MAY 2018 | VOLUME 103 NUMBER 5 | AMERICAN COLLEGE of SURGEONS Bulletin Contents

MAY 2018 | VOLUME 103 NUMBER 5 | AMERICAN COLLEGE OF SURGEONS Bulletin Contents

FEATURES COVER STORIES: Implementing WHA 68.15: A global update 15 Cross-cutting health: Global surgery, obstetrics, anesthesia, and the World Health Organization 16 Rachel W. Davis, MD, and Walter D. Johnson, MD, MPH, MBA, FACS, FAANS

Countries and colleges collaborate to improve access in Oceania and Southeast Asia 21 David A. Watters, OBE, ChM, FRCSEd, FRACS; Lord Viliami Tangi, MB, BS, FRACS; Glenn Douglas Guest, MB, BS, FRACS; John Batten, MB, BS, FRACS; Stephen J. Robson, BMedSc, MB, BS, MM, MPH, MD, FRANZCOG, FRCOG; David A. Scott, MB, BS, FANZCA; and Michael G. Cooper, MB, BS, FANZCA, FFPMANZCA

The Royal Colleges of Surgeons in the U.K. and Ireland: | 1 A common vision for global surgery 31 The Royal Colleges of Surgeons in the U.K. and Ireland

COSECSA collaborates to address surgical shortages in sub-Saharan Africa 41 Miliard Derbew, MD, FRCS, FCS(ECSA)

WFSA describes its vision for implementation of WHA 68.15 44 Julian Gore-Booth, MA; Jannicke Mellin-Olsen, MD; Wayne W. Morriss, BS, MB, ChB, FANZCA; Carolina Haylock-Loor, MD; Bisola Onajin-Obembe, MB, BS, MBA, FWACS; and Adrian W. Gelb, MB, ChB, FRCPC

Obstetrics and gynecology in global health: Lessons learned for advancing public health to achieve universal health care 49 Frank W. J. Anderson, MD, MPH; Lina Roa, MD; Chiara Benedetto, MD, PhD; Isabelle Citron, MB, BCh; Luis Curet, MD; Carla Eckhardt; Clark Johnson, MD, MPH; Barbara S. Levy, MD; Dereje Negussie, MD, MPH; Stephen Rulisa, MD, PhD; Rubina Sohail, MD; Rachel Spitzer, MD, MPH; Michael Stark, MD; Bellington Vwalika, MD, MSc; and Kwabena Danso, MB, ChB

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MAY 2018 BULLETIN American College of Surgeons Contents continued

FEATURES (CONTINUED) COVER STORIES (continued): West African College of Surgeons and its role in global surgery 60 Prof. King-David Terna Yawe, MD, FWACS

ACS: Global engagement for the care of the surgical patient 63 Girma Tefera, MD, FACS, and Patricia L. Turner, MD, FACS

2017 state legislative update: Lawmakers engage on MOC, trauma funding, and other issues 67 Christopher Johnson, MPP, and Christian Johnson, JD

COLUMNS From the Archives: The Great War Dr. Pellegrini receives Seattle 2 | and the evolution of plastic and Business Leaders in Health Care Looking forward 12 reconstructive surgery 80 Lifetime Achievement Award 95 David B. Hoyt, MD, FACS Raymond F. Morgan, MD, DMD, FACS, ABS announces details of What surgeons should know about... and Elizabeth A. Morgan, MA new Continuous Certification The 2018 inpatient-only list 72 A look at The Joint Commission: Program 96 Kenneth Simon, MD, FACS Stemming the tide of violence 82 New oral histories added to the ACS Archives 97 ACS quality and safety case Carlos A. Pellegrini, MD, FACS, studies: Texas Children’s Hospital FRCSI(Hon), FRCS(Hon), FRCSEd(Hon) Coming next month in JACS and online now 97 introduces standardized protocol NTDB data points: A slice in time: to reduce pediatric baclofen pump Lower extremity compartment Making quality stick: Optimal infections 74 syndrome 85 Resources for Surgical Quality and Safety: Lifelong learning: Sandi K. Lam, MD, MBA, and Richard J. Fantus, MD, FACS, A key responsibility of the Daniel J. Curry, MD and Victoria Schlanser, DO individual surgeon 98 ACS Clinical Research Program: Duration of adjuvant therapy for NEWS MEETINGS CALENDAR stage III colon cancer: No longer Report on ACSPA/ACS activities, one size fits all 77 Calendar of events 100 February 2018 87 Jeffrey A. Meyerhardt, MD, MPH; Diana L. Farmer, MD, FACS, FRCS Judy C. Boughey, MD, FACS; and Y. Nancy You, MD, MHSc, FACS Members in the news 93

V103 No 5 BULLETIN American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient CLINICAL and to safeguarding standards of care in an optimal and ethical practice environment. CONGRESS 2018 The Best Surgical Education. All in One Place.

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Bulletin of the American College of Surgeons (ISSN 0002-8045) is without charge up to 72 hours prior to arrival. published monthly by the American College of Surgeons, 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295. It is distributed without Customer service. onPeak is your advocate for charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health hotel questions or concerns. personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, Free transportation. Enjoy free shuttle bus MO 63043. Canadian Publications Mail Agreement No. 40035010. service between most ACS-contracted hotels Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at and the Boston Convention Center. 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295; tel. 312- 202‑5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. facs.org/clincon2018/hotel Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2018 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

2018_CC_Bulletin_HalfPage_onPeak_3.75x9.83in_v01.indd 1 3/12/2018 2:04:30 PM Officers and Staff of the American College of Surgeons

James K. Elsey, MD, FACS Christian Shalgian Officers Atlanta, GA Advisory Council Director Henri R. Ford, MD, FACS AMERICAN COLLEGE OF Barbara L. Bass, MD, FACS Los Angeles, CA to the Board SURGEONS FOUNDATION Houston, TX Gerald M. Fried, MD, FACS, FRCSC of Regents Shane Hollett PRESIDENT Executive Director Courtney M. Townsend, Jr., Montreal, QC (Past-Presidents) James W. Gigantelli, MD, FACS ALLIANCE/AMERICAN MD, FACS Kathryn D. Anderson, MD, FACS COLLEGE OF SURGEONS Galveston, TX Omaha, NE Eastvale, CA CLINICAL RESEARCH PROGRAM IMMEDIATE PAST-PRESIDENT B. J. Hancock, MD, FACS, FRCSC W. Gerald Austen, MD, FACS Kelly K. Hunt, MD, FACS Charles D. Mabry, MD, FACS Winnipeg, MB Boston, MA Chair Pine Bluff, AR Enrique Hernandez, MD, FACS FIRST VICE-PRESIDENT L. D. Britt, MD, MPH, CONVENTION AND MEETINGS Philadelphia, PA FACS, FCCM Robert Hope Basil A. Pruitt, Jr., MD, Lenworth M. Jacobs, Jr., MD, FACS Norfolk, VA Director FACS, FCCM, MCCM Hartford, CT San Antonio, TX John L. Cameron, MD, FACS DIVISION OF EDUCATION SECOND VICE-PRESIDENT L. Scott Levin, MD, FACS Baltimore, MD Ajit K. Sachdeva, MD, Philadelphia, PA Edward M. Copeland III, MD, FACS FACS, FRCSC Edward E. Cornwell III, Director MD, FACS, FCCM Fabrizio Michelassi, MD, FACS Gainesville, FL Washington, DC New York, NY A. Brent Eastman, MD, FACS EXECUTIVE SERVICES SECRETARY Linda G. Phillips, MD, FACS Rancho Santa Fe, CA Maxine Rogers Director, Leadership Operations William G. Cioffi, Jr., MD, FACS Galveston, TX Gerald B. Healy, MD, FACS Providence, RI Wellesley, MA FINANCE AND FACILITIES TREASURER Anton N. Sidawy, MD, FACS Washington, DC Gay L. Vincent, CPA David B. Hoyt, MD, FACS R. Scott Jones, MD, FACS Director Chicago, IL Beth H. Sutton, MD, FACS Charlottesville, VA Wichita Falls, TX HUMAN RESOURCES 4 | EXECUTIVE DIRECTOR Edward R. Laws, MD, FACS AND OPERATIONS Gay L. Vincent, CPA Gary L. Timmerman, MD, FACS Boston, MA Michelle McGovern Chicago, IL Sioux Falls, SD LaSalle D. Leffall, Jr., MD, FACS Director CHIEF FINANCIAL OFFICER Steven D. Wexner, MD, FACS Washington, DC INFORMATION TECHNOLOGY Weston, FL LaMar S. McGinnis, Jr., MD, FACS Brian Harper Douglas E. Wood, MD, Atlanta, GA Director Officers-Elect FACS, FRCSEd David G. Murray, MD, FACS DIVISION OF INTEGRATED (take office October 2018) Seattle, WA Syracuse, NY COMMUNICATIONS Michael J. Zinner, MD, FACS Patricia J. Numann, MD, FACS Lynn Kahn Ronald V. Maier, MD, FACS Coral Gables, FL Director Seattle, WA Syracuse, NY PRESIDENT-ELECT Carlos A. Pellegrini, MD, FACS JOURNAL OF THE AMERICAN Seattle, WA COLLEGE OF SURGEONS Mark C. Weissler, MD, FACS Board of Timothy J. Eberlein, MD, FACS Chapel Hill, NC J. David Richardson, MD, FACS Editor-in-Chief FIRST VICE-PRESIDENT-ELECT Governors/ Louisville, KY Philip R. Caropreso, MD, FACS DIVISION OF MEMBER SERVICES Executive Richard R. Sabo, MD, FACS Patricia L. Turner, MD, FACS Iowa City, IA Bozeman, MT SECOND VICE-PRESIDENT-ELECT Committee Director Seymour I. Schwartz, MD, FACS M. Margaret Knudson, MD, FACS Diana L. Farmer, MD, FACS, FRCS Rochester, NY Sacramento, CA Medical Director, Military Health Board of Regents CHAIR Frank C. Spencer, MD, FACS Systems Strategic Partnership Steven C. Stain, MD, FACS New York, NY Girma Tefera, MD, FACS Leigh A. Neumayer, MD, FACS Albany, NY Andrew L. Warshaw, MD, FACS Director, Operation Giving Back Tucson, AZ VICE-CHAIR Boston, MA CHAIR PERFORMANCE IMPROVEMENT Daniel L. Dent, MD, FACS Will Chapleau, RN, EMT-P Marshall Z. Schwartz, MD, FACS San Antonio, TX Director Philadelphia, PA SECRETARY VICE-CHAIR Executive Staff DIVISION OF RESEARCH AND Terry L. Buchmiller, MD, FACS Anthony Atala, MD, FACS EXECUTIVE DIRECTOR OPTIMAL PATIENT CARE Boston, MA David B. Hoyt, MD, FACS Clifford Y. Ko, MD, Winston-Salem, NC MS, MSHS, FACS Therese M. Duane, MD, DIVISION OF ADVOCACY John L. D. Atkinson, MD, FACS MBA, CPE, FACS, FCCM Director Rochester, MN AND HEALTH POLICY Fort Worth, TX Frank G. Opelka, MD, FACS David P. Winchester, MD, FACS James C. Denneny III, MD, FACS Nicole S. Gibran, MD, FACS Medical Director, Quality Medical Director, Cancer Alexandria, VA Seattle, WA and Health Policy Ronald M. Stewart, MD, FACS Margaret M. Dunn, MD, FACS David A. Spain, MD, FACS Patrick V. Bailey, MD, MLS, Medical Director, Trauma Dayton, OH Stanford, CA FACS Timothy J. Eberlein, MD, FACS David J. Welsh, MD, FACS Medical Director, Advocacy St. Louis, MO Batesville, IN

V103 No 5 BULLETIN American College of Surgeons Author bios*

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

a b c

d e f | 5

g h i

PROF. ALDERSON (a) is emeritus DR. BOUGHEY (e) is professor of DR. COOPER (h) is senior anaesthetist, professor of surgery, University of surgery, division of breast, endocrine, Children’s Hospital at Westmead and St. Birmingham, U.K., and president, Royal metabolic, and gastrointestinal surgery; George’s Hospital, Sydney, Australia; adjunct College of Surgeons of England. and vice-chair of research, department professor of anaesthesiology, school of of surgery, Mayo Clinic, Rochester, medicine and health sciences, University of DR. ANDERSON (b) is professor, department MN. She is Chair, American College of Papua, New Guinea; and chair, paediatric of obstetrics and gynecology (OB/GYN) Surgeons Clinical Research Program anaesthesia committee, World Federation and director, global initiatives, OB/GYN (ACS CRP) Education Committee. of Societies of Anaesthetists (WFSA). department, University of Michigan, Ann Arbor. PROF. BRUGHA (f) is head, department of DR. CURET (i) is professor emeritus, DR. BATTEN (c) is president, Royal Australasian epidemiology and public health medicine, department of obstetrics and gynecology, College of Surgeons (RACS), and general Royal College of Surgeons in Ireland (RCSI), University of New Mexico, Albuquerque. orthopaedic surgeon, Tasmania, Australia. and coordinator, Clinical Officer Surgical He is past-chairman, New Mexico section DR. BENEDETTO Training in Africa (COST-Africa) project. and district 8, American College of (d) is professor, Obstetricians and Gynecologists (ACOG). department of gynecology and obstetrics, DR. CITRON (g) is a surgical resident He is past-coordinator, ACOG’s CAFA and head, University Division 1, St. Anna and fellow, Program in Global Surgery (Comité de Acreditación Federation of Hospital, Torino, Italy; and director, school and Social Change (PGSSC), Harvard Central American Associations and Societies of specialization, University of Torino. Medical School, Boston, MA. of Obstetrics and Gynecology-ACOG). She is chair, committee for women’s health and human rights, International Federation of Gynaecology and Obstetrics. continued on next page

MAY 2018 BULLETIN American College of Surgeons Author bios continued

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DR. CURRY (j) is associate professor, DR. DERBEW (m) is professor of pediatric DR. FARMER (p) is a pediatric surgeon, department of neurosurgery, Baylor surgery; consultant pediatric surgeon; and Pearl Stamps Stewart Professor, and chair, College of Medicine, section of pediatric medical education partnership initiative junior department of surgery, University of neurosurgery, Texas Children’s Hospital; faculty project principal investigator, school California Davis, Health System, Sacramento. and director, pediatric surgical epilepsy of medicine, College of Health Sciences, She is Chair, ACS Board of Governors. and functional neurosurgery, Texas Addis Ababa University, Ethiopia. He is Children’s Hospital, Houston. past-president, College of Surgeons of East, MR. FERGUSSON (q) is specialty registrar, Central and Southern Africa (COSECSA). general surgery, Royal Alexandra Hospital, DR. DANSO (k) is professor, department of Paisley, U.K.; honorary clinical lecturer, obstetrics and gynecology, Kwame Nkrumah MS. ECKHARDT (n) is clinic administrator, University of Glasgow, Scotland; and Scottish University of Science and Technology, implementation and operations specialist, and Clinical Leadership Fellow, 2016–2017. School of Medical Sciences, and consultant senior director, Global Women’s Health, ACOG. obstetrician/gynecologist, Komfo Anokye DR. GAJEWSKI (r) is a health sociologist Teaching Hospital, Kumasi, Ghana. DR. FANTUS (o) is vice-chairman, and former lead researcher, COST-Africa. department of surgery; medical director, At present, he is working on the Scaling DR. DAVIS (l) is a global surgery fellow, trauma services; and chief, section of surgical up Safe Surgery for District and Rural Michael E. DeBakey Department of Surgery, critical care, Advocate Illinois Masonic Populations in Africa (SURG-Africa) project Baylor College of Medicine, Houston, TX. Medical Center, Chicago. He is clinical in Malawi, Zambia, and Tanzania. professor of surgery, University of Illinois College of Medicine, Chicago, and Past- continued on next page Chair, ad hoc Trauma Registry Advisory Committee, ACS Committee on Trauma.

V103 No 5 BULLETIN American College of Surgeons Author bios continued

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PROF. GALLOWAY (s) is president, PROF. GUEST (v) is professor of PROF. HYLAND (x) is president, RCSI. He Royal College of Physicians and Surgeons surgery, Deakin University and Epworth is professor of clinical surgery, University of Glasgow. He is honorary professor Hospital Geelong; and RACS director College Dublin, and consultant surgeon, of surgery, University of Glasgow, and of Australia Timor-Leste Assistance in St. Vincent’s University Hospital, Dublin, visiting professor of surgery, University Specialist Services, University Hospital Ireland. He is past-president, Association of of Malaya, Kuala Lumpur, Malaysia, and Geelong, Victoria, Australia. Coloproctology of Great Britain and Ireland the Chinese University of Hong Kong. and the Irish Society of Gastroenterology. DR. HAYLOCK-LOOR (w) is medical DR. GELB (t) is secretary, board of directors, director, interventional pain unit, and staff MR. CHRISTIAN JOHNSON (y) is State WFSA. He also is board secretary, Global member, department of anesthesiology and Affairs Associate, ACS Division of Advocacy Alliance for Surgical, Obstetric, Trauma, intensive care, Hospital del Valle, San Pedro and Health Policy, Washington, DC. and Anaesthesia Care (G4 Alliance), and is Sula; and assistant professor, anesthesiology the Edward Dickinson Emeritus Professor, residency program, Tegucigalpa, Honduras. MR. CHRISTOPHER JOHNSON (z) University of California, San Francisco. She is a WFSA council member and a is State Affairs Associate, ACS Division past-elected member of the board. of Advocacy and Health Policy. MR. GORE-BOOTH (u) is chief executive officer, WFSA. Prior to continued on next page joining the WFSA, he worked for the Red Cross and the United Nations.

MAY 2018 BULLETIN American College of Surgeons Author bios continued

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DR. CLARK JOHNSON (aa) is assistant PROF. LAYER (dd) is vice-president, DR. MELLIN-OLSEN (gg) is president- professor, maternal fetal medicine, Royal College of Surgeons of Edinburgh; elect, WFSA, and former assistant secretary department of gynecology and obstetrics, visiting professor of surgical sciences, and chair, WFSA education committee. Johns Hopkins School of Medicine, Surrey University; and specialist consultant She is consultant anaesthesiologist, Baltimore, MD. He is ACOG legislative breast and general surgeon, Royal Surrey Baerum Hospital, Sandvika, Norway. chair for Maryland, and chair, Maryland County Hospital, Guildford, U.K. He is Maternal Mortality Review Committee. a former member, Specialist Advisory DR. MEYERHARDT (hh) is clinical Committee in General Surgery of the director, Gastrointestinal Cancer DR. WALTER JOHNSON (bb) is lead, Joint Colleges, U.K.; Governor of the ACS; Center; deputy clinical research officer Emergency and Essential Surgical and chair, Intercollegiate Committee and Douglas Gray Woodruff Chair in Care Programme, World Health on Professional Development. Colorectal Cancer Research, Dana-Farber Organization, Geneva, Switzerland. Cancer Institute, Boston; and associate DR. LEVY (ee) is vice-president, professor of medicine, Harvard Medical DR. LAM (cc) is associate professor, health policy, ACOG. School. He is co-chair, Gastrointestinal department of neurosurgery, Baylor Cancer Committee for Alliance. College of Medicine, section of pediatric MS. MANGAOANG (ff) is assistant neurosurgery, Texas Children’s programme director, RCSI/COSECSA DR. MORGAN (ii) is Milton T. Edgerton Hospital; faculty affiliate, Baylor Center Collaboration Programme, Dublin. Professor, department of plastic surgery, for Ethics and Health Policy; and University of Virginia, Charlottesville. faculty advisor, Texas Medical Center Innovation Institute, Houston. continued on next page

V103 No 5 BULLETIN American College of Surgeons Author bios continued

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MS. MORGAN (jj) is a freelance MR. O’FLYNN (mm) is programme director, DR. ROA (pp) is a research fellow, writer, Winchester, VA. RCSI/COSECSA Collaboration Programme. PGSSC, Harvard Medical School, and a resident, obstetrics and gynecology, DR. MORRISS (kk) is consultant DR. ONAJIN-OBEMBE (nn) is consultant University of Alberta, Edmonton. anesthesiologist, Christchurch Hospital, New anesthesiologist, University of Port Harcourt Zealand. He is director of programs, WFSA Teaching Hospital, and assistant professor of PROF. ROBSON (qq) is associate professor, board. He is active in overseas development anaesthesia, College of Health Sciences of the Australian National University, John James work with the New Zealand Society of University of Port Harcourt, Nigeria. She is Medical Centre, Deakin, Australia; and Anaesthetists, the Australian Society of president, Nigerian Society of Anaesthetists; president, Royal Australian and New Zealand Anaesthetists, and the Australian and New council member, WFSA; and past president, College of Obstetricians and Gynaecologists. Zealand College of Anaesthetists (ANZCA). Africa regional section, WFSA. She is Bellagio Commissioner, The Lancet Commission DR. RULISA (rr) is professor, department DR. NEGUSSIE (ll) is consultant obstetrician, on Global Surgery, and permanent council of obstetrics and gynecology, and dean, gynecologist, and senior public health secretary/director, G4 Alliance. school of medicine and pharmacy, specialist. He is immediate past-president, University of Rwanda, Kigali. Ethiopian Society of Obstetricians and DR. PELLEGRINI (oo) is chief medical Gynecologists; honorary treasurer, African officer, UW Medicine, and vice-president for continued on next page Federation of Obstetrics and Gynaecology; medical affairs, University of Washington, and vice-secretary, The Eastern, Central and Seattle. He is Past-President of the ACS. Southern Africa College of Obstetricians and Gynecologists (ECSACOG).

MAY 2018 BULLETIN American College of Surgeons Author bios continued

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DR. SCHLANSER (ss) is trauma critical DR. SOHAIL (vv) is professor, obstetrics DR. STARK (xx) is president, New care fellow, Cook County Health and and gynecology, Services Institute of European Surgical Academy, Berlin, Hospital System and Advocate Illinois Medical Sciences, Lahore, Pakistan. She Germany, and scientific advisor, Masonic Medical Center, Chicago. is president, South Asian Federation of ELSAN Hospital Group, France. Obstetrics & Gynaecology, and vice- PROF. SCOTT (tt) is director, department president, Pakistan Menopause Society. LORD TANGI (yy) is chief surgeon, Ministry of anaesthesia and acute pain medicine, of Health, Kingdom of Tonga; and President, St. Vincent’s Hospital, Fitzroy, Victoria, DR. SPITZER (ww) is vice-chair, advocacy Pacific Islands Surgical Association. Australia; and president, ANZCA. and global women’s health, department of obstetrics and gynecology, University DR. TEFERA (zz) is Medical Director, DR. SIMON (uu) is a physician surveyor, of Toronto, ON; and obstetrician and Operation Giving Back Program, ACS division of accreditation and operations, gynecologist, Mt. Sinai Hospital, Women’s Division of Member Services, Chicago, IL. The Joint Commission, Oakbrook, IL, and College Hospital, and Hospital for Sick member, ACS General Surgery Coding Children, Toronto. She is co-chair, Global continued on next page and Reimbursement Committee. Women’s Health Committee, Society of Obstetricians and Gynaecologists of Canada.

V103 No 5 BULLETIN American College of Surgeons Author bios continued

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PROF. TIERNEY (aaa) is professor of PROF. WATTERS (ddd) is the Alfred Deakin DR. YOU (fff) is associate professor, surgical informatics and dean of professional Professor, Deakin University and Barwon section of colorectal surgery, department development and practice, RCSI. Health University Hospital Geelong, Victoria, of surgical oncology; and medical director, Australia; and past-president, RACS. Familial High Risk Gastrointestinal Cancer DR. TURNER (bbb) is Director, ACS Clinic, University of Texas MD Anderson Division of Member Services. PROF. YAWE (eee) is consultant breast Cancer Center, Houston. She is Vice- and endocrine surgeon, University of Chair, ACS CRP Education Committee. DR. VWALIKA (ccc) is associate Abuja and University of Abuja Teaching professor, department of obstetrics and Hospital, Nigeria. He is president, gynecology, and head, department of West African College of Surgeons. obstetrics and gynecology, University of Zambia School of Medicine, Lusaka. He is secretary general, ECSACOG.

MAY 2018 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

he feature section of this issue of the Bulletin focuses largely on global efforts to improve access Tto surgical, obstetric, and anesthesia care, and I am proud to say it will be distributed at the World Health Assembly (WHA) 71, May 21−26 in Geneva, Switzerland. The idea for this special issue originat- ed with John G. Meara, MD, DMD, MBA, FACS, co- chair of The Lancet Commission on Global Surgery (LCoGS); director, Program in Global Surgery and Social Change, Harvard Medical School, Boston; and chair, department of plastic and oral surgery, Boston Children’s Hospital, MA, in collaboration with Gir- ma Tefera, MD, FACS, Director, American College of Surgeons (ACS) Operation Giving Back program. In this issue, you will find a collection of provocative and informative articles submitted by professional societies and colleges from around the world. These ar- 12 | ticles highlight not only the organizations’ important efforts, but also their recommendations for moving forward and a call to action for the surgery, obstetrics, and anesthesia communities to work together toward a common goal of universal access to safe, affordable essential care. Both Dr. Meara and Dr. Tefera worked tirelessly to solicit articles from the leaders of the organizations that have committed to this goal. My hat is off to them.

Watershed moments Efforts to promote access to surgical care as essential to the well-being of all people began in 1980, when Halfdan Mahler, MD, then director-general of the World Health Organization (WHO), addressed the XXII Biennial World Congress of the International College of Surgeons with his lecture Surgery and Health for All. In a speech that was ahead of its time, Dr. Mahler alluded to the Alma-Ata International Conference, calling for health equity and social justice, and, most notably, for the inclusion of surgical care in the pursuit of health care for all. Including surgery in the realm of global health was somewhat of an anathema at that time. What ensued after his bold speech was relative silence—a 28-year lapse in the development of global surgery policy.

V103 No 5 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

In this issue, you will find a collection of provocative and informative articles submitted by professional societies and colleges from around the world.

