advocacy and Health Policy Front cover design

Future meetings

Clinical Congress 2006 Chicago, IL, October 8-12 2007 New Orleans, LA, October 7-11 2008 San Francisco October 12-16

Spring Meeting 2006 Dallas, TX, April 23-26 2007 Las Vegas, NV, April 21-24 2008 To be announced On the cover: Robert H. Ruby, MD, FACS (right), has spent many decades chronicling the histories of Native Americans (see page 14). NEWS Bulletin of the American College of Surgeons (ISSN 0002-8045) is published Kathryn D. Anderson installed as 86th ACS President monthly by the American Col- 28 lege of Surgeons, 633 N. Saint Donald D. Trunkey receives Distinguished Service Award 29 Clair St., Chicago, IL 60611. It is distributed without charge to College names three Honorary Fellows 32 Fellows, to Associate Fellows, to participants in the Candi- Citation for Prof. Bruce Neil Benjamin 32 date Group of the American Gerald B. Healy, MD, FACS College of Surgeons, and to medical libraries. Periodicals postage paid at Chicago, IL, Citation for Prof. Alfred Cuschieri 33 and additional mailing offices. Frederick L. Greene, MD, FACS POSTMASTER: Send address changes to Bulletin of the Citation for Prof. Sergio Pecorelli 34 American College of Surgeons, Karl C. Podratz, MD, FACS 633 N. Saint Clair St., Chicago, IL 60611-3211. Canadian Pub- Young Surgical Investigators lications Mail Agreement No. Conference to be held in March 2006 35 40035010. Canada returns to: Station A, PO Box 54, Windsor, Report of the 2005 ACS Traveling Fellowship to Germany 36 ON N9A 6J5. Joe Hines, MD The American College of Surgeons’ headquarters is ACS issues call for submissions located at 633 N. Saint Clair for 2006 Congress in Chicago 38 St., Chicago, IL 60611-3211; tel. 312/202-5000; toll-free: Disciplinary actions taken 39 800/621-4111; fax: 312/202- 5001; e-mail:postmaster@ Advances in Trauma seminar to be held in Kansas City 40 facs.org; Web site: www.facs. org. Washington, DC, office Trauma meetings calendar 40 is located at 1640 Wisconsin Ave., NW, Washington, DC ACOSOG news: Clinical trials update: 20007; tel. 202/337-2701, fax New trials highlight surgical innovations 41 202/337-4271. Unless specifically stated R. Scott Jones, MD, FACS otherwise, the opinions ex- pressed and statements made NTDB™ data points: in this publication reflect the A-hunting we will go 44 authors’ personal observations Richard J. Fantus, MD, FACS, and John Fildes, MD, FACS and do not imply endorse- ment by nor official policy of the American College of Sur- geons.

©2005 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

Space sold by Elsevier From my perspective

ike the rest of the nation, we at the American College of Surgeons were deeply saddened by the human toll that Hurricane LKatrina wrought on New Orleans and the surrounding Gulf coast region this summer. In the wake of such enormous tragedy, we simply wouldn’t be human if we didn’t feel a tremendous sense of loss and vulnerability. These feelings of helplessness are particularly frustrating for members of the medical and surgical professions. We are trained to take control when catastrophe, natural or manmade, strikes. To the medical professionals We plunge into the maelstrom and try to salvage as many lives as possible. who fought to save lives under It’s not surprising, therefore, that so many “ physicians, residents, interns, nurses, and even the most grueling and primitive administrative staff stayed at their institutions throughout the hurricane and in its aftermath of circumstances, we extend our to ensure that patients were evacuated safely. I’ve heard several surgeons recount instances in thanks and admiration. which they or their residents dodged gunfire to get patients onto helicopters, worked handheld ventilators to keep children alive, and carried ’’ patients down darkened stairwells on their backs. Such heroics warrant our most profound respect and deepest thanks. We will highlight some of these stories in an upcoming issue of the Bulletin. Despite these individuals’ best efforts, some ripping though the plains) turns into a calamity, patients perished. The September 14 New York people are driven to point fingers and try to find Times reported that staff at Memorial Medical some rational explanation for how the situation Center in New Orleans, where 45 bodies were became uncontrollable. Many of the physicians discovered earlier that week, said they could do who were on site in New Orleans report that little more than comfort patients. Charity and their hospitals were prepared to make it through University Hospitals, both part of the Louisiana a typical hurricane, stocked with enough extra State University system, reportedly did not food, generators, and supplies to last at least have the money to hire helicopter companies to a week. What they weren’t prepared for was evacuate patients. Hence, they were among the the levees breaking and Lake Pontchartrain last to be evacuated and were forced to rely almost overflowing into the city. Moreover, the response exclusively on the military and federal agencies for from federal, local, and state relief agencies rescue activities. The two facilities were unable to was clearly inadequate and too slow. As Simon evacuate their 28 infant patients (18 in intensive Winchester noted in the September 8 New York care) until the morning of the Friday after Katrina Times, “The last time a great American city was hit and the levees broke. A total of 20 bodies were destroyed by a violent caprice of nature, the left behind at the two facilities; 12 of the patients response was shockingly different....” Referring had died before the storm. to the earthquake that upended San Francisco in 1906, killing 3,000 people and leaving 225,000 What went wrong? homeless, Mr. Winchester noted that the entire Whenever an inevitability (such as a hurricane nation responded to the disaster with speed and slamming into the southeast portion of the determination. Troops were quickly dispatched country, an earthquake in California, a tornado into the city to control looters and blast through 

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS some of the wreckage. The mayor requisitioned for cataclysmic events. In addition, our Advanced boats to the Oakland telegraph office to inform Trauma Life Support® course trains health care the country that San Francisco was in ruins and professionals in providing prompt and effective needed help. Relief trains began arriving that care for individuals who are injured or otherwise same night. Congress convened and quickly passed in need of emergency care. legislation to pay all bills. Finally, I am proud to say that the College still At the time of the San Francisco earthquake, plans to hold its 2007 Clinical Congress in New no government-run agencies, such as the Federal Orleans. Many of you have fond memories of the Emergency Management Agency, were in place city, and we have always had a good experience to declare when disaster had struck and how to dealing with the convention center and hotels. By respond. The people of San Francisco reported bringing our meeting there, we will be doing our their dire situation, and the state and federal gov- part to help the city of New Orleans rebuild. ernment heard their plea and acted accordingly. To those individuals who lost family, friends, It was that simple. homes, and livelihoods to Hurricane Katrina, we offer our condolences and solemn wishes for Emerging from the flood better days ahead. To the medical professionals Despite the cripplingly slow pace of relief efforts who fought to save lives under the most grueling in New Orleans, I believe that this historically and primitive of circumstances, we extend our significant and unique city will eventually emerge thanks and admiration. All of you exemplify from this tragedy with the same grace as San that a disaster may demolish buildings and Francisco did nearly 100 years ago. To help the infrastructures but not the human spirit. hurricane survivors—patients and surgeons—the College has been working at several levels. First, Operation Giving Back was in regular contact with the major federal agencies that co- ordinated the response and through an electronic alert to our members provided surgeons with regular updates on how they could offer their Thomas R. Russell, MD, FACS services. Many of you volunteered your time and skills. The College applauds your generosity and compassion. In addition, our Job Bank is helping displaced surgeons find positions elsewhere. Equally as important, the surgical boards’ residency review committees are assisting trainees who need to be placed, at least temporarily, in other programs. I would strongly encourage all program directors to embrace these residents. By all accounts, they were key in evacuating patients and deserve the highest respect and consideration. Some of their stories will be told in the upcoming Bulletin article that I mentioned earlier. In an effort to ensure that our members are prepared for any disasters—natural or man- made—that may occur in this country, we con- tinue to offer educational programs in disaster preparedness. Our Governors’ Committee on Blood-Borne Infection and Environmental Risk monitors these types of situations and develops If you have comments or suggestions about this or other recommendations on how surgeons can prepare issues, please send them to Dr. Russell at [email protected]. 

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dateline Washington prepared by the Division of Advocacy and Health Policy

Soon after Hurricane Katrina ripped through the Gulf coast this CMS acted to summer, the Centers for Medicare & Medicaid Services (CMS) took ensure care for action to ensure that individuals enrolled in the Medicare, Medicaid, and State Children’s Health Insurance programs would receive emer- Katrina’s victims gency care. Many of the programs’ normal operating procedures were relaxed to speed care to the elderly, children, and people with disabili- ties. For example, because many hurricane victims were evacuated to facilities in neighboring states, CMS waived the normal burden of documentation for patients’ eligibility to receive benefits. In addition, federal officials worked with state Medicaid agencies to coordinate interstate payment agreements. Other forms of relief that the CMS offered, which may be of interest to surgeons, are as follows: • Normal licensing requirements for physicians, nurses, and other health care professionals who cross state lines to provide emergency care in stricken areas were waived, provided that they had been li- censed in their home states. • Certain privacy requirements were waived so that physicians could speak with family members about a patient’s condition, even if the patient could not grant that permission. • Hospital emergency departments were not be held liable under the Emergency Medical Treatment and Active Labor Act for transfer- ring patients to other facilities for assessment, if the original facility was in an area where a public health emergency had been declared. For more information about CMS’ hurricane relief activities, go to www.cms.hhs.gov/katrina.

A study by the Agency for Healthcare Research and Quality (AHRQ) AHRQ assesses published in the August issue of Critical Care Medicine indicates that ICU safety, issues patients in hospital intensive care units (ICUs) are at significant risk for preventable adverse events and serious medical errors. The Critical data on uninsured Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care shows that more than 20 percent of the patients admitted to two ICUs at an academic medical center experienced adverse events. Approximately 45 percent of those adverse events were considered preventable, and more than 90 percent occurred during routine care. AHRQ’s press release about the study may be viewed at http://www.ahrq.gov/news/press/pr2005/icuerrpr.htm. AHRQ also recently released data from the agency’s 2004 Medical Expenditure Panel Survey, indicating that 48.3 million Americans (16.8% of the civilian population) were uninsured in early 2004. The study indicates that young adults aged 19 to 24 years were most likely to be uninsured, and 35 percent lacked coverage. Only 11.7 percent of children younger than age 18 were uninsured, but 29.4 percent had public insurance only. Additional survey data are available at www. meps.ahrq.gov/papers/st83/stat83.pdf.

CMS and the Hospital Quality Alliance have added two measures CMS expands for preventing postoperative infections, as well as a measure for treat- quality efforts ment of pneumonia to the Hospital Compare Web site. The first two measures are part of a larger set of patient safety measures that will 

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS be collected as part of the Surgical Care Improvement Project (SCIP). The SCIP—developed in collaboration with federal agencies, hospitals, and surgical organizations, including the College—is designed to im- prove patient safety and reduce the postoperative complications in U.S. hospitals by 25 percent by 2010. Hospital Compare is intended to serve as a tool for patients seeking to assess the quality of care at their local hospitals and can be accessed at http://www.hospitalcompare.hhs.gov. In addition, CMS announced September 9 that it is soliciting proposals for the Medicare Health Care Quality Demonstration, a five-year initiative to uncover means for identifying, developing, testing, and disseminating health system improvements at the lo- cal or regional level. The goal is to support the adoption and use of medical decision-support tools, such as evidence-based guidelines. For further information about how and when to apply for participa- tion in the project, visit the CMS Web site at http://www.cms.gov/ researchers/demos/mma646/.

The National Institutes of Health (NIH) is accepting applications NIH offers student for its five loan repayment programs. The five loan repayment pro- loan repayments grams that the NIH offers are in clinical research, clinical research for individuals from disadvantaged backgrounds, contraception and infertility, health disparities, and pediatrics. Through these programs, the NIH repays up to $35,000 of the qualified educational debt of health professionals pursuing careers in biomedical and behavioral research. To qualify, applicants must possess a doctoral-level degree, devote 50 percent or more of their time to research funded by a domestic not-for- profit organization or government entity, and have educational debt equal to or exceeding 20 percent of their institutional base salary. Ap- plications must be submitted by December 1. To apply for or to learn more about the loan repayment programs, go to www.lrp.nih.gov.

As of October 1, CMS is no longer processing electronic Medicare HIPAA contingency claims for payment that do not conform to the standards required in plan for claims the Health Insurance Portability and Accountability Act (HIPAA). HIPAA required CMS to adopt standards for health care claims submissions ends and other financial and administrative transactions in order to streamline claims processing, decrease paperwork, and reduce the cost of health care administration. The effective date for the claims submission standards was October 16, 2003, but CMS implemented a contingency plan to allow continued payment of claims that are not HIPAA-compliant until providers had sufficient time to become fully compliant. As of June 2005, fewer than 1 percent of Medicare fee-for-service providers has submitted electronic claims that are not HIPAA- compliant, demonstrating that all providers can become compliant. CMS has made software available at little or no cost through Medicare carriers and intermediaries to enable providers to submit HIPAA- compliant claims. To find out more about the HIPAA claims submission requirements, go to the CMS “Medlearn Matters” article at: http:// www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3956.pdf. 