The standstill ended in 2008, when Paul E. Farmer, The final watershed moment occurred during the MD, PhD, Kolokotrones University Professor, Global WHA in May 2015 with the adoption of Resolution Health and Social Medicine, Harvard Medical School, 68.15, a formal WHO declaration and commitment to and Jim Yong Kim, MD, PhD, president of The World “emergency and essential surgical care and anesthesia Bank, called surgery “the neglected stepchild of global as a component of universal health coverage.”5 This health” in their article, “Surgery and global health: resolution was a call for all Member States to commit A view from beyond the OR.”2 This vivid metaphor to the following actions: brought to the forefront the reality that in low- and middle-income countries, access to surgical care elud- • Develop adequate infrastructure and equipment in ed the poor, yet for decades the public health com- district hospitals munity had written off surgical care as expensive and unnecessary. Drs. Farmer and Kim countered these • Train appropriate surgical health care workforce arguments with data and drove home the message that without a holistic approach to health system strength- • Ensure surgical information management for data to ening—a paradigm shift from the age-old vertical ap- drive informed health policy | 13 proach to siloed, disease-specific global programs— health care equity and social justice were unattainable. • Provide essential medicines and medical devices The tipping point for global surgery, obstetrics, and anesthesia occurred in 2015. Three events aligned • Mobilize adequate financial resources to surgical that focused the global health community on surgi- service delivery cal care. The third edition of The World Bank’s Dis- ease Control Priorities (DCP3) was published in early • Avoid catastrophic expenditures by citizens on 2015, and the first of nine volumes was devoted to surgical services “Essential Surgery.”3 DCP3 made a strong case for the cost-effectiveness of basic surgical procedures in low- • Improve referral systems resource settings, identified district hospitals as key to providing acute and lifesaving surgical care, and The WHO made a permanent commitment to sur- proposed a list of 44 essential operations to prioritize gery in 2017 with WHA Decision Point 70.22, which in scaling up surgical systems. required submission of biennial progress reports on the Later that same year, the LCoGS released a report status of global surgery to the WHO director-general. that defined the extent of global surgical need and quantified the human and financial implications of inaction. The report also outlined a surgical, obstet- Looking to the future ric, and anesthesia planning process that would allow We are now in an era in which global health care is Ministries of Health to map national needs and plan defined by sustainable development goals (SDGs), with system-level interventions. Finally, the commission a renewed focus on universal health coverage and an proposed a set of six key performance indicators to acknowledgment of health care as a human right.6 In enable standardized global assessments of surgical the context of the SDGs and WHA 68.15, countries systems and to track the progress of health system have a mandate to acknowledge access to safe, afford- strengthening programs that included surgical, an- able surgical, obstetric, and anesthesia care as part of esthesia, and obstetric care.4 this right.

MAY 2018 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

The WHO also has a new director-general—Tedros REFERENCES Adhanom Ghebreyesus, PhD, MSc—a proven health 1. Mahler H. Surgery and Health for All. Address from the care reformer from Ethiopia who enthusiastically director-general, World Health Organization, to the XXII welcomes surgery, anesthesia, and obstetrics to the Biennial World Congress of the International College of global health care community. With the recognition Surgeons, Mexico City, Mexico, June 1980. 2. Farmer PE, Kim JY. Surgery and global health: A view from of surgery and anesthesia as an integral component beyond the OR. World J Surg. 2008;32(4):533-536. of universal health coverage, data collection systems 3. Debas HT, Donkor P, Gawande A, Jamison T, Kruk M, and national surgical, obstetric, and anesthesia plans Mock CN (eds). Disease Control Priorities, Third Edition: (NSOAPs) are critical next steps in surgical system Volume 1. Essential Surgery. Washington, DC: World Bank; strengthening. Managing complex health systems re- 2015. Available at: http://dcp-3.org/surgery. Accessed April 12, 2018. quires measurement, and national surgical data that 4. Meara JG, Leather AJM, Hagander L, et al. Global Surgery is beginning to be collected must flow each year from 2030: Evidence and solutions for achieving health, welfare, Ministers of Health to WHO to The World Bank to and economic development. Lancet. 2015;386(9993):569-624. promote transparent accountability. NSOAPs need 5. World Health Organization. World Health Assembly 14 | to be created and integrated into national health care Resolution 68.15: Strengthening emergency and essential 7 surgical care and anaesthesia as a component of universal agendas. health coverage. Sixty-Eighth World Health Assembly. The concept of surgery as a vertical program is Available at: http://apps.who.int/gb/ebwha/pdf_files/ gone. Surgery, anesthesia, and obstetrics harmonious- WHA68/A68_R15-en.pdf. Accessed March 20, 2018. ly woven into national health and wellness planning 6. United Nations. Sustainable development goals. Available efforts must become the norm. The implementation at: www.un.org/sustainabledevelopment/sustainabledevelopment-goals/. Accessed March 19, 2018. of these plans will need solid financial support that 7. Harvard Medical School Program in Global Surgery and likely will stem from new funding models, includ- Social Change. National Surgical, Obstetrics and Anesthesia ing a symbiotic partnership between the private and Planning. Available at: www.pgssc.org/national-surgical- public sectors, as seen with The World Bank’s new planning. Accessed March 19, 2018. Global Financing Facility.8 8. World Bank Group. Global Financing Facility. Available at: All of these changes bring about new opportuni- www.globalfinancingfacility.org/. Accessed March 19, 2018. ties. In recognition of the responsibility we as clinician- advocates have of supporting health equity and social justice, the ACS is pleased to offer this issue of the Bul- letin for dissemination at the WHA 71. We wish you all a productive and fruitful meeting that will lead to improved health care for surgical patients around the world. ♦

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

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MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

Cross-cutting health: Global surgery, obstetrics, anesthesia, and the World Health Organization

by Rachel W. Davis, MD, and Walter D. Johnson, MD, MPH, MBA, FACS, FAANS

16 | It is no secret that surgery has often been left HIGHLIGHTS behind in this competitive arena. Often considered too complex and expensive, surgical care (surgery, obstet- • Describes four pivotal events in 2015 that rics, and anesthesia) has been dismissed as a public established the need for access to surgical health challenge only achievable after all other sys- and anesthesia care around the world tems have been built. But financial support of surgery • Identifies the five WHA 68.15 areas of cannot be responsibly deferred and should be viewed focus aimed at providing necessary by Ministries of Health as an investment, rather than surgical and anesthesia care a cost. Improved access to quality surgical, obstetrical, • Outlines the 2017 WHA Decision 70.22, and anesthesia care should not be treated as merely a which calls for continued biennial reporting consequence, but rather as a driver of general health of emergency and essential surgery care needs. and anesthesia by Member States • Highlights the goals of five WHO collaborating centers and their role in increasing access Background: Improving access to surgical and anesthesia care to surgical care worldwide The World Health Organization (WHO) is the health care arm of the United Nations (UN). Since the WHO e are fragmented as a world. We are split was first established in 1948, the organization has among hundreds of nations, even more eth- committed itself to the improvement of health Wnicities, and seemingly innumerable political around the globe, seeking to bridge the fragmenta- ideologies. Our health care, too, is fragmented, sliced tion created by geographic and political boundaries into organ systems, disease categories, and regions to promote wellness for all. But despite its best inten- of anatomy. Priorities for achieving health vary as tions, efforts may have suffered from a myopic focus well, often favoring those problems that readily on specific aspects of health care—a vertical approach engage our empathy, are visually striking, or carry to providing care—that have been deemed as most the greatest funding. urgent and most achievable.

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It is imperative that we no longer neglect surgical financial data, the publication makes a clear assertion care when approaching overall public health pro- that “the large burden of surgical conditions, the cost grams. With robust economic, political, and needs effectiveness of essential surgery, and strong public data documented in the literature, researchers have demand for surgical services suggest that universal amplified the evidence that an investment in surgery coverage of essential surgery should be financed early and anesthesia is both a health care and economic on the path to universal health coverage.”2 necessity. Providing timely access to safe and afford- The third event occurring that year was the pub- able surgical and anesthesia care to the 5 billion lication of the “Global Surgery 2030: Evidence and people without access worldwide not only curbs the solutions for achieving health, welfare, and eco- detrimental consequences of surgical disease, it also nomic development” report (GS 2030) by The Lancet boosts financially emerging economies and bolsters Commission on Global Surgery (LCoGS).3 A collab- infrastructure. orative effort by representatives from more than 110 In 2015, through the combination of four major countries, GS 2030 presents a robust economic case events that occurred in quick succession, international for global investment in surgical care, as well as an demand for increasing surgical access gained signifi- overwhelming needs case for surgical and anesthesia cant momentum. In the span of months, the economic, care delivery. The LCoGS estimates that surgical con- | 17 political, and needs cases for prioritizing global surgery ditions are responsible for roughly 30 percent of the and anesthesia became clearly and publicly established. global burden of disease and that 5 billion people do The first crucial event was the UN transition from not have timely access to safe and affordable surgical the millennium development goals to the era of sus- and anesthesia care.3 The report calls for an increase tainable development. The 17 sustainable development in surgical care to meet a goal of 80 percent coverage goals (SDGs)1 are notable for their specific inclusion of essential surgical services by 2030, including 5,000 of a number of surgical issues, specifically eight of procedures per 100,000 population and 100 percent the targets listed within SDG 3: “Ensure healthy lives of countries exceeding 20 surgical, anesthesia, and and promote well-being for all at all ages.” Many of obstetric licensed providers per 100,000 population. the itemized health targets directly involve surgically In addition, a data target was set for tracking periop- treatable disease, such as the reduction of maternal and erative mortality rate of 80 percent of countries by neonatal mortality, death from road traffic accidents, 2020 and 100 percent by 2030. and premature mortality from noncommunicable dis- The LCoGS also investigated the monetary con- ease (NCD). sequences for patients accessing surgical care, and A second critical occurrence in 2015 was the publi- as a result of that study seeks 100 percent protection cation of Essential Surgery,2 the first volume of the third globally against impoverishing and catastrophic out- edition of Disease Control Priorities (DCP3). Published of-pocket expenditures for surgical and anesthesia care by The World Bank, Essential Surgery establishes an by 2030. The LCoGS asserts that a critical investment economic and financial case for investment in surgical of $350 billion (U.S.) until 2030 will prevent estimated care. In addition, it specifically highlights 44 individual losses of $12.3 trillion (U.S.) during this time in lost basic and essential surgical procedures that are cost- productivity and health care expenses. effective, deliverable, and address significant global The fourth turning point that occurred in 2015 need. The authors assert that providing essential sur- was the unanimous passage of the World Health gery would prevent an estimated 1.5 million deaths Assembly (WHA) Resolution 68.15,4 which calls for annually, while providing a financial benefit-to-cost strengthening of emergency and essential surgical ratio of investment exceeding 10:1. With detailed care and anesthesia as a component of universal

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

Establishment of an adequate surgical and anesthesia workforce in LMICs requires not only an increase in workforce volume, but also an enhancement of training programs, increased efforts by credentialing bodies, and possibly support by mid-level providers.

health coverage. This landmark resolution for surgi- the overwhelming need for surgeons, anesthesiolo- cal prioritization emphasizes that a significant portion gists, and obstetrician/gynecologists. of the global burden of disease can be successfully A second essential focus of WHA 68.15 is informa- treated with surgical intervention and specifically notes tion management. The WHO list of 100 Core Health the beneficial effect of surgery on morbidity and mor- Indicators provides a starting place for data collection tality rates due to obstructed labor, cancer, road traffic in the areas of health status, risk factors, service cover- accidents, and violence, all of which disproportionately age, and health systems. This list includes the LCoGS affect low- and middle-income countries (LMICs). six surgical indicators, as follows:

• Perioperative mortality rate WHA 68.15 WHA 68.15 identifies five key surgical areas of focus: • Total surgical volume surgical and anesthesia workforce, information management, service delivery, essential medicines, and • Geographic access of surgical facility advocacy and resource development. Establishment 18 | of an adequate surgical and anesthesia workforce in • Licensed surgical, obstetric, and anesthesia health LMICs requires not only an increase in workforce workforce density volume, but also an enhancement of training programs, increased efforts by credentialing bodies, • Catastrophic surgical and anesthesia care-related and possibly support by mid-level providers. Meet- expenditures ing these workforce needs worldwide relies heavily on strong partnerships between regional surgical • Impoverishing expenditures organizations and professional societies, as well as the development of mutually beneficial twinning All of these indicators, taken together, allow for partnerships. The leadership of associations—such more accurate needs assessment by location and as the College of Surgeons of East, Central and South- ability to track improvements or changes in surgi- ern Africa (COSECSA); the West African College of cal capacity.3 Surgeons; the Royal Colleges in the U.K., Ireland, Improved data collection facilitates quality ser- and Australasia; and the American College of Sur- vice delivery. In highlighting service delivery, WHA geons, among others—is foundational for building 68.15 acknowledges that surgical access must not be and maintaining a skilled surgical global workforce. confined to urban centers. Often limited by geo- In addition, Ministries of Health, Finance, and Educa- graphic boundaries, transportation infrastructure, tion are key partners, uniting involved governmental and insufficient health care providers and facili- and nongovernmental organizations (NGOs) toward ties, the accessibility of care is a significant barrier common goals. In collaboration with regional societ- to treatment of surgical disease. To reduce delay in ies and governments, NGOs also provide training for surgical access, improvement in systems integration medical professionals. One example is the Pan-African is a necessity. Academy of Christian Surgeons, which, through an A fourth major aim of WHA 68.15 is to emphasize affiliation with COSECSA and Loma Linda University, the need for access to essential medicines. Though CA, has provided residency training to more than 100 often restricted by governmental agencies due to a surgeons across Africa. Teamwork and communica- potential for abuse, narcotic medications and anes- tion between these organizations is critical to meet thetics such as ketamine are crucial for the daily,

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sustained function of surgical systems, particularly one of the first countries to develop an NSOAP that in resource-limited settings. Appropriate anesthesia is fully embedded in the National Health Strategic during surgical interventions and quality pain con- Plan 2017–2021.7 Subsequently, numerous Member trol both for the acute postoperative setting and for States have begun preparing and designing their long-term palliative care for adults and children are own national plans. High demand for strategic integral to the total spectrum of surgical disease man- NSOAPs soon exceeded capacity for individual agement and treatment. With necessary safeguards country-specific development. In partnership with in place to limit illegal use, these essential medicines the Harvard Program in Global Surgery and Social must be made available for appropriate access to sur- Change (PGSSC), Boston, MA, the WHO Emer- gical patients. gency and Essential Surgical Care (EESC) program Finally, the resolution highlights advocacy and has begun to plan multiple regional workshops to resource development. With a staggering global assist Member States and encourage groups to share burden of disease and disproportionately poor avail- their successes and challenges so that each may learn ability of financial and human resources, surgical, from the experiences of others. obstetric, and anesthesia care is in great need of WHO continues to bring together countries of international champions. To adequately improve varying resource levels and contexts in collaboration | 19 access to care requires a global effort by physicians, toward quality health care for all people. Strate- patients, government agents, economists, epidemi- gies for achieving this goal are ever-evolving in ologists, and those in the public eye. Advocacy efforts response to changing needs and data, but always by these key stakeholders is essential for building the rely on healthy partnerships and international com- capacity of essential surgical and anesthesia service munication. The diplomatic involvement of the UN delivery to all. permanent mission health attachés in advocating for surgical access to political, business, educational, and trade organizations remains vital. WHO today In addition, WHO has approved five official col- As we further develop strategies for global surgical laborating centers (CCs), each dedicated to particular development, continuation of accurate and thorough niches of research and expertise in surgical care data collection and progress reporting has become and anesthesia, and is in the process of developing increasingly vital. In 2017, WHA Decision 70.22 was three additional centers. These WHO CCs are begin- passed, calling for the continued biennial reporting ning to transition from bilateral relationships with of emergency and essential surgery and anesthesia WHO toward multilateral networks of integration progress by Member States coinciding with NCD and support. The Mongolia WHO CC is located in reporting until the expiration of the SDGs in 2030.5 a country with one of the lowest population densi- More robust data collection will allow for a more ties. It is housed within the department of surgery, detailed understanding of the status of surgical care Mongolian National University of Medical Sciences, around the world, which, in turn, will allow more Ulaanbaatar, and specializes in distance surgical edu- targeted goal setting. cation. At Lund University, Sweden, the CC focuses Member States’ desire to track improvements and on global density of surgeons, anesthesiologists, and set national goals for surgical and anesthesia care obstetricians, including migration patterns, whereas has led to the creation and popularization of the the CC located at the University of Western Ontario, National Surgical, Obstetric, and Anesthesia Plan London, is dedicated to perioperative issues and anes- (NSOAP).6 In 2017, the Republic of Zambia became thesia in low-resource settings. The Mumbai, India,

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WHO CC specializes in innovative methods for build- REFERENCES ing rural surgery capacity, and the PGSSC focuses on 1. United Nations. Sustainable development knowledge development of national surgical plans. platform. Transforming our world: The 2030 agenda The WHO EESC is in official discussions with a for sustainable development. 2015. Available at: number of NGOs, such as the International College of https://sustainabledevelopment.un.org/post2015/ transformingourworld/publication. Accessed March Surgeons, the World Federation of Societies of Anes- 13, 2018. thesiologists, the World Federation of Neurosurgical 2. Debas HT, Donkor P, Gawande A, Jamison T, Kruk Societies, the International Society of Orthopaedic Sur- M, Mock CN (eds). Disease Control Priorities, Third gery and Traumatology, and the International Federation Edition: Volume 1. Essential Surgery. Washington, DC: of Surgical Colleges. These relationships bring important World Bank; 2015. Available at: http://dcp-3.org/ surgery. Accessed April 12, 2018. global leadership, contribute vision and personnel, and 3. Meara JG, Leather AJM, Hagander L, et al. Global assist with quality improvement through educational Surgery 2030: Evidence and solutions for achieving programming. health, welfare, and economic development. Lancet. 2015;386(9993):569-624. 4. World Health Organization. World Health Assembly 20 | Resolution 68.15: Strengthening emergency Conclusion and essential surgical care and anaesthesia as a The WHO strives to bridge the fragmented relationship component of universal health coverage. Sixty- between medicine and politics to achieve quality health Eighth World Health Assembly. Available at: http:// care for all. By responding to medical needs, convening apps.who.int/gb/ebwha/pdf_files/WHA68/A68_ international partners, and leading worldwide initiatives, R15-en.pdf. Accessed March 20, 2018. 5. World Health Organization. World Health Assembly WHO works to meet health care challenges on both a Resolution 70.22: Progress in the implementation global and local scale. It is time for global recognition of the 2030 agenda for sustainable development. of surgery and anesthesia as necessary components of Seventieth World Health Assembly. Available at: universal health care and to help the world meet the chal- http://apps.who.int/gb/ebwha/pdf_files/WHA70/ lenge of providing surgical access to its people. A70_35-en.pdf. Accessed March 20, 2018. 6. World Health Organization. Surgical care For years, anecdotal needs cases for surgery have systems strengthening: Developing national existed; we have known that access to safe surgical care surgical, obstetric and anaesthesia plans. Geneva, has not been a reality for much of the world’s popula- Switzerland: World Health Organization; 2017. tion. But with the impact of the LCoGS and DCP3 now Available at: www.who.int/surgery/publications/ showing the depth of the economic case and the WHA scss/en/. Accessed March 20, 2018. 7. Republic of Zambia Ministry of Health. National resolution and transition to SDGs demonstrating the Surgical, Obstetric, and Anaesthesia Strategic Plan political case, we are able to see the full extent of the (NSOASP): Year 2017–2021. Available at: www. need for access to quality surgery, and obstetric and anes- cosecsa.org/sites/default/files/NSOAP_May%20 thesia care. We now know that it is critical to integrate 2017.pdf. Accessed March 6, 2018. and promote all aspects of surgery—including pediatric surgery, orthopaedics, urology, obstetrics, gynecology, neurosurgery, and many others —to improve global health infrastructure and well-being. In collaboration with governments and NGOs around the world, the WHO EESC program will continue working for safe, timely, and affordable surgical and anesthesia care until it is available to all people, everywhere. ♦

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HIGHLIGHTS • Summarizes collaborative programs that enhance access to surgical care in the Asia-Pacific • Describes how the Asia-Pacific is responding to WHA Resolution 68.15, which calls for the provision of universal access to emergency and essential surgical care by 2030 • Describes the role of medical societies in generating partnerships to improve specialist medical education in this region • Outlines the work of the LCoGS specifically related to data collection and health care planning in the Pacific and Southeast Asia

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by David A. Watters, OBE, Countries and ChM, FRCSEd, FRACS; colleges collaborate Lord Viliami Tangi, MB, BS, FRACS; to improve access in Glenn Douglas Guest, MB, BS, FRACS; John Batten, MB, BS, FRACS; Oceania and Southeast Asia Stephen J. Robson, BMedSc, MB, BS, MM, MPH, MD, FRANZCOG, FRCOG; David A. Scott, MB, BS, FANZCA; and Michael G. Cooper, MB, BS, FANZCA, FFPMANZCA

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

he independent island nations of the South of Anaesthetists (ASA).6 The Royal Australian and Pacific (population 10,000–1 million each), New Zealand College of Obstetricians and Gynae- TPapua New Guinea (PNG) (7.5 million), and cologists (RANZCOG) supports maternal health and Timor-Leste (1.3 million) are low- and middle-income the professional development of obstetricians in the countries (LMICs) with limited access to safe, Pacific, whereas the Australian College of Emergency affordable surgery and anesthesia (see Table 1, page Medicine has pioneered specialist training in PNG,7,8 23). Although all of these nations offer free national Myanmar,9 and the Pacific. health care coverage, a high proportion of their Today, surgical, anesthesia, and obstetric (SAO) populations still lack access to surgical care because specialists are in every country in this region with a of a shortage of appropriately trained health care population of more than 100,000, although the SAO workers, infrastructure, facilities, and geographic density per 100,000 population is well below the desir- boundaries. The training of specialists in surgery, able levels in most countries (see Table 1).10 The local anesthesia, and obstetrics began through the Uni- health and clinical leadership has been established 22 | versity of PNG, Port Moresby, in 1975, but only progressively in each of these island nations and is a since 1999 has this training been available at the direct result of localized training involving a univer- Fiji School of Medicine, Suva, which is now part of sity master of medicine qualification that represents Fiji National University for other Pacific Nations.1,2 at least four years of general specialist training, and The Australia Timor-Leste Program of Assistance two to four years of further subspecialist training for Specialist Services (ATLASS) developed by the (for example, in orthopaedics, urology, neurosurgery, Royal Australasian College of Surgeons (RACS) has or pediatric surgery).5 The workforce that provides employed a range of training programs in PNG, Fiji, safe anesthesia includes nonphysician anesthesia pro- Indonesia, and Malaysia to support a small cohort viders (NPAP), such as anesthesia scientific officers of physicians who have met specialist qualifications in PNG and nurse anesthetists in Timor-Leste, who in the following areas: surgery, anesthesia, ophthal- typically work in the major health care centers under mology, obstetrics and gynecology (OB/GYN), and the supervision of a specialist anaesthetist.3 pediatrics.3 The Australia and New Zealand specialist medical colleges’ fellows have a long history of collaborating Principles of partnership and engagement to provide support to the Asia-Pacific region, often RACS Global Health and its partner colleges support through their specialty societies and in conjunction the Paris Declaration on Aid Effectiveness and its five with specialty-specific nongovernment organizations. main principles: ownership, harmonization, alignment, Since 1995, RACS, through its international develop- results, and mutual accountability. The declaration was ment program RACS Global Health, has managed adopted in 2005 and expanded by the Pacific Islands Australian aid-funded programs to provide special- Forum in 2007 to emphasize the need for development ist services, strengthen health care systems, build partners to make multi-year commitments and for a capacity, and provide continuing medical education greater employment of local systems.11,12 This collabo- and professional development for trained health care ration has resulted in RACS-managed programs being professionals.4,5 The Australian and New Zealand increasingly and strategically directed in-country, incor- College of Anaesthetists (ANZCA) has provided sim- porating needs assessment and evaluation of results ilar support, together with the Australian Society led by local clinicians and their Ministries of Health.

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TABLE 1. LCoGS METRICS IN OCEANIA

Indicator 1 Indicator 2 Indicator 3 Indicator 4 Country Population Access < 2hrs SAO density Surgical volume POMR (%) (%) SAO/100,000 case/100,000 Nauru 10,084 100 30 7,130 0.24 Tuvalu 10,837 56 18.5 3,417 1.0 Cook Islands 13,229 88 22 6,758 0.11 Micronesia 102,109 Not available 7 Not available Not available Tonga 103,000 85 14 5,061 0.24 Kiribati 110,000 65 8.2 Not available Not available Samoa 187,000 68 1.6 1,552 0.82 Vanuatu 260,815 44 3.2 1,277 0.28 Solomon Islands 602,000 20 2.5 868 0.46 Fiji 933,000 67 5.8 1,490 0.83 Timor-Leste 1,300,000 50 0.9 433 0.84 PNG 7,500,000 20 2.3 1,264 0.5 New Zealand 4,452,300 90 43 5,308 0.43 Australia 23,946,300 98.85 63.9 10,156 0.19

The information in this table was collected by members of the Oceania Collaboration on Global Surgical Metrics. | 23

The governance of Australian Aid programs national health planning in order to collect data to demands that policies be put in place to ensure eco- generate metrics 5 and 6, which are measures of cata- nomical, efficient, and effective program outcomes; risk strophic and impoverishing expenditure. management; and procedures to manage adverse events In September 2017, the PNG Medical Society’s and patient complaints. The RACS Global Health poli- 53rd medical symposium in Port Moresby centered cies, available at www.surgeons.org/policies-publications/ on access to safe, affordable surgery and anesthesia policies/racs-global-health/, embrace inclusiveness, and resulted in a demonstration of regional and cross- diversity, anti-discrimination, and child protection specialty consensus by the presidents of PISA, RACS, and govern team selection and standards—as well as ANZCA, and RANZCOG. requirements for transparency, sound financial management, evaluation and monitoring with timely reporting of outcomes, and assessment of impact (see Perspectives from the colleges Tables 2 and 3, pages 26 and 27). and associations

PISA Progress on global surgical metrics PISA was inspired by global health forums organized In 2016, the RACS Annual Scientific Congress in at the RACS, which took place in Melbourne, Aus- Brisbane and the Pacific Islands Surgical Association tralia, in conjunction with the annual meeting of the (PISA) Symposium in Samoa provided an opportu- Alliance for Surgery and Anesthesia Presence in nity for member nations to present their first four October 2012, and a follow-up regional meeting in The Lancet Commission on Global Surgery (LCoGS) March 2013, which was attended by the president of metrics (see Table 1).13 Participants in these meetings the PISA, other surgeons from the Pacific, and repre- agreed to advocate for using these metrics to inform sentatives of RACS, ANZCA, and RANZCOG. This

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

meeting achieved consensus on the importance of OCEANIA COLLABORATION measuring perioperative mortality rate (POMR) as ON GLOBAL SURGICAL METRICS a global surgical/anesthesia metric.14 • Glenn Douglas Guest, MB, BS, FRACS (Australia) At their annual meeting in Nadi, Fiji, in April 2013, the leaders of Pacific region clinical services • Elizabeth McLeod, MB, BS, FRACS (Australia) agreed to start collecting data pertaining to the • Deacon Teapa, MMed (Cook Islands) POMR. This process was relatively straightforward, as it only required the collection of the number • Jemesa Tudravu, MMed (Fiji) of operations performed in the operating theater • Bwabwa Oten, MMed (Kiribati) (denominator), and the number of patients who 14 • Kabiri Itaka, MMed (Kiribati) died in the hospital after a procedure (numerator). Having proved its feasibility, POMR became the • Johnny Hedson, MMed (Micronesia) entry point for health care leaders in the Pacific 24 | • James Kong, MB, BS, FRCSEd, to recognize the value of the other LCoGS indica- FRACS, FHKAM (Myanmar) tors when presented by John G. Meara, MD, DMD, • Htun Oo, MB, BS, MMedSc, FRCSEd (Myanmar) MBA, FACS, co-chair of the LCoGS, and David Wat- ters, OBE, ChM, FRCSEd, FRACS, a co-author of • Leona Wilson, MB, BS, FRANZCA (NZ) this article, at the RACS Global Health triennial • Will Perry, MB, BS, FRACS (NZ) forum in October 2015. The success of this presenta- tion resulted in a collaborative effort to report these • Noah Tapua, MMed (Papua New Guinea) metrics in the Pacific based on the involvement of • Douglas Pikacha, MMed (Solomon Islands) senior clinicians working with heads of clinical ser- 10 • Ponifasio Ponifasio, MMed (Samoa) vices and directors of health. It is crucial that our Ministries of Health become more directly involved • Joao Pedro, MMed (Timor-Leste) in this practice. • Lord Viliami Tangi, MB, BS, FRACS (Tonga) • Basil Leodoro, MMed (Vanuatu) RACS Since 1995, 17 countries across the Asia-Pacific have partnered with RACS Global Health projects and programs featuring clinical activities, which have resulted in the provision of consultant services to more than 221,733 individuals and more than 43,055 procedures performed (see Table 4, page 28). Education and training are key to providing these clinical services, with RACS Global Health facilitating more than 100 workshops and courses, including the American College of Sur- geons Advanced Trauma Life Support® course since 1993, resulting in the instruction of an estimated 2,087 health professionals across the Asia-Pacific.

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Today, surgical, anesthesia, and obstetric (SAO) specialists are in every country in this region with a population of more than 100,000, although the SAO density per 100,000 population is well below the desirable levels in most countries.

Visiting medical teams (VMTs) offer skills transfer, mentoring, and professional development and AUSTRALIA AND NEW ZEALAND provide essential surgery, such as pediatric surgery, SPECIALIST COLLEGES WORKING GROUP cardiac surgery, club foot management, and cleft ON GLOBAL HEALTH lip and palate repair. The programs include the The Australia and New Zealand specialist Pacific Islands program (PIP),4 the ATLASS pro- 3 colleges working group on global health includes gram, The East Timor Eye Program (ETEP), and representatives of the following organizations: a Myanmar program that has included primary trauma care, emergency medicine, surgical skills, • Australian and New Zealand College of Anaesthetists and the management of surgical emergencies (see • Australasian College of Emergency Medicine Table 4). Other programs in Southeast Asia include • Australian Society of Anaesthetists the Asia Paediatric Surgery Education Project and the Eastern Indonesia program (Nusa Tenggara • College of Intensive and Critical Care Medicine | 25 Timur and Papua). • Royal Australian and New Zealand College RACS continues its more than 40-year relation- of Obstetricians and Gynaecologists ship with PNG through a program in which its fellows visit as examiners, as members of VMTs, • Royal Australian and New Zealand and through the provision of traveling fellowships College of Ophthalmology and scholarships. Further discussions are ongoing • Royal College of Pathologists of Australasia to expand our support to health education and • Royal Australasian College of Physicians clinical services in PNG. Since 1988, the RACS scholarship program has benefited 225 individu- • Royal Australian and New Zealand als from 34 countries. Evaluation of the impact of College of Psychiatrists returning scholars in their home country suggest • Royal Australian and New Zealand that these scholars go on to become high-profile College of Radiologists leaders, offering many new and expanded services • Royal Australasian College of Surgeons to their patients.15,16

ANZCA Safe and affordable access to anesthesia is a pillar of global health. ANZCA has a number of programs and scholarships managed and supported by its Overseas Aid Committee. The focus of ANZCA’s educational outreach has been PNG, where teams of specialist anesthetists have been providing training, capacity development, and essential resources for more than 20 years. The ASA and the New Zea- land Society of Anaesthetists (NZSA) have been providing similar support in the Pacific Islands, including Fiji, Tonga, the Solomon Islands, and

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

TABLE 2. GOALS AND OUTCOMES ALIGNMENT FOR RACS GLOBAL HEALTH PROGRAM DEVELOPMENT

Health care is affordable, appropriate to local needs, of good quality, and accessible

Broader Clinical health professionals Strong national health goals provide quality services Strong collaboration on leadership for delivering and contribute to regional clinical services effective clinical services educational programs and workforce issues and health workforce throughout the regions development

National bodies value Partner countries Postgraduate students are and actively engage in receive quality visiting representative of the region, regional fora on relevant medical teams that meet and successfully graduate clinical services and their priority clinical with relevant competency health workforce issues and training needs End of program outcomes Ministries of Health (MOH) better identify and Prioritized specialized Improved local educational prioritize clinical service clinical service resources and skills and training/continuing professionals have professional development improved competencies needs, to inform planning

26 |

Micronesia. The ASA Overseas Development and medicine physicians, the Essential Pain Management Education Committee former chair, Rob McDou- Program, has not only become accessible to local gall, MD, also has led global collaboration with the educators across the Pacific, but also has been taken World Federation of Societies of Anaesthesiologists up globally following its success in the Asia-Pacific.18 (WFSA). The building of in-country and within- Coordination between colleges and societies is region capacity to self-train has been paramount. We necessary to avoid duplication of effort and assist in have further supported in-setting appropriate stan- managing resources. The ANZCA and ASA overseas dards for practice, as well as assisting with resources committees work collaboratively with the RACS and delivery of both education and care.6 We have Global Health Committee and have a single volun- collaborated with other colleges’ activities to help teering database for anesthetists. deliver primary trauma care courses.17 Throughout One of the great achievements in addressing the the Asia-Pacific region, anesthetists are partners anesthesia workforce’s needs has been the estab- in the delivery of all the surgical clinical outreach lishment of a WFSA Global Anesthesia Workforce programs. To this end, they are involved in coordi- Survey and map, to which ANZCA Fellows from nation with RACS, ASA, and other involved societies the Asia Pacific have made a major contribution.19 or specialist groups, such as Interplast or Orthopae- dic Outreach. Anesthesia teaching and training also RANZCOG extends to Mongolia, Cambodia, and Laos. For 25 years, RANZCOG has supported OB/GYN We have implemented the successful global colleagues and women’s health professionals in the Lifebox pulse-oximetry project in the Pacific region Western Pacific region. From a logistical and orga- through a partnership between Lifebox, ASA, NZSA, nizational perspective, RANZCOG has found it Interplast Australia & New Zealand, and ANZCA. mutually beneficial to collaborate with RACS in the A course developed by ANZCA faculty of pain continued on page 28

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

TABLE 3. GENERIC EVALUATION AND MONITORING FRAMEWORK BASED ON RACS PACIFIC ISLANDS PROGRAM OVERALL OBJECTIVE

To strengthen and consolidate access to safe, affordable surgery and anesthesia as needed in the Asia-Pacific region OUTCOMES O1. O2. O3. O4. Specialist clinical practitioners VMTs meet individual country and Local ownership: MOH better Educational providers have (SCPs) in LMICs have regional clinical and training needs identify and prioritize specialist enhanced skills, greater resources, improved competencies clinical services, training and CPD and sufficient faculty to meet needs, to inform MOH planning clinical training, medical/surgical education, professionalism, and standards needs OUTPUTS O1.1 O1.2 O2.1 O2.2 O3.1 O3.2 O4.1 O4.2 Increased Increased Increased High-quality Increased Increased quality Increased quality Increased participation of knowledge and engagement and safe care capability and of processes, and diversity regional SCP in clinical skills of SCP in of MOH in with good capacity of MOH protocols, and of educational engagement and assessment, clinical specialty, identifying postoperative in SCS delivery systems for resources being networking of procedures, leadership, audit, VMT objectives outcomes management SCS delivery offered by SCS stakeholders and quality management, and priorities and planning management national and/ to address assurance/quality and advocacy for specialist and planning or regional common issues, improvement clinical service institutions set priorities, and (SCS) delivery plan advocacy

ACTIVITIES (INPUTS)

A1.1.1 A1.2.1 A2.1.1 A2.2.1 A3.1.1 A3.2.1 A4.1.1 A4.2.1 | 27 Identify Conduct training Facilitate MOH Maintain a Conduct training Support the Support Establish and workforce and workshops identification of network of and workshops development educational systematize service delivery and facilitate gaps in service ANZ, Pacific, to support MOH of systems and institutions to professional gaps to enable other CPD delivery to set and regional in capacity processes for develop tailored, development priorities for opportunities VMT clinical professionals building, SCS promoting specialized networks specialist training through skill and training and professional delivery, and its clinical clinical between ANZ to be set, as well transfer, objectives institutions management governance, professional and the region, as mapping and mentorship, and to support and planning, quality development including selection of SCPs specific training the delivery including improvement, and training collaboration for participation opportunities of specialist participation and continuing programs, between ANZ in VMT visits or scholarships medical and contribution professional including and regional for selected education to regional or development training of professional sponsored and VMTs local in-country specialists bodies individuals planning meetings A1.1.1 A1.2.2 A2.1.1 A2.2.1 A3.1.2 A3.2.2 A4.1.2 A4.2.2 Provision of on- VMT members Conduct VMT Deployment of Provide reports Engagement Sharing of Facilitate the-job training provide ongoing review meetings VMTs to countries to MOH to inform of clinical educational links between opportunities mentorship with MOH as appropriate to planning and leaders and expertise, the relevant and skill transfer and support personnel, identified needs use the annual MOH personnel develop courses specialist colleges during VMT visits after VMT visit clinical staff, and planning process with role model on specialist in ANZ and Department of to review and institutions medical professional Foreign Affairs advise MOH for clinical education colleges or and Trade of key issues governance, (for example, societies, representatives identified the quality surgical teachers including to assess VMT previous year assurance, course or sponsorship to trip outcomes and quality Foundation attend meetings improvement for Surgical and present Educators), on scientific including meetings provision of and strategic train-the-trainer discussions, courses or places as well as on such courses presidential to develop round tables local faculty at scientific congresses

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

TABLE 4. RACS GLOBAL HEALTH-MANAGED PROGRAMS AND PARTNERS IN THE ASIA-PACIFIC REGION Clinical visits Health professionals Program Years Consultations Operations or courses training Pacific Islands Since 1995 807 93,863 24,356 341 Program* 103 surgeons (23 subspecialists) Papua New 1995–2012 158 17,174 6,777 29 anesthetists Guinea 90 ASO & NPAPs 59 obstetricians 183 enrolled 96 diplomates Timor-Leste resident 4–5 resident specialists 10 pediatricians specialists and Since 2001 providing in-country N/A N/A visiting teams supervision and training 7 surgeons 1 anesthetist 21 nurse anesthetist NPAPs 1 ophthalmologist East Timor 2000 93 100,636 10,888 6 senior registrars Eye Program 4 postgraduate candidates

2 eye care nurses Sumba Eye Program 2011 11 10,000+ 1,004 28 | 10 junior ophthalmologists

377 Asia Pediatric 15 courses 2016 60 30 Aimed at competency Surgery Education 2 clinical mentoring training

Myanmar 2009 62 courses† N/A N/A 1,175

*Pacific Islands Program-Cook Islands, Fiji, Kiribati, Marshall Islands, Federated States of Micronesia, Nauru, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu

†Primary Trauma Care, Emergency Life Support, Advanced Trauma Life Support, Essential Pain Management, Emergency Medicine, Management of Surgical Emergencies, Surgical Skills Education and Training

All visiting team members and course faculty provide their services pro bono. No salaries are paid except to the resident specialists and staff in Timor-Leste.

PIP and ATLASS Programs. The RANZCOG also and resources available to Pacific OB/GYN trainees, has provided education and training in gynecology which continues through formal associate member- surgery in PNG. Collaboration between colleges, as ship of RANZCOG and is available to graduates well as with regional partners and clinical organiza- with the master of medicine qualification from tions, strengthens and informs the training activities the Pacific medical schools. At present, 52 prac- we provide both together and individually. Such a ticing OB/GYN specialists in the Pacific have an collaborative approach avoids the potential for silos, associate membership in RANZCOG. Associate which can easily occur in the absence of effective membership requires participation in a compul- communication and cooperation. sory continuing professional development (CPD) RANZCOG support for OB/GYN colleagues in program. Our evaluation of this program has the Pacific is typically delivered through networking revealed that it motivates and stimulates practicing

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OB/GYN specialists to focus on their professional REFERENCES development throughout their career while reduc- 1. Watters DA, Theile DE. Progress of surgical training in Papua ing feelings of isolation.20 These specialists and New Guinea to the end of the 20th century. Aust N Z J Surg. trainees also have benefited from more than 150 2000;70(4):302-307. scholarships or short-term traveling fellowships 2. Watters DA, Scott DF. Doctors in the Pacific. Med J Aust. 2004;181(11-12):597-601. since 1995. Building a culture of research is another 3. Guest GD, Scott DF, Xavier JP, et al. Surgical capacity key goal to improve access to and delivery of care building in Timor-Leste: A review of the first 15 years of the in the future. A research workshop has been made Royal Australasian College of Surgeons-led Australian Aid available regularly through the Pacific Society for programme. ANZ J Surg. 2017;87(6):436-440. Reproductive Health,21 and the first RANZCOG 4. Watters DA, Ewing H, McCaig E. Three phases of the Pacific Islands Project (1995–2010). ANZ J Surg. 2012;82(5):318- Global Health research grant was awarded in 2016 324. to a Papua New Guinean OB/GYN specialist. 5. Kevau I, Watters DA. Specialist surgical training in Papua A priority for RANZCOG is reducing maternal New Guinea: The outcomes after 10 years. ANZ J Surg. and perinatal mortality, and improving access to 2006;76(10):937-941. | 29 safe surgery and anesthetic services is fundamental 6. Cooper MG, Wake PB, Morriss WW, Cargill PD, McDougall RJ. Global safe anaesthesia and surgery initiatives: in cases where cesarean section is the best or only Implications for anaesthesia in the Pacific region. Anaesth 22 option for the safety of the mother and her baby. Intensive Care. 2016;44(3):420-424. Cesarean section rates are less than 10 percent in 7. Curry C, Annerud C, Jensen S, Symmons D, Lee M, Sapuri most Pacific Island countries; however, they are M. The first year of a formal emergency medicine training increasing to 20 percent in Fiji. programme in Papua New Guinea. Emerg Med Australas. 2004;16(4):343-347. 8. Aitken P, Annerud C, Galvin M, Symmons D, Curry C. Scholarships Emergency medicine in Papua New Guinea: Beginning RACS, ANZCA, ASA, and RANZCOG offer short- of a specialty in a true area of need. Emerg Med (Fremantle). term traveling fellowships to their annual scientific 2003;15(2):183-187. or subspecialty meetings, as well as a range of 9. Phillips GA, Soe ZW, Kong JH, Curry C. Capacity building for emergency care: Training the first emergency specialists three- to 12-month hospital placements for specialist in Myanmar. Emerg Med Australas. 2014;26(6):618-626. training or extended scope of practice. These oppor- 10. Guest GD, McLeod E, William WRG, et al. Collecting data tunities are normally awarded after obtaining the for global surgical metrics: A collaborative approach in the relevant specialist qualification from the scholar’s Pacific Region. BMJ Glob Health. 2017;2:e000376. doi:10.1136/ home country. A number of specialty groups offer bmjgh-2017-000376. 11. The Paris Declaration on Aid Effectiveness (2005) and the similar opportunities, such as Orthopaedic Outreach, Accra Agenda for Action (2008). Available at: www.oecd. the Asia Pacific Orthopaedic Association, Interplast org/dac/effectiveness/34428351.pdf. Accessed November 21, Australia and New Zealand, and ANZCA’s pain fac- 2017. ulty. RANZCOG has facilitated resident placements 12. Pacific Aid Effectiveness. Principles Pacific Islands Forum or exchanges, often with Australians or New Zea- Secretariat, 2007. Available at: www.forumsec.org/ resources/uploads/attachments/documents/Pacific_Aid_ landers filling positions in the Pacific, rather than vice Effectiveness_Principles.pdf. Accessed November 21, 2017. versa, due to licensure requirements. ANZCA also offers a scholarship to enable a trainee to accompany continued on next page a VMT to expose them to global health issues, as do some orthopaedic VMTs.

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

Summary REFERENCES, CONTINUED The development programs described in this arti- 13. Meara JG, Leather AJ, Hagander L, et al. Global Surgery cle have fostered professional networks between 2030: Evidence and solutions for achieving health, welfare, individuals and institutions across the Asia-Pacific. and economic development. Lancet. 2015;386(9993):569-624. The specialist medical colleges, together with the 14. Watters DA, Hollands MJ, Gruen RL, et al. Perioperative mortality rate (POMR): A global indicator of access to safe scholarships they provide, have generated great surgery and anaesthesia. World J Surg. 2015;39(4):856-864. opportunities for professional collaboration and 15. RACS Global Health. Sharing the benefits. Surgical News. partnership in the region. The work of the LCoGS, 2014. Available at: www.surgeons.org/media/20877795/ with its clearly defined messages and achievable july_2014_sn_sharing_the_benefits.pdf. Accessed March metrics, has inspired surgeons, anesthetists, and 19, 2018. 16. Masterton JP, Moss D, Korin SJ, Watters DA. Evaluation of obstetricians to become more engaged in public the medium-term outcomes and impact of the Rowan Nicks health and to advocate for safe, affordable, and Scholarship Programme. ANZ J Surg. 2014;84(3):110-116. timely access to emergency and essential surgery.13 17. Wilkinson D, McDougall R. Primary trauma care. 30 | To realize the goals of World Health Assembly Anaesthesia. 2007;62 Suppl 1:61-64. Resolution 68.15 by 2030 and help our colleagues 18. Goucke CR, Jackson T, Morriss W, Royle J. Essential pain management: An educational program for health care in the LMICs of our region deliver services to workers. World J Surg. 2015;39(4):865-870. their populations, ongoing and sustained support 19. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth is needed.23 The leadership, ownership, and strategic J. The WFSA Global Anesthesia Workforce Survey. Anesth direction of these initiatives should be established Analg. 2017;125(3):981-990. by the individual countries themselves. The people 20. Ekeroma A, Walker C. Pacific Associate membership program evaluation. O&G. 2016;18(3):74. of the Pacific and Southeast Asia deserve quality 21. Ekeroma AJ, Kenealy T, Shulruf B, McCowan LM, Hill A. health care, but this goal can only be achieved with Building reproductive health research and audit capacity access to safe, affordable surgery and anesthesia. ♦ and activity in the Pacific Islands (BRRACAP) study: Methods, rationale and baseline results. BMC Med Educ. 2014;19(6):121-130. 22. Dennis AT. Reducing maternal mortality in Papua New Guinea: Contextualizing access to safe surgery and anaesthesia. Anesth Analg. 2018;126(1):252-259. 23. World Health Organization. Emergency and essential care. Events. World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia in the context of universal health coverage. Available at: www.who.int/ surgery/wha-eb/en/. Accessed April 19, 2018.

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The Royal Colleges of Surgeons in the U.K. and Ireland: A common vision for global surgery

by the Royal Colleges of Surgeons in the U.K. and Ireland

| 31 of Surgeons in the U.K. and Ireland work together to HIGHLIGHTS contribute to the development and delivery of these activities and provide career-long support for their • Summarizes the efforts of the Royal Colleges fellows and members who work to end health care of Surgeons in the U.K. and Ireland to address disparities in LMICs. disparities in surgical care in LMICs This article describes contributions from the four • Identifies the benefits of collaborating with surgical Royal Colleges in the U.K. and Ireland. Much COSECSA to train and retain local surgeons of this work is collaborative, especially in relation to • Describes the role of advocacy efforts advocacy and support for the mission of the World in surgical capacity building Health Organization (WHO), as well as in curriculum development, quality assurance, and the assessment of young surgeons. These efforts are coordinated activities, and this article summarizes the main areas in he Royal Colleges of Surgeons in the U.K. and which we operate. Ireland have real concerns about the inequity Tof care in low- and middle-income countries (LMICs). These organizations also recognize the RCSI: A partnership approach opportunities that exist to contribute to system to global surgery strengthening and to develop standards, education, Since its inception in 1784, the purpose of the Royal Col- assessment, and advocacy initiatives in order to lege of Surgeons in Ireland (RCSI) has been to educate enhance access to quality surgical care. A particularly and train surgeons to meet the needs of patients. Today, important area of this work relates to the contextu- its reach is more extensive than its founders could have alized provision of curriculum development and envisioned, as the RCSI helps develop health care lead- suitable clinical examinations that allow surgeons to ers worldwide. In LMICs, the RCSI achieves this goal benchmark their training and skills against an inter- by partnering with local institutions and unlocking nationally recognized standard. The Royal Colleges potential at the regional level.1

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

COSECSA collaboration CONTRIBUTING AUTHORS In 2007, collaborative efforts between the RCSI and the College • Derek Alderson, MD, FRCS of Surgeons of East, Central and Southern Africa (COSECSA) began to support the training of surgeons in Africa.2 COSECSA • Ruairi Brugha, MD, MSc, FFHMI launched in Nairobi in 1999, and one of its aims was to stop • Stuart Fergusson, BSc (Med Sci), MB, the “brain drain” of African surgeons who trained abroad and ChB, ChM, MRCS, DRCOG, PGCAP, FHEA never returned home. With funding from Irish Aid,3 the Irish government’s official agency for international development, • Jakub Gajewski, PhD RCSI and COSECSA embarked on a collaborative program to • David Galloway, MD, FACS, FRCS, help COSECSA train more surgeons in the region. FRCP, FAIS, FAMM, FCSSL, FICP Prior to this initiative, COSECSA’s cumulative total of gradu- • John Hyland, FRCSI ates was 17. By December 2016, that number reached 206, which is an average increase of 39 percent in graduating surgeons • Graham Layer, DM(Oxf), MCh, year-to-year (see Figure 1, page 33). 32 | FACS, FRCSEd, FRCSEng • Deirdre Mangaoang, MBA College without walls • Eric O’Flynn, MA COSECSA is a college without walls. It trains surgeons through an expanding network of 99 accredited hospitals and 165 accred- • Sean Tierney, FRCSI ited trainers in 12 member countries. All trainees follow the same program of training for the first two years. They then are eligible to sit for COSECSA’s membership exams. In the final three years, trainees choose one of seven specialties and then are eligible to take COSECSA’s fellowship exams.4 The COSECSA training model is shorter than that of many comparable international surgical training institutions and is focused on clinical exposure. The RCSI has provided support in curriculum development, examinations, and a variety of training and leadership courses. Together, both colleges have designed information technology (IT) resources, such as a mobile-optimized e-logbook and an e-learning portal with content relevant for the region.5 As the number of trainees enrolling in the program has increased, many RCSI departments, including finance, IT, communications, and quality assurance, have supported specific projects managed by COSECSA’s secretariat, a role that oversees the day-to-day administration of COSECSA training and examination processes. COSECSA is now the largest single contributor to the surgical workforce in the region, and, in fact, the organization has developed an interactive map to document surgeon density.6,7 Significantly, research has shown that surgeons who train locally

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 1. COSECSA GRADUATES 2006–2016

| 33 are increasingly retained in the region.8 More specifi- many African countries. In Malawi, COST-Africa, cally, 85 percent of surgeons practice in the country in also known as Clinical Officer Surgical Training in which they trained, 88 percent are practicing in East, Africa, accredited and rolled out a national bachelor Central, and Southern Africa, and 93 percent remain in of science in surgery for clinical officers (COs).9 As a Africa. The brain drain in Africa has become a myth.8 result, the volume of general surgical cases at district Other positive outcomes from the RCSI’s collabora- hospitals increased by 89 percent. The outcomes of tion offer significant potential for the future financial hernia operations done by COs in district hospitals support of global surgery programs. With real-time were comparable with those performed in central data on operations performed by more than 500 surgi- hospitals.10 cal trainees in 12 countries, COSECSA is now uniquely COST-Africa also developed a supervision positioned to engage in collaborative research on the model in Zambia, enabling specialists from cen- training of surgeons and practice of surgery in sub- tral hospitals to travel to district hospitals to Saharan Africa, and this research could generate vital, deliver on-the-job training, to supervise, and to translational data for governments and potential fund- mentor surgically active district NPCs. This model ing bodies. improves the quality and scope of surgical care at the district level and allows hospitals to save Surgery at the district level: COST- and SURG-Africa money on referrals. These NPCs help build the Most countries in the region have a critical need surgical skills of general medical officers and pro- for surgically trained clinicians who are willing to vide a potentially sustainable strategy for making work in district hospitals. Since 2011, RCSI research- surgery available to rural populations.11 ers have been leading two European Union-funded In a second European Union-funded study, Scaling projects aiming to generate evidence that a safe sur- up Safe Surgery for District and Rural Populations gery model for district hospitals is feasible, effective, in Africa (SURG-Africa), NPCs in three countries and sustainable. are being trained in clinical decision making, safe Nonphysician clinicians (NPC) are the backbone anesthesia, peri- and postoperative monitoring, safe of clinical care services for rural communities in surgery for Ministry of Health (MOH)-approved

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

elective and common emergency conditions, as well the mutual benefits of engagement in global health as surgical team leadership and management skills.12 (see Figure 2, page 35). The report made eight rec- RCSI has chosen a point of entry—surgical train- ommendations to the government, which focused ing and supervision—that best leverages its strengths. on improved support and coordination of interna- Ultimately, it will not be institutions or individuals in tional volunteering efforts by National Health Service high-income countries, but our partners, including workers. Scotland’s Minister for International Devel- governments, that must provide the infrastructure opment welcomed the report at its launch, and the and institutions to train the future surgical provid- leaders of this initiative anticipate that the recom- ers in Africa. mendations will be taken forward fully in the coming years. The RCPSG also has realized its potential to advo- RCPSG: Training, advocacy, and delivery cate for the prioritization of surgical capacity building The Royal College of Physicians and Surgeons of in resource-challenged environments. Together with Glasgow (RCPSG) was founded in 1599 by Maister other U.K. surgical colleges, we established a cor- 34 | Peter Lowe, who left his native Scotland for surgi- respondence with Tedros Adhanom Ghebreyesus, cal training in France, where he remained for many PhD, MSc, around the time of his election to WHO years. He then returned to improve the medical stan- director-general, and urged him to place resources dards of his local community. More than 400 years behind the World Health Assembly (WHA) land- later, the RCPSG’s vision remains “the highest pos- mark 2015 Resolution 68.15 on building capacity sible standards of healthcare.” It pursues this vision in emergency and essential surgical and anesthetic through the provision of academic resources, exami- care. Dr. Tedros responded with a letter that dem- nations, educational activities, and contributions to onstrated his commitment to work in consultation medical regulation and public policy. Uniquely for a with Member States to build national capacity for U.K. Royal College, the Glasgow College membership emergency and surgical care to implement WHA encompasses surgeons, physicians, dentists, travel 68.15. “As stated in WHA 68.15, surgical capacity is medicine specialists, and podiatrists.13 an essential part of universal health coverage and Having demonstrated in the 16th century that health our political commitment and programs must reflect care training and experience gained outside a local com- that,” Dr. Tedros wrote in the letter.14,15 This corre- munity can ultimately serve home populations, as well spondence was subsequently circulated to multiple as build bridges abroad, the RCPSG continues to main- nation states at the 2017 WHA to establish his com- tain and promote this perspective today. mitment to surgical capacity building, and the RCPSG intends to monitor progress carefully. Advocacy With the support of the Scottish government, the Facilitation of medical training RCPSG has recently taken a leading role in reviewing Alongside other Royal Colleges, the RCPSG sup- and analyzing the policy background that surrounds ports the U.K. Department of Health’s Medical global health volunteering work in Scotland. This Training Initiative (MTI), which offers a time- endeavor resulted in a major report, Global Citizenship limited opportunity for postgraduate medical in the Scottish Health Service: The Value of International professionals, primarily from LMICs, to obtain Volunteering, published in May 2017, which challenged training experience in the U.K. before returning to the Scottish government to institutionally recognize their country of origin. In addition to sourcing and

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 2. MUTUAL BENEFITS FOR GLOBAL HEALTH VOLUNTEERING WORK IN SCOTLAND

| 35

Source: Royal College of Physicians and Surgeons of Glasgow. Global citizenship in the Scottish Health Service: The Value of International Training. Available at: https://rcpsg. ac.uk/college/influencing-healthcare/policy/global-citizenship. Accessed March 8, 2018.

coordinating placements for a range of applicants on opportunities with the Malawian College of Med- a cost-recovery basis, the RCPSG has instituted its icine and other institutions. RCPSG fellows and own MTI bursary scheme, the Livingstone Fellow- members from around the world can access a vari- ship, which supports some of the start-up costs for ety of travel bursaries, which aim to support the Malawian trainee physicians or surgeons coming to delivery of high-quality clinical input overseas the U.K. for targeted training. Physicians who have and ensure the effective transfer of learning back benefited from this program recently include Wone into the home environment. Recipients of college Banda, MB, BS, MSCS, FCS, and T.K. Itaye, MB, BS, support include general surgeons, orthopaedic sur- MMed (respectively training in plastic surgery and geons, and gastroenterologists. The college has general and breast surgery), and following a success- provided resources to provide training and capital ful year of training in Scotland they have returned equipment for endoscopic services, which is much- to posts in Malawi as consultant specialist surgeons. needed care in a country with a high incidence of Glasgow College fellows and members have a esophageal varices related to schistosomiasis and history of supporting underserved communities upper gastrointestinal cancer. beyond their home environment. The college has The Glasgow College has restructured to enhance delivered some of its standard educational courses in these vital areas of global health involvement and has low-income environments, including the Basic Sur- active projects in sub-Saharan Africa, Sierra Leone, gical Skills course, and is scoping future educational Tamil Nadu, India, Sri Lanka, and Malaysia.