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Paying for quality: Making policy and practice work for patients

by Shawn Friesen, Government Affairs Associate, Division of Advocacy and Health Policy

ince the Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health Sys- Stem for the 21st Century (2001)1 and Leadership by Example: Coordinating Government Roles in Improving Healthcare Quality (2002),2 the conversation among health care policymakers has shifted. Whereas the focus previously was on patient safety efforts, prevention of errors, and their application to public health programs, the emphasis now includes the implementation of qual- ity improvement (QI) processes and outcome measures across the health care system. Following the route established by these IOM reports—as well as through efforts at the National Quality Forum (NQF) and pri- vate sector entities such as the Leapfrog Group—the QI conversation has progressed beyond the theoretical academic applications of the late 1990s and early 2000s to the practical, more tangible world of health policy and health care delivery through the work of the Medicare Payment Advisory Commission (MedPAC), the Centers for Medicare & Medicaid Services (CMS), and, most noticeably, the U.S. Congress. 

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In his testimony before the U.S. Senate Com- and specialty societies to submit specific measures mittee on Finance in July, Mark Miller, executive each year to a consensus-based entity, such as the director of MedPAC, stated, “MedPAC has con- NQF. That entity, in turn, would make recom- cluded that Medicare is ready to implement pay for mendations to CMS regarding specific quality performance [P4P] as a national program and that measures for inclusion in the P4P system, and differentiating among providers based on quality CMS would then publish its proposed measures for is an important first step toward purchasing the review and comment before final implementation best care for beneficiaries and assuring the future each year. H.R. 3617 would establish a phased ap- of the program.”3 Miller was restating the broad proach to P4P, starting with the required reporting recommendations of the March 2005 MedPAC of particular processes in 2007 and phasing into Report to the Congress,4 in which the commission full P4P in 2009. Under H.R. 3617, those physi- specifically recommended that Congress establish cians who report required data in 2007 and 2008, quality incentive payment policies for physicians and those who meet the measure requirements in and other providers. In light of these recom- 2009 and future years, would receive a payment mendations, Congress has responded by holding increase equivalent to the Medicare Economic hearings on how such a payment system might Index (MEI), which measures the annual increase be implemented.5 Furthermore, given the chal- in physicians’ practice costs. Physicians who do lenges posed by the sustainable growth rate (SGR) not meet the requirements will receive a payment methodology for calculating Medicare physician increase of MEI less 1 percent. payments (which, left in its current form, will cut Similar to H.R. 3617, S. 1356 would set up a physician payments between 4 and 5% per year phased approach to P4P, starting with the report- for the next six years), congressional discussions ing of data in 2007; but unlike the House bill, have focused largely on how the SGR might be S. 1356 would implement full P4P in 2008. The replaced by a physician P4P system. penalties for failure to report data or to meet per- formance thresholds also would be greater under Congress moves ahead on legislation S. 1356: Physicians not submitting data in 2007 Following the issuance of MedPAC’s March would receive the payment update provided under report, conversations between policymakers and law less 2 percent, and starting in 2008, physicians physician stakeholders, such as the College, began not meeting quality thresholds would receive the to focus in earnest on possible forms of legislation payment update less 1 percent. The amount sub- that would establish a comprehensive P4P sys- tracted for physicians who do not reach thresholds tem under Medicare. On June 30, Sens. Charles would increase incrementally each year to a full 2 Grassley (R-IA) and Max Baucus (D-MT)—Chair percent reduction in 2012. and Ranking Member of the Senate Finance Com- Although all of these differences are significant, mittee, respectively—were the first to introduce the most marked difference between the bills is legislation, the Medicare Value Purchasing Act that H.R. 3617 would repeal the SGR and replace of 2005 (S. 1356).6 Similarly, Rep. Nancy John- it with payment updates that guarantee increases son (R-CT), Chair of the House Ways and Means for all physicians in 2006 and almost certainly Subcommittee on Health, introduced the Medicare would guarantee increases regardless of their Value-Based Purchasing for Physicians’ Services quality measure status for all physicians in 2007 Act of 2005 (H.R. 3617) on July 29.7 Both bills and beyond. Because S. 1356 leaves the SGR in would establish a process for setting quality mea- place, it would merely add P4P to the already sures and both would create financial incentives broken physician payment structure. for physicians to report on particular measures effective in 2007. CMS sets the stage According to their authors, both S. 1356 and Although much attention is currently (and H.R. 3617 envision a consultative process between rightfully) being paid to these congressional ef- the physician community and CMS in establishing forts, it is important to note that CMS has been those measures; however, H.R. 3617 more clearly setting the stage for P4P for several years. In No- establishes a process for physician organizations vember 2001, Tommy Thompson, then-Secretary 

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of the U.S. Department of Health and Human Hospitals: A model for surgical P4P? Services, announced the CMS Quality Initiative, Beyond the College’s efforts within SCIP, the which began with the Nursing Home Quality HQI approach taken by CMS—and, to a lesser Initiative (NHQI). Through a collaborative effort extent, Congress—should serve as a helpful with NQF and nursing home stakeholders, CMS guide for surgery and the physician community developed quality measures for the facilities that as a whole when considering the possibilities of were included in a pilot project that commenced physician P4P—partly because of the considerable in April 2002. In November 2002, the NHQI was interaction that physicians and hospitals have in launched in nursing homes nationally. In 2003, caring for patients, and partly because of similar this initiative was extended to include home political realities that hospitals faced when qual- health agencies through the Home Health Qual- ity reporting requirements were first linked to ity Initiative and hospitals through the Hospital their payment under the Medicare Prescription Quality Initiative (HQI); in 2004, it was extended Drug, Improvement, and Modernization Act of to dialysis facilities that treat end-stage renal dis- 2003 (MMA).10 ease patients and the Physician Focused Quality Over the past year, the course adopted by the Initiative, which at present is focused largely on HQI, which provided for a collaborative process primary care demonstration projects.8 between CMS and the Hospital Quality Alliance Consistent with the logical progression of the (HQA), is one that CMS and congressional NHQI, CMS has turned its focus this year toward policymakers and physician stakeholders have quality measures for physicians. Although CMS’ used as a model for developing a physician P4P authority for development of these broad quality program. The HQA is a public/private effort measures is uncertain, and no formal physician that includes a wide range of organizations and P4P measures have been proposed as of press supporters, including the American Hospital time, CMS has forged ahead in communications Association, the Federation of American Hospitals, with the physician community about possible the American Medical Association, the Agency for measures for inclusion in a physician P4P pro- Healthcare Research and Quality (AHRQ), CMS, gram; whether the program would be of national NQF, the Joint Commission on the Accreditation of scope or initially limited to a pilot program re- Healthcare Organizations, consumer groups, and mains to be determined. labor representatives. Through HQA, a starter With respect to surgery, draft measures cir- set of 10 basic quality measures were developed, culated by CMS staff are based largely on the and under the MMA, those hospitals that report College’s collaboration with CMS, the Centers on the starter set measures are guaranteed a full for Disease Control and Prevention, and other inflationary update for fiscal years 2005, 2006, partners through the Surgical Care Improvement and 2007; for those same years, those hospitals Project (SCIP),9 and include measures to prevent not reporting data have their payment update postoperative complications, such as surgical site reduced by 0.4 percent. In addition, the public infection, adverse cardiac events, and postopera- is able to compare various hospitals on up to 17 tive pneumonia. However, while the College has measures via the CMS Hospital Compare Web site been closely involved in the development of the (http://www.hospitalcompare.hhs.gov/) ; similar SCIP criteria, to date these measures have been quality comparison Web sites exist for the nursing largely hospital-based. Concerns have been raised home and home health efforts. within the profession about the application of Under the HQI, CMS has also been exploring hospital-based surgical measures to surgeons, P4P in the hospital setting through the Premier who see a more narrow scope of patients. In re- Hospital Quality Incentive Demonstration,11 a sponse, the College and the surgical specialties three-year study that began in October 2003. It are working to ensure that any surgical mea- includes 274 hospitals nationwide and studies sures, whether implemented in a demonstration linking hospital payments with quality measures project or more broadly, appropriately account in the following five clinical areas: (1) acute myo- for the risk associated with particular patients cardial infarction, (2) congestive heart failure, and particular conditions. (3) coronary artery bypass graft, (4) hip and 10

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS knee replacement, and (5) community-acquired community was experiencing at the time of the pneumonia. Hospitals performing in the top 10 MMA’s enactment. In light of the March 2003 percent for a given diagnosis receive a 2 percent MedPAC Report to the Congress,13 hospitals were bonus for payments for the measured condition, recommended to receive less than a full inflation- and hospitals in the second 10 percent receive a 1 ary update for inpatient services in 2004; instead percent bonus. In the third year of the demonstra- of the full inflationary increase of 3.5 percent, tion, hospitals not reaching baseline thresholds MedPAC recommended that inpatient payments for performance improvement will have adjusted to hospitals increase by 3.1 percent. With Congress payments; the baseline will be set by hospitals prepared to act on MedPAC’s recommendations, performing in the ninth and tenth deciles in the the hospital community, in exchange for a full first year. Specifically, in year three, hospitals inflationary update, agreed to initial data report- performing below the ninth decile threshold from ing on quality measures. As mentioned previously, the first year for a given condition will receive a those hospitals not reporting data receive an infla- 1 percent reduction of payments for the diagno- tionary update minus 0.4 percent. As in the case sis; those below the tenth decile will receive a 2 of hospitals two years ago, policymakers are again percent reduction in payments. Although these using Medicare payment formulas to enact their established baselines would set penalties for QI goals. However, whereas hospitals stood to hospitals not meeting these thresholds, CMS and receive lower payment increases than previously Premier have stated their belief that all partici- expected, physicians stand to have their Medicare pating hospitals will exceed these thresholds and payments actually cut in January 2006. In spite of not be financially penalized.12 this notable difference, though, by engaging poli- In May of this year, CMS and Premier released cymakers now, the physician community is laying data regarding hospital quality under the dem- a foundation for physician P4P under Medicare onstration’s first year, during which the median that can be based on a consultative partnership composite performance scores for all participating between CMS and the physician community, much hospitals increased by 7.5 percent.12 Although like the process in place for hospitals. For surgery, there was improvement in all five clinical areas, this means building on the success of SCIP and the most significant improvements were realized applying its lessons to the surgeon as well as the in care provided to heart failure and pneumonia hospital, in addition to building on broader QI patients. In addition, an initial finding of particu- efforts such as the College’s leadership in the lar interest that should be no surprise to the surgi- National Surgical Quality Improvement Program cal community is that a key component to hospital (NSQIP).14 QI is actively engaging the staff physicians in the QI effort. In the case of several measures—for Physician P4P efforts under way example, the administration of prophylactic anti- Beyond hospital P4P efforts, it is also important biotics, which is consistent with SCIP measures for surgery to look at other efforts to link payment supported by the College and circulated by CMS to quality of physician services that are already staff for possible inclusion in surgical P4P—the under way. In 2004, CMS launched the Physician surgeon is ultimately responsible for ensuring that Focused Quality Initiative. Under the initiative, care is delivered to the patient. So long as physi- initial efforts to establish payment incentives for cian QI efforts remain consistent with the HQI improved quality have included multiple demon- model and the Premier demonstration, surgeons stration projects, such as the following: can be encouraged about policymakers’ desire • Doctor’s Office Quality (DOQ) Project:D OQ to establish a consultative process, which uses is a one-year demonstration administered by process measures that surgery has helped develop Medicare quality improvement organizations and that most surgeons are already implementing (QIOs) in Iowa, California, and New York; DOQ on behalf of their patients. includes clinical measures on chronic disease and From a political perspective, there are simi- preventive care services and an evaluation survey larities between the situation facing the physi- of patient experiences. cian community today and the one the hospital • DOQ Information Technology (IT): DOQ-IT 11