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

This article describes contributions from the four surgical Royal Colleges in the U.K. and Ireland. Much of this work is collaborative, especially in relation to advocacy and support for the mission of the World Health Organization (WHO), as well as in curriculum development, quality assurance, and the assessment of young surgeons.

FIGURE 3. RCSEng: Global surgery INTERNATIONAL STRATEGY 2016–2020 research and training The Royal College of Surgeons of England (RCSEng)16 has developed a broad portfolio of activities in recent years as highlighted in the International Strategy, 2016–2020 (see Figure 3, this page). These efforts are designed to create sustainable surgical services in LMICs. The RCSEng is a member of the G4 Alliance (also known as the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care).17

International development project The RCSEng’s international development project focuses on resource-poor countries to establish 36 | basic practices that support continuous quality improvement. At present, the following five projects are under way:

• Core surgical skills training. This project involves working in Gaza at the Al-Shifa Hospital to train local surgeons to become leaders of basic surgical skills courses.

• The safe operating theater. This program involves training a multidisciplinary team to develop best practices in operating theater function and management. This project is taking place in Ethiopia, where a local team will be trained at a large center, enabling these physicians to deliver training to a Source: Royal College of Surgeons of England. Launch of RCS International Strategy wider community of health care professionals else- 2016–2020. Available at: www.rcseng.ac.uk/ where in the country. news-and-events/news/archive/international- strategy/. Accessed March 8, 2018. • Objective structured clinical examinations development. This project has been initiated in Ethiopia in conjunction with the Ministry of Health and provides examinations for trainee surgeons specifically contextualized for local health problems.

• Surgical capacity building. This project has been developed for northern Sri Lanka and involves week-long workshops in a number of surgical

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specialties intended to develop skills to manage prior- first trainee-led surgical trial centered on LMICs and ity surgical challenges at the local level. involving 5,500 patients.18 Oversight committees and policy and implementation committees to support • Development of hub-and-spoke training models. These this organization are both provided through RCSEng. models are based in Vellore, India, and involve teaching The RCSEng also provides individual support (full general surgeons in district hospitals how to identify, salary plus running costs) to enable U.K. trainees to treat, or refer pediatric surgical conditions. undertake research activities abroad. At present, the college supports three fellows in North Amer- ica, one in mainland Europe, and one in sub-Saharan International surgical training program Africa. International traveling fellowships also were As part of the U.K. MTI, surgeons from LMICs are awarded in 2017 to seven trainees, four of whom are admitted to two-year surgical training placements in overseas trainees visiting the U.K. from Myanmar, the U.K. through the RCSEng. Approximately 40 sur- Ethiopia, and India, with three U.K. trainees visiting gical trainees are successfully placed annually, and the Democratic Republic of Congo for trauma, Nepal the college assists other overseas surgeons with visa for pediatric surgery, and Ethiopia for head and neck | 37 (tier 2) procurement and registration with the general surgery. medical council, and serves as a source of education, support, and advice. RCSEd: The value of specific partnerships Global Surgical Frontiers Conference The Royal College of Surgeons of Edinburgh (RCSEd) The RCSEng hosted the sixth annual Global Surgi- has historically been involved in education and assess- cal Frontiers Conference in April 2017. This meeting ment on many continents.19,20 It also shares its innovative involves collaboration between the college, inter- surgical distance learning masters programs, ESSQ national organizations, surgical trainee bodies, and (Edinburgh Surgical Sciences Qualification), in asso- student societies with the goal of introducing young ciation with the University of Edinburgh since 2007, surgeons to the needs and opportunities related to with 1,750 students enrolled in some 70 countries over the development of surgery at a global level. The next 10 years (see Figure 4, page 38).21 In 2017–2018, the total conference will take place in June, and the theme will number of surgical trainees includes 530 students be trauma. enrolled for the master of science in surgical sciences and for the ChM (master of surgery) programs in surgi- Global surgical research cal specialties. These programs typify the global impact The RCSEng has played a pivotal role in the develop- of the RCSEd on surgical education and training.22 ment of trainee-led clinical research, establishing a In an effort to focus on global surgery specifically, trials network in the U.K. that now covers all surgical this section of this article concentrates on capacity- specialties. In the last two years, this system has been building initiatives of the RCSEd in two major areas: expanded to an international trainee-led research Malawi and Myanmar, with which the college has had group—GlobalSurg. This group has already under- longstanding relationships. The RCSEd has recently taken cohort studies, accumulating data on more developed a partnership with the University of North than 27,000 patients involving more than 1,000 col- Carolina (UNC) at Chapel Hill to facilitate the deliv- laborators in more than 100 countries, half of which ery of its surgical training program initiative based are LMICs. The group recently initiated the world’s in Lilongwe, Malawi.

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 4. EDINBURGH SURGERY ONLINE PROGRAMS 2007–2017

The RCSEd has bases of operation in Edinburgh and Blantyre, and the Malawi College of Medicine; the 38 | in Birmingham in the U.K., and it has an international Edinburgh College was a cofounder of COSECSA, of office in Kuala Lumpur, Malaysia. It aims to improve which Malawi is a member. The RCSEd continues to the health of our LMIC partners by delivering what support COSECSA through an annual traveling fellow- they have requested of us, rather than attempting to ship, awards, courses, and assistance with assessments. identify the problems and enforcing change or perhaps RCSEd members and fellows also contribute to human- providing unwanted resources or systems. Similarly, the itarian work in Malawi, largely independent efforts that RCSEd does not donate large sums of money without the college does not directly oversee. restriction, but instead directs its funding to specific projects where there will be a measurable impact Training fellowships and outcome. The RCSEd’s recent initiative offers a fundamental new direction for surgical training in Malawi, follow- Malawi ing publication of the LCoGS. The RCSEd provides Scotland has provided support to Malawi for decades, financial and professional support for the training of specifically through the organization’s overseas devel- Malawian-born surgeons for five years in their own opment fund, as well as via the Scotland Malawi country under COSECSA guidelines. This effort rep- Partnership, the largest community-based international resents true capacity building, and the aspiration is development network in the U.K.23 The RCSEd also has that the total number will rise to five trainees on a longstanding links with the government of Malawi, rolling cycle as each year’s activity is assessed for suc- and Malawian surgical students are well-represented in cessful training outcomes and financial tolerances. the postgraduate surgical distance-learning programs The UNC department of surgery has close links with offered jointly with the University of Edinburgh, ESSQ the RCSEd and is facilitating financial support and resulting in an MSc (loosely equivalent to membership training on-site with a model that parallels the path of of the Royal Colleges of Surgeons’ examination) and their own students, and as a result, the college will be the ChM in specialty surgery (similar to Fellowship offering appropriate courses for visiting teams. The of the Royal Colleges of Surgeons examination stan- first surgical trainee is badged as an RCSEd training dards at the completion of training). Fellows of the fellow with college benefits. She commenced training RCSEd are involved in the Queen Elizabeth Hospital, in March and is expected to visit the college in the

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U.K. at its expense and for mutual benefit. This model REFERENCES presumably could safely be replicated elsewhere. 1. Royal College of Surgeons of Ireland. Available at: www. rcsi.com/dublin/. Accessed March 7, 2018. Myanmar 2. College of Surgeons of East, Central and Southern Africa. Myanmar has been an RCSEd partner for more than Available at: www.cosecsa.org/. Accessed March 7, 2018. 3. Royal College of Surgeons in Ireland. Department of four decades. Training and assessments are pro- Foreign Affairs and Trade Irish Aid. Available at: www. vided in Yangon (formerly known as Rangoon) and rcsi.com/dublin/. Accessed March 7, 2018. Mandalay, with membership examinations and a 4. College of Surgeons of East, Central and Southern Africa. biannual diploma ceremony occurring in Yangon. Training and exams. Available at: www.cosecsa.org/ Collaboration between the RCSEd and surgeons training-exams/examination. Accessed March 7, 2018. 5. College of Surgeons of East, Central and Southern Africa. in Myanmar is underpinned by a memorandum of E-logbook. Available at: www.cosecsa.org/e-logbook- understanding (MoU) with the Department of Medi- portal. Accessed March 7, 2018. cal Science in the Ministry of Health and Sport. The 6. O’Flynn E, Andrew J, Hutch A, et al. The MoU terms reflect the importance of maintaining specialist surgeon workforce in East, Central and standards, sustainability, responsibility, and owner- Southern Africa: A situation analysis. World J Surg. | 39 2016;40(11):2620-2627. ship of a health care partnership project. The five-year 7. College of Surgeons of East, Central and Southern agreement commenced in 2013 and provides sup- Africa. Global surgery map. Available at: www.cosecsa. port for surgical training, education, and assessment org/global-surgery-map. Accessed March 7, 2018. activities. In addition to specific surgical training 8. Hutch A, Bekele A, O’Flynn E, et al. The brain drain resources, topics such as working with multidisci- myth: Retention of specialist surgical graduates in East, Central and Southern Africa, 1974–2013. World J Surg. plinary teams, morbidity and mortality conferences, 2017;41(12):3046-3053. grand rounds, and other topics related to profes- 9. Clinical Officer Surgical Training in Africa (COST-Africa). sional practice are embedded in the program. Clinical Officer Surgical Training in Africa. Available at: The RCSEd carried out an early needs assessment www.costafrica.eu/. Accessed March 7, 2018. for surgical training, with support from a start-up 10. Gajewski J, Conroy R, Bijlmakers L, et al. Quality of surgery in Malawi: Comparison of patient-reported grant from the Tropical Health Education Trust outcomes after hernia surgery between district and (THET), a charitable funding organization linked central hospitals. World J Surg. Available at: https:// to the U.K. government. This assessment led to a rd.springer.com/article/10.1007/s00268-017-4385-9. successful bid for funding from U.K. Aid, managed Accessed March 7, 2018. by THET, as part of the Trust’s Health Partnership 11. Clinical Officer Surgical Training in Africa (COST-Africa). Data collection. Zambia. Available at: www.costafrica.eu/ project. This funding has enabled the RCSEd to data-collection.html. Accessed March 27, 2018. work closely with the Myanmar Nephro-Urological 12. Royal College of Surgeons in Ireland. Irish-led research to Society to facilitate capacity building in an underpro- bring safe surgery to rural populations in Africa. Available vided specialty, resulting in 17 trained government at: www.rcsi.ie/index.jsp?n=110&p=100&a=10293. urologists for a population of 53 million in 2013. Accessed March 7, 2018. 13. Royal College of Physicians and Surgeons of Glasgow. The two-year pilot program consisted of visits Available at: https://rcpsg.ac.uk/. Accessed March 8, 2018. by senior British urologists acting as visiting professors to operate and teach clinical skills, as well continued on next page as provide general professional training in Yangon and Mandalay. These visits were complemented by short visits of selected Myanmar trainees to specific

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

“As stated in WHA 68.15, surgical capacity is an essential part of universal health coverage and our political commitment and programs must reflect that,” Dr. Tedros wrote.

departments in the U.K. The selected surgeons were REFERENCES, CONTINUED accorded observer status with full participation in 14. World Health Assembly. Strengthening emergency and the host department’s activities, short of direct essential surgical care and anaesthesia as a component patient treatment. of universal health coverage. May 20, 2015. Available at: This effort has resulted in effective sustainable http://apps.who.int/medicinedocs/documents/s21904en/ local delivery of a new surgical training program in s21904en.pdf. Accessed March 19, 2018. 15. Response letter to the Royal College of Surgeons. Tedros urology incorporating workplace-based assessments, Adhanom Ghebreyesus, Minister, Special Advisor to the a quality improvement program, portfolio develop- Prime Minister of Ethiopia. April 21, 2017. Available at: ment, and an annual appraisal of trainees. Ultimately, www.who.int/surgery/DrTedrosLetter.pdf. Accessed these activities will be delivered locally to a high March 27, 2018. standard, while maintaining a role for the RCSEd 16. Royal College of Surgeons of England. Available at: www. rcseng.ac.uk/. Accessed March 8, 2018. in quality assurance and guidance where requested. 17. G4 Alliance. Available at: www.theg4alliance.org/. Again, this model could be readily adopted for other Accessed March 8, 2018. specialties. 18. GlobalSurg. Available at: http://globalsurg.org/. Accessed 40 | Both of these international initiatives are exam- March 8, 2018. ples of local requests for directed assistance, which 19. Royal College of Surgeons of Edinburgh. Available at: www.rcsed.ac.uk/. Accessed March 8, 2018. the RCSEd, through its examinations and education 20. Royal College of Surgeons of Edinburgh. Welcome to the departments, is able to achieve. ♦ International School of Surgery. Available at: www.iss. rcsed.ac.uk/. Accessed March 8, 2018. 21. Royal College of Surgeons of Edinburgh. ESSQ MSc in Acknowledgments surgical sciences. Available at: www.essq.rcsed.ac.uk/. Accessed March 8, 2018. The authors gratefully acknowledge the contributions of 22. Royal College of Surgeons of Edinburgh. ChM in general the following individuals: David Tolley, MB, FRCSEd, past- surgery. Available at: www.chm.rcsed.ac.uk/chm- president, RCSEd; Mike Lavelle-Jones, MB, ChB, president, overview/. Accessed March 8, 2018. RCSEd; and O. James Garden, CBE, BSc, MB, ChB, MD, 23. Scotland Malawi Partnership. Available at: www.scotland- FRCSEd, FRCPEd, FRSE, regius professor of clinical sur- malawipartnership.org/. Accessed March 8, 2018. gery, dean international, University of Edinburgh.

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COSECSA collaborates to address surgical shortages in sub-Saharan Africa

by Miliard Derbew, MD, FRCS, FCS(ECSA)

Surgical workforce in the ECSA region HIGHLIGHTS Access to surgical care remains one of the most significant and underreported issues in the region. A • Summarizes surgical workforce issues in situational analysis of the COSECSA region workforce East, Central, and Southern Africa was recently conducted. The study results indicate that | 41 • Defines the COSECSA plan for growth, the region has only 1,690 surgeons serving a population including graduating 500 surgeons by 2020 of more than 320 million. Of these surgeons, 53 percent • Describes the benefits of the School for Surgeons are general surgeons, whereas the others have addi- mobile-optimized, e-learning platform tional subspecialty training. The surgeon-to-population ratio is 0.53 per 100,000 population.2 In addition to the workforce shortage, the region he College of Surgeons of East, Central and has a significant misdistribution issue. The data indi- Southern Africa (COSECSA) was founded in cate that 71 percent of surgeons practice in urban areas T1999. COSECSA is a not-for-profit organiza- with populations greater than 500,000. Women are tion that operates in 12 countries in sub-Saharan underrepresented, comprising only 7 percent of the Africa and is an independent body that fosters post- surgical workforce.2 graduate education in surgery and provides In partnership with the Royal College of Surgeons surgical training throughout sub-Saharan Africa in Ireland (RCSI) and other members of the Interna- (see Figure 1, page 42). COSECSA’s primary objec- tional Collaborators for Essential Surgery network of tives are to advance education, training, standards, surgeons and public health specialists, an interactive research, and practice in surgical care in this region. map showing the location of all surgeons throughout More specifically, COSECSA shapes and leads the the ECSA region has been created. The interactive map training of surgeons in East, Central, and South- shows the number of surgeons per 100,000 individuals ern (ECSA) Africa. The College offers a surgical in any given COSECSA region.3 training program with a standardized examination that is internationally recognized. To date, 214 specialist surgeons have graduated from Strategic plan and implementation COSECSA-affiliated programs. Admission to of WHA Resolution 68.15 the College is open to all registered health care A five-year strategic plan for implementing the World practitioners who comply with the professional Health Assembly (WHA) Resolution 68.15 in 2016−2020 requirements for admission.1 has been developed and is under way. The COSECSA

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 1. COSECSA MEMBER COUNTRIES WITH SUDAN AND NAMIBIA AS NEW ADDITIONS

Source: College of Surgeons of East, Central and Southern Africa. What is COSECSA? Available at: www.cosecsa. org/about/what- cosecsa. Accessed March 9, 2018.

strategic plan is a dynamic blueprint for the growth of supervises each grant, and the research findings are COSECSA as an organization and is based on four key due to be published soon. goals. These strategic goals are as follows. COSECSA has a comprehensive e-learning platform known as School for Surgeons (SFS), which Graduate 500 surgeons by 2020 contains mandatory learning materials for train- 42 | COSECSA training sites have been increasing steadily. ees in the following programs: Fellowship of the A recent count shows 99 accredited sites. The enroll- College of Surgeons (also known as FCS) and Mem- ment of surgical trainees continues to increase, with bership of the College of Surgeons (also known as 127 enrollees in 2017 and 135 in 2018. Because of the MCS).4 The SFS was fully redeveloped in 2016 to innovative approach to hospital-based training in match the new COSECSA branding and make it the COSECSA region, the attrition of graduates has more user-friendly and accessible. The new features been minimal. A study on the retention rate of surgi- of the SFS included mobile optimization of the plat- cal graduates (COSECSA and 24 master of medicine form. This platform is viewed as a more effective institutions) from 1974 to 2013 across eight COSECSA and efficient way of delivering mobile-optimized countries was completed in October 2017. The data learning for trainees. showed that 85.1 percent of graduates were retained Increasing knowledge and competence in surgery in their home country, 88.3 percent in the COSECSA through skills courses is one of the strategies the region, and 93.4 percent of graduates remained within College has been developing. In 2016, more than 40 Africa. courses were conducted for different surgical specialties in the COSECSA member countries. The number Achieve excellence in training and research of courses conducted increased to 45 in 2017. Together with international partners, COSECSA is Essential surgical training (EST) aims to ensure building the research infrastructure. Data collection that standardized, cost-efficient, and high-qual- through a resident logbook has been centralized, ity essential surgical services are accessible to the and the electronic logbook contains records of more rural population in the district’s hospitals in Zim- than 100,000 cases. In 2016, four COSECSA trainees babwe (ZEST) and Rwanda (REST). A total of 102 (Philip Blasto, MD, from Kenya; Gift Mulima, MD, nonsurgeons participated in ZEST courses, and 87 from Malawi; Vanda Amado, MD, from Mozam- nonsurgeons participated in REST courses. bique; and Ryuba Nyamsogoro, MD, from Tanzania) In addition to these basic courses, four additional received research grants of $3,500 (U.S.) each to basic surgical skills courses took place in conjunc- undertake independent research projects in the tion with the RCSI COSECSA Mobile Surgical Skills ECSA region. A COSECSA country representative Unit in 2016.

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Maintain best practice in examinations and assessment REFERENCES The COSECSA Council has recently passed a resolution to inau- 1. College of Surgeons of East, Central gurate the college’s own court of examiners from among its senior and Southern Africa. Candidate fellows. The main responsibility of the examiners will be to par- registration. Available at: www.cosecsa. ticipate in a training workshop prior to the examinations and org/registration-information. Accessed to administer the clinical examinations. We anticipate that the March 9, 2018. 2. O’Flynn E, Andrew J, Hutch A, et al. The establishment of the court will improve the postgraduate surgical specialist surgeon workforce in East, examining process and the standardization of the exam. Central and Southern Africa: A situation analysis. World J Surg. 2016;40(11):2620- Build to organizational excellence, 2627. ﬁnancial sustainability, and partnerships 3. College of Surgeons of East, Central and Southern Africa. Global surgery map. Within the COSECSA, Women in Surgery Africa (WISA) was Available at: www.cosecsa.org/global- founded in December 2015, with the aim of increasing the number surgery-map. Accessed March 9, 2018. of women surgeons in the region by supporting women physicians 4. College of Surgeons of East, Central and who train in surgery. The college will ensure these physicians are Southern Africa. School for Surgeons. mentored while they complete the training program and beyond. Available at: www.cosecsa.org/school- | 43 This initiative will increase the number of women surgeons, which surgeons-portal. Accessed March 9, 2018. comprise just 9 percent of the total number of surgeons in the region. COSECSA’s standing and recognition in the region is growing, as evidenced by the fact that more countries in Africa have joined our organization. We continue to build international partnerships based on mutual benefits. Over the last few years, COSECSA has partnered with the American College of Surgeons to support the increase of women in surgery efforts, sharing educational resources, and supporting leadership training when there is greatest need. COSECSA’s relationships with the Royal Colleges of Surgeons in the U.K. and Ireland have been very productive. COSESCA and the RCSI just celebrated 10 years of collaboration—a partnership that has been the most productive for our college.

Conclusion The COSECSA region is facing one of the greatest surgical workforce shortage crises in the world. It is of paramount importance that the organization’s partnerships focus on workforce development. COSECSA is looking forward to improving the quality of our trainees, as well as scaling up the overall number of trainees. We welcome support and collaborative partnerships with surgical organizations from high-income countries and nongovernmental organizations dedicated to improving the care of the surgical patient to help us achieve our goal of graduating 500 surgeons by 2020. ♦

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

WFSA describes its vision for implementation of WHA 68.15

by Julian Gore-Booth, MA; Jannicke Mellin-Olsen, MD; Wayne W. Morriss, BS, MB, ChB, FANZCA; Carolina Haylock-Loor, MD; Bisola Onajin-Obembe, MB, BS, MBA, FWACS; and Adrian W. Gelb, MB, ChB, FRCPC

perioperative care, resuscitation, intensive care medi- 44 | HIGHLIGHTS cine, and pain management. • Summarizes the mission and goals of the WFSA to support universal access WHA 68.15, safe anesthesia, and safe surgery to safe surgery and anesthesia The year 2015 marked a turning point for the 5 billion • Describes the WFSA Global Anesthesia out of 7 billion people in the world without access to Workforce Survey and how it is used to safe, affordable, and timely surgery and anesthesia measure the scope of this health care crisis care.2 With the release of the following publications and reports—the third edition of Disease Control Pri- • Outlines the four WFSA program areas, 3 including advocacy, training, safety, and orities: Essential Surgery; The Lancet Commission on research, to ensure proper anesthesia care Global Surgery (LCoGS) “Global surgery 2030: Evi- dence and solutions for achieving health, welfare, and • Highlights the challenges to economic development”;2 and the unanimous passage WHA 68.15 implementation of World Health Assembly (WHA) Resolution 68.15, Strengthening Essential and Emergency Surgery and Anaesthesia as a component of Universal Health Cov- he World Federation of Societies of Anaesthe- erage4—a platform was established to ensure that the siologists (WFSA) is composed of 135 member surgical patient is included in any commitment and Tsocieties in more than 150 countries and rep- action to ensure universal health coverage (UHC), as resents hundreds of thousands of anesthesiologists outlined in the United Nations’ sustainable develop- around the world. ment goal (SDG) 3.5 The WFSA’s vision is of “universal access to safe The WFSA has official liaison with the World anesthesia,” and its mission is “to unite anaesthesi- Health Organization (WHO) and was part of the ologists around the world to improve patient care campaign to promote the passage of WHA Resolution and access to safe anaesthesia and perioperative med- 68.15, which is intended to ensure that safe anesthesia icine.”1 Anesthesiologists are leaders in teamwork is an indivisible and indispensable element of safe sur- and patient safety and are experts in anesthesia and gery, and that both are a human right.

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 1. WFSA GLOBAL ANESTHESIA WORKFORCE MAP

Source: World Federation of Societies of Anaesthesiologists. The WFSA Global Anesthesia Workforce Map. Available at: www.wfsahq.org/workforce-map. Accessed March 22, 2018.

| 45

In addition to supporting the resolution, the WFSA required to ensure safe, affordable, and timely anesthe- has been active in ensuring that key indicators, such sia care. The standards also can be used to inform the as perioperative mortality rate and surgical work- development of national guidelines, which are useful force density, are included in the WHO list of 100 in achieving more local buy-in, targets, legislation, and Core Health Indicators,6 and that the WHA commits national improvement plans. to regular progress reporting against the resolution. The WFSA Global Anesthesia Workforce Survey Ongoing reporting is an essential requirement if we highlights the breadth of this health care crisis and are to convert WHA 68.15 into action and measur- helps measure how it progresses in the future.8 Con- able change. ducted in 2015–2016, the survey documented the shortage of anesthesia providers against the LCoGS recommendation of 20 specialist surgeons, anesthesiol- Our framework for action ogists, and obstetricians (SAOs) per 100,000 population, As part of its response, the WFSA defined its goals, with an interim target for the number of anesthesiolo- described the size of the crisis in anesthesia, and out- gists set at five per 100,000 population. The survey lined a plan for achieving its mission and measuring showed the stark differences in physician and nonphy- its progress. sician anesthesia provider numbers between different The plan is based on the WFSA International Stan- regions of the world and between resource-rich and dards for a Safe Practice of Anesthesia.7 The latest resource-poor countries. The study also found that to revision of these standards will be published in 2018 meet the target, at least an additional 136,000 anesthe- and will be a shared WFSA-WHO set of guidelines siologists are needed—mostly in low-income countries. establishing the minimum standards required for the To measure differences in anesthesia provider num- provision of safe anesthesia in the areas of workforce, bers, the aim is to repeat the survey every four years. equipment and infrastructure, and medicine. With Notably, the survey also is augmented by a web-based the establishment of a clear description of safe anes- map, which is a real-time tool for tracking the anesthesia practice, the WFSA can define which efforts are thesia workforce and is updated as new information

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 2. THE WFSA FELLOWSHIP PROGRAMS

Source: World Federation of Societies of Anaesthesiologists. The WFSA Fellowship Programmes. Available at: www.wfsahq.org/wfsa-fellowship-programmes. Accessed March 22, 2018.

46 |

is received (see Figure 1, page 45). The survey also the role of anesthesia and positioning it as a prior- is enhanced by ongoing support of advocacy efforts. ity for all stakeholders, including the United Nations’ In 2017, the WFSA member societies unanimously WHO/WHA, government bodies, nongovernmental approved a position statement on anaesthesiology and organizations, industry, and funders, as well as for the UHC,9 describing how the federation and anesthe- surgical team itself. As part of its mission to inform sia providers will respond. The statement describes and support anesthesia care health policy, the WFSA anaesthesiology as a medical specialty, one that is organized the inaugural SAFE-T (Safe Anaesthesia potentially high-risk and that must, wherever and For Everybody–Today) Summit, which took place in whenever possible, be provided, led, or overseen by London, U.K., in April 2018. physicians. The statement explains that in many coun- Education and training priorities include the tries, nonphysician providers (nurses, clinical officers, expansion of the WFSA’s fellowship program—a sub- and technicians) are and will be part of any solution specialty mentoring program that provides clinical and and acknowledges that a range of trained providers are leadership training for up to 50 young anesthesiologists necessary to achieve UHC by 2030. Teamwork is vital every year. The WFSA also intends to expand short- to meeting this goal, as is the development of a task- term Safer Anaesthesia From Education (also known sharing approach across the anesthesia-surgical team. as SAFE) training aimed at all anesthesia providers, including those who work in obstetrics, pediatrics, and operating room settings, as well as training for Four programs for accessibility those who work in pain management. In addition, the The WFSA has four program areas that are intended WFSA supports the attendance of young anesthesi- to ensure access to proper anesthesia care for all global ologists at scientific conferences, including the World populations, including: advocacy, education and train- Congress of Anaesthesiologists, through the WFSA ing, safety and quality, and innovation and research. scholarship program. The WFSA’s advocacy-related priorities include The WFSA will continue to produce a range of informing both the public and policymakers about online educational materials, including the web-based

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

Anaesthesia Tutorial of the Week,10 the continuing medical REFERENCES 11 education journal Update in Anaesthesia, and the global health 1. World Federation of Societies of section in Anesthesia and Analgesia via our partnership with Anaesthesiologists. Vision and mission. the International Anesthesia Research Society. The federa- Available at: www.wfsahq.org/about-us/vision- tion plans to engage in ongoing improvement of in-person and-mission. Accessed March 20, 2018. and online education resources available through the WFSA, 2. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions member societies, and other partners. for achieving health, welfare, and economic The safety and quality goals include all WFSA program development. Lancet. 2015;386(9993):569-624. areas, specifically the ongoing revision and dissemination of 3. Mock CN, Donkor P, Gawande A, et al. the international standards, as well as the support of profes- Essential surgery: Key messages from sional well-being programs for anesthesiologists.12 The WFSA Disease Control Priorities, 3rd edition. Lancet. 2015;385(9983):2209-2219. soon will expand its role and that of its member organiza- 4. World Health Assembly Resolution 68.15: tions in the development of national surgical, obstetric, and Strengthening Emergency and Essential Surgical anesthesia plans.13 The WFSA has developed an anesthesia Care and Anaesthesia as a Component of capacity assessment tool (based on the standards) to help with Universal Health Coverage. Sixty-Eighth World the expansion process.14 Health Assembly. Available at: http://apps.who. | 47 int/gb/ebwha/pdf_ﬁles/WHA68/A68_R15-en. The innovation and research goals include a global innova- pdf. Accessed November 30, 2017. tion awards program and research fellowships. Alongside these 5. United Nations. Sustainable Development programs, our publications aim to encourage more research Goals. Available at: www.un.org/ in low- and middle-income countries (LMICs) where the lack sustainabledevelopment/sustainable- of evidence and data hinders the drive for policy change and development-goals/. Accessed March 4, 2018. 6. World Health Organization. Global Reference action. List of 100 Core Health Indicators, 2015. Available at: www.who.int/healthinfo/ indicators/2015/en/. Accessed March 4, 2017. WHA 68.15: 7. Merry AF, Cooper JB, Soyannwo O, Wilson IH, The main challenge to implementation Eichhorn JH. International standards for a safe practice of anesthesia 2010. Can J Anaesth. The WFSA maintains that the primary hurdle to the imple- 2010;57(11):1027-1034. mentation of WHA 68.15 is the workforce deficit—a deficit 8. Kempthorne P, Morriss W, Mellin-Olsen J, Gore- that is heightened when one considers the concentration of Booth J. The WFSA global anesthesia workforce anesthesiologists in urban centers and, as is often the case, in survey. Anesth Analg. 2017;125(3):981-990. private practice. Other resources, such as equipment and medi- 9. World Federation of Societies of Anaesthesiologists. WFSA position statement on cines, are also important, but workforce needs must be met universal health coverage. Available at: www. first, both as a driver for change and as the essential resource wfsahq.org/latest-news/latestnews/682-wfsa- to ensure that equipment and medicines are used appropri- releases-position-statement-on-anaesthesiology- ately and safely. and-universal-health-coverage-uhc. Accessed Although the WFSA has a well-developed strategy for March 19, 2018. strengthening the skills, knowledge, competencies, and lead- continued on next page ership of anesthesia providers who are already qualified and providing anesthesia, the Federation recognizes that much more needs to be done to qualify and retain new anesthesia providers. In response to WHA 68.15, the WFSA is now developing a framework for anesthesia training that will help

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

national societies determine the different levels of compe- REFERENCES, CONTINUED tency required for specific operations at different levels of 10. World Federation of Societies of hospitals. In some countries, the guidelines might go on to Anaesthesiologists. Anaesthesia Tutorial of the provide a foundation for training programs to develop an Week. Available at: www.wfsahq.org/resources/ expanded cadre of nonspecialist nurse and physician anes- anaesthesia-tutorial-of-the-week. Accessed March thesia providers who can be trained, mentored, and overseen 19, 2018. 11. World Federation of Societies of by anesthesiologists (see Figure 2, page 46). Anaesthesiologists. Update in anaesthesia. August The data suggest that less than 1 percent of global health 2017. Available at: www.wfsahq.org/resources/ funding is spent on any aspect of anesthesia-surgical care, update-in-anaesthesia. Accessed March 19, 2018. despite surgical conditions accounting for 30 percent of the 12. Occupational Well-Being in Anesthesiologists. global burden of disease.15 These disparities must change, Sociedade Brasileira de Anestesiologia. 2014. Available at: www.wfsahq.org/images/ and the WFSA will continue to work with partners such as Occupational_Well-Being_in_Anesthesiologists-2. the WHO and the G4 Alliance (also known as the Global pdf. Accessed March 19, 2018. Alliance for Surgical, Obstetric, Trauma, and Anaesthesia 13. Surgical care systems strengthening: Developing Care) to ensure that health care leaders and funders are national surgical, obstetric and anaesthesia plans. 48 | aware of these inequities. World Health Organization 2017. Available at: http://apps.who.int/iris/handle/10665/255566. Governments seem to have a tendency to undervalue Accessed March 19, 2018. anesthesia, with providers in many LMICs unable to qual- 14. World Federation of Societies of ify in and go on to develop careers in the specialty. Indeed, Anaesthesiologists. Anaesthesia Capacity in some low-income countries, anesthesia trainees do not Assessment Tool. Available at: www.wfsahq.org/ receive a salary. Strengthened partnership with surgeons will our-work/advocacy/national-anaesthesia-plans. Accessed March 20, 2018. be helpful in this regard, as will a broader acknowledgment 15. Dieleman JL, Yamey G, Johnson EK, Graves of the role of anesthesia care in health system strengthening, CM, Haakenstad A, Meara JG. Tracking global mother and child health, pain management, palliative care, expenditures on surgery: Gaps in knowledge noncommunicable diseases, and trauma and critical care. hinder progress. Lancet Glob Health. 2015 Apr 27;3 Supplement 2:S2-4.

The WFSA’s solutions Advocacy and education are paramount in the WFSA’s implementation of Resolution 68.15. The WFSA will continue to scale up activity, provided that funding and resources are available. The WFSA recognizes that large numbers of new providers are required and is working with national societies, educational organizations, and other stakeholders to scale up training of specialists and nonspecialist providers. In so doing, the WFSA is aware of both the urgency of the need and the economics involved, but is also determined to help every patient achieve access to safe and timely anesthesia. The WFSA’s network is unique. Physician-led but patient- focused, this organization provides extraordinary and investible resources to ensure the realization of the goal of universal access to safe anesthesia and surgery. ♦

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HIGHLIGHTS • Describes models for building academic and professional association partnerships to improve surgical and obstetrical care • Identifies NSOAP’s six domains for improving access to quality care, which are applicable to the reduction of maternal and neonatal mortality • Summarizes lessons learned to build global clinical research capacity

| 49 by Frank W. J. Anderson, MD, MPH; Obstetrics and gynecology Lina Roa, MD; in global health: Chiara Benedetto, MD, PhD; Isabelle Citron, MB, BCh; Lessons learned for Luis Curet, MD; advancing public health to Carla Eckhardt; achieve universal health care Clark Johnson, MD, MPH; Barbara S. Levy, MD; Dereje Negussie, MD, MPH; Stephen Rulisa, MD, PhD; Rubina Sohail, MD; Rachel Spitzer, MD, MPH; Michael Stark, MD; Bellington Vwalika, MD, MSc; and Kwabena Danso, MB, ChB

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

ddressing global health inequities requires a Although the MDGs for neonatal and maternal health comprehensive response from the world’s sur- were not achieved, substantial progress was made, and gical, anesthesia, and obstetrics and gynecology the maternal mortality ratio (MMR) fell from 385 to A 4 (OB/GYN) communities. These health care profes- 216 deaths per 100,000 live births. sionals need to share evidence-based knowledge Upscaling high-quality obstetrical interventions and experience and collaborate to develop training continues to be part of the response to the new sus- programs and initiatives that ensure sustained, func- tainable development goal (SDG) of eliminating tioning health care systems. The world has experienced preventable maternal and early neonatal mortality. significant improvements in health care for millions The SDG now calls for reducing global MMRs from because of effective global public health programs. 216 per 100,000 live births in 2015 to less than 70 per However, these improvements have exposed the sig- 100,000 live births by 2030 (SDG 3.1). This objective nificant burden of obstetrical and surgical disease will be achieved only by expanding comprehensive facing most of the world’s population. Tremendous obstetrical, anesthesia, and surgical care to a level not gaps exist in expertise, workforce, and infrastructure, offered by community workers, general physicians, all of which are essential to provide critical surgical, or midwives. These interventions will require novel 50 | anesthesia, and modern OB/GYN care in low- and partnership approaches and evidence-based strategies middle-income countries (LMICs). that go beyond relief and vertical programs and work International efforts are under way to address these toward long-term, sustainable capacity development.5 gaps. In 2015, the 68th World Health Assembly (WHA) OB/GYN services are linked to the environments passed Resolution 68.15 to strengthen emergency and that support the treatment of other surgical conditions, essential surgical care and anesthesia as a component both requiring widely available anesthesia capabilities. of universal health care.1 That same year, The World Providing safe deliveries, including cesarean sections Bank released the third edition of Disease Control Priori- (C-sections), has been shown to be cost-effective.6,7 ties, highlighting surgical procedures as cost-effective Furthermore, investing in improving access to safe health care interventions and advocating for universal reproductive health care, including family planning coverage of emergency surgery.2 Further evidence for and abortion, when coupled with obstetric surgical care the need to strengthen health care systems was pro- powerfully synergize cost-effectiveness.8 The impor- vided by The Lancet Commission on Global Surgery tance of providing these services is based not only on (LCoGS), which reported that 5 billion people lack ethical grounds, but on sound economic policy.6,9 access to safe and affordable surgical and anesthesia The maternal health community benefits from care, recommending six core indicators to monitor many years of global prioritization on these issues with the strength of surgical systems.3 Within this frame- funding and programmatic momentum. Moving for- work, the OB/GYN, surgery, and anesthesia global ward to address more comprehensively the surgical communities have a unique opportunity to develop a burden of disease requires the coalescence of a global comprehensive partnership approach that provides the health agenda, with a strong collaboration between level of expertise needed to lead a coordinated public OB/GYN, surgery, and anesthesia to lead the next gen- health response. eration of global public health interventions. The Millennium Development Goals (MDGs) proj- The LCoGS created a road map for the way for- ect, led by the United Nations (UN) from 2000 to 2015, ward and recommended a list of key indicators to included eight primary goals, ranging from halting assess the strength of surgical systems and provide a the spread of the human immunodeficiency virus baseline for measuring improvement. The improved (HIV) to reducing neonatal and maternal mortality. health outcomes measured by these indicators can

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Through strong partnerships to build OB/GYN residency programs, strengthen professional societies, and create certification programs, we are growing and mentoring leaders in research, clinical care, education, and policy development.

be accomplished if surgery, OB/GYN, and anesthesia between the local medical community, the Minis- unite for a coordinated global effort of prospective data try of Health, and academic partners in the U.S., the collection. Coordinating the collection and reporting U.K., and the West African College of Surgeons.10 of these indicators at the national level with The World As of July 2017, according to Frank W. J. Anderson, Bank Development Indicators will provide the metrics MD, MPH, a co-author of this article, the program for the global community to measure progress and to has graduated 246 certified OB/GYNs, 238 of whom achieve the 2030 targets. have remained in Ghana, providing clinical services, This article describes some of the major inter- academic leadership, and contributing to governmen- ventions that the global OB/GYN community has tal policymaking. Those physicians choosing faculty implemented to build long-term and sustainable capac- positions are conducting high-quality basic science ity around the world. It identifies successful models for and clinical research, and many are working in rural academic and professional society partnerships and district hospitals, opening new facilities, and leading highlights areas of collaboration to build surgical, OB/GYN departments in four new medical schools obstetrical, and anesthesia capacity. Through strong in Ghana.10,11 Subspecialty training in maternal-fetal partnerships to build OB/GYN residency programs, medicine (MFM), gynecologic oncology, urogynecol- strengthen professional societies, and create certifica- ogy, and reproductive health is now available. | 51 tion programs, we are growing and mentoring leaders This model of academic partnership is being in research, clinical care, education, and policy devel- replicated in Ghana in other specialties, including opment. The lessons learned from these interventions emergency medicine, family medicine, and otolaryn- can be applied to other surgical specialties and pave the gology, as well as in nonclinical departments. Notably, way forward in building capacity to provide sustain- the “Charter for Collaboration” was created as part of able, high-quality obstetrical, gynecological, surgical, the program implementation plan by partners in the and anesthesia care globally. U.S. and Ghana to foster an open dialogue on how to optimize the partnership. A concerted effort was made to ensure the priorities and concerns of both partners Academic partnerships were integrated into the project’s development and Partnerships between OB/GYN departments in sub- implementation. A series of guiding principles were Saharan Africa with academic OB/GYN departments articulated by the group and featured in the charter, in high-income countries are a feasible and resilient including trust, mutual respect, accountability, lead- approach to building obstetric capacity in LMICs. ership, transparency, inclusion, communication, and These partnerships increase the capacity of faculties sustainability.12 Now, the charter serves the function and departments to provide clinical service, education, as a guideline for new collaborative projects.12 and research in the African OB/GYN community. The Ghana experience in training OB/GYNs These model programs are informative and present and developing a model for partnerships provides a opportunities for replication in surgery and anesthesia. road map for numerous OB/GYN departments. At Ghana, for example, has used a university part- least four new OB/GYN partnerships have emerged nership approach to advance obstetric capacity and are actively training new OB/GYNs and other development when faced with a health care work- specialists.13-17 force crisis. Until 1989, Ghana sent OB/GYN trainees The 1000+ OBGYNs Project is another collab- to train in the U.K. with only three out of 30 specialists orative effort, led by the department of OB/GYN at returning in a 20-year period. The residency program the University of Michigan, Ann Arbor, comprising established in 1989 resulted from a collaboration a network of U.S. and African academic OB/GYN

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 1. 10 CRITICAL COMPONENTS OF COMPREHENSIVE OB/GYN TRAINING PROGRAMS

Critical components of comprehensive OB/GYN training, as identified Authentic during Rome (2010) and partnership Accra (2014) meetings Certification/ professional of the 1000+ OBGYNs Infrastructure Project partners society engagement

Curriculum Quality development improvement 1000+ OBGYNs PROJECT CRITICAL COMPONENTS Faculty Monitoring and development evaluation

52 | Deployment for Research health systems/ training Work with human capacity Ministries of Health and Education

departments. The project was created after two global between North American academic health centers and meetings of OB/GYN leadership in Rome, Italy, in 2012 Moi University School of Medicine, Eldoret, Kenya.21 and in Accra, Ghana, in 2014 and is poised to train more The partnership was initially focused on the depart- than 1,000 new OB/GYNs in the sub-Saharan region ment of internal medicine and progressed into a holistic over the next decade.18 At these meetings, 10 critical HIV treatment program. A decade ago, the partnership components of OB/GYN training were identified to pro- expanded to include the University of Toronto, ON; vide a base from which to replicate these partnerships Indiana University, Indianapolis; and Moi University to (Figure 1, this page).19 The educational programs will be build capacity in OB/GYN. AMPATH leverages the tri- supported by lectures, videos, textbooks, and curricula partite academic mission of clinical care, research, and provided without cost. Online materials, together with education. The focus has been prevention of maternal the Global Library of Women’s Medicine, provide hun- mortality and prevention and treatment of gyneco- dreds of OB/GYNs in sub-Saharan Africa with access logic malignancies. AMPATH has instituted numerous to quality standardized material on the most prevalent hospital-based training and protocol initiatives and has issues in the region, as well as content related to general started a two-year training program in gynecologic OB/GYN care, family planning, and cancer screening.20 oncology in Kenya. The program’s success has led to The Academic Model Providing Access to Health- its expansion to a similar two-year in-country MFM care (AMPATH) is an academic medical partnership fellowship in 2018.

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

Professional societies have great potential to play a significant role in promoting national policies, establishing national standards, developing quality assurance and outcome measures, and monitoring health care indicators.

The Human Resources for Health (HRH) pro- The effort to build workforce capacity is best gram in Rwanda resulted from the Ministry of achieved starting at the education level, then con- Health’s (MOH) vision to strengthen and sustain tinuing through participation in lifelong learning a specialized health workforce. With the help of opportunities. Certification programs lead to the cre- the Clinton Health Access Initiative, an academic ation of an objectively assessed professional status, consortium was formed by U.S. universities, medi- which is critical for public confidence. Ongoing main- cal centers, and schools of nursing, dentistry, and tenance of certification allows for peer learning and public health to develop a seven-year partnership participation in continuing education while in prac- for sustained collaboration and the establishment tice. The content of the training must be informed of new medical residency programs.22 Since 2012, by the local context, academic curriculum, and pro- the program has deployed nearly 100 U.S. faculty fessional associations and defined by best clinical members to Rwanda annually to partner with local evidence. faculty in clinical and academic teaching. A total A process for certification of specialists in of 19 OB/GYNs have participated in this program, OB/GYN is in development in Ethiopia. In 2005, a including 11 MFM specialists who have provided new health care strategic plan was created to increase training in high-risk obstetric management, curricu- the number of trained medical physicians annually | 53 lum development, teaching, and testing. from 120 to 3,000, and the national government Ultrasound is an essential diagnostic tool for increased the number of OB/GYN residency pro- OB/GYN. MFM specialists provide ongoing train- grams from three to 12. The Ethiopian Society of ing in ultrasound diagnosis, and more than 90 Obstetricians and Gynecologists (ESOG) was well- percent of admitted patients at the partnership suited to define the quality of medical training and sites receive an ultrasound in the triage unit. Fur- standards for providers. Together with consultation thermore, the number of OB/GYN residents has from the American College of Obstetricians and increased by 45 percent in Rwanda, and quality Gynecologists (ACOG) and with endorsement from improvement measures, such as guidelines devel- the MOH, ESOG launched a national harmonized opment and maternal mortality conferences, have residency curriculum in July 2017. The project has been initiated.23 The partnerships facilitate research ambitious goals to expand collaboration between capacity, clinical teaching, and the development universities in the areas of education, research, and of Rwandan specialists to address the specialized service, not only focusing on technical capabilities health care workforce shortage. and quality assurance, but also on leadership, social accountability, and advocacy. The curriculum development resulted from the ESOG-ACOG partnership, Professional society partnerships a supportive government, and collaboration between After completion of residency training, physicians experts and residency program directors. This model need ongoing medical education and access to pro- has been successful, and other national associations fessional associations to maintain their knowledge are considering replicating it. base and provide quality care, sustain the specialty, Similarly, the Federation of Central American and inform policy development. Unlike high-income Associations and Societies of Obstetrics and Gyne- countries (HICs) where these institutions and their cology (FECASOG) and ACOG partnered in 2003 to infrastructure exist, many LMICs have yet to create strengthen residency training in Central America. The their own national societies, or have young and Comité de Acreditatión FECASOG-ACOG (CAFA) nascent programs. created a residency accreditation committee and an

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

in-service examination for residents and a certifica- A substantial proportion of intraoperative adverse tion exam for graduates, allowing them to become events are due to surgeons’ poor behavior and a lack fellows. ACOG fellows assisted the programs seeking of communication.26 An example of an association accreditation, facilitating and mentoring local leaders actively enhancing communication skills is the Soci- to institutionalize regular quality assurance measures. ety of Obstetricians and Gynaecologists of Canada, Residency programs received feedback and accredita- which has long been involved in organizational tion. An annual examination process was developed capacity development through the International for administration to OB/GYNs in six countries across Federation of Gynecology and Obstetrics’ (FIGO) Central America. CAFA examinees receive a detailed Leadership in Obstetrics and Gynecology for Impact report on their performance relative to peers nation- and Change (LOGIC) program. The LOGIC program ally and internationally, and CAFA members get an has developed a toolkit for professional associations in-depth review and track performance at the indi- to strengthen capacity or institute organizational vidual, program, and national level over time. change. The toolkit focuses on the areas of culture, Professional societies have great potential to play organizational capacity, performance, external rela- a significant role in promoting national policies, tions, and function. 54 | establishing national standards, developing quality OB/GYN societies have recognized the need for assurance and outcome measures, and monitoring comprehensive education inclusive of advocacy. health care indicators. Professional associations are FIGO is the international coordinator of many global well-positioned to influence national policy and advo- OB/GYN professional development projects. FIGO’s cate for prioritization of improved health services and strategy to achieve SDG 5 on gender equality and strengthening of surgical systems.24 The ability of empowerment of women involves an advocacy and professional societies to assume this leadership role education strategy to eliminate gender violence and relies on their overall organizational capacity, their ensure universal access to sexual and reproductive ability to identify gaps and solutions, and the ongoing health. Advocacy actions prompt policymakers and development of a vibrant professional cadre. OB/GYN regulators to further the recognition, promotion, and societies have recognized the need for comprehensive protection of girls’ and women’s human rights. education that includes nontechnical skills. Leverag- In addition, an essential component of women’s ing the experience of mature OB/GYN associations, health advocacy is education of women to take own- partnerships between established and newer profes- ership of their health, and education of professionals sional societies promote credibility with policymakers to integrate a human rights framework into projects and facilitate advocacy for comprehensive training, and policies. As part of the training, regular work- thereby expanding the role of physicians as drivers shops take place in several countries to raise awareness of change. on providing human rights-based health care assis- Quite often, physicians without training or experi- tance to women. Furthermore, FIGO is in the process ence find themselves in leadership roles that use these of publishing a handbook titled Women’s Health and skill sets.25 Training future specialists in the impor- Human Rights: Mapping Possible Contributions to the tance of nontechnical skills and teamwork among United Nations Selected Bodies for More Conductive Leg- surgery, obstetrics, and anesthesia is key in the provi- islation, Regulations and Policies at Country Levels. sion of safe surgery. Professional OB/GYN societies Standardization of surgical methods is essential for are able to assume a leadership role in the develop- comparison of surgical outcomes and meta-analysis.27 ment of these skills for practicing physicians and those To address the need for evidence-based and stan- in training. dardized procedures, FIGO initiated the All-African

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 2. NSOAP’S SIX DOMAINS OF SURGICAL SYSTEMS DEVELOPMENT

6 2 Service delivery

Governance Workforce NSOAP 5 3

4 Finance Infrastructure

Information management | 55

Surgical Database project focusing on C-section, hys- strategy document.29 The Association of Professors terectomy, and basic endoscopy. FIGO partnered with in Gynecology and Obstetrics, through its global the New European Surgical Academy (NESA) and health committee, contributes faculty development the International Society for Gynecologic Endoscopy resources, scholarships, and educational materials for to standardize and transfer evidence-based surgical the international OB/GYN community.30 The Council knowledge to LMICs. The Université Cheikh Anta on Resident Education in Obstetrics and Gynecology Diop, Dakar, Senegal, provides the platform for train- offers scholarships for the residency director pro- ing, which includes lectures, workshops, and live gram “school,”31 whereas the Society for Maternal operations. Furthermore, NESA and the Institute of and Fetal Medicine has created capacity-building fel- Numerical Mathematics in Russia have partnered to lowships through its global health committee, which establish a standardization of surgical methods with seeks to improve outcomes for pregnant women in a detailed collection of surgical steps that allow for resource-limited areas of the world.32 The Interna- comparison between different surgeons and institutional Urogynecological Association has extended its tions.28 The All-African Surgical Database project is mission to assist in training OB/GYNs and others in the first of this type, and its model can be applied to pelvic surgery and fistula repair.33 different disciplines and localities with high potential to measure and improve surgical outcomes worldwide. Bringing obstetrical, anesthetic, Other professional clinical and certifying orga- and surgical capacity together nizations have been critical in expanding clinical Efforts to reduce maternal and neonatal mortal- and research expertise across the globe. The Royal ity have traditionally been a central part of the College of Obstetricians provides extensive clini- global health agenda as reflected by the MDG and cal and certification support, as outlined in its SDG frameworks. Consequently, most LMICs have