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS is a two-year demonstration led by the California under Medicare is questionable, the agency, un- QIO, Lumetra, which will include up to five states der Section 646 of the MMA, was mandated to and is designed to promote the use of electronic establish a five-year, budget-neutral demonstra- health records in small- to medium-sized physi- tion program to examine factors that lead to QI cians’ offices in the delivery of the chronic care in patient care. From recent conversations with and preventive services measured by DOQ. CMS staff, barring congressional action, the • VistA—office electronic health records:C MS most likely scenario would be a demonstration is working with the Veterans Health Admin- project under Section 646 for a broad range of istration (VHA) to configure VistA, the VHA’s physician services, including surgery. Although electronic health records technology, to promote the details of any such effort remain to be de- adoption of this program in private physician termined, it is likely that any demonstration for office settings across the U.S. Among its appli- surgery would bear similarities to some of the cations, VistA’s technology will assist in disease examples highlighted, in which payments are management and in interfacing practice manage- linked to particular processes and best practices, ment and billing systems. improved quality outcomes, and actual savings • Medicare Physician Group Practice Demon- to the Medicare program. stration: This three-year demonstration includes 10 large group physician practices and evaluates Surgery’s leadership in QI them on the care management they provide to As the prospect of linking payment to quality chronically ill, high-risk Medicare beneficiaries for physician services moves increasingly closer by measuring the effectiveness of the disease to reality, surgery must determine what role it management and preventive services they pro- will play. Although the clearly defined efforts of vide. Payment awards to practices will be based CMS have focused on QI in primary care, the on their success in improving quality and avoid- College has arguably been a pioneer in the QI ing high-cost complications. effort, essentially setting the stage for surgical • Medicare Care Management Performance P4P through its efforts with SCIP and NSQIP. Demonstration: This three-year demonstration, Likewise, health policy leaders in Congress are which is limited to four sites, promotes the use preparing to expand CMS authority so that com- of IT by physicians in managing the care of mitment might be realized. chronically ill patients. Those physicians meet- In addition to the partnership at SCIP and ing certain standards for quality improvement NSQIP, the College, along with the surgical spe- set by CMS will be eligible for bonus payments. cialties, continues to be an active participant The demonstration must be budget neutral. in the Physician Consortium for Performance In addition to these efforts, which were high- Improvement, which has served a vital role in lighted in the September Bulletin,15 the Ambu- the review and approval of evidence-based qual- latory Care Quality Alliance (AQA) released a ity measures that recognize the best clinical proposed starter set of 26 measures for use in practices across physician services. In the near the primary care setting earlier this year. future, the consortium is expected to complete Surgery’s efforts have not gone unnoticed by its work on measures for perioperative cardiac CMS and the College receives frequent men- risk assessment. As Congress and CMS consider tion by CMS leaders, such as Mark McClellan, how to pay for quality, the College will continue MD, PhD, CMS Administrator, and Herb Kuhn, its history of commitment to QI through its col- Director of the Center for Medicare Manage- laborations with the physician community, CMS, ment, when discussing the success of SCIP.16-17 VHA, and quality organizations, such as AHRQ In addition, as mentioned previously, surgery, and NQF, and through its internal efforts in the along with a wider range of specialties, appears Division of Research and Optimal Care. Through to be likely to be included in some type of CMS- these ongoing efforts, and through the Division led P4P effort in the near future. Even though of Advocacy and Health Policy, the College is CMS’ authority to implement measures to link working to ensure that any quality measures for payment to quality for all physician payments surgery are based on such efforts and are linked 12

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to better outcomes for patients. able at: http://thomas.loc.gov/bss/d109query.html. While paying for quality performance may be a Accessed August 30, 2005. 7. Medicare Value-Based Purchasing for Physicians’ relatively new concept to Medicare, for more than Services Act (H.R. 3617). Available at: http:// 90 years the College and its Fellows have set the thomas.loc.gov/bss/d109query.html. Accessed Au- standard for quality outcomes and improvement in gust 30, 2005. surgery. Since the College’s founding in 1913, its 8. CMS Quality Initiatives. Available at: http://www. cms.hhs.gov/quality/. Accessed August 25, 2005. chief mission has been to ensure the highest qual- 9. Surgical Care Improvement Project (SCIP). Avail- ity in surgical care for patients. Practically, this able at: http://www.medqic.org/scip/. Accessed mission has been most noticeably realized in the August 30, 2005. educational, professional, and ethical standards 10. Medicare Prescription Drug, Improvement, and associated with College Fellowship. Consistent Modernization Act of 2003 (MMA, Public Law 108-173). Available at: http://frwebgate.access.gpo. with the requirements of Fellowship, the College gov/cgi-bin/getdoc.cgi?dbname=108_cong_public_ has also realized that promoting the highest-qual- laws&docid=f:publ173.108.pdf. Accessed August ity surgical care means educating Fellows about 30, 2005. advances in practice and technology that stand 11. Premier Hospital Quality Incentive Demonstra- tion. Available at: http://www.premierinc.com/all/ to improve the quality of surgical outcomes for quality/hqi and http://www.cms.hhs.gov/quality/ patients. In linking reimbursement to quality, hospital/. Accessed August 30, 2005. policymakers’ success or failure will ultimately 12. Premier Inc. “Groundbreaking Pay for Perfor- be determined by their ability to align payments mance Project Reports Quality of Care Improve- with such advances rather than hindering them. ment at Participating Hospitals” [press release]. May 3, 2005. Available at: http://www.premierinc. While we proceed cautiously, the College sees hope com/all/newsroom/press-releases/05-may/pay-for- in paying for quality—hope for better outcomes performance.jsp. Accessed August 30, 2005. for patients and hope for the recognition that 13. Medicare Payment Advisory Commission. Report Fellows deserve.  to the Congress: Medicare Payment Policy. March 2003. Available at: http://www.medpac.gov/publica- tions/congressional_reports/Mar03_Entire_report. References pdf. Accessed August 30, 2005. 14. National Surgical Quality Improvement Program 1. Committee on Quality of Health Care in America. (NSQIP). Available at: https://acsnsqip.org/main/ Crossing the Quality Chasm: A New Health System default.asp. Accessed August 30, 2005. for the 21st Century. Washington, DC: Institute of 15. Opelka FG, Brown CA. Understanding pay for per- Medicine, National Academy of Sciences; 2001. formance. Bull Am Coll Surg. 2005;90(9):12-17. 2. Committee on Enhancing Federal Healthcare Qual- 16. McClellan, MB. Testimony on “Value-Based Pur- ity Programs. Leadership by Example: Coordinat- chasing for Physicians under Medicare” before ing Government Roles In Improving Healthcare the U.S. House of Representatives, Committee on Quality. Washington, DC: Institute of Medicine, Ways and Means, Subcommittee on Health, July National Academy of Sciences; 2002. 21, 2005. Available at: http://waysandmeans.house. 3. Miller M. “Pay for Performance in Medicare.” gov/hearings.asp?formmode=view&id=2930. Ac- Statement before the Committee on Finance, U.S. cessed August 30, 2005. Senate, July 27, 2005. Available at: http://www. 17. Kuhn H. Testimony on “Improving Quality in Medi- medpac.gov/publications/congressional_testimony/ care: The Role of Value-Based Purchasing,” before Testimony_P4P.pdf?CFID=12535187&CFTOKEN the U.S. Senate, the Committee on Finance, July 27, =99217837. Accessed August 30, 2005. 2005. Available at: http://www.senate.gov/~finance/ 4. Medicare Payment Advisory Commission. Re- hearings/testimony/2005test/hktest072705.pdf. Ac- port to the Congress: Medicare Payment Policy. cessed August 30, 2005. March 2005. Available at: http://www.medpac.gov/ publications/congressional_reports/Mar05_ EntireReport.pdf. Accessed August 30, 2005. 5. House of Representatives Ways and Means Subcom- mittee on Health hearing on July 21, 2005. Avail- able at: http://waysandmeans.house.gov/Hearings. asp?congress=17; Senate Committee on Finance hearing of July 27, 2005. Available at: http://www. senate.gov/~finance/sitepages/hearings.htm. Ac- cessed August 30, 2005. 6. Medicare Value Purchasing Act (S. 1356). Avail- 13

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical lifestyles

Surgeon chronicles Native American history

by Karen Sandrick, Chicago, IL

14

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS isps of fog swirled outside the mission to the Cayuse Indians at Waiilatpu in Walla Walla Valley, WA, muffling the sounds of indigenous wildlife on the Wmorning of November 29, 1847. But the stillness amplified the cacophony of violence within: the harsh bursts of angry accusations, the thwack of a tomahawk on the skull, and then the rapid retorts of gunfire as five Cayuse Indians, led by Tilaukait and Tomahas, killed 14 of the local mission’s 72 residents, including physician and Presbyterian elder Marcus Whitman and his wife, Narcissa.1,2 Vagabonding from tribal area to tribal area for the next three years, hardly welcome even in Cay- use or Nez Perce Indian communities while white settlers clamored for retribution, the band of five finally surrendered to Oregon Territory authori- ties in April 1850. Indicted on May 21, 1850, these Cayuse Indians went to trial for murder under the first Oregon Territory justice, Orville C. Pratt. After listening to testimony from several women who saw the five kill the Whitmans and other missionaries as well as a Cayuse Indian named Stickus and a white missionary to the Nez Perce tribe who had warned the Whitmans about the Dr. Ruby on duty at the Pine Ridge Indian Hospital on murder plot, the jury on May 24 returned a verdict the Pine Ridge Reservation, South Dakota, in 1953. of guilty, and the five Cayuse were sentenced to death, hanged on June 3, 1850, and buried in the Oregon Territory.3 But as retired general surgeon Robert H. Ruby, MD, FACS, Moses Lake, WA, argued in a 2004 let- Indians in 1955. His first book, The Oglala Sioux, ter to Sens. Ron Wyden (D-OR), Maria Cantwell Warriors in Transition, was written while he was (D-WA), and Gordon Smith (R-OR), and Rep. Doc chief of the department of surgery at the hospital Hastings (R-WA), the attack was not a rampant on the Pine Ridge Reservation in South Dakota. crime spree but the first salvo in a two-year war After serving as a member of the Army Air Corps between the Cayuse nation and American troops during the occupation of Japan in the late 1940s, that ended with the loss of independence of the Dr. Ruby completed a fellowship in cancer surgery Cayuse people.2 The five Cayuse were not wanton at the Sugarbaker Cancer Clinic in Jefferson City, murderers but victims of terrorism fomented MO, a year of postgraduate work at the Washing- by what Dr. Ruby calls mixed-blood bullies who ton University School of Medicine in St. Louis, claimed white settlers were insurgents, usurping MO, and a four-year residency in pathology and the ownership and farming of Cayuse land, and that surgery at the St. Louis County Hospital. Dr. Whitman was spreading poison, not medicine, to the Cayuse from bottles containing measles. How Dr. Ruby began his second career This is one of many stories chronicled by Dr. In July 1953, Dr. Ruby joined the U.S. Public Ruby since he began writing histories of American Health Service (PHS) and was assigned to the Indian Service. Reigniting a boyhood interest Opposite page: Dr. Ruby with Crow Dog. All photos © in the lifestyle and lore of Native Americans, Robert H. Ruby, MD, FACS; courtesy of the Eastern Dr. Ruby befriended members of the Sioux, at- Washington State Historical Society, Spokane, WA. tended their traditional ceremonies of worship, 15

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS witnessed their rituals, and became one of the first authors to report on the use of peyote by American Indians. After completing his service in the PHS, Dr. Ruby and his wife, Lelia Jeanne Henderson, moved to Moses Lake, WA, a semi-arid basin that had recently been transformed into a fertile agricultural area through irrigation. Dr. Ruby set up a private practice in general surgery, which concentrated on orthopaedics and abdominal surgery, and continued his research into the past and present lives of Native Americans, beginning a more than 40-year collaboration with John A. Brown, former professor of history at Wenatchee Valley College, Wenatchee, WA. Independently scavenging depositories in state and university libraries and ordering documents about the same topic—Chief Moses of the Salish Tribe, who refused to lead 200 warriors onto the Yakima Reservation in 1878—Dr. Ruby and Mr. Brown were brought together by a librarian in Olympia, WA, in 1958. Until Mr. Brown’s illness in 2003 and subsequent death in 2004, theirs “was a perfect cooperative arrangement,” says Dr. Ruby. “What I couldn’t do, he did; what he couldn’t do, I did. We meshed. That is the rea- son we produced so much.” The two authored 13 books on the American Indians of the Pacific Northwest, contributed to biographical sketches of North American Indians, and wrote more than two dozen articles and book reviews on Native Dr. Ruby (left) presented a copy of his book, The Chinook Americans for academic journals. Indians: Traders of the Lower Columbia Basin, to Their hunt for primary sources of information Clement Conger, Archivist of the White House, in the about Native American history took Dr. Ruby Map Room, May 6, 1977. and Mr. Brown to depositories along the West Coast—at the University of Washington, Wash- ington State University, and in British Columbia, which was part of Indian tribal lands until the northwestern lines of the U.S. were drawn—as Northwest on the Oregon Trail wrote letters well as to sailors’ and fur traders’ logs in librar- about their encounters with Native Americans. ies on the East Coast. Dr. Ruby explained that Newspapers recorded major events—treaties before white settlers established communities with the tribes of the Oregon coast; wars and in the Pacific Northwest, visitors to the area skirmishes between and within tribes; and laws arrived by sea. “Sailors who came from Britain that banned the Indian languages, tribal organi- and the eastern U.S. had to travel around the zations, religions, and family life.4 Government end of South America and come up to the West documents traced the transfer of Indian lands to Coast, and the sailors and traders who bought white settlers, the consolidation of tribes, and the furs from the American Indians kept journals formation of tribal reservations for the Colville, and diaries,” he says. Spokane, and Yakima tribes in Washington; the Pioneers who later journeyed to the Pacific Umatilla and Siletz in Oregon; the Coeur d’Alene 16

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Ruby on the set of the Hallmark film Dreamkeeper, 2003.

and Nez Perce in Idaho; and the Salish and Koo- The authors’ style tenai in Montana.5 The authors also consulted The authors’ attention to the details of Indian other sources of information, such as letters life and lore placed them on the cutting edge from pioneers who later journeyed to the Pacific of scholarship in studies of Pacific Northwest Northwest on the Oregon Trail and wrote about American Indians, observes William L. Lang, their encounters with Native Americans. professor of history at Portland State University.6 Working before photocopy machines were According to Professor Lang, the first edition widely available in libraries, Dr. Ruby and Mr. of the book The Cayuse Indians came at a time Brown transcribed entries from different sets of renewed interest in the histories of Native of original source documents, copied them, and American tribes in the region and a wish to pres- placed them in duplicate three-ring notebooks ent these histories in a fresh light “by putting so they could confer with one another, by letter, American Indian interests at the center of the across the 90 miles that separated them, about narrative.”6 The book, therefore, dwells on the the meaning of individual facts within an overall most contentious and critical events of the past: historical context. On average, the historians the murders of Marcus and Narcissa Whitman, created 20 to 30 three-ring notebooks for each the ensuing war, and the Walla Walla Treaty of their books. Council of 1855, which resulted in opening the 17

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Pacific Northwest to white set- tlers and driving the Indian tribes of the Columbia Plateau off most of their land.6 Despite their exhaustive re- search of primary and second- ary unpublished documents, as well as interviews with Native American elders, Dr. Ruby and Mr. Brown added vibrancy and depth to their storytell- ing. In one book, for example, they juxtaposed descriptions of the geological formation of the Spokane River with tales of Spokane Indian mythology, Dr. Ruby with Mr. Kunstler and Ms. Wanrow, February 21, 1976. which trace the creation of the riverbed to a dragon that dragged trees and rocks from the mouth of the Columbia River to Lake Coeur d’Alene.4 In another, they explained that the Flathead, or Salish, Tribe did not get its name be- cause their ancestors flattened their heads. The authors re- lated other explanations for the name: sign language identified the tribe by pressing hands to the sides of the head. “Salish” means “we the people,” which is designated by striking the head with the flat of the hand. The Flatheads did not flatten their heads, but left them in a normal configuration, flat on top rather than forcing them Dr. Ruby with Mr. Bellacourt (right), February 20, 1976. to slope toward the crown. The tribes that did flatten their heads included the Chinook, who lived along the coast of Or- egon, Washington State, and British Columbia. Savoie Lottinville, the director of the University The objective of the authors was to reach the of Oklahoma Press in the 1960s, wanted to pub- average reader. “Few academic books about Ameri- lish well-researched and well-documented books can Indians have been written for the general that were nonetheless good reads, and the style public. Anthropologists and archaeologists have of Ruby’s and Brown’s books fit this vision. done extensive studies and published work in jour- Dr. Ruby and Mr. Brown, and their books, nals, but the average person doesn’t read those have been widely praised. Dr. Ruby has received things. And a lot of what the academic people write literary awards, including the Northwest Author doesn’t read like a good story,” Dr. Ruby says. But Award, Pacific Northwest Booksellers Award, and 18

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the Eastern Washington State Historical Society Leschi of the Nisqually Tribe because he was act- Distinguished Author of History Award, as well ing in a time of war when he killed a militiaman as recognition for his contributions to history in 1858. “The U.S. Congress was the Supreme from the Washington State Historical Society Court of the Territory, so it has the jurisdiction and the Center for Columbia River History, and to exonerate the Cayuse,” Dr. Ruby explains. he was named Soo Huk Min (Caretaker of Tribal If Congress acts on this idea, Dr. Ruby will not History) by the Okanogan Tribe in 2003. only be a recorder of history—he will have played a part in changing it.  Authorship leads to more Dr. Ruby also served as cultural advisor for References the award-winning Hallmark Entertainment Presentation, Dreamkeeper, a 2003 made-for- 1. Whitman Massacre. Available at: http://www. oregonpioneers.com/whitman2.htm. television film that traced the spiritual journey 2. New Perspectives on the West. Available at: of 17-year-old street-gang member, Shane Chas- http?www.pbs.org/weta/thewest/. ing Horse, as he learned the tradition of story- 3. Ruby RH. Letter to Sens. Ron Wyden, Maria telling and the legends of the Pine Ridge Sioux Cantwell, Gordon Smith, and Rep. Don Hastings. Oct. 30, 2004. from his grandfather, Old Pete Chasing Horse 4. Ruby RH, Brown JA. The Spokane Indians. Chil- (see photo, page 17). “The filmmakers wanted dren of the Sun. Norman, OK: University of Okla- the film to be as correct as possible, so they came homa Press; 1982. to me asking about the costumes, the tools, the 5. Ruby RH, Brown JA. A Guide to the Indian Tribes types of housing of the American Indians,” Dr. of the Pacific Northwest. Norman, OK: University of Oklahoma Press; 1986. Ruby recalls. 6. Ruby RH, Brown JA. The Cayuse Indians. Impe- His explorations of Indian history have brought rial Tribesmen of the Old Oregon. Norman, OK: Dr. Ruby in contact with many prominent and University of Oklahoma Press; 2005. notorious present-day Native Americans. When he and Mr. Brown were writing Dream Prophets of the Columbia Plateau: Smohalla and Skolas- kin (University of Oklahoma Press, 1989 and 2002), Dr. Ruby interviewed Crow Dog, author of a book about Wounded Knee and spiritual advi- sor on the Rosebud Reservation in South Dakota (see photo, page 14). He met with attorney and defender of Indian activists William Kuntsler, lead counsel for Yvonne Wanrow, who had shot and killed a man who molested her child in 1976; Vernon Bellacourt, a member of the Ojibway tribe and one of the founders of the American Indian Movement in 1976 (see photos, page 18); and David Sohappy, upon his release from jail for committing a fishing violation in 1988. Dr. Ruby’s work with American Indians con- tinues today. Just last year he finished updating The Cayuse Indians: Imperial Tribesmen of Old Oregon. He regularly visits and consults with elders from the Umatilla Tribe from northeast- ern Oregon about their history. He is lecturing widely about the five Cayuse Indians from the Whitman Massacre and hopes the U.S. Congress will take the same path as the Washington State Supreme Court, which in 2004 exonerated Chief Karen Sandrick is a freelance writer in Chicago, IL. 19

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 20

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS any people believe that the movement The blueprint for reform toward reform of the medical liabil- The primary objectives of this legislation were ity system has stalled somewhat at the elimination of suits by plaintiffs’ lawyers M the state and federal levels. There against insurance companies that refuse to settle seems to be an aura of pessimism, which could in medical liability cases, an increase in the size be the result of the extremely partisan nature of the jury from six to 12, requirement of a docu- of the discussion, the fact that insurance pre- ment from the court certifying that a case has a miums appear to have peaked, or just a feeling minimum level of merit before it could proceed, of lethargy because of the lack of progress in and permission granted to physicians who wanted Washington and certain state capitals. and needed coverage to purchase liability insur- Despite the frustrations of many surgeons and ance from the state Board of Insurance and Risk other health care providers, there are bright Management. Availability of insurance was no spots around the country. The purpose of this longer an issue, but affordability was still a major article is to provide specifics from the experience concern. of one such state. Perhaps these details may Over the next few months, liability rates contin- provide strategic guidance to others and create ued to increase and there remained considerable some optimism that medical liability reform is unrest in the physician community. Moreover, not a hopeless cause. there were rumblings that other private insurers might leave the state. Despite these concerns, Gov. The need for reform in West Virginia Bob Wise (D) continued to say that before consid- In 2001, West Virginia, like much of the rest ering additional liability legislation, he wanted to of the country, was in the midst of a medical see what effect S.B. 601 would have. liability crisis. Rates had risen considerably As spring moved into summer in 2002, pressure over the previous two years and affordability for further action was building. During the state- was clearly an issue, but as insurers left or wide primary election in May, several physicians considered leaving the state, availability was ran for the state legislature, and many of them also becoming a problem. Responding to the were successful. There was also a growing public previous liability crisis of the mid-1980s, a concern about the loss of physicians practicing $1 million cap on noneconomic losses was in West Virginia and the difficulty of recruiting signed into law, and rates rose only modestly others. This concern reached a climax in August, until early 1999. Although these minimal re- when, with the loss of two orthopaedic surgeons forms were certainly helpful, far more impor- (one to relocation and the other to a change in tant to rate control were that the insurance practice situation), the orthopaedic call schedule market was soft and that competition was in- at the Level I trauma center at Charleston Area creased by new companies entering the market Medical Center remained unfilled and the designa- in West Virginia. tion was downgraded to Level III. This situation Whether attempts by the insurers to secure caught the attention of public policymakers as market share during this time kept rates ar- it had in a similar situation in Nevada several tificially low can’t be said with certainty, but months earlier. This series of events provided the when premiums started to increase by 30 to 40 final element of the crisis: the threat to access to percent a year in 1999, physicians became sensi- quality care. Governor Wise, a lawyer who had tized. Contributing to the woes, a major carrier been heavily supported by plaintiff attorneys in went out of business, leaving many physicians the 2000 election, became much more engaged without adequate protection. Because of the almost overnight and responded to the widespread turmoil within the medical community, a special public outcry. Members of his administration were session of the state legislature was convened in immediately called upon to find a solution. Within the fall of 2001. The constituencies supporting a few weeks, a formal agreement was reached, liability reform were poorly organized but still whereby those private physicians providing direct were able to exert enough pressure for some trauma care would receive some of their liability modest reforms in S.B. 601. coverage from the original state program for 21

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS state employees and university physicians. With laboration with the governor, the Speaker of the the governor’s quick action, the trauma center’s House had carefully made several new appoint- Level I designation was restored. ments to the House Judiciary Committee, where When the governor realized the true severity of such legislation had died in past years. On the first the problem, he concluded that something more Monday of the regular session, the Speaker’s bill, dramatic in the way of legislation would be de- H.B. 2122, was placed on the agenda for the House manded by the public. Added emphasis was given Judiciary. This bill was similar to that proposed by to this realization in November, as two physicians the governor, but it went further in some respects, were elected to the House of Delegates, a rare most conspicuously by proposing a more rigid cap occurrence in West Virginia. Just as importantly, of $250,000 for noneconomic damages. After a several high-profile trial lawyers were defeated debate of approximately nine hours and with few in legislature reelection bids. In the aftermath of changes, H.B. 2122 was reported out of commit- the election, the Speaker of the House, a strong tee and three days later it passed the House by a supporter of tort reform, reviewed legislative large margin. strategy regarding the issue and the governor’s The situation in the state senate was a bit more inner circle began working on new substantive complicated, but with the assistance of the new legislation in preparation for the beginning of the chairman of the Senate Judiciary Committee, a regular session in January 2003. trial lawyer with a balanced approach, the pro- A sense of optimism about impending tort cess was much smoother than anticipated. The reform was palpable. This was enhanced by the only substantive modification was refinement of increasingly aggressive and well-organized activi- the concept of the Patient Injury Compensation ties of a large group of health and business entities Fund, which was to be created to deal with situ- that collectively educated the public on the likely ations in which the trauma cap and the joint and risks to the future of health care in West Virginia several liability changes could leave a victim with if there were no action on the issue. uncompensated economic damages. After some additional tweaks to the bill in committee, it was Passage of reform given to the full senate, where the vote was 33-1 With positive dynamics clearly falling into place, in favor. an additional event occurred just before the be- To pass legislation that was considered by many ginning of the session in early January: because experts to be the most comprehensive state ef- the liability climate was considered particularly fort in medical liability reform in more than 25 onerous in Wheeling, there was a brief work stop- years since MICRA (Medical Injury Compensation page by surgeons from that area. There was risk Reform Act) in California was unbelievable, con- associated with this action, but, in retrospect, it sidering the possibilities only a year before. When unquestionably had an effect on the governor’s the governor signed the bill a few weeks later, it “state of the state” address later that week. was truly a celebration, with a massive turnout Somewhat unexpectedly, a tort reform proposal of business leaders, health care providers, and that went far beyond what had been previously grateful patients. considered was included. That night, there was Although premiums did not immediately de- a sense of exhilaration within the medical com- crease, the rate of increase certainly slowed in munity and other patient interest groups, but this comparison to other states. Within a few months, was just the beginning. optimism was prevalent among all interested The governor’s bill included a variety of mea- parties. Fewer physicians were leaving the state sures, including a flexible cap on noneconomic and recruiting efforts were much more success- damages of $350,000; allowance of collateral ful even in the high-risk specialties, enhancing source information in the courtroom; enhance- access to quality care in West Virginia. Less than ment of the joint and several provision; a total a year after the effective date of the new legisla- trauma and emergency cap of $500,000; and state tion, there were credible data showing a decreased government capitalization of a new physicians’ frequency and intensity of medical liability law- mutual insurance company. Seemingly in col- suits. In fact, the total number of lawsuits and 22