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

TABLE 1. integrated initiatives to reduce maternal mortality KEY LESSONS LEARNED IN OB/GYN into core elements of national strategic health plans. TO BUILD GLOBAL CAPACITY These programs have succeeded to the extent to which emergency care, capacity building of community • Academic institutions and hospital-based training health workers and midwives, and decentralization programs: Engage in long-term multidisciplinary of services to increase facility-based deliveries can be partnerships with LMIC institutions to build effective. However, universal access to comprehen- clinical, research, and leadership capacity sive, modern obstetrics and essential and emergency to create a sustainable workforce surgery by qualified specialists and anesthesia is still lacking. The LCoGS proposed a framework to assist • Global researchers: Ensure long-term research countries in creating national surgical, obstetrical, projects are driven by local needs and and anesthetic plans (NSOAP) which, when imple- experts while supporting the development mented, would comprehensively address the need for of research training among clinicians universal, safe, and affordable surgery, anesthesia, and obstetrical services.3 The NSOAP originally set forth 56 | • Professional societies: Create global networks five domains for improvement of access and quality: to strengthen residency program certification, service delivery, infrastructure, workforce, informa- accreditation, and continuing medical education tion management, and financing.3 A sixth domain, • Clinical professional organizations: governance, has subsequently been recommended Facilitate and share resources to (see Figure 2, page 55). Leveraging the success around standardize clinical care and training programs to reduce maternal and neonatal mortality, to expand obstetric, anesthesia, and surgical capacity • MOH: National surgical, obstetric, and anesthesia is key to improving health outcomes. plans offer platforms for interdisciplinary Monitoring and evaluation through a common set collaborations at the national level to of health indicators, with a consistent method of data strengthen universal access to care collection is another key area of collaboration between the maternal health and the surgical communities. • Collection and reporting of the surgical indicators One LCoGS indicator focuses on tracking surgical recommended by the LCoGS will require the volume, with a target of 5,000 surgical procedures collective efforts of the surgery, anesthesia, per 100,000 population by 2030.3 Data on C-section and OB/GYN communities to measure progress volumes are widely collected, and these reporting sys- and achievement of the 2030 targets tems could be expanded to report more broadly on other surgical procedures. Another indicator of a strong surgical system is tracking of perioperative mortality.3 Countries have been reporting maternal mortality ratio for several years, and, as a result, many have started systems for quality improvement review around mortality cases. These review and reporting systems could go beyond obstetrics and expand to cover perioperative mortality from all surgical procedures. By leveraging existing structures, surgery and anesthesia can leapfrog many

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Monitoring and evaluation through a common set of health indicators, with a consistent method of data collection is another key area of collaboration between the maternal health and the surgical communities.

years of slow and costly institutional reform by REFERENCES learning from the advances achieved by the 1. World Health Organization. WHA Resolution 68.15— maternal health community. Strengthening Emergency and Essential Surgical Care and Another key area of synergy between NSOAP Anaesthesia as a Component of Universal Health Coverage. May and maternal health planning is the sharing of 2015. Available at: apps.who.int/gb/ebwha/pdf_files/WHA68/ A68_R15-en.pdf. Accessed March 13, 2018. infrastructure and workforce resources. Most 2. Mock CN, Donkor P, Gawande A, et al. Essential surgery: Key maternal health plans dedicate resources to messages from Disease Control Priorities, 3rd edition. Lancet. decentralization of comprehensive emergency 2015;385(9983):2209-2219. obstetric and newborn care (CEMONC) ser- 3. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: vices to ensure the provision of C-sections at the Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. district- or health-center level. This endeavor 4. Alkema L, Chou D, Hogan D, et al. Global, regional, and national will require significant investment in functional levels and trends in maternal mortality between 1990 and 2015, and well-equipped operating theaters, as well with scenario-based projections to 2030: A systematic analysis as qualified personnel. For example, Tanzania’s by the UN Maternal Mortality Estimation Inter-Agency Group. national health strategy includes upgrading all Lancet. 2016;387(10017):462-474. 5. Anderson FWJ, Johnson TRB, de Vries R. Global health ethics: | 57 district hospitals and 50 percent of the health The case of maternal and neonatal survival. Best Pract Res Clin centers to provide CEMONC. This move has Obstet Gynaecol. 2017;43:125-135. resulted in significant upgrading or construc- 6. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara tion of operating rooms to provide C-sections. JG. Obstructed labor and caesarean delivery: The cost and benefit The incremental infrastructure required to of surgical intervention. PLoS One. 2012;7(4):e34595. 7. Deboutte D, O’Dempsey T, Mann G, Faragher B. Cost- convert a CEMONC-ready facility to one that effectiveness of caesarean sections in a post-conflict environment: provides all other emergency and essential sur- A case study of Bunia, Democratic Republic of the Congo. gical procedures expected at the district level Disasters. 2013;37 Suppl 1:S105-S120. is minimal. The expansion of surgical services 8. Erim DO, Resch SC, Goldie SJ. Assessing health and economic should be tied to expansion in the workforce outcomes of interventions to reduce pregnancy-related mortality in Nigeria. BMC Public Health. 2012;12(1):786-797. of qualified anesthesia and surgery providers. 9. Yamin AE, Boulanger VM, Falb KL, Shuma J, Leaning J. Costs Zambia has been a leader in NSOAP. Facing of inaction on maternal mortality: Qualitative evidence of the a workforce shortage, weak infrastructure, and impacts of maternal deaths on living children in Tanzania. PLoS poor referral systems that resulted in high mor- One. 2013;8(8):e71674. tality, morbidity, and financial catastrophe for 10. Anderson FW, Obed SA, Boothman EL, Opare-Ado H. The public health impact of training physicians to become patients led the MOH to prioritize access to obstetricians and gynecologists in Ghana. Am J Public Health. surgery as an essential component of universal 2014;104 Suppl 1: S159-S165. health care. In May 2017, the Zambian MOH 11. Klufio CA, Kwawukume EY, Danso KA, Sciarra JJ, Johnson drafted, budgeted, and signed the world’s first T. Ghana postgraduate obstetrics/gynecology collaborative NSOAP to be integrated into Zambia’s National residency training program: Success story and model for Africa. 34 Am J Obstet Gynecol. 2003;189(3):692-696. Health Strategic Plan. By coordinating and 12. Anderson F, Donkor P, de Vries R, et al. Creating a charter of leveraging existing momentum around mater- collaboration for international university partnerships: The nal and neonatal health, surgery and anesthesia Elmina Declaration for Human Resources for Health. Acad Med. can accelerate progress in implementing NSOAP, 2014;89(8):1125-1132. with the overarching goal of decreasing the continued on next page global burden of disease preventable with timely accessible surgery.

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

REFERENCES, CONTINUED Conclusion 13. Institute for Global Health and Infectious Diseases. Ob-Gyn Improving health for all requires expansion of residency program in Malawi. Available at: http://globalhealth. public health interventions to include obstet- unc.edu/education/global-health-fellowships/global-residency- rics, surgery, and anesthesia. Consequently, a programs/ob-gyn-residency-program-in-malawi/. Accessed professional class of surgeons, OB/GYNs, and March 13, 2018. 14. Icahn School of Medicine at Mount Sinai. Africa. Liberia. anesthesiologists will need to define and main- Available at: http://icahn.mssm.edu/about/departments/surgery/ tain quality standards, provide leadership and global-health/africa. Accessed March 13, 2018. supervision, and promote growth of their medi- 15. Cameroon-Arizona Partnership. Available at: http:// cal fields. To achieve these outcomes, strong cameroonarizonapartnership.org/. Accessed March 5, 2018. university and hospital-based training programs 16. University of Michigan. University of Michigan team helps perform first kidney transplants in Ethiopia. Press release. must exist in every country. In many LMICs, September 29, 2015. Available at: www.uofmhealth.org/news/ the ability to train, certify, and maintain the archive/201509/university-michigan-team-helps-perform-first- programs, institutions, and infrastructure that kidney. Accessed March 13, 2018. define surgical professions is weak and cannot 17. University of Michigan. Growing collaborations in Ethiopia. be initiated again without significant inputs 58 | Press release. July 24, 2017. Available at: http://global.umich.edu/ newsroom/growing-collaborations-in-ethiopia/. Accessed March from experienced academic and professional 13, 2018. society partners. Leaders in OB/GYN, surgery, 18. 1000+ OBGYNs Project. Available at: www.1000obgyns.org/. and anesthesia who participate in functioning Accessed March 13, 2018. departments and supportive policy environ- 19. Anderson FW, Johnson TR. Capacity building in obstetrics and ments have a unique opportunity to share their gynaecology through academic partnerships to improve global women’s health beyond 2015. BJOG. 2015;122(2):170-173. expertise for replication in LMICs. 20. The Global Library of Women’s Medicine. Available at: www. Established departments anywhere in the glowm.com/. Accessed March 13, 2018. world can initiate a process for mutually benefi- 21. AMPATH. Available at: www.ampathkenya.org/. Accessed cial partnerships to strengthen research, service, March 13, 2018. and education. Success in these partnerships 22. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human resources for health program in Rwanda—new partnership. has been demonstrated by OB/GYN in Ghana, N Engl J Med. 2013;369(21):2054-2059. Ethiopia, and Kenya, among other locations, 23. Hill W, Small M, Magriples U, Chazotte C, et al. Global health and serves as a template for any specialty to opportunities for the MFM specialists in the human resources work in global health. Creating the appropriate for health (HRH) program in Rwanda. Am J Obstet Gynecol. context for academic partnerships is a critical 2015;212(1):S133. 24. Lalonde AB, Menendez H, Perron L. The role of health first step in sharing expertise across the world. professional associations in the promotion of global women’s A long-term capacity-building context also is health. J Womens Health (Larchmt). 2010;19(11):2133-2137. critical. When authentic partnerships are cre- 25. Uneke CJ, Ezeoha AE, Ndukwe CD, Oyibo PG, Onwe ated, the goals, barriers, and opportunities must FD. Enhancing leadership and governance competencies be clearly defined.12 The examples described to strengthen health systems in Nigeria: Assessment of organizational human resources development. Healthc Policy. previously did not include short-term clinical 2012;7(3):73-84. interventions, surgical camps, or one-week training workshops. The sustainably success- continued on next page ful interventions are those that lead to benefits for faculty and students on both sides. In this context, efforts to improve research, education, and service can all occur within the overall goal

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of long-term capacity building, professional REFERENCES, CONTINUED and leadership development, and measurably 26. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of improved clinical outcomes. errors reported by surgeons at three teaching hospitals. Surgery. As the number of professionals increases, 2003;133(6):614-621. certification and ongoing continuing medical 27. Stark M, Gerli S, Di Renzo GC. The importance of analyzing and standardizing surgical methods. J Minim Invasive Gynecol. education are critical components that must be 2009;16(2):122-125. strengthened or, in many cases, created for each 28. Danilova YA, Yurova A, Stark M, Mynbaev O, Vassilevski Y. country. Professional associations ensure their Towards a unified evidence-based Cesarean section in the African members meet high professional and ethical continent—the introduction of the All-African Surgical Database. standards while promoting collegiality, mentor- Clin Obstet Gynecol Reprod Med. May 12, 2017. Available at: www. oatext.com/Towards-a-unified-evidence-based-cesarean-section- ing, and lifelong learning. Creating professional in-the-african-continent-the-introduction-of-the-all-african- association partnerships in surgery, anesthesia, surgical-database.php#Article. Accessed March 20, 2018. and OB/GYN to achieve this goal must be ini- 29. Royal College of Obstetricians and Gynaecologists. Global health tiated in tandem with academic partnerships. strategy. Available at: www.rcog.org.uk/en/global-network/ By creating partnerships between strong, long- global-health-strategy/. Accessed March 13, 2018. 30. Association of Professors of Gynecology and Obstetrics. Global | 59 standing professional associations in HICs with initiatives. Available at: www.apgo.org/global-initiatives/. nascent societies in LMICs, the sustainable infra- Accessed March 5, 2018. structure for creating quality, consistent, and 31. American College of Obstetricians and Gynecologist. CREOG properly staffed surgical, obstetrical, and anes- school for program directors and program managers. Available thesia services can be developed. at: www.acog.org/About-ACOG/ACOG-Departments/CREOG/ CREOG-Search/CREOG-School-for-Program-Directors-and- This article discusses only some of the initia- Program-Managers. Accessed March 5, 2018. tives the global OB/GYN community has led to 32. Society for Maternal and Fetal Medicine. Policy initiatives. build long-term and sustainable capacity around Available at: www.smfm.org/advocacy/initiatives. Accessed the world (see Table 1, page 56). By developing March 5, 2018. residency programs, strengthening professional 33. International Urogynecological Association. Ghana. 2017. Available at: www.iuga.org/?ghana. Accessed March 5, 2018. societies, and creating certification programs, 34. World Health Organization. Progress Report. Resolution WHA the field of OB/GYN is growing and mentoring 68.15. 2017. Available at: www.who.int/surgery/publications/ leaders in research, clinical care, training, and WHA-progress-report-annex.pdf. Accessed March 20, 2018. policy development. The lessons learned from these endeavors can be applied to all surgical specialties and anesthesia. Furthermore, the opportunity to leverage ongoing national efforts in maternal health with NSOAP is compelling. As public health interventions are expanded to include global surgery, anesthesia, and modern, comprehensive obstetrics and gynecology, these disciplines must support each other and partner to achieve the SDGs and the global goal of strengthening universal health coverage. ♦

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

West African College of Surgeons and its role in global surgery

by Prof. King-David Terna Yawe, MD, FWACS

ship heading to Nigeria from the U.K. Both men iden- 60 | HIGHLIGHTS tified the need for a forum of practicing surgeons in West Africa to exchange ideas and share experiences. • Describes the history and mission of the WACS Letters of invitation were sent to known individuals • Summarizes the WACS diplomate programs and Ministries of Health of all West African coun- and their role in curbing workforce shortages tries, describing the formation of the Association of in West Africa Surgeons of West Africa (ASWA) and announcing the • Outlines the WACS strategies for implementing inaugural meeting on December 3, 1960, in Ibadan, WHA resolutions Nigeria. This organization eventually transformed into a College in 1973 to address the growing demand for surgical specialists in the region, as it had become he West African College of Surgeons (WACS) obvious that the cost of overseas training was unsus- started as an association in 1960, with a mem- tainable. Tbership of 25 surgeons.* According to Ajayi and The WACS membership now consists of more co-authors in Knife in Hand: History of the West African than 6,000 Fellows in seven surgical specialities, from College of Surgeons, the end of World War II resulted in 18 countries in West Africa (see map, page 61, for a a wave of disentanglement from colonial vestiges in visual representation of the West Africa sub-region). Africa, Asia, and around the world.† This decoloniza- The mission of the WACS is to promote postgraduate tion resulted in a need to focus on the surgical needs of professional surgical education, disseminating surgical these newly independent countries. It was in this envi- knowledge and technical skills toward the attainment ronment that Victor Anomah Ngu, MD, FWACS, a of the highest possible standards, with the overall goal 33-year-old Cameroon-born, English-trained surgeon, of protecting the health of the peoples of West Africa, met an Irish surgeon, Charles Bowesman, MD, on a through cooperation among member countries. The WACS now has more than 220 accredited *West African College of Surgeons. Available at: www.wacscoac.org/. surgical training programs in 120 institutions, and Accessed March 9, 2018. between 4,000 and 5,000 trainees sit for examinations †Ajayi OO, Quartey JKM, Adebonojo SA, editors. Knife in Hand: His- tory of the West African College of the Surgeons (1960–2010). Ibadan, Nigeria: annually. In 2017, the WACS examined the first post- BookBuilders. Editions Africa; 2010. fellows in trauma care within the faculty of surgery.

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

FIGURE 1. WEST AFRICA SUB-REGION

The WACS mission Today, the WACS has introduced the member- The main objectives of the WACS include the ship program as an exit platform to serve workforce | 61 following: needs of the sub-region and fast-track capacity building. There is a mandatory supervised rural surgery post- • The promotion, organization, and conduct of postgrad- ing for membership level trainees, intended to scale up uate education, training, and certification in surgery, rural surgical services and improve trainee retention related disciplines, and specialties in West Africa in the rural district and rural hospitals that serve the bulk of the population in West Africa. • Cooperation with appropriate national and international bodies worldwide with aims and objectives likely Endowment funds to promote, assist, develop, and advance the interests Introduced in 1990, the endowment fund program was of the WACS designed to help meet the needs of local surgical training programs for the enhancement of surgical practice Although the mission of the WACS is broad, the for community health care facilities (district and gen- core has always been training skilled surgical spe- eral hospitals) in member countries. All member cialists to provide surgical services to the population countries have such funds, which are used under the of member countries. In its 57 years of existence, direction of a board of trustees to fund locally iden- the WACS has made significant strides in achiev- tified relevant surgical training or programs. The ing its objectives, including middle-level workforce endowment fund in each constituent country is re- training, endowment funding, and professional launched each time the WACS Scientific and Annual development. Conference is held in that country.

Middle-level workforce training Professional development programs In response to the immense need for surgical services, As part of its mission to update surgical knowledge the WACS in the late 1980s introduced diplomate and skills, the WACS organizes regional courses and programs in anesthesia, ophthalmology, and otorhi- workshops during the year using local, regional, and nolaryngology. Approximately 1,000 physicians have international faculty. These workshops are well- been trained so far under this model. attended and some are mandatory for trainee eligibility

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

to sit for examinations. These courses include the Challenges, goals, and following: opportunities for collaboration Despite significant strides, much more work is neces- • Manuscript writing workshop sary to achieve the goals of the organization. Surgical workforce density is extremely low, and with a pop- • Health management and ethics course ulation of 300–350 million in the sub-region, West Africa is far below the minimum of 20 specialist sur- • Research methodology course geons, anesthesiologists, and obstetricians per 100,000 recommended by The Lancet Commission on Global • Basic surgical skills courses Surgery. In addition to these workforce shortages, rapid • Basic laparoscopic and endoscopic skills training population expansion and frequent disease outbreaks in the sub-region increase the burden for existing • Advanced Trauma Operative Management course health care providers and highlight the need for a larger, more robust surgical workforce. The following • Disaster management course areas are ripe for collaboration with our international partners: 62 | The WACS role in • Improve the quality of skills training by supporting implementing WHA resolutions more basic skills programs within existing training Most of the functions of the WACS are already in institutions and expanding the number of institutions tandem with the resolutions of the World Health Orga- with basic skills training programs nization’s World Health Assembly (WHA). Examples of WACS programs that directly address the WHA • Establish a small number of regional advanced skills resolutions include the following: acquisition centers with simulation

• The development of a sub-regional surgical, obstetric, • Improve the efficiency of fellowship examinations using anesthesia, and nursing plan, which aims to update new technology and modernized testing methods information about the capacity of member countries and use data to appropriately determine need and dis- • Enhance research capacity building and attract fund- tribution of surgical care. ing for regional multi-institutional research projects

• Surgical outreach programs, which are regularly con- • Streamline data collection of basic surgical health indi- ducted in various countries, are truly a collaborative ces from member countries through the West African effort involving international teams of surgeons, anes- surgical obstetrics and anaesthesia planning commit- thetists, and nurses. Participants in these programs tee of the WACS address complex surgical cases and ensure proper follow-up by handing over patients to the local surgeons It is our hope that our sister colleges in North who are always part of the team. The most recent out- America and Europe will find value in working with reach program took place in February in Gambia. the WACS to accomplish these goals. ♦

• Provision of various surgical specialists on a short- to mid-term basis to member countries that are particularly disadvantaged due to natural or man-made disasters.

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ACS: Global engagement for the care of the surgical patient

by Girma Tefera, MD, FACS, and Patricia L. Turner, MD, FACS

he American College of Surgeons (ACS) was 326 surgeons from 70 countries have received this founded 105 years ago to provide opportunities scholarship and have benefited from this program.2 Tfor the continuing education of surgeons, rooted | 63 in a deep and effective concern for the improvement of surgical patient care and for the ethical practice of Other scholarships for international surgeons medicine in the U.S. and Canada.1 The ACS always The ACS offers a variety of scholarships for surgeons has been a global organization, now with more than outside of the U.S. and Canada. Examples are as 80,000 members representing six continents. It is the follows: premier surgical organization in the world—a recognized leader with respect to surgical education, with • ACS/AAST International Scholarship: This scholarship is its mission to ensure access to quality surgical care awarded to surgeons in acute care surgery, trauma, and and to develop trauma systems and educational pro- emergency general surgery in countries other than the gramming worldwide. U.S. and Canada to improve the quality of acute care This article outlines some of the College’s global surgical services. Preference is given to applicants from engagement activities and future initiatives. developing nations. The scholarship, in the amount of $5,000, provides scholars with an opportunity to attend the annual meeting of the American Association for the International Guest Scholarships program Surgery of Trauma (AAST) and to visit one or two Level For half a century, the International Guest Scholar- I trauma centers and/or the Trauma Quality Improve- ships have provided young surgeons from around the ment Program (TQIP®) at the College’s headquarters in globe with opportunities to visit clinical, teaching, and Chicago, IL, to learn about the standards for a trauma research facilities in North America with the goal of program/database and the importance of multidisci- enhancing the scholars’ patient care and research prac- plinary acute care surgery. tices when they return to their respective countries. The scholarships, in the amount of $10,000 each, also • ACS/ASBrS International Scholarship: This scholarship provide scholars with the opportunity to participate in is awarded to breast cancer surgeons in countries other the annual ACS Clinical Congress and to observe and than the U.S. and Canada to improve the quality of participate in clinical, teaching, and research activities breast cancer surgical services. Preference is given to in the U.S. and Canada. Over the years, approximately applicants from developing countries. The scholarship,

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

in the amount of $5,000, provides the scholars with an has spread to more than 60 countries. The MyATLS app, opportunity to attend the annual meeting of the Ameri- a mobile electronic platform, has been downloaded in can Society of Breast Surgeons (ASBrS) and to visit the more than 170 countries. National Accreditation Program for Breast Centers headquarters in Chicago, IL, to learn about the standards for a breast cancer program/database and the importance Operation Giving Back of multidisciplinary breast cancer care. Operation Giving Back (OGB) is the volunteer arm of the ACS. OGB grew out of an interest in surgical • Community Surgeons Travel Awards: The ACS Interna- volunteerism expressed both by the ACS Board of Gov- tional Relations Committee provides travel awards for ernors Committee on Socioeconomic Issues and by the surgeons ages 30 to 50. This award supports community membership-at-large as represented in a study span- surgeons in countries outside the U.S. and Canada to ning from 2001 to 2003. OGB was established in 2004 attend and participate fully in the educational activities with the mission to “leverage the passion, skills, and at the ACS Clinical Congress. humanitarian ethos of the surgical community to effec- 64 | tively meet the needs of the medically underserved.” • International ACS NSQIP Scholarships: The College’s The organization’s objective is to serve as a compre- National Surgical Quality Improvement Program® (ACS hensive resource center for surgeons at any level of NSQIP®) and the International Relations Committee training who want to participate in volunteer activities, offer International ACS NSQIP Scholarships for two encouraging the formation of a cohesive community surgeons from countries other than the U.S. or Canada of volunteers.3 who demonstrate strong interest in surgical quality The web-based OGB resource center matches fellow improvement. surgical volunteers of the ACS with opportunities to provide patient care and teaching in low-resource communities. Over the years, thousands of volunteers have Further educational opportunities been placed to provide much-needed care to under- for international surgeons served populations. One of the activities of OGB is to The ACS Division of Education and the International support peer-initiated selection of the recipients of the Relations Committee provide two international schol- ACS/Pfizer Surgical Humanitarian and Volunteerism arships focused on surgical education. These awards Awards each year.4 are for young faculty members from countries other To underscore the need for global surgical system than the U.S. and Canada and provide opportunities improvement, the World Health Organization (WHO) for these individuals to participate in a variety of edu- passed the World Health Assembly Resolution 68.15 in cational opportunities for faculty development and May 2015. The resolution, which includes surgery as enhancement that will result in the acquisition of new an essential component of universal health care, was knowledge and skills in surgical education and training. accepted and signed by all participating countries with The Advanced Trauma Life Support® (ATLS®) the understanding that more than 5 billion people lack program is designed to teach a systematic and reliable access to basic surgical care and that the major deficit is approach to the care of trauma patients. With leader- a shortage of surgical workforce. Following a retreat on ship from the ACS Committee on Trauma, ATLS was global engagement in 2016, the ACS Board of Regents first widely introduced in the U.S. and abroad in 1980. (the highest governing body of the College) provided Since its inception, ATLS for health care professionals strategic direction for the ACS leadership to engage

V103 No 5 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

First cohort of ACS-COSECSA Women Scholars, from left: Barbara Lee Bass, MD, FACS, FRCS(Hon), ACS President; Mahder Eshete Yilma, MD; Woubedel Kiflu Aklilu, MD; Wambui Njoroge, MB, BCh, FCS; Nardos Worku Ketema, MD; Mukagaju Francoise, MD; Ananya Kassahun, MD; Florence Umurangwa, MD; and Dr. Tefera

| 65

First cohort of ACS-COSECSA Women Scholars, from left: Gita Mody, MD, ACS Associate Fellow; Sherry M. Wren, MD, FACS, FCS(ECSA), 2017 International Surgical Volunteerism Awardee; Dr. Yilma; Dr. Ketema; Hilary A. Sanfey, MB, BCh, MHPE, FACS, FRCSI, Immediate Past-First Vice-President of the ACS; Dr. Bass; Drs. Njoroge, Kassahun, and Aklilu; Kathleen Casey, MD, FACS, Past-Director, OGB; and Ann O’Rourke, MD, FACS directly in the training of surgical workforce in low- and have developed working relationships based on local middle-income countries (LMICs). ACS OGB, in addi- priorities, including the following: tion to improving existing services, is actively working to develop programs to implement this strategic direc- • The ACS-COSECSA Women Scholars program pro- tion. Developing partnerships with surgical colleges motes and encourages women to join the surgical and societies in LMICs based on mutual benefits and workforce (see photos, this page). shared goals is our guiding principle. ACS Fellows have been engaged in volunteerism • The ACS Surgeons as Leaders: From Operating Room across sub-Saharan Africa. OGB and the College of Sur- to Boardroom Course is a recognized national pro- geons of East, Central and Southern Africa (COSECSA) gram. COSECSA leaders have attended this training

MAY 2018 BULLETIN American College of Surgeons IMPLEMENTING WHA 68.15: A GLOBAL UPDATE

ACS Fellows participating as external examiners, December 2017. Front row, from left (all ACS Fellows pictured are MD, FACS): Bruce Steffes, Dr. Helder de Miranda (COSECSA member), Keir Thelander, Stephen Bickler, Dr. O’Rourke, Neil Wetzig (Australia), and Andrew Chew (PAACS Australia). Middle row: Timothy Berg, Jim Brown, John Tarpley, Adrian Park, Dr. Sanfey, Dr. Wren, Ohwofiemu Nwariaku, Dr. Tefera, and Benedict Nwomeh. Back row: Three unidentified COSECSA fellows, Marilyn W. Butler, Erik Hansen, Doruk Ozgediz, and Russ White.

program with the intention of recreating a contextually REFERENCES relevant leadership course for COSECSA. 1. American College of Surgeons. History of the American College of Surgeons. Available at: facs.org/ • The OGB has supported the COSECSA fellowship exam- about-acs/archives/acshistory. Accessed on March 25, ination process by recruiting ACS Fellows to serve as 2018. external examiners (see photo, this page). 2. American College of Surgeons. Scholarships for international surgeons. Available at: facs.org/ member-services/scholarships/international. • The East and Central African Journal of Surgery is develop- Accessed March 26, 2018. ing a twinning partnership with the Journal of the American 3. American College of Surgeons. Operation Giving 66 | College of Surgeons to improve its standing in quality as Back. Available at: facs.org/ogb. Accessed March 26, reflected in impact factor and PubMed indexing. 2018. 4. American College of Surgeons. ACS/Pfizer Surgical Volunteerism and Humanitarianism Awards. • A proposed partnership between COSECSA; the ACS; Available at: facs.org/ogb/award-winners. Accessed U.S. Consortium of Academic Global Surgery Programs, March 27, 2018. in development at present; and a COSECSA-accredited training program in Hawassa, Ethiopia, would develop a surgical training center of excellence. The goal is for this site to serve as a training hub with local and regional impact that will encourage improved innovation, clinical research, and patient care. The pilot project for this initiative will be implemented by fall 2018.