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the dollar amount of judgments and settlements to be emphasized constantly while other, more had dropped to less than 50 percent of their previ- self-serving, approaches should be downplayed ous levels. This dynamic did not change over the or eliminated. subsequent year. The leaders of all the West Virginia organiza- There still remained concern on the part of tions supporting medical liability reform showed the liability insurance underwriters that there remarkable commitment to the strategy outlined might be a successful court challenge that could here. It wasn’t easy and it wasn’t always pretty, overturn the hard-fought reforms. Since then, two but the result was more than satisfactory. Despite early challenges to these reforms ended in deci- health care and civil justice systems that still have sions favorable for physicians and their patients. imperfections, the state and its people can now Even more importantly, a new, more conservative move forward to a much more stable playing field Supreme Court justice was elected in November than they had just a few years ago. More impor- 2004, defeating a sitting judge who was perceived tantly, for physicians, compared with many other as more accommodating to the trial lawyer lobby. states, West Virginia just may be, as the John Then two additional bills—“I’m Sorry” and “Inno- Denver song claims, “almost heaven.”  cent Prescriber”—passed during the 2005 regular session. Taken together, these events calmed the This article was generated through the efforts of the insurers, and it became a virtual certainty that ACS Committee on Patient Safety and Professional there would be a substantial decrease in liability Liability. Members of the committee believe that this premiums. and other articles published in the Bulletin should stimulate thought and possible action on a wider spec- trum of issues related to patient safety and professional What can be learned from West Virginia? liability. Comprehensive tort reform at the federal level, which most physicians agree is the ideal solution, appears to be out of reach in the short term. With tort reform at the state level currently receiving the most attention, one could ask if there are any lessons to be learned from the tort reform experi- ence in West Virginia. At the risk of overgeneral- ization, I believe there is much food for thought in the West Virginia story. There is little doubt that persistence is a virtue in these complex political altercations. Losing a battle should not create a culture of despair but rather a commitment to better understand the process and to play the game more cleverly. Forming a broad-based coalition that includes Dr. Foster is a West the medical and public health communities, busi- Virginia state sena- nesses, senior citizen groups, and even labor or- tor; physician advisor for the Charleston ganizations can pay great dividends. Brute force Area Medical Center, and self-righteousness rarely work in these circles Charleston; clinical and that is why civility and empathy should be professor of surgery, among the guiding principles for anyone joining West Virginia School of the fight for liability reform. Medical liability Medicine, Charleston reform is not a partisan issue—it is not about Division; and a member Republicans versus Democrats, physicians versus of the ACS Committee lawyers, or even about who is hurt financially on Patient Safety and and who isn’t. It is about access to high-quality Professional Liability. health care for all our citizens, whether they live in cities or rural communities. This idea needs 23

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Statement on blunt suture needles

The following statement was prepared by uts or needlestick injuries occur in 1 percent to 15 the Committee on Perioperative Care and percent of operations. The most common cause of approved by the Board of Regents at its June C 2005 meeting. suture needle injury is suturing fascia, during which 59 percent of all suture needle injuries occur. Blunt suture needles permit suturing of fascia and other structures with minimal risk of injuring the team, even when the glove is punctured. All published studies to date have demonstrated that the use of blunt suture needles can substantially reduce or eliminate needlestick injuries from surgical needles. The ACS supports the universal adoption of blunt suture needles as the first choice for fascial suturing to minimize or eliminate needlestick injuries from surgical needles. Blunt suture needles should be available in various sizes and with a range of sutures adequate for different surgical applications. The ACS encourages further investigation of blunt suture needles for use in other surgical applications.

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VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In compliance... with HIPAA’s NPI provisions—Part II by the Division of Advocacy and Health Policy

n June, this column presented a general overview of the National Provider Identifier Around the corner (NPI) provisions in the Health Insurance Portability and Accountability Act (HIPAA). November I Economedix will hold three teleconferences This month, this column provides more detailed information about the NPI. this month. The first, on November 2, is “E&M To briefly summarize, the major provisions Coding…Beyond the Basics.” The second, on related to the NPI in HIPAA are as follows: November 16, is “CPT Coding and 2006 Updates • The Centers for Medicare & Medicaid for Surgeons.” The third, on November 30, is Services (CMS) is responsible for assigning the “Building a Bottom-Line Budget for 2006.” For NPI. more information and to register, go to http:// • The existing numbers used by each payor yourmedpractice.com/ACS. to identify physicians and other health care pro- December viders will be done away with sometime between Economedix will hold a teleconference December now and May 23, 2007. (Small health plans have 14 on Billing Compliance: Avoiding Fraud and an additional year to convert to the new num- Abuse. For more information and to register, go bers.) to http://yourmedpractice.com/ACS. • Generally, the surgeon is responsible for ap- plying for a NPI but large practices may submit an electronic file of bulk applications. • You must have a NPI and your system must be able to handle it before the first payor you deal with requires one. ance of a NPI does not replace the enrollment process with health plans; enrolling with health Overview of NPIs plans authorizes the person or entity to bill and All individuals and organizations that bill for be paid for services. their services electronically must obtain and use a NPI. Hence, physicians, advanced practice Applying nurses, physical therapists, hospitals, nursing According to CMS, health care providers should homes, ambulance companies, durable medical apply for their NPI as soon as possible and defi- equipment suppliers, and other health care pro- nitely before the date on which their first payor viders must have a NPI. Obviously, the NPI will requires the NPI. CMS believes early issuance of be used to identify the provider who performs a the NPI will facilitate the testing and transition service on an electronic claim or other electronic processes and will decrease the possibility of any transaction. It will also be used on an electronic interruption in claims payment. claim for a service ordered by a physician. For Physicians may apply for a NPI in one of three example, Medicare will require a clinical labora- ways: tory to show the referring physician’s NPI on • A Web-based application process is available the claim for a laboratory service instead of the at https://nppes.cms.hhs.gov. That is the Web ad- existing, or “legacy,” number now required. dress of Fox Systems, Inc., the enumerator under Once issued, the NPI will not change and contract to CMS to handle issuance of NPIs and remains with the provider regardless of job or all inquiries about NPIs from providers. location changes. A NPI is never reissued to • A paper application is available at https:// another provider. The application for and issu- nppes.cms.hhs.gov or by calling 800/465-3203. 25

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Individuals with hearing impairments may call maxillofacial surgery as specialties. General 800/692-2326 for TTY service. The enumerator’s surgeons are recognized simply as “surgery” mailing address will be supplied with the paper and have code 208600000X. The subspecialties application. of surgery are pediatric, plastic and reconstruc- • With the physician’s permission, an orga- tive, hand, critical care, oncology, trauma, and nization, such as an employer, will be able to vascular surgery. submit an application on behalf of a physician For several specialties, there is more than one via an electronic file interchange. When available choice of specialty code. For example, hand sur- later this fall, this option may be attractive to gery appears under orthopaedic surgery, plastic large group practices. surgery, and surgery, each with different code CMS says that it takes about 20 minutes to com- numbers. The entire specialty of plastic surgery plete an application. The organization also says appears twice: once as its own specialty and that physicians who apply online may get their again as a plastic and reconstructive subspecialty NPI in minutes, but offer no other information on of surgery. Subspecialists should remember this the time that could elapse between submission of overlap if they expect the enumerator to select an application and issuance of a NPI. the specialty code. For example, if you are a As noted in the June column, one possible com- hand surgeon and want to be classified under plication for physicians is selecting a specialty. orthopaedic surgery, indicate your specialty as Selecting a specialty requires either consulting “orthopaedic surgery, hand surgery.” a list of codes on the Internet at http://www. Surgical practices may also need to register wpc-edi.com/codes/taxonomyr o writing the spe- other people, such as advanced practice nurses cialty (in English) for the enumerator to convert and physician assistants. Their specialty codes to the proper code. In addition to the specialties are under the headings of “nursing service pro- that the College recognizes, the enumerator viders,” and “physician assistants and advanced also includes transplant surgery and oral and practice nursing providers.”

Medicare implementation

Date claim Medicare processing reaches Medicare

Medicare systems will accept claims with a NPI, but a legacy Medicare number also must be on the claim. Medicare systems will reject as unprocessable any claim that includes only January 3, 2006– a NPI. Medicare will send the NPI as primary provider identifier and legacy identifier as October 1, 2006 secondary identifier in outbound claims, claim status response, and eligibility response electronic transactions.

Medicare systems will accept claims with a NPI and/or a legacy Medicare number on the claim. However, if there is any issue with the NPI and the Medicare legacy number was not on the claim, it may be denied. Therefore, Medicare strongly recommends continuing October 2, 2006–May to submit the legacy identifier as the secondary identifier. Medicare will send the NPI 22, 2007 as primary provider identifier and legacy identifier as secondary identifier in outbound claims, claim status response, remittance advice, and eligibility response electronic transactions.

May 23, 2007, Medicare systems will accept only the NPI and will not accept any legacy identifiers. This and after is also the deadline for most health plans although small health plans have an additional year to become NPI-compliant. 26

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the NPI and the application process is available In addition to getting a NPI … at http://www.cms.hhs.gov/medlearn/npi/npiv- iewlet.asp. That site has a copy of the application • Know each insurer’s implementation schedule that is annotated with tips on completing it. and plans for the use of legacy numbers. The latest information about the NPI, includ- • Be sure your billing system or service can ing frequently asked questions and guidance handle a NPI. documents, is available at http://www.cms.hhs. • Share your NPI with those who must identify gov/hipaa/hipaa2. you on claims. • Find out how both the performing and referring Your Medicare carrier has information and, of physician should be identified on paper claims. course, other insurers should have information, especially when May 27, 2007, approaches. Finally, local collaborative organizations may be working to address NPI implementation issues. 

NPI implementation schedule Watch for information on the NPI imple- mentation schedule from your health plans. Health plans should also provide information on whether you need to supply legacy numbers. Keep in mind that each health plan will have its own schedule and rules regarding the use of legacy numbers. Medicare has announced its implementation schedule and plans for legacy numbers (see table, page 26). In addition to getting a NPI in plenty of time, remember to ensure that your billing system or service can handle a NPI by the time the first payor requires it. In addition, you are respon- sible for sharing your NPI with any entity that must identify you in a claim or other standard transaction. Hence, surgeons must share their NPI with the same entities that have their legacy identifying numbers. Finally, find out what num- bers should be used for the performing physician and the referring physician on paper claims. It is important to note that HIPAA and its provisions apply only to electronic transactions. Some states require the NPI to be used on paper claims but others are silent on the subject, leav- ing the decision to the insurers.

Additional information Many additional sources of information about the NPI are available. The enumerator, of course, has all of the necessary information and is avail- able by telephone or at the Web site. See the telephone numbers and Web address listed on pages 25 and 26. A helpful and electronically sophisticated tool that provides an overview of 27

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Kathryn D. Anderson installed as 86th ACS President

Kathryn D. Anderson, MD, of assistant professor, associate FACS, FRCS, a pediatric sur- professor, and then professor of geon from San Marino, CA, was surgery and pediatrics at George installed as the 86th President Washington University, Wash- of the American College of Sur- ington, DC. Dr. Anderson also geons during the Convocation served as a surgical consultant ceremonies that preceded the to the U.S. Army at the Walter College’s 2005 Clinical Con- Reed Army Medical Center in gress in San Francisco, CA. Dr. Washington, DC (1976-1992). Anderson is professor emeritus From 1984 to 1992, she served at the Keck School of Medicine, as an adjunct scientist in the University of Southern Califor- molecular hematology branch nia (USC), Los Angeles. of the National Institutes of A native of Ashton-under- Health, National Heart, Lung, Lyne, Lancashire, UK, Dr. An- and Blood Institute in Bethesda, derson is a 1964 graduate of MD, where she also served as a Harvard Medical School, Bos- consulting surgeon from 1978 ton, MA. She completed an to 1992. internship in pediatric medi- Dr. Anderson then moved to Dr. Anderson cine (1964-1965) at Boston southern California to assume Children’s Hospital, Boston, responsibilities as surgeon-in- MA, before serving as a resident chief, vice-president of surgery, the Finance Committee (1992- (1965-1969) and chief resident and head of the division of pe- 1995), a member of the Hon- (1969-1970) in the department diatric surgery, Childrens Hos- ors Committee (1992-2002), a of surgery at Georgetown Uni- pital Los Angeles. During this member (1995-2002) and Chair versity Hospital, Washington, time, she served as vice-chair (1998-2002) of the Organiza- DC. From 1970 to 1972, she had in the department of surgery tion Committee, a member of a fellowship in pediatric surgery and professor of surgery at the the Communications Commit- at Children’s National Medical USC. Since 2004, she has been tee (1995-2002), an ex-officio Center in Washington, DC. In professor emeritus, Keck School member of the Board of Regents 1971, Dr. Anderson became of Medicine, USC. (1992-2002), ACS Secretary a diplomate of the American A Fellow of the College since (1992-2001), ACS First Vice- Board of Surgery and achieved 1975, Dr. Anderson is the first President (2001-2002), and ACS board certification in pediatric woman to be elected President President-Elect (2004-2005). surgery in 1975. of the American College of In addition to her service Dr. Anderson spent many Surgeons. She has served as an to the College, Dr. Anderson years teaching and practicing in active participant in and leader has held many leadership the Washington, DC, area. She of numerous College activities, positions in organized sur- founded the division of pediatric including service as a mem- gery. She has served as chair surgery and served as assistant ber of the Board of Governors of the American Academy of professor of surgery and pediat- (1986-1992), a member (1986- Pediatrics Surgical Section rics at Georgetown University 1992) and Chair (1990-1991) (1985-1986), president of the from 1972 to 1974. From 1974 of the Advisory Council for American Pediatric Surgical to 1992, she held the positions Pediatric Surgery, a member of Association (1999-2000), and 28

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS second vice-president of the editor of both the Journal of the hospitals and universities and American Surgical Association American College of Surgeons lecturer at medical meetings (2004-2005). Dr. Anderson has and Journal of Pediatric Surgery around the world. She has been also served as both a guest and as a member of the editorial a lecturer at the Lucile Salter examiner and a senior board boards of the Journal of the Packard Children’s Hospital, examiner (pediatric surgery American College of Surgeons, Children’s Hospital–Denver, certification) for the American Journal of Pediatric Surgery, the Royal Australian College of Board of Surgery and as a site Pediatric Surgery International, Surgeons, the Royal College of visitor for the Residency Re- the Annals of Surgical Oncol- Surgeons of Canada, St. Jude view Committee for Pediatric ogy, Practice of Surgery, and Children’s Research Hospital, Surgery. She is also a member Journal of Women’s Health. Mt. Sinai Medical Center, and of many surgical organiza- Dr. Anderson has devoted a the Children’s Hospital of Hali- tions, including the Royal major part of her career to sur- fax, NS. In 2003, the National College of Surgeons of Eng- gical research. She has studied Library of Medicine held an land, the Society of University esophageal replacement in in- exhibition, “Women Pioneers in Surgeons, and the Association fants and children, surgical im- Medicine,” in which Dr. Ander- of Women Surgeons. plantation of gene-engineered son was featured. Dr. Anderson has shown a hepatocytes, and transplanta- Dr. Anderson currently re- strong commitment to the dis- tion of vascular grafts. sides in San Marino, CA. semination of surgical knowl- In addition, Dr. Anderson has edge, having served as associate served as a visiting professor at

Donald D. Trunkey receives Distinguished Service Award

Donald D. Trunkey, MD, tion in numerous surgical and FACS, a general surgeon from trauma societies on the local, Portland, OR, received the 2005 state, regional, and interna- Distinguished Service Award, tional levels. Dr. Trunkey was the highest honor of the Ameri- also commended for service to can College of Surgeons, dur- his patients, community, state, ing the Clinical Congress last and country that he has pro- month in San Francisco, CA. vided throughout his surgical The Board of Regents pre- career. sented Dr. Trunkey with this A nationally recognized award in recognition of his expert on trauma care, Dr. dedicated service as a Fellow of Trunkey presently serves as the College, his service on Col- professor, department of sur- lege committees, his commit- gery, Oregon Health and Sci- ment and unselfish dedication ence University, Portland. Dr. to the surgical profession, and Trunkey received his medical his distinctive service to the degree from the University of surgical community through Washington in 1963 and then membership and participa- performed a rotating internship Dr. Trunkey 29

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS with J. Englebert Dunphy, MD, the Army Reserves and served Surgical Association, Pacific FACS, at the University of Or- during Operation Desert Storm Coast Surgical Association, egon Medical School, Portland in 1991. North Pacific Surgical Asso- (1963-1964). After completing A Fellow since 1974, Dr. ciation, Society of University his internship, he spent two Trunkey has made outstanding Surgeons, American Associa- years in the U.S. Army as a contributions on behalf of and tion for Vascular Surgery, In- general medical officer and was to the College. He served as ternational Society of Surgery, stationed in Germany. a member of the Long Range American Association for the Dr. Trunkey returned to the Planning Committee of the Surgery of Trauma, American U.S. for his general surgery Board of Regents (1978-1981); Burn Association, Association residency, which he completed as a member (1972-1982) and for Academic Surgery, and the at the University of Califor- chair (1979-1982) of the North- Surgical Infection Society. He nia Hospitals, San Francisco ern California Committee on has also served as a member of (UCSF), from 1966 to 1970, Trauma; a member of the Task the Accreditation Council for where he also served as chief Force on Optimal Criteria for Graduate Medical Education resident from 1970 to 1971. Trauma Centers (1977-1982); Residency Review Committee During his residency train- chair of the National Commit- for Surgery and as a member ing, Dr. Trunkey concurrently tee on Trauma (1982-1986); a of the organization’s appeals served as a researcher in the member of and reviewer for the panel. Organ Preservation Lab at Committee on Trauma Verifica- Furthermore, Dr. Trunkey the UCSF on a postdoctoral tion and Consultation Program has held key leadership posi- research training grant (1968- for Hospitals Committee (1989- tions in a number of societies, 1969). From 1971 to 1972, he 1990); a member of the Ad including serving as director completed a fellowship with the Hoc Legislative Committee on and vice-chair of the American National Institutes of Health Trauma (1989); a member of Board of Surgery, president of in the trauma unit at the Uni- the Ad Hoc Nominating Com- the American Association for versity of Texas Southwestern mittee of the Committee on the Surgery of Trauma, and Medical School, Dallas. During Trauma; and a member of the president of the Society of Uni- that time, he also served as an Surgical Education and Self- versity Surgeons. He was the assistant research professor of Assessment Program Commit- recipient of the National Safety surgery at the medical school. tee (1993). Council’s Surgeons’ Award for After he returned to the Dr. Trunkey delivered sev- Service to Safety in 1989. UCSF department of surgery eral lectures at past Clinical In recognition of Dr. Trun- in 1972, Dr. Trunkey held the Congresses: he delivered the key’s continued and dedicated positions of assistant professor Scudder Oration on Trauma service to and on behalf of the (1972-1976), director of surgery at the 1989 Clinical Congress College and the surgical com- (1973-1976), associate profes- in Atlanta, GA; the Opening munity, the Board of Regents sor (1976-1978), vice-chairman Ceremony Lecture in San Fran- is pleased to present Dr. Trun- (1978-1986), and professor of cisco in 1993; and the Charles key with the College’s highest surgery (1979-1986), until his G. Drake Lecture on the His- honor, the 2005 Distinguished departure in 1986. During his tory of Surgery in 2004 in New Service Award. tenure at UCSF, Dr. Trunkey Orleans, LA. also served as chief of surgery at In addition to Dr. Trunkey’s San Francisco General Hospital involvement with the College, from 1978 to 1986. He returned he has also been an active mem- to Oregon Health Sciences ber and leader of numerous University in 1986, to serve as organizations within the surgi- professor and, until 2001, chair cal and trauma care communi- of the department of surgery. ties, including the American In 1985, Dr. Trunkey rejoined Surgical Association, Western 30

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Space sold by Elsevier College names three Honorary Fellows

Honorary Fellowship in the and St. Luke’s Hospital, Sydney, lowships on behalf of the Col- American College of Surgeons Australia. lege were: Gerald B. Healy, MD, was awarded to three promi- • Prof. Sir Alfred Cusch- FACS, Boston, MA; Frederick L. nent surgeons from Australia, ieri, FRS (Edin), MD, MD Greene, MD, FACS, Charlotte, the United Kingdom, and Italy (Hon), ChM, FRCS (Edin, NC; and Karl C. Podratz, MD, during Convocation ceremo- Eng), FRCPS (Glas)(Hon), FACS, Rochester, MN. nies at last month’s Clinical FRCSI (Hon). Sir Alfred is a During the College’s Convoca- Congress in San Francisco, CA. professor of surgery at the In- tion ceremonies this year, 1,336 The awards presentation is one stitute of Medical Science and surgeons from around the world of the highlights of the Clinical Technology at the University of were admitted into Fellowship. Congress. The recipients were Dundee, Dundee, Scotland, and Sir Rickman Godlee, President as follows: the Scuola Superiore S’Anna di of the Royal College of Surgeons • Bruce Benjamin, MB, Studi Universitari, Pisa, Italy. (England), was awarded the first DLO, FRACS, FAAP. Professor • Prof. Sergio Pecorelli. Honorary Fellowship in the Col- Benjamin is clinical professor of Professor Pecorelli is chair of lege during the College’s first otolaryngology–head and neck the department of obstetrics Convocation in 1913. Since then, surgery at Sydney University, and gynaecology and professor 395 internationally prominent and is a visiting medical officer of gynaecologic oncology at the surgeons, including the three at Sydney Hospital, Royal Al- University of Brescia, Brescia, chosen this year, have been exandra Hospital for Children, Italy. named Honorary Fellows of the Royal North Shore Hospital, Presenting the Honorary Fel- American College of Surgeons.

Citation for Prof. Bruce Neil Benjamin by Gerald B. Healy, MD, FACS, Boston, MA

Mr. President, it is my dis- care, academic pursuit, and the tinct privilege to present Prof. training of young physicians. Bruce Neil Benjamin of Sydney, This career pathway has been Australia, to you for Honorary recognized by his professorship Fellowship in the American at Sydney University, but, more College of Surgeons. Professor importantly, it has earned him Benjamin is a son of Australia, recognition as the premier pe- but he is a physician, teacher, diatric otolaryngologist in the mentor, and medical ambassa- world. Professor Benjamin’s dor to the world. contributions and innovations Bruce Benjamin was born in the diagnosis and treatment in Wagga Wagga, New South of disorders of the pediatric Wales, and received his medical airway are legendary. His early education at Sydney Univer- attention to the assessment sity. He completed his training of surgical outcomes has led in otolaryngology at Sydney to pioneering changes in the Hospital and then began his treatment of tracheoesophageal Professor Benjamin lifelong dedication to patient fistula, esophageal atresia, la- 32

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ryngeal cleft, and many other in the world, and his atlas and by the Australasian Society of congenital and acquired dis- teaching slide collection are Pediatric Otolaryngology. eases of the upper aerodiges- used by students and teachers On a personal note, he is the tive tract. He was also found- on every continent. dedicated father of Gregory ing secretary of the Board of Dr. Benjamin has trained and Susanne and a devoted Otolaryngological Studies in countless registrars and fel- husband to his wife, Nellie. He his native Australia. lows who have brought his also can very adeptly defend Professor Benjamin has per- innovations to many of the Australia’s honor on the golf sonally designed an arsenal world’s medically devastated course. of 21st century endoscopic in- children. He has been awarded Mr. President, I am deeply struments that are utilized in the Order of Australia, the honored and immensely proud most pediatric operating rooms Order of the British Empire, to present to you and the throughout the world. His sem- the Chevalier Jackson Award, American College of Surgeons inal contributions have helped and countless other honors my dear friend, Bruce Neil countless children everywhere by more organizations than Benjamin, who has taught the overcome the devastation of there is time or space to relate. world, and me personally, so acute and chronic airway ob- Perhaps his most cherished much about how to care for struction. He is also the pre- recognition is the medal named and love sick and vulnerable mier endoscopic photographer in his honor given annually children.