As we celebrate the passage of the third anniversary of the WHA Resolution 68.15, the ACS will continue to engage in the implementation of the global surgery agenda. To this end, the College looks forward to working closely with WHO and the office of the Global Initiative for Emergency and Essential Surgical Care. ♦

V103 No 5 BULLETIN American College of Surgeons Contents

FEATURES COVER STORY: Presidential Address: Do what’s right for the patient: Franklin H. Martin and the American College of Surgeons 12 Courtney M. Townsend, Jr., MD, FACS

Improving quality in geriatric surgery: A blueprint from the American College of Surgeons 22 Marcia M. Russell, MD, FACS; Julia R. Berian, MD, MS; Ronnie A. Rosenthal, MD, MS, FACS; and Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS

Using the ACS NSQIP Surgical Risk Calculator for surgical education and quality improvement 29 Jonathan S. Abelson, MD; Heather L. Yeo, MD, MHS; Alfons Pomp, MD, FACS; David Fehling, MA; and Fabrizio Michelassi, MD, FACS | 1 The 2017 Inpatient Prospective Payment System: What it means for surgery 32 Molly Peltzman, MA

2016 state legislative year in review and a look ahead 35 Amy E. Liepert, MD, FACS, and Tara Leystra Ackerman, MPH

Women’s role in otolaryngologic medicine 40 Remy Friedman, BS; Christina H. Fang, MD; Mays Zubair, MD; and Evelyne Kalyoussef, MD, FACS

Executive Director’s annual report 46 David B. Hoyt, MD, FACS

DEC 2016 BULLETIN American College of Surgeons

STATE LEGISLATIVE WRAP-UP STATE LEGISLATIVE ACTIVITY SHUTTERSTOCK.COM THIS PAGE: NAGELTHIS PAGE: PHOTOGRAPHY/

2017 state legislative update: Lawmakers engage on MOC, trauma funding, and other issues

by Christopher Johnson, MPP, and Christian Johnson, JD

he 2018 state legislative sessions started off with In December 2017, a similar bill, H.B. 1263, was a flurry of health care-related legislation intro- introduced in Missouri, which would initiate a study duced across the country. Bills affecting trauma to provide a recommendation on whether to install T | 67 funding, injury prevention, out-of-network billing, bleeding control kits in public. California legislation, the Uniform Emergency Volunteer Health Practitio- A.B. 238, formerly an unrelated bill which was origi- ners Act (UEVHPA), and Maintenance of Certification nally introduced in January of 2017, was completely (MOC) started working their way through state capi- amended to include language pertaining to public tols as early as December 2017. bleeding control kits, similar to provisions in other By February, less than halfway through the legisla- 2017 legislation, A.B. 909. A bill in South Carolina, H. tive session, State Affairs staff in the American College 5003, would require the installation of bleeding control of Surgeons (ACS) Division of Advocacy and Health kits in all public schools, as well as require training of Policy sent out Action Alerts to more than 5,800 Fel- employees to use the kits. lows, tracked more than 6,000 health care-related bills, submitted comment letters in nearly a dozen states, Stop the Bleed® and participated in six chapter lobby day events. State A state resolution declaring February 14 “Georgia Affairs staff members will continue to work diligently Stop the Bleed Day” was introduced to coincide with with ACS state chapters to stay engaged and support the Georgia Society of the ACS lobby day. Other Stop legislation that promotes high-quality surgical care. the Bleed resolutions were introduced in Wisconsin, declaring March 31 as Wisconsin Trauma Awareness Day, and in Utah, declaring March 31 as Stop the Bleed Trauma Education Day. The College received a record number of appli- Public bleeding control kits cations for its 2018 State Lobby Day Grant Program. At press time, the Massachusetts legislature was cur- Several of the applicants for the grants have included a rently considering introducing a bill based on the bleeding control program at their lobby day. ACS Chap- College’s model bill for the installation of bleeding ters in Washington (January 10), Kansas (January 24), control kits in public buildings and spaces. The Mas- Florida (January 30), Georgia (February 14), Arkan- sachusetts Chapter has engaged with the sponsor, sas (February 28), Oregon (March 5), and Louisiana Rep. Shawn Dooley (R), to support introduction and (March 21) conducted Stop the Bleed training sessions passage of the bill. in their respective state capitols during their 2018 lobby

MAY 2018 BULLETIN American College of Surgeons STATE LEGISLATIVE ACTIVITY SHUTTERSTOCK.COM THIS PAGE: NAGELTHIS PAGE: PHOTOGRAPHY/

days. Stop the Bleed training not only helps to expand On January 10, the Nebraska Senate rejected legis- the number of people able to respond to a traumatic lation L.B. 368, which would have repealed the state’s bleeding injury, but also builds goodwill with legisla- universal motorcycle helmet law. Nebraska is a uni- tors, helping them to be more receptive to discussing cameral state with only one legislative chamber. The other important surgical- and patient-care issues. bill was carried over from the 2017 session, where it Other states receiving the lobby day grants in 2018 had previously failed to receive the necessary support include: Alabama, Arizona, California, Illinois, Indi- for passage. The Nebraska Chapter engaged members ana, Massachusetts, Michigan, Nebraska, New York, to contact their senators on the bill, which helped to North Carolina, Ohio, Tennessee, Texas, Virginia, and influence its defeat. It is expected that the legislation Wisconsin. will not be recalled again this year. In Connecticut, an effort is under way to build a Trauma funding coalition of medical and other organizations to revital- The Virginia Chapter sent letters in support of bills ize legislation to enact a universal helmet law in the that would increase and protect funding of the com- state. The Connecticut Chapter and COT are pushing monwealth’s trauma system. Virginia H.B. 1513, which forward to build support for the coalition. A universal 68 | was introduced in January, would require individuals helmet bill was tabled at a hearing in the legislature convicted of a violent felony to pay a $50 fine to the during the 2017 session. Trauma Center Fund. The fine already applies to individuals convicted of certain vehicle violations, such as UEVHPA speeding and impaired driving. A proposed amendment On March 6, the Washington State Senate approved to Virginia’s 2018 budget bill, H.B. 30, would delete S.B. 5990 to adopt the model legislation for UEVHPA. language authorizing the transfer of more than $8 mil- The legislation passed out of the legislature and was lion out of the Trauma Center Fund and into the state’s signed by the governor March 22. A similar UEVHPA general fund. bill in Maine was carried over from the 2017 legisla- Preliminary discussions have taken place in Dela- tive year, but at press time had not yet been called for ware to have the state or a coalition of trauma centers a hearing or vote. hire a third-party consultant to evaluate the state’s ability to establish a funding source of public money for the state’s trauma system. Although there is inter- MOC est in the study, sources of funding have yet to be MOC continues to be a contentious issue in 2018, identified. sparking conflicting opinions among physician organizations. Opponents of MOC have asked state Injury prevention legislatures to step in to prohibit the use of MOC in In New Hampshire, Committee on Trauma (COT) licensure, reimbursement, and privileging decisions, State Chair Lisa Patterson, MD, FACS, testified on Janu- therefore interfering with professional self-regulation, ary 11 before the House Transportation Committee in private contracting rights, and hospital medical staff- support of H.B. 1259, which would have required all ing decisions. These critics have succeeded in getting New Hampshire drivers to wear seat belts. The bill, anti-MOC legislation introduced in 16 states so far. which was introduced in November 2017, ultimately Of those, the following 10 are still considering bills: failed to pass out of committee and died in March. New Massachusetts, Missouri, New Hampshire, New Hampshire is the only state in the U.S. to not have any Jersey, New York, Ohio, Rhode Island, South Caro- type of legal requirement to wear a seat belt. lina, Tennessee, and Wisconsin.

V103 No 5 BULLETIN American College of Surgeons in writing letters, testifying at hearings, and meeting with with meeting and at hearings, testifying letters, writing participate in legislative efforts to clarify contradictory contradictory clarify to efforts legislative in participate 2017 session. the from legislative to advance continued school in by children of sunscreen use the permitting and use, bed tanning and purchase for tobacco age minimum the raising coverage, ing screen cancer covering legislation prevention Cancer Cancer prevention [email protected]. at staff Affairs State contact or at available MOC toolkit the download should issue this involved in getting in to representatives and senators. Surgeons interested letters writing and capitols, state lobby in days soring spon legislators, individual with meeting hearings, at testimony by topic providing ofthe MOC reform on advocates grassroots as working still are country only. licensure for initial MOC restricts bill The 22. March signed was which Washington is far so passed has that bill MOC only The consideration. for further committee Oklahoma California in bills representatives. their with self-governance and physician certification of board importance the cuss to dis Fellows encouraging lobby agendas day chapter MOC on their have included chapters state adozen half To legislation. nearly date, anti-MOC to oppose ings Indiana in and legislators, their with to meet statehouse to the visits scheduled leaders ter Indiana of MOC. In use the restrict that bills oppose to officials elected urging letters draft and ana InIndi bills. anti-MOC oppose to officials elected their Virginia failed to receive enough support in asub in support to receive enough failed Virginia Surgeon advocates have responded to this issue by by issue to this have advocates responded Surgeon The The the across surgeons success, early of this spite In chapters, ACS engaged of efforts to the part in Due , Virginia Oklahoma Indiana Indiana , chapter leaders testified at committee hear at committee testified leaders , chapter , and Utah , and ,

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CS FOTO | 69 70 V103 5 BULLETIN No

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JAMES KIRKIKIS PHOTOGRAPHY/ SHUTTERSTOCK.COM is still being considered in Iowa in considered being still is Dakota gent failure to diagnose a malignant tumor or cancer.” tumor amalignant to diagnose failure gent negli “alleged involving for cases of limitations statute liability medical 2017, June the since expands which S.6800/A. to oppose governor 8516, pending legislation and legislature the targeting Alerts Action initiated ters Act. state’sthePractice with Optometric conflict in was that a rule proposing in authority beyond legislative its acted IDFPR the College, of the opinion the In ments. require education and new training without injections and surgery to include scope optometrists’ to expand rule to a proposed response in (IDFPR) Regulations Professional and of Financial Department Illinois the of optometry. Illinois In practice the from injections and surgery, laser surgery, through treatment exclude to specifically amended was bill The procedures. surgical certain to perform optometrists to allow abill to oppose legislature state Virginia The residency. surgical or undergone school medical attended having without eye surgery or laser scalpel to perform ability the trists Nebraska as such states However, in procedures. legislation medical performing with conjunction in substances controlled or administer limitations, to certain ject sub injections pharmaceutical to perform optometrists Tennessee Massachusetts ing includ of states, anumber in have introduced been bills certificate. described avaguely obtaining upon authority scribing - pre full anesthetists nurse grant also would proposal The agreement. collaborative defined apoorly with it (CRNAs) replace and anesthetists nurse registered for certified requirement supervision physician the remove would which ernor’s bill, budget proposed gov the in aprovision to oppose state that in Fellows The The The The scope-of- optometrist of different A variety California , and Wyoming , and New York New Brooklyn-Long Island Brooklyn-Long , and and

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STEPHEN EMLUND American College of Surgeons of College American

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| ZRF PHOTO 71 WHAT SURGEONS SHOULD KNOW ABOUT...

The 2018 inpatient-only list

by Kenneth Simon, MD, FACS

he Centers for Medicare & as typically only provided in the Medicaid Services (CMS) inpatient setting and therefore For services and procedures Tcreated and implemented the not paid under OPPS. Many of that were identified as hospital Outpatient Prospective the services on the inpatient-only Payment System (OPPS) in list are surgical procedures that inpatient only, CMS created 2001, as required by the Social may be complex, complicated, an “inpatient-only list” that Security Act. The OPPS required and/or require the care and that CMS identify those services coordinated services provided in is updated annually in the that could safely be provided the inpatient setting of a hospital. OPPS final rule, published to Medicare patients in the It is important that surgeons be November 1 each year. outpatient setting of a hospital, aware of procedures that are on 72 | initially considered a stay of less this list because of the potential than 24 hours. For services and impact on reimbursement and procedures that were identified interactions with their hospital. as inpatient only, CMS created an “inpatient-only list” that is updated annually in the OPPS Does the Medicare inpatient- final rule, published November 1 only list change? each year. This article provides Each year, clinicians, an update to a previous Bulletin specialty societies, and other column, “What surgeons should stakeholders contact CMS know about…The inpatient to request that procedures list,” published in June 2013.* identified by American Medical Association Current Procedural Terminology What is the Medicare (CPT)† codes be reviewed and inpatient-only list? considered for addition to or The Medicare inpatient-only removal from the inpatient- list refers to procedures and only list. Since the inception services that CMS has identified of the OPPS, some hospital *Ollapally V. What surgeons should stays have extended beyond 24 know about…The inpatient list. Bull Am hours and up to 48 hours. In Coll Surg. 2013;98(6):54-55. Available at: addition, medical technology bulletin.facs.org/2013/06/the-inpatient- list. Accessed March 13, 2018. has improved, coordination †All specific references to CPT codes and of care has improved across descriptions are ©2017 American Medical different clinical settings, and Association. All rights reserved. CPT and CodeManager are registered trademarks the effective and successful of the American Medical Association. management of non-Medicare

V103 No 5 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

TABLE 1. 2018 CHANGES TO INPATIENT-ONLY LIST Inpatient-only list CPT Code Long descriptor 2018 status change Arthroplasty, knee, condyle and plateau; medial and lateral compartments with 27447 Removed or without patella resurfacing (total knee arthroplasty)

Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 43282 Removed when performed; with implantation of mesh

Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable 43772 Removed gastric restrictive device component only

Laparoscopy, surgical, gastric restrictive procedure; removal and replacement 43773 Removed of adjustable gastric restrictive device component only

Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable 43774 Removed gastric restrictive device and subcutaneous port components

Laparoscopy, surgical prostatectomy, retropubic radical, including nerve 55866 Removed sparing; includes robotic assistance, when performed Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass 92941 Added graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel

patients in the outpatient procedure meets requirements patient safety or quality. The | 73 setting has led to many for medical necessity. The ACS also comments against the services being removed from hospital, however, will not proposed removal of procedures the inpatient-only list. be paid for the procedure. from the list. The changes to When considering whether Consequently, hospitals will the inpatient-only list for 2018 to add or remove a procedure often have someone from the are provided in Table 1, this from the inpatient-only list, CMS quality or case management page. For a list of all the CPT considers the type of procedure team review the medical record codes that are included in the or service being performed, early in the patient’s stay to Medicare 2018 inpatient-only list, whether the procedure is assess the appropriateness see Addendum E of the OPPS safely being performed on of the admission and assess final rule at www.aq-iq.com/cms- non-Medicare patients in the whether medical necessity for inpatient-only-list-cy2018/. ♦ outpatient setting, and whether inpatient care is supported any published data on outcomes by the documentation in are available to help in the the medical record. decision-making process.

Were there any changes to the Will I get paid if I perform inpatient-only list in 2018? a procedure in the The American College of outpatient setting if it is on Surgeons (ACS) reviews the the inpatient-only list? procedures on the inpatient- A physician who performs an only list on an annual basis and inpatient-only list procedure makes recommendations to in the outpatient setting of a CMS regarding those procedures hospital may receive payment that can be removed from the if the documentation for the list without compromising

MAY 2018 BULLETIN American College of Surgeons ACS QUALITY AND SAFETY CASE STUDIES

Texas Children’s Hospital introduces standardized protocol to reduce pediatric baclofen pump infections

by Sandi K. Lam, MD, MBA, and Daniel J. Curry, MD

ntrathecal baclofen pumps hospital with more than 650 nursing, and acute care nursing are placed for movement beds. Advanced QI is valued in “micro-team” fronts. Each Idisorders, such as dystonia the organization. In addition, the micro-team had a point person and spasticity. Surgical site neurosurgery division runs a data- in charge of peer education infections and deep infections driven research program, which and compliance with steps related to implant surgery are further motivated this QI activity. of the protocol pertaining to a problem in this challenging In weekly ongoing quality their field. With a surgical patient population.1 Known risk assurance conferences, the schedule and team members on factors and special considerations team reviewed American different working schedules, it include low body mass index, College of Surgeons National was difficult to carve out in- presence of percutaneous Surgical Quality Improvement person meeting times. It was gastrointestinal access, and Program® Pediatric metrics reassuring to find over time that scoliosis, among others. Most and ongoing occurrences. All the contemporaneous efforts of 74 | infections occur within 60 days of stakeholders recognized the different micro-teams worked an operation, reported at a rate of need for QI over the course of well, with monthly check-ins 4 percent in the first 60 days and information dissemination. via e-mail reporting. Weekly 1 percent per year thereafter.1,2 The team designed an Surgical Quality Assurance Using national benchmarks, intervention for QI using a case conferences also provided Texas Children’s Hospital, plan-do-study-act model.5 The a forum for adjustments in Houston, found it had an treating physicians conducted a workflow and for addressing any unacceptably high rate of infection literature review of best practices; problems or concerns that arose. (23 percent) in comparison with the pediatric neurosurgery The protocol was implemented other hospitals.3 Surgical team team reached consensus for starting in August 2014. Our QI leaders aimed to address implant- steps in the perioperative project was published in Journal of related infections. Specifically, treatment pathway where no Neurosurgery: Pediatrics in 2018.3 they conducted a quality recommendation could be found improvement (QI) initiative, in the literature. As a result, the following an infection prevention team developed and implemented Resources used and bundle with evidence-based an infection prevention bundle, skills needed best practices,2,4 and examined which included preoperative, This QI effort received no funding the pre- and post-protocol- intraoperative, and postoperative and had no additional staff implementation outcomes of steps. We modeled our process support beyond the usual clinical perioperative infection and after the Hydrocephalus care efforts. Workflow and clinical postoperative complications. Clinical Research Network care processes were restructured shunt infection protocol, which according to an agreed-upon is a successful example of QI protocol, and in so doing, allowed Putting the QI activity in place in pediatric neurosurgery.4 for standardization of workflow. Texas Children’s Hospital is The implementation was The goal was to reduce variation a freestanding metropolitan pushed forward with team effort in care, which, in turn, produced quaternary referral and teaching from surgery, perioperative improved clinical results.

V103 No 5 BULLETIN American College of Surgeons ACS QUALITY AND SAFETY CASE STUDIES

The key to physician-led and provider-led QI without additional financial support is designing a clinical workflow that can be incorporated into daily practice.

The implementation depended with four (6.3 percent) There was no “hard stop” on efforts from surgery, infections were documented. mechanism to ensure full perioperative nursing, and acute The total complication rate compliance in every operation, care nursing micro-team fronts. was significantly reduced so implementation depended The lead surgeon knew the after protocol implementation on people and their behaviors. protocol (and provided education (p = 0.032), with absolute The 88 percent compliance to other surgeons), and asked and relative risk reductions rate is viewed favorably and for the protocol form and help of 14.1 percent [95 percent is higher over time given in adherence to the steps during confidence interval (CI): penetration of educational operations. The lead operating 1.5–26.7 percent] and efforts across the entire room nurse educated the rest 60 percent, respectively. surgical and nursing team. of the perioperative nursing The infection rate The protocol was reviewed team, filled out the protocol essentially was cut in half, from monthly, and steps of the forms, ensured adherence to 12.5 percent to 6.3 percent. protocol were discussed | 75 the protocol steps by providing The infection rate was not regularly, seeking to enhance supplies and reminders, a statistically significant workflow to prepare for and and made enhancements in reduction (p = 0.225), with ensure proper execution of operative workflow to make absolute and relative risk each step at the right time. the protocol the “default” reductions of 6.3 percent For instance, storage places of behavior. The lead acute care [95 percent CI: -3.8–16.3 percent] specific dressings were relocated nurse educated peers, ensured and 50 percent, respectively. to allow for easier access. adherence to the protocol steps, A relatively small sample size and activated enhancements to date may contribute to in workflow to make the limited ability in achieving Cost savings protocol the default behavior statistical significance. Because this project had in the postoperative phase. no budget and required no additional personnel, Setbacks the amount invested is not Results Compliance to every step of quantifiable in financial terms. A total of 128 cases were included the protocol was 88 percent. The team ultimately believes for study: 64 cases in each of Barriers included personnel that quality improvement the preimplementation and turnover. Education of all initiatives are the right thing postimplementation groups. In perioperative and acute to do for patient care. The key the preimplementation group, 15 care nursing members took to physician-led and provider- complications (23.4 percent) and some time; new nursing staff led QI without additional eight infections (12.5 percent) members were continually financial support is designing with Clavien-Dindo grade II or coming on board as well. The a clinical workflow that can be higher were documented. After surgical team also had rotating incorporated into daily practice. protocol implementation, six trainees who switched on and Savings per case have total complications (9.4 percent) off service every four months. not been fully quantified

MAY 2018 BULLETIN American College of Surgeons ACS QUALITY AND SAFETY CASE STUDIES

in our patient population. of striving to improve for our REFERENCES Extrapolating from comparative patients provided the best 1. Spader HS, Bollo RJ, Bowers CA, literature of spinal surgery reason to come together as a Riva-Cambrin J. Risk factors for infections—which have team and to do our best. ♦ baclofen pump infection in children: reported incrementally A multivariate analysis. J Neurosurg Pediatr. 2016;17(6):756-762. increased treatment costs 2. Albright AL, Turner M, Pattisapu (compared with non-infection Acknowledgments JV. Best-practice surgical techniques controls) of $12,619 to $38,701— Special thanks to JoWinsyl for intrathecal baclofen therapy. total savings in the reduction Montojo, RN; Valentina Briceno, J Neurosurg. 2006;104(4 Supp):233-239. of complications would range RN; Virendra R. Desai, MD; 3. Desai VR, Raskin JS, Mohan AC, et al. A standardized protocol to reduce from $113,571 to $348,309 in Jeffrey S. Raskin, MD, MS; and the pediatric baclofen pump infections: inpatient hospital costs alone. entire pediatric neurosurgery and A quality improvement initiative. Implications for quality of movement disorders team at Texas J Neurosurg Pediatr. 2018;21(4):395-400. 76 | life of the patient and family Children’s Hospital, including 4. Kestle JR, Riva-Cambrin J, Wellons are targets for future study. consultants, trainees, nursing JC 3rd, et al. A standardized protocol to reduce cerebrospinal fluid shunt staff, allied health staff, office infection: The Hydrocephalus staff, and operating room staff. Clinical Research Network Quality Tips for others Improvement Initiative. J Neurosurg In a surgical team setting, Pediatr. 2011;8(1):22-29. implementation did not require 5. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic multiple meetings, which review of the application of the would take away from clinical plan-do-study-act method to improve care or require cancellation of quality in healthcare. BMJ Qual Saf. scheduled operations. Once 2017;23:290-298. motivated stakeholders were on board, feedback continued regularly with updates and scorecards on compliance and complications. Existing in- person clinical quality assurance conferences provided a forum for weekly check-ins as needed. Regularly updated data and feedback are essential, as is providing meaning to daily work. Positive feedback functions as a great motivator. On the other hand, setbacks also provide extra incentive to do better. A shared value

V103 No 5 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Duration of adjuvant therapy for stage III colon cancer: No longer one size fits all

by Jeffrey A. Meyerhardt, MD, MPH; Judy C. Boughey, MD, FACS; and Y. Nancy You, MD, MHSc, FACS

n 1990, a National Institute reduce or prevent neuropathy interval (CI) of the hazard ratio of Health consensus were unsuccessful. Given that (HR) needed to be less than 1.12. Iconference concluded that neuropathy from oxaliplatin Over the span of nearly a adjuvant chemotherapy should is cumulative and dependent decade, 12,834 patients from be recommended to patients on total dose delivered, around the world were enrolled, with stage III colon cancer researchers have expressed treated, and followed in the IDEA after surgical resection to great interest in testing collaboration on six randomized reduce the risk of recurrence shorter duration of therapy. clinical trials.8 In June 2017, and improve survival.1 The the results of non-inferiority initial trials that led to this were presented. As anticipated, conclusion tested 12 months IDEA collaboration toxicities were significantly less of adjuvant fluoropyrimidine- The International Duration after three versus six months of | 77 based (either intravenous Evaluation of Adjuvant therapy. Of particular interest, 5-FU or oral capecitabine) therapy (IDEA) collaboration grade 2 or higher neuropathy rate therapies; however, at least included six trials to test was 16 percent versus 47 percent three trials demonstrated that three versus six months of (p < 0.0001). When considering six months of therapy was adjuvant fluoropyrimidine and all patients randomized who non-inferior to 12 months.2-4 oxaliplatin (see Table 1, page received at least one dose of Six months of therapy 78).8 Based on data from the chemotherapy, the disease relapse remained the standard for the metastatic setting, the efficacy HR comparing three versus subsequent decade of trials of FOLFOX (5-fluorouracil, six months of therapy was 1.07, testing multidrug regimens leucovorin, and oxaliplatin) and with 95 percent CI of 1.00–1.15. that combine fluoropyrimidine of capecitabine and oxaliplatin Since the CI crossed 1.12, non- with oxaliplatin, irinotecan, (CAPOX) was assumed to be inferiority was not demonstrated. bevacizumab, or cetuximab. similar in the adjuvant setting.9 At least three trials showed Balancing goals of minimizing improved disease-free survival relapse risk with reducing IDEA results (DFS) with the addition of toxicity (particularly cumulative Notably, several preplanned oxaliplatin.5-7 Although moving neuropathy), the international subgroup analyses also were the bar on the cure rate was team agreed on a non-inferiority presented. First, approximately an important advancement, margin for disease relapse that 60 percent of patients received oxaliplatin led to additional allowed for up to 12 percent FOLFOX and approximately toxicities, particularly long- relative risk increase, when 40 percent received CAPOX lasting neuropathy that can comparing three versus six across the six trials. For patients affect patients for extended months of adjuvant therapy. This who received FOLFOX, three- periods and can become margin for relapse practically year DFS was 73.6 percent permanent. Multiple trials translates to the fact that the upper versus 76 percent (three versus to test supportive agents to limit of the 95 percent confidence six months, HR 1.16 [95 CI

MAY 2018 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

TABLE 1. TRIALS INCLUDED IN IDEA COLLABORATION

Stage III Trial Regimen(s) Enrolling country colon cancer patients

TOSCA (Three or six colon adjuvant trial) CAPOX or FOLFOX4 2,402 Italy

U.K., Denmark, Spain, SCOT (Short course oncology therapy) CAPOX or FOLFOX4 3,983 Australia, Sweden, New Zealand

IDEA France CAPOX or FOLFOX4 2,010 France

CALGB/SWOG 80702 (Cancer and leukemia group B/ mFOLFOX6 2,440 U.S., Canada Southwest Oncology Group) HORG (Hematology-oncology research group) CAPOX or FOLFOX4 708 Greece

ACHIEVE (Adjuvant chemotherapy for colon cancer CAPOX or mFOLFOX6 1,291 Japan with high evidence)

1.06–1.26]); these results suggest difference in fluoropyrimidine (95 percent CI 0.90–1.12), whereas inferiority of three months dosing (more continuous the HR for patients with T4 or 78 | of therapy when treated with with CAPOX) or total dosage N2 tumors was 1.12 (95 percent FOLFOX. In contrast, and to of oxaliplatin in the initial 1.03–1.23), suggesting non- the surprise of investigators month of the treatment also inferiority with three months of given the data for metastatic are possible explanations. therapy for better-risk tumors disease, for patients who Additionally, subgroup but inferiority for higher-risk received CAPOX, three- analyses by T and N stage were tumors (see Table 2, page 79). year DFS was 75.9 versus presented. The initial analysis 74.8 percent (three versus six plan considered subgroup by T months, HR 0.95 [95 CI 0.8– stage (T 1–2 versus T3 versus T4) Unanswered questions remain 1.06]); this subgroup met the and N stage (N1 versus N2). There The IDEA collaboration is criteria for non-inferiority.8 were no statistically significant the largest prospective effort Because patients were not interactions by T stage (p = 0.36) in colon cancer conducted, randomized to FOLFOX versus or N stage (p = 0.44), though demonstrating the feasibility of CAPOX, it is impossible to T4 tumors showed inferiority publicly funded international conclude CAPOX is a more with three months of therapy research. While the intention efficacious adjuvant regimen, compared with six months. was to arrive at a simple but the interaction by regimen However, higher-risk tumors answer of whether three was significant (p = 0.0051) (T4 or N2), which constituted months is sufficient or six and thus if one chooses 40 percent of the cohort, had months is necessary, stepping CAPOX as an adjuvant therapy, a clinically meaningful worse back, it is not surprising that three months of therapy is three-year DFS (60 percent) as it is more complicated because non-inferior to six months. compared with better-risk tumors stage III colon cancer is not a The biological rationale for (T1–3, N1; 80 percent three-year single disease biologically. this apparent difference by DFS). When considering risk Many unanswered questions treatment regimen is unclear. groups, the HR for three versus remain, including how to Chance or bias by indication six months of therapy for patients apply these data to rectal are possible reasons, but the with T1–3 N1 tumors was 1.10 cancer or stage II colon cancer,

V103 No 5 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

TABLE 2. DFS BY REGIMEN AND T AND N STAGE-BASED RISK GROUPS

Regimen

Three-year DFS rate CAPOX * FOLFOX * CAPOX/FOLFOX combined (percent) and HR Three-year DFS, by risk group and Three-year DFS, percent Three-year DFS, percent percent HR (95 percent CI) HR (95 percent CI) HR regimen (95 percent CI) (95 percent (95 percent (95 percent CI) CI) CI) 3 m 6 m 3 m 6 m 3 m 6 m

83.1 Low-risk 85.0 0.85 81.9 83.5 1.10 83.1 83.3 1.01 (81.1- (T1-3 N1) (83.1-86.9) (0.71-1.01) (80.2-83.6) (81.9-85.1) (0.96-1.26) (81.8-84.4) (82.1-84.6) (0.90-1.12) 85.2) Risk group High-risk 64.1 64.0 1.02 61.5 64.7 1.20 62.7 64.4 1.12 (T4 and/or (61.3-67.1) (61.2-67.0) (0.89-1.17) (58.9-64.1) (62.2-67.3) (1.07-1.35) (60.8-64.4) (62.6-66.4) (1.03-1.23) N2)

*CAPOX = capecitabine + oxaliplatin; FOLFOX = infusional 5-fluorouracil, leucovorin, oxaliplatin

Non-inferior Non-inferiority of three months compared Not proven with six months of adjuvant therapy Inferior }

whether a mixed strategy of REFERENCES three months oxaliplatin-based 1. NIH Consensus Conference. Adjuvant therapy for patients with colon and rectal therapy followed by three cancer. JAMA. 1990;264(11):1444-1450. | 79 months of fluoropyrimidine 2. Haller DG, Catalano PJ, Macdonald JS, et al. Phase III study of fluorouracil, only would be a better option, leucovorin, and levamisole in high-risk stage II and III colon cancer: Final report of Intergroup 0089. J Clin Oncol. 2005;23(34):8671-8678. and the possibility of further 3. O’Connell MJ, Laurie JA, Kahn M, et al. Prospectively randomized trial of refining prognostic features postoperative adjuvant chemotherapy in patients with high-risk colon cancer. J Clin that can be considered to Oncol. 1998;16(1):295-300. determine duration of therapy. 4. Dencausse Y, Hartung G, Sturm J, et al. Adjuvant chemotherapy in stage III colon Although IDEA will not cancer with 5-fluorouracil and levamisole versus 5-fluorouracil and leucovorin. Onkologie. 2002;25(5):426-430. answer all of these questions, 5. Kuebler JP, Wieand HS, O’Connell MJ, et al. Oxaliplatin combined with weekly many ongoing efforts seek bolus fluorouracil and leucovorin as surgical adjuvant chemotherapy for stage II to further classify phenotype and III colon cancer: Results from NSABP C-07. J Clin Oncol. 2007;25(16):2198-2204. and molecular markers to 6. André T, Boni C, Mounedji-Boudiaf L, et al. Multicenter international study of eventually develop a model that oxaliplatin/5-fluorouracil/leucovorin in the adjuvant treatment of colon cancer (MOSAIC) investigators. Oxaliplatin, fluorouracil, and leucovorin as adjuvant can be used to individualize the treatment for colon cancer. N Engl J Med. 2004;350(23):2343-2351. duration of adjuvant therapy 7. Haller DG, Tabernero J, Maroun J, et al. Capecitabine plus oxaliplatin compared for each stage III patient. ♦ with fluorouracil and folinic acid as adjuvant therapy for stage III colon cancer. J Clin Oncol. 2011;29(11):1465-1471. 8. Grothey A, Sobrero AF, Shields AF, et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378:1177-1188. 9. Cassidy J, Clarke S, Díaz-Rubio E, et al. Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer. J Clin Oncol. 2008;26(12):2006-2012.

MAY 2018 BULLETIN American College of Surgeons FROM THE ARCHIVES

The Great War and the evolution of plastic and reconstructive surgery

by Raymond F. Morgan, MD, DMD, FACS, FRANKLIN MARTIN, MD, FACS, and Elizabeth A. Morgan, MA FOUNDER OF THE AMERICAN COLLEGE OF SURGEONS

he assassination of were introduced to kill and French-American dentist, and Archduke Franz debilitate enemy troops. Hippolyte Morestin, MD, a TFerdinand of Austria on When World War I began plastic surgeon skilled in facial June 28, 1914, helped to trigger in 1914, the combatants wore reconstruction techniques. the start of World War I, and only cloth hats as part of their While serving in the British within weeks, the Allies (the uniforms. Soldiers had worn military, Dr. Gillies worked U.K., the Russian Empire, and body armor in the past, but it to establish a specialized the French Third Republic) became less effective after the facial reconstructive unit, were at war with the Central long rifle was invented, so this which evolved into Queen’s Powers (Germany and Austria- early form of body armor was Hospital, located just outside Hungary). The Allies were eventually abandoned. Because London. More than 5,000 later joined by Italy, Japan, trench warfare exposed the patients received reconstructive 80 | and the U.S., whereas the head and neck area to gunfire procedures there primarily to Ottoman Empire and Bulgaria and artillery assaults, many rehabilitate facial injuries. joined the Central Powers. soldiers died as the result of John Staige Davis, MD, To defeat the enemy, the penetrating intracranial injuries. FACS, was born in 1872 in Allies and the Central Powers In 1916 the British, and then the Norfolk, VA, and received used trench warfare to create German and French, adopted his medical degree in 1899 strong defensive positions that widespread use of steel helmets. from the Johns Hopkins were hard to breach. Frequently, Although the number of fatal University School of Medicine, these trenches were constructed cranial injuries was reduced after Baltimore, MD. Dr. Davis in three interconnected rows, the introduction of helmets, was the first U.S. surgeon to which enabled the combatants soldiers now survived with more devote his career to the study to retreat and continue fighting devastating facial injuries. and advancement of plastic to maintain their positions. and reconstructive surgery. Tens of thousands of miles of In 1917, the U.S. entered trenches were quickly built Plastic and reconstructive World War I and established from the Belgian coast to surgery’s evolution treatment units at the specially the border of Switzerland. Sir Harold Delf Gillies, MD, constructed Fort McHenry Reliable, rapid-fire machine FRCS, was a talented surgeon U.S. Army General Hospital guns became widely used and born in 1882 in New Zealand No. 2 in Baltimore to care forced troops to seek protection and received his medical degree for injured servicemen. More in the trenches. Barbed wire at Cambridge University in than 20,000 wounded soldiers was used extensively to inhibit the U.K. He then trained were treated in this 3,000-bed movement on the ground as an otolaryngologist and receiving hospital from 1917 between trenches, and tanks developed an interest in to 1923, when it was closed. were used for the first time in facial reconstruction, so he In 1919, just one year before 1916. Later in the war, poison traveled to France to study Dr. Gillies published Plastic gases and flamethrowers with Charles Valadier, a Surgery of the Face, Dr. Davis

V103 No 5 BULLETIN American College of Surgeons FROM THE ARCHIVES

Dr. Gillies Dr. Davis

| 81

published Plastic Surgery: American Board of Medical BIBLIOGRAPHY Its Principles and Practice. Specialties (ABMS), which Davis JS. Plastic Surgery: Its Principles maintains the standards for and Practice. Blakiston and Co., physician certification. In 1946, Philadelphia, 1919. Conclusion Dr. Davis was elected to serve Davis WB. The life of John Staige Davis, M.D. Plast Reconstr Surg. The texts by Drs. Gillies as a Regent of the American 1978;62(3):368-378. and Davis on plastic and College of Surgeons. Both the Gillies HD. Plastic Surgery of the Face. reconstructive surgery formed College and the ABMS focus Hodder and Stoughton, London, the foundation for the surgical on improving the quality 1920. specialty both in the U.S. and of health care for patients, Morgan RF. The Fort McHenry General Hospital for plastic and maxillofacial in the world. Dr. Davis was an families, and communities surgery. Plast Reconstr Surg. early member in the American through continuous 1983;72(2):255-259. Association of Plastic Surgeons professional development. ♦ Sargent LA, Morgan RF, Davis WB. (AAPS), which was founded in John Staige Davis: Pioneer American 1921. He served as the president plastic surgeon. Clin Plast Surg. of the AAPS in 1944. Dr. Davis Acknowledgments 1983;10(4):653-656. eventually established the The authors gratefully American Board of Plastic acknowledge the assistance Surgery (ABPS) and served as of Meghan P. Kennedy, ACS its first chairman. The ABPS Archivist, and Michael Beesley, established the specialty, which Assistant Archivist, Division became one of the 24 specialty of Member Services. boards now recognized by the

MAY 2018 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Stemming the tide of violence

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

he recent rise in mass 2,867 people in the U.S. died as In a study published in shootings and firearm a result of firearm violence.2 An Tviolence across the U.S. has estimated 4,880 were injured as March 2016 issue of the taken an emotional toll on all a result of firearm violence in American Journal of Medicine, Americans, but we as surgeons the U.S. during the same time witness firsthand the devastating period, according to the website.2 the authors found that the effects of firearm injuries. To The ACS first issued a homicide rate involving help effect change, the American Statement on Firearm Injuries College of Surgeons (ACS) issued in 1991.3 The statement was later firearms was 25.2 times a letter on violence, its impact on revised and updated in both higher in the U.S. than in health care, and how surgeons 2000 and 2013—the latter in other high-income countries. 82 | can take the lead in finding response to the mass casualty solutions by addressing this event at Sandy Hook Elementary crisis as a public health issue.1 School in Newtown, CT.3 According to the 2013 ACS Statement on Firearm ACS perspective on Injuries, the College supports violence prevention the following initiatives: “We understand that not all of our Fellows agree on • Enacting laws that would ban firearms, but the College is civilians from accessing assault dedicated to improving care weapons, high-capacity clips, and for the surgical patient, and as munitions intended for use by frontline caregivers for survivors the military or law enforcement of these tragedies, we must convene and lead where these • Strengthening and requiring issues are concerned,” the letter background checks for to all ACS Fellows reads. individuals seeking to In February, a gunman purchase a gun, including at took the lives of 17 people—14 gun shows and auctions of whom were students—at a high school in Parkland, FL. • Creating programs that educate An additional 17 people were and improve safe gun storage wounded. But firearm violence practices, as well as teach doesn’t only involve mass nonviolent conflict resolution casualty events. Indeed, the Gun Violence Archive website • Researching firearm injuries shows that, as of March 15, 2018, and creating a database on

V103 No 5 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

To help effect change, the ACS issued a letter on violence, its impact on health care, and how surgeons can take the lead in finding solutions by addressing this crisis as a public health issue.

these types of injuries to inform systems and the Stop the Bleed to consider for health care federal health policies program, as well as access to workers who are involved in bleeding control kits in public an “active shooter” situation. After the Sandy Hook mass places, across the country An active shooter is defined as shooting event—during which an individual who is actively a gunman shot and killed 20 • Gathering gun-owning engaged in killing or attempting first-graders and six adults— Fellows to discuss violence to kill people, most commonly in ACS Regent Lenworth M. Jacobs prevention strategies, as well confined and populated areas.5 Jr., MD, MPH, FACS, convened as surveying ACS members to These safety actions a number of experts, and better understand their views include the following: they developed the Hartford on firearm ownership and Consensus.4 This consensus injury prevention strategies • Involving local law enforcement | 83 of recommendations dealt in emergency plans primarily with the issue of • Supporting programs that aim to how health care providers counsel patients on safe firearm • Developing a communication and law enforcement could storage practices and injury plan for these types of events work together to provide prevention methods in order to medical service to injured reduce violence-related injuries • Establishing processes and victims. The consensus led procedures to ensure patient later to the development of • Conducting research and and employee safety the Stop the Bleed® program, supporting efforts to strengthen which trains laypeople in background checks and • Training and drilling employees first-response measures to enforcement of laws designed on these procedures and help individuals who are to keep firearms out of for these types of events experiencing blood loss. To the hands of criminals date, the program has trained • Planning how to handle more than 100,000 people. the event after it ends In addition, the ACS Active shooter situation Committee on Trauma (COT) in health care facilities Additional resources is working to create an action The Joint Commission also is from The Joint Commission plan to reduce firearm violence. acutely aware of the issue of include the following: Nine recommendations— firearm violence and its impact which are still being fine- on health care institutions. • Quick Safety, Issue 5: Preventing tuned—have been developed A Quick Safety advisory on violent and criminal events6 and include the following: preparing for active shooter situations updated as of February • Sentinel Event Alert, Issue • Continuing to support the 2017 provides additional 45: Preventing violence in development of trauma resources and safety actions the health care setting7

MAY 2018 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

These data demonstrate that a clear problem exists in this nation, which is why the ACS and The Joint Commission have taken action to try to better manage these emergencies and, hopefully, minimize injuries and deaths.

• A Workplace Violence Prevention web portal that REFERENCES includes emergency management resources for 1. American College of Surgeons. Violence prevention. security, violence, and active shooter situations Available at: facs.org/quality-programs/trauma/violence- prevention. Accessed March 26, 2018. 2. Gun Violence Archive. Available at: www. gunviolencearchive.org/. Accessed March 15, 2018. A challenge that must be addressed 3. American College of Surgeons. Statement on Firearm In a study published in the March 2016 issue Injuries. Available at: facs.org/about-acs/statements/12- of the American Journal of Medicine, the authors firearm-injuries. Accessed March 26, 2018. found that the homicide rate involving firearms 4. American College of Surgeons. The Hartford Consensus. was 25.2 times higher in the U.S. than in other Available at: www.facs.org/about-acs/hartford-consensus. Accessed March 26, 2018. high-income countries.8 The results of the study 5. The Joint Commission. Quick Safety, Issue 4. Available at: 84 | also showed that the gun homicide rate among www.jointcommission.org/issues/article.aspx?Article=h1w 15- to 24-year-olds was 49 times higher in the Y0qOAjXjKMD9Np15aXCoh6JDFt4iaFxb%2f%2fTKfNWE U.S. than in other high-income countries.8 %3d. Accessed March 26, 2018. These data demonstrate that a clear problem 6. The Joint Commission. Quick Safety, Issue 5: Preventing violent and criminal events. Available at: www. exists in this nation, which is why the ACS and jointcommission.org/issues/article.aspx?Article=kPXQxso The Joint Commission have taken action to 3Rvf%2by4zxRHf0Tbsma%2bstHA5lm6nrsN3mnm8%3d. try to better manage these emergencies and, Accessed March 26, 2018. hopefully, minimize injuries and deaths. 7. The Joint Commission. Sentinel Event Alert, Issue 45: These actions are important, but more Preventing violence in the health care setting. Available at: www.jointcommission.org/sentinel_event_alert_ involvement from the surgical community is issue_45_preventing_violence_in_the_health_care_ needed. The ACS and The Joint Commission join setting_/. Accessed March 26, 2018. our nation’s students, parents, teachers, patients, 8. Grinshteyn E, Hemenway D. Violent death rates: The U.S. nurses, and physicians in asking Congress to act. compared with other high-income OECD countries, 2010. Americans need our leaders to adopt the mantra that Am J Med. 2016;129(3):266-273. gained traction hours after the tragedy at Marjory Stoneman Douglas High School: “No more.” ♦

Disclaimer The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

V103 No 5 BULLETIN American College of Surgeons NTDB DATA POINTS

A slice in time: Lower extremity compartment syndrome

by Richard J. Fantus, MD, FACS, and Victoria Schlanser, DO

he definition of compartment injury, prompt diagnosis and Physicians now agree that syndrome has evolved treatment of compartment Tover the last two centuries. syndrome is essential. compartment syndrome Volkmann first introduced The classic signs of acute occurs when pressure within the concept of compartment compartment syndrome include syndrome when he described the six “Ps”: pain, paresthesia, a closed space increases past post-traumatic ischemic muscle poikilothermia (differing a critical pressure (typically injury leading to paralytic limb temperatures between limbs contractures, which he termed with affected side being cooler), greater than 30 mmHg), Volkmann’s Contracture in 1881.* pallor, paralysis, and pulselessness. resulting in decreased The more modern definition Pain that is disproportionate to perfusion to the components from Carter et al describes muscle injury must trigger a workup swelling within a fixed muscular for compartment syndrome. of the compartment and compartment impairing distal Pain is often described as a the sequelae following such blood supply leading to necrosis.† dull, deep, aching worsened by | 85 Physicians now agree that passive stretching of the involved an insult (muscle edema, compartment syndrome occurs muscles in the lower extremity ischemia, and necrosis). when pressure within a closed or dorsiflexion of the foot. space increases past a critical Paresthesias in the web space pressure (typically greater than between the first and second 30 mmHg), resulting in decreased toes is also an early indicator of perfusion to the components of compartment syndrome. Paralysis the compartment and the sequelae and pulselessness is often a following such an insult (muscle late indicator of compartment edema, ischemia, and necrosis). syndrome and many times results after irreversible nerve and muscle injury have already occurred. Prompt diagnosis and treatment Suspicion of compartment Lower extremity gunshot syndrome should prompt further wounds, stab wounds, fractures workup or definitive treatment. as a result of blunt injuries, Compartment pressures may and prolonged pressure on an have a limited role in diagnosis extremity are common causes of but are useful in patients without lower extremity compartment a reliable physical examination. syndrome in trauma patients. Several commercially available No matter the mechanism of devices allow for pressures to be measured within the muscular *Griffiths DV. Volkmann’s ischaemic compartments of concern. An contracture. Br J Surg .1940;28:239-260. absolute compartment pressure †Carter AB, Richards RL, Zachary RB. The anterior tibial syndrome. greater than 30 mmHg is Lancet. 1949;2(6586):928-934. concerning for compartment

MAY 2018 BULLETIN American College of Surgeons NTDB DATA POINTS

FIGURE 1. HOSPITAL DISCHARGE STATUS

syndrome. Calculating the A22 (traumatic compartment slice in time that will go a long “delta-p” (diastolic blood pressure syndrome of left lower extremity). way to reduce the potential minus intracompartment A total of 979 records were morbidity of lower extremity pressure) is an additional way to found, of which 937 contained a compartment syndrome. 86 | determine the need for operative discharge status, including 656 Throughout the year, we intervention. Whitesides in 1975 patients discharged to home, will be highlighting these data suggested that a compartment 160 to acute care/rehab, and 87 through brief reports in the was at risk when the to skilled nursing facilities; 34 Bulletin. The NTDB Annual compartment pressure was within died (see Figure 1, this page). Of Report can be found on the on 10–30 mmHg of the diastolic these patients, 82 percent were the ACS website as a PDF file at blood pressure.‡ The definitive men, on average 38.1 years of facs.org/quality-programs/trauma/ treatment of compartment age, had an average hospital ntdb. In addition, information is syndrome is fasciotomy. length of stay of 12.8 days, an available on the website about To examine the occurrence intensive care unit length of stay how to obtain NTDB data for of lower extremity compartment of 7.7 days, an average injury more detailed study. To submit syndrome in the National Trauma severity score of 9.4, and were your trauma center’s data, contact Data Bank® (NTDB®) research on the ventilator for an average Melanie L. Neal, Manager, admission year 2016, medical of 7.2 days. Of those tested, NTDB, at [email protected]. ♦ records were searched using the 26 percent (105 out of 403) were International Classification of over the legal limit for alcohol. Diseases, 10th Revision Clinical Several different mechanisms Acknowledgment Modification codes. Specifically of injury may result in a lower Statistical support for this article searched were records that extremity compartment was provided by Ryan Murphy, contained a diagnosis code syndrome. No matter the etiology, Data Analyst, NTDB. of either T79.A21 (traumatic if the diagnosis and treatment compartment syndrome of are delayed, serious sequelae right lower extremity) or T79. will occur. Examples include muscle loss, permanent nerve ‡Whitesides TE, Haney TC, Morimoto K, injury, functional loss, or even Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. amputation. However, urgent Clin Orthop Relat Res. 1975;113:43-51. operative fasciotomy provides a

V103 No 5 BULLETIN American College of Surgeons NEWS

Report on ACSPA/ACS activities, February 2018

by Diana L. Farmer, MD, FACS, FRCS

The Board of Directors • Statement on Credentialing be introduced. The rebranded of the American College and Privileging and Volume and revised program will of Surgeons Professional Performance Issues formally launch in spring 2018. Association (ACSPA) and the Board of Regents (B/R) of the • Statement on Medical Student Use Academy of Master American College of Surgeons of the Electronic Health Record Surgeon Educators (ACS) met February 2–3 at The Academy of Master Surgeon the College’s headquarters in In addition, the Board of Educators™, which recognizes Chicago, IL. The following is Regents accepted resignations and assembles a cadre of Master a summary of key activities from 11 Fellows and changed Surgeon Educators of national discussed. The information the status from Active or Senior and international renown, will provided was current as of to Retired for 99 Fellows. The select the inaugural cohort of the date of the meeting. Regents also approved the members in spring 2018 for reinstatement of 177 Fellows. induction into the Academy in summer 2018. Members of ACSPA the Academy will be selected | 87 From January 1 to December Division of Education through a rigorous peer-review 31, 2017, the ACSPA and its process and are expected political action committee, Clinical Congress 2017 to engage in activities in ACSPA-SurgeonsPAC, collected A total of 8,228 surgical conjunction with the Division $505,000 in donation receipts professionals attended Clinical of Education to advance the from more than 1,200 Congress 2017, October 22–26 science and practice of avant- individual ACS members in San Diego, CA. This total garde surgical education and staff. SurgeonsPAC also included the highest numbers and training. Goals include disbursed $377,990 to more than of Initiates and residents in defining megatrends in surgical 170 congressional candidates, attendance since 2008. education training, steering leadership PACs, and political advances in the field, fostering campaign committees. In TTP Program innovation and collaboration, line with congressional party The Transition to Practice (TTP) supporting faculty development ratios, 57 percent of the amount Program in General Surgery and recognition, and given was to Republicans and was established five years ago, underscoring the critical 43 percent to Democrats. primarily in response to concerns importance of surgical about readiness for independent education and training in the general surgery practice among changing milieu of health care. ACS graduating surgery residents. In addition to reviewing To better reflect its mission and Committee on Ethics reports from the ACS division goals, TTP will be renamed the The Committee on Ethics, directors, the Regents reviewed Program for Mastery in General which is housed in the Division and approved the following Surgery. The basic tenets of the of Education, released Ethical policy statements, both of program will remain the same, Issues in Surgical Care at Clinical which were published in the and additional educational and Congress 2017. More than April issue of the Bulletin: networking opportunities will 30 authors contributed to 21

MAY 2018 BULLETIN American College of Surgeons NEWS

chapters that are organized by surgical professional. The Opioid strategies as needed. A far- the predominant arenas in which Workgroup, which includes reaching examination has ethical issues in surgical care members from all surgical included analyzing data on the arise, including the surgeon- specialties and several other transition to the online Bulletin, patient relationship, the surgeon external organizations, such as the to the effectiveness of various and the surgical profession, Centers for Disease Control and online marketing campaigns, and the surgeon and society. Prevention and the Association to data on which types of Chapters feature case scenarios of Hospital Pharmacists, has Twitter posts generate the most to ground discussions in the worked on several activities, “likes” and “retweets.” The realities of clinical practice. including the following: Comprehensive Communications The Fellowship in Surgical Committee continues to provide Ethics, sponsored by the • A College Statement on the leadership and guidance to refine Division of Education and the Opioid Abuse Epidemic, the College’s messaging to ensure MacLean Center for Clinical which was published in the it resonates with key audiences. Medical Ethics, University of August 2017 Bulletin 88 | Chicago, IL, prepares surgeons Bulletin for careers that combine • Clinical Congress Panel Sessions As of January 1, 2018, the clinical surgery with scholarly Bulletin has been a mostly online studies in surgical ethics. • Development of six professional publication for a full year. Two fellows will complete e-learning programs The Bulletin team surveyed all the program in June 2018. Domestic Members in December • Dedicated web page 2017 to determine whether the Safe and Effective Pain transition has been successful. Control Initiative • Creation of an office sign At the time of the B/R meeting, The Division of Education’s and patient handout on Safe staff was analyzing the results Patient Education Committee and Effective Pain Control from the survey and preparing launched the Safe and Effective available to all ACS members to make recommendations Pain Control Initiative in 2017 for moving forward. with grant funding support • Easy access to state Continuing from the ACS Foundation. The Medical Education (CME) facs.org goals of the program include pain management and opioid The division continues to preventing chronic opioid use prescribing requirements provide a contemporary, user- following surgery; reducing friendly website experience for opioid distribution into the local members and all facs.org visitors. communities, which may lead Division of Integrated In 2017, several new outward- to misuse and nonmedical use Communications facing features were made to through improved disposal and In 2017, the Division of Integrated the College’s website, including pursuit of opioid-sparing options; Communications put an increased the ability to search and filter and implementing a patient- emphasis on data analysis Clinical Congress sessions by centered approach to safe opioid to ensure that the College is Webcast availability, Credit to prescribing through education communicating effectively and Address Regulatory Mandates, of the patient, caregiver, and fine-tuning its communications and Credit to Address ACS