Citation for Prof. Alfred Cuschieri by Frederick L. Greene, MD, FACS, Charlotte, NC

Mr. President, it is both an Professor Cuschieri began honor and a privilege to pres- his early training in his home ent my friend and colleague, country of Malta, where he Prof. Sir Alfred Cuschieri, graduated from medical school from Dundee, Scotland, and with honors. He traveled to the Pisa, Italy, as he receives this U.K. in the 1960s to complete prestigious Honorary Fellow- his surgical training at the Liv- ship in the American College erpool Royal Infirmary, where of Surgeons. For many years, his surgical brilliance started Sir Alfred has been a mentor, to blossom. Sir Alfred remained teacher, surgical innovator, on the faculty of the Univer- and consummate scientist role sity of Liverpool until he was model to the myriad students, named professor of surgery and house staff, and practicing molecular biology at the Uni- surgeons who have had the versity of Dundee in Scotland, privilege to work with him. His the institution where his cre- achievements have been recog- ativity truly flourished. At this Professor Cuschieri nized worldwide, and his prow- juncture of his academic life, ess as a teacher and surgeon he recognized the future impor- has culminated in the singular tance of endoscopic surgery and recognition of achieving in 1998 was truly the prophet who told Hospital in Dundee, he created the designation of Knight Bach- of the significance of minimally hands-on laboratories where elor from Her Majesty, Queen invasive approaches for the young surgeons could train on Elizabeth II. surgical patient. At Ninewells simulators and black boxes to 33

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS learn the intricacies of hand- sociation to promote futuristic countless surgical patients eye coordination that would be approaches for patients with throughout the world. beneficial in the reality of the cancer and gastrointestinal Mr. President, it is my great operating theater. surgical illnesses. and special honor to present For these efforts and for his We not only honor Professor to you and to the Fellows of monumental contributions to Cuschieri for his major scien- the American College of Sur- the surgical literature, he has tific contributions evidenced geons a surgical pioneer and been recognized throughout through 430 peer-reviewed innovator who has literally the world by organizations publications and 19 books on redefined surgical approaches dedicated to endoscopic sur- surgical topics, but also pay to the abdominal and thoracic gical pursuits and minimally tribute to him for his honor- cavities and who—through his invasive surgery. Through his ary memberships in many of concepts of surgical technology, editorship of both the Journal the leading surgical societies robotics, surgical simulation, of the Royal College of Surgeons throughout the world. In addi- and training—has given us the of Edinburgh and Surgical tion, we respect him for his vi- tools and the encouragement Endoscopy, Professor Cuschieri sionary pursuits of novel ideas to seek innovations that were has fostered the concepts of that two decades ago were not previously unimagined. Mr. surgical science and has been even considered. More impor- President, I present my friend a spokesperson for surgical tantly, we acknowledge him this and fellow surgeon, Prof. Sir innovation. He has used his evening for launching new sur- Alfred Cuschieri, for Honorary presidencies of both the Brit- gical ideas and for giving us the Fellowship in the American ish Association of Surgical conceptual building blocks that College of Surgeons. Oncology and the International have enlightened thousands of Hepato Pancreato Biliary As- surgeons and have benefited

Citation for Prof. Sergio Pecorelli by Karl C. Podratz, MD, FACS, Rochester, MN

Mr. President, it is my hon- surgery in the U.S. In addition, or to introduce Prof. Sergio he earned a doctoral degree for Pecorelli, a pelvic surgeon from cogent investigative strategies Brescia, Italy, for Honorary Fel- in gynecologic oncology. lowship in the American College Professor Pecorelli is recog- of Surgeons. nized internationally for his Professor Pecorelli is chair dedication to improving the of the department of obstetrics early detection, diagnosis, and and gynaecology and director treatment of cancers of the of the division of gynaecologic female reproductive tract, the oncology at the University of leading cause of death from Brescia. He received his medi- cancer among women in the cal degree from the University world. Particularly noteworthy of Pavia in 1969. Thereafter, has been his ability to harness he completed a residency in the energies of international obstetrics and gynecology, a communities through partici- fellowship in surgical oncology, pation in clinical trials focused Professor Pecorelli and advanced training in pelvic on improving the outcomes for 34

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cancers unique to women. His Pecorelli with developing a na- Cancer for the International influential role as the chair of tional cancer research program, Federation of Gynecology and the gynaecologic cancer division which includes a government- Obstetrics. He has been an ac- within the European Organiza- funded clinical trials program. tive member of and involved in tion for Research and Treatment Professor Pecorelli’s ability to the administrative activities of of Cancer resulted in demonstra- objectively communicate ob- multiple organizations and has ble advances in the management servations gained from his in- recently served as president of of gynecologic malignancies. Such volvement in clinical outcomes the International Gynecologic advances include the multicenter assessments has resulted in Cancer Society. studies pertaining to ovarian ongoing requests that he par- Professor Pecorelli is acknowl- cancer, which documented the ticipate in regional and inter- edged globally for his resolve meritorious role of adjuvant national educational forums, to decrease the loss of life from therapy in early disease, the many of which he is asked to gynecologic cancers through value of cytoreductive surgery in direct. His contributions to education and clinical trials. Mr. advanced disease, and the benefit the gynecologic literature are President, it is a distinct privi- of neoadjuvant chemotherapy in chronicled in more than 200 lege to present my distinguished facilitating more optimal surgical peer-reviewed publications. colleague in gynecologic oncology, cytoreduction. He is a member of numerous Prof. Sergio Pecorelli, to you The Minister of Health in editorial boards and edits the for Honorary Fellowship in the Italy has charged Professor Annual Report on Gynecologic American College of Surgeons.

Young Surgical Investigators Conference to be held in March 2006

The American College of and Canadian academic medi- ground, and preliminary re- Surgeons is offering the Eighth cal centers. The conference sults Biennial Young Surgical Inves- provides opportunities to meet • Grant-writing strategies tigators Conference March 3–5, and talk with key NIH staff • Mock study sections for 2006, at the Bethesda North as well as many of the leading reviewing model grants Marriott Hotel and Conference surgeon-scientists who have The conference fee is U.S. Center in North Bethesda, MD. been successful in obtaining $1,750 (or $1,575, if registra- The conference is designed to NIH grant support for their tion and payment are received assist surgeon-scientists in work and participate in the by December 16, 2005). This obtaining extramural, peer- conference as leaders of various fee includes all related confer- reviewed grant support for their small group meetings and as ence materials, meals, breaks, work and to introduce them to plenary session speakers. receptions, and lodging for two the process, content, style, and The program includes inten- nights. The deadline for regis- people involved in successful sive exposure to the following: tration is January 6, 2006. grant-writing and interactions IH• N programs and poli- Information and a registra- with the National Institutes of cies tion form are available on the Health (NIH). • How to apply to the pro- College Web site at www.facs. A s participants, y o u n g grams most appropriate for the org/cqi/src/youngsurg.html. Di- surgeon-scientists meet their participant’s research rect questions to mfitzgerald@ peers, selected mostly from • Workshops in hypoth- facs.org, or call 312/202-5319. surgery departments in U.S. esis testing, methodology, back- 35

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Report of the 2005 ACS Traveling Fellowship to Germany by Joe Hines, MD, Los Angeles, CA

When the American College of Surgeons announced the first Traveling Fellowship to Ger- many last fall, I was ecstatic. It had always been a goal to partici- pate in a fellowship to another country, and this opportunity was ideal. Over the previous seven years, Howard Reber, MD, FACS, and I had hosted five Ger- man surgical residents in our laboratory at the University of California–Los Angeles (UCLA), where each investigated various Dr. Hines (in darker green in background) and Dr. Peter Buchler (right) aspects of pancreatic cancer biol- observing a Whipple procedure performed by Prof. Marcus Buchler ogy. I established close ties with (underneath overhead lights on left) and Prof. Friess. these colleagues, and we often talked about surgical training and departmental structure in Germany. In addition, I had had I was sure my understanding of report and had the opportunity the honor to meet their mentors the German language had pro- to watch Professors Buchler and from Germany at various meet- gressed to the point that I was Helmut Friess perform a num- ings in the U.S. These relation- comprehending the content. The ber of pancreatic procedures. ships piqued my interest in Ger- German Surgical Society was The department graciously al- man surgery and I was elated to very nice to ask me to speak on lowed me to speak about our have been given the opportunity the recent progress in multimo- pancreatic cancer research. Pe- to experience this first-hand. dality treatment of pancreatic ter Buchler, MD, also a former During the two-week fellow- cancer. laboratory fellow and friend, ship, I visited Munich, Heidel- Moritz Wente, a surgery resi- spent much time with me. He berg, and Berlin. The first week dent and former laboratory fel- and his wife, Manuela, hosted in Munich was spent at the low, escorted me by train to the me in their home for a lovely annual Congress of the German next destination: Heidelberg. dinner. The visit to Heidelberg Surgical Society (Deutschen Ge- This city is idyllic, complete with was extraordinary, and I hope sellshaft fur Chirurgie). I met my a castle and an old town dating the association with Professor host, Norbert Senninger, MD, back to the early 1700s. The Buchler, Professor Friess, Moritz FACS, at a traditional German Heidelberg department of sur- Wente, and Peter Buchler will restaurant. While in Munich, I gery, under the direction of Prof. continue and thrive. saw some of my former labora- Marcus Buchler, MD, is a world The trip then moved to Berlin, tory fellows and met several leader in pancreatic surgery, where Hubert Hotz, MD, and well-known German surgeons. so I was especially glad to visit Heinz Buhr, MD, FACS, served The Congress talks were instruc- this department. While there, as my hosts. Dr. Buhr, the chair tive, and by the end of the week, I observed the daily morning of the department of surgery 36

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS at the Benjamin Franklin Uni- German surgeons are a proud with many surgeons as well as versity, invited me to his home and traditional group. The his- strengthen existing connections. for a great dinner. Berlin is a tory of surgery is deep in this After 13,500 miles traveled, beautiful and bustling city, and country—this is where the inno- four talks delivered, a dozen op- the weather was perfect while I vation of many modern surgical erations observed, many liters of was there. Many members of the procedures and teachings began. weissbeer consumed, and many department talked about their Now, the practice of German handshakes with new and old current research efforts and I medicine appears to be evolving friends, I am eternally grateful especially enjoyed observing a with the advent of “fast track” to the American College of Sur- variety of operations, including to shorten hospital stay and the geons and the German Chapter a Whipple, thyroidectomy, and use of diagnosis-related groups for this opportunity. colectomy. I had the chance to for reimbursement. At the same Finally, I especially want to discuss the UCLA experience time, in the operating room, thank my sponsors for this fel- with pancreaticoduodenectomy the strong traditions of sharp lowship application: Howard and some of our recent research dissection and suture ligation Reber, MD, FACS; Fred Eilber, findings. This department is continue; it reminds me of the MD, FACS; and Ronald Busuttil, busy and vibrant, and I look importance of anatomic knowl- MD, PhD, FACS. forward to continuing my close edge and surgical precision. ties with my friends, Drs. Hotz This travel award allowed Dr. Hines is associate professor of and Buhr. me to make new connections surgery at UCLA in Los Angeles, CA.

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NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS issues call for submissions for 2006 Congress in Chicago

The American College of Surgeons Division of www.facs.org/education/congress/paperssession. Education welcomes submissions to the follow- html. ing programs to be considered for presentation Submission deadline: 5:00 pm (CST), March 1, at the 92nd Annual Clinical Congress, October 2006. Late submissions not permitted. 8–12, 2006, in Chicago, IL. Presentation type: Oral. Abstract specifications for each program will be posted on the ACS Web site at www.facs.org. Posters Session The submission period will begin on November 1, Program Coordinator: Lisa Richards (lrichards@ 2005. Submission of a single abstract to more facs.org). than one program is not permitted Abstracts are to be submitted online only, via www.facs.org/clincon2006/sciexhibit.html. Video-Based Education Session Submission deadline: 5:00 pm (CST), March 1, Program Coordinator: GayLynn Dykman 2006. Late submissions not permitted. ([email protected]). Presentation type: Poster display. Submission method: 200-word abstract and ap- plication submitted electronically via ACS Web Surgical Forum site at www.facs.org. Videos to be submitted via For surgical residents and scientific investiga- first class mail. tors in-training. Submission deadline: February 1, 2006. Program Coordinator: Kathryn Koenig- Presentation type: Video (acceptable formats: Matousek ([email protected]). Mini-DV, SVHS, Betacam SP, DVCPRO, DV- Abstracts are to be submitted online only, via CAM). www.facs.org/sfabstracts/index.html. Submission deadline: 5:00 pm (CST), March 1, Papers Session 2006. Late submissions not permitted. Program Coordinator: Molly Clear (mclear@ Presentation type: Oral facs.org). The Division of Education appreciates your Abstracts are to be submitted online only, via continued support of its programs.

Pay your dues online! Just visit www.facs.org and go to the “Members Only” tab

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VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Disciplinary actions taken

The Board of Regents took from Mount Morris, NY, was monished after being charged the following disciplinary ac- censured after being charged with violation of Article VII, tions at their June 11, 2005, with violation of Article VII, Sections 1(f) and (i) of the meeting: Sections 1(f) and (i) of the Bylaws. This action was taken • An ophthalmic surgeon Bylaws for providing expert in response to expert witness from Anaheim Hills, CA, was witness testimony that was testimony that was found to placed on probation follow- false or misleading. be false or misleading. ing charges that he violated • Peter M. Schick, a gener- • A general surgeon from Article VII, Sections 1(b), (f), al surgeon from Santa Monica, Wilson, NC, had his full Fel- and (i) of the Bylaws. This CA, was suspended from the lowship privileges reinstated surgeon’s Fellowship status College after being charged following a period of proba- will remain on probation until with violation of Article VII, tion. The probation followed he has a full and unrestricted Section 1(b) of the Bylaws. charges that he violated Ar- medical license; full and un- This action was taken follow- ticle VII, Section 1(b) of the restricted surgical privileges ing disciplinary action by the Bylaws, when his license in an accredited hospital; and California Medical Board for to practice medicine in the his practice pattern has been unprofessional conduct and State of North Carolina was reviewed and approved by the committing dishonest acts. restricted and he was referred Central Judiciary Commit- The suspension will remain to the Physicians Health Pro- tee. in effect until this surgeon has gram. This action was taken fol- a full and unrestricted medical This surgeon fulfilled the lowing disciplinary action by license; full and unrestricted requirements of having a the California Medical Board surgical privileges in an ac- full and unrestricted medical for self-administering con- credited hospital; and has had license; full and unrestricted trolled substances, violating his practice pattern reviewed privileges in an accredited drug statutes, and making and approved by the Central hospital; and having his prac- false statements during the Judiciary Committee. tice pattern reviewed by the course of an investigation. • A general surgeon from Central Judiciary Commit- • An orthopaedic surgeon Scotch Plains, NJ, was ad- tee.

Change your address online! Just visit www.facs.org and go to the “Members Only” tab

39

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Advances in Trauma seminar to be held in Kansas City

The College’s Committee on the Open Abdomen: Tricks of Ludwig, MD, FACS; Robert C. Trauma, Region 7 (Iowa, Kansas, the Trade; Controversies in Mackersie, MD, FACS; Kenneth Missouri, and Nebraska), is Thoracic Trauma; and Cases L. Mattox, MD, FACS; Frank L. sponsoring the 28th annual from Region 7. Mitchell, Jr., MD, FACS; Frank Advances in Trauma seminar The program continues on L. Mitchell III, MD, FACS; J. at the Westin Crown Center Saturday with the following David Richardson, MD, FACS; in Kansas City, MO, December presentations: Initial Treatment Thomas M. Scalea, MD, FACS; 9–10, 2005. of the Burn Patient in a Rural R. Stephen Smith, MD, FACS; The regional and state chairs Center; Ground, Rotor Wing, or Donald D. Trunkey, MD, FACS; have planned a program that will Fixed Wing? Optimal Transfer and David W. Tuggle, MD, benefit all involved in trauma of the Injured; Errors in the FACS. patient care. The objective of Initial Treatment of the Multi- For more information, visit this two-day continuing medical Trauma Patient; Nonoperative the ACS Trauma Committee education course is to present Management of Solid Organ Web site at: http://www.facs.org/ nationally recognized faculty Injuries: State of the Art; The trauma/cme/traumtgs.html. who will discuss timely trauma Injured Spleen: Have We Gone and critical care issues aimed Too Far?; Resuscitation from at improving care of the acutely Shock: What Fluids? What injured patient. Current trauma Endpoints?; Level I, Level II, Trauma meetings diagnostic and therapeutic Level III: Where Should the calendar techniques will provide the Injured Patient Go?; What Have audience with the most up-to- We Learned? From Oklahoma The following continuing date information available. City to the Next Terrorist Attack!; medical education courses in The program on Friday Contemporary Management trauma are cosponsored by the will include the following of Pelvic Fractures; Pitfalls American College of Surgeons presentations: Optimal Pediatric in the Treatment of Injured Committee on Trauma and Regional Committees: Resuscitation before Transfer to Geriatric Patients; Bones, • Advances in Trauma, a Trauma Center; Why Rural Thoracic Injuries: Should They December 9–10, Kansas City, Hospitals Should Have ACS Be Treated Operatively?; The MO. Verification; Optimal Trauma Injured Child: Essentials of • Trauma and Critical Care in a Dysfunctional Health Care; and Cases for Region 7: Care 2006, March 20–22, Las Care System; The Mangled Stump the State Chairs. Vegas, NV. Extremity: State of the Art; Faculty members include • Trauma and Critical The Acute Care Surgeon: A New the following: L. D. Britt, Care 2006—Point/Coun- Model; Prehospital Care for the MD, MPH, FACS; Reginald A. terpoint XXV, June 5–7, Trauma Patient: Does It Make Burton, MD, FACS; Philip R. Williamsburg, VA. Complete course informa- a Difference?; Diagnosis and Caropreso, MD, FACS; Chris ® tion can be viewed online (as it Treatment of Shock: Is ATLS Cribari, MD, FACS; Demetrios becomes available) through the Right?; The ACS Trauma System Demetriades, MD, FACS; David American College of Surgeons Consultation Program; The V. Feliciano, MD, FACS; Robert Web site at: http://www.facs. DaMattox Code—A Traumatic P. Foglia, MD, FACS; Thomas S. org/trauma/cme/traumtgs. Mystery; Cavitary Endoscopy Helling, MD, FACS; G. Patrick rhtml, o contact the Trauma i n T r a u m a ; A b d o m i n a l Kealey, MD, FACS; Anna M. Office at 312/202-5342. Compartment Syndrome and Ledgerwood, MD, FACS; Lee V. 40

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACOSOG news: Clinical trials update New trials highlight surgical innovations by R. Scott Jones, MD, FACS, Director, Division of Research and Optimal Patient Care, Chicago, IL

The American College of mary breast cancer, local exci- ity, both through ACOSOG and Surgeons Oncology Group sion plus neoadjuvant therapy the Cancer Trials Support Unit (ACOSOG) is excited to offer for early rectal cancer. (CTSU). several new trials with advance- Three times a year, we will Future efforts will be di- ments in surgical innovations, summarize new concepts, new rected toward creating dialogue including cryoablation for pri- trials, and ongoing trial activ- between the American Col-

Figure 1—Z1052

Figure 2—Z4032

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NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS lege of Surgeons members and Phase II Trial Evaluating Phase III Study of Sublobar Re- ACOSOG on surgical innova- the Efficacy of Pre- and Post- section versus Sublobar Resec- tions of clinical trial interest. Treatment Imaging to De- tion Plus Brachytherapy in High Further information on other termine Residual Diseases in Risk Patients with Non-Small opportunities to participate in Patients with Invasive Breast Cell Lung Cancer (NSCLC), 3 clinical trials is also available Carcinoma Undergoing Cryo- cm or Smaller on the Web sites provided. We ablation Therapy. PI: Heran Fernando, MD. encourage you to join the effort Primary investigator (PI): Web posting: July 15, 2005 of creating tomorrow’s practice Rache Simmons, MD. • Z6041—Local Excision through today’s clinical trials. Neoadjuvant Chemoradiation New trials for Early Rectal Cancer. A Phase New trial concepts • Z4032—Brachytherapy and II Trial of Neoadjuvant Chemo- • Z1052—Cryoablation for Sublobar Resection in Non-Small radiation and Local Excision Primary Breast Cancer. (See Cell Lung Cancer. (See Figure 2, for uT2uN0 Rectal Cancer. (See Figure 1, previous page.) A previous page.) A Randomized Figure 3, this page.)

Figure 3—Z6041

Figure 4—Z1031

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VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACOSOG-led and ACOSOG-endorsed (CTSU*) protocols open to accrual

A clinical trial comparing anastrozole with tamoxifen in postmenopausal patients Breast NSABP B-35* with ductal carcinoma in situ (DCIS) undergoing lumpectomy with radiation therapy.

NSABP B-39* A randomized phase III study of conventional whole breast irradiation (WBI) versus partial breast irradiation (PBI) for women with stage 0, I, or II breast cancer.

Head Z0360 A trial of lymphatic mapping and sentinel node lymphadenectomy for patients with T1 or T2 clinically N0 oral cavity squamous cell carcinoma and Neck RTOG 0234* A phase II randomized trial of surgery followed by chemoradiotherapy plus C225 (cetuximab) for advanced squamous cell carcinoma of the head and neck.

GI Z5031 A phase II study of interferon-based adjuvant chemoradiation in patients with resected pancreatic adenocarcinoma

Sarcoma Z9001 A phase III randomized double-blind study of adjuvant ST1571 versus placebo in patients following the resection of primary gastrointestinal stomal tumor (GIST)

Z9031 A phase III randomized study of preoperative radiation plus surgery versus surgery alone for patients with retroperitoneal sarcomas (RPS)

SWOG S0344/ A phase II surgical trial of intralesional resection of low-grade intracompartmental chondrosarcoma of bone. Z9041* Thoracic Z4031 Use of proteomic analysis of serum samples for detection of non-small cell lung cancer

SWOG A phase II trial of induction chemoradiotherapy with cisplatin/etoposide followed by surgical resection, followed by docetaxel for non-small cell lung cancer S0220* involving the superior sulcus (Pancost tumors).

PI: Julio Garcia-Aquilar, MD. PI: Matthew Ellis, MD. ported clinical research), http:// Web posting: August 15, 2005 Web posting: September 15, www.clinicaltrials.gov • Z1031—Neoadjuvant Ani- 2005 • Coalition of National mates Inhibitors in Breast Can- Cancer Cooperative Groups, cer. (See Figure 4, page 42.) A Clinical trials Web sites 877/520-4457, http://www. Randomized Phase III Trial Visit the following Web sites cancertrialshelp.org Comparing 16 Weeks of Neo- for more information on clini- • EmergingMed.com (a free adjuvant Exemestane (25 mg cal trials: referral service for clinical tri- daily), Letrozole (2.5 mg daily) • National Cancer Institute, als), 877/601-8601, http://www. or Anastrozole (1 mg daily) in 800/4-CANCER, http://www. emergingmed.com Postmenopausal Women with nci.nih.gov/clinicaltrials • Association of Cancer Clinical Stage II or III Estro- • ClinicalTrials.gov (pro- Online Resources, http://www. gen Receptor Positive Breast vides updated information on acor.org Cancer federally and privately sup- 43

NOVEMBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NTDBTM data points A-hunting we will go by Richard J. Fantus, MD, FACS, Chicago, IL, and John Fildes, MD, FACS, Las Vegas, NV

According to the most recent National Survey of Fishing, Drug-related hunting injury Hunting, and Wildlife-Associ- ated Recreation by the U.S. Fish and Wildlife Service, 82 million U.S. residents aged 16 and older participated in wildlife-related recreation and spent more than $108 billion enjoying their pas- time during one year. Thirteen million hunters donned camou- flage while spending more than $20 billion, and each hunted an average of 18 days. Unfortu- nately, the animals are not the E922.2 (shotgun and hunting ri- the sights of the shotgun. The only ones injured in the process. fle). Much to our surprise, there National Safety Council’s an- One would expect that, with were only 485 records. These nual statistical report on unin- 13 million armed individuals injuries resulted in an overall tentional injury rated hunting wandering around the woods mortality rate of 4 percent, an with seven injuries per 100,000 and streams of our great land, average length of stay of seven participants, whereas football there would be a significant risk days, an intensive care unit was rated at 2,740 injuries per of unintentional injury from a length of stay of just more than 100,000 participants. Individuals fellow hunter. After all, the only one day, and average charges who participate in this outdoor thing separating the game from close to $31,000. Of those in- activity should be encouraged the hunters is their bright, blaze jured while hunting who were to shoot responsibly and be orange hat and/or vest, which tested for drugs, almost one in reminded to wear their blaze are mandated by law in many three tested positive. Roaming orange cap—and “a-hunting we states. the woods with a loaded gun will go.” In order to examine the oc- should be a drug-free activity! Throughout the year, we currence of these injuries in the These data are depicted in the will be highlighting these data National Trauma Data BankTM figure on this page. through brief monthly reports Annual Report 2004,e w used For drug-impaired hunters, in the Bulletin. The full NTDB cause of injury codes (E codes) even 400 square inches of blaze Annual Report Version 4.0 is for place of injury E849.4 and orange material may not be suf- available on the ACS Web site E849.8, which relate to inju- ficient to separate the hunter as a PDF file and a PowerPoint ries occurring at a place for from the hunted. Limited na- presentation at http://www.ntdb. recreation and sport or other tional statistics are available org. If you are interested in sub- specified places (for example, a for hunting injuries but appear mitting your trauma center’s forest, lake, or mountain) and to demonstrate that hunting is data, contact Melanie L. Neal, cross-referenced with E codes relatively safe—that is, unless Manager, NTDB, ta mneal@ for cause of injury E922.1 and you are the 12-point buck in facs.org. 44

VOLUME 90, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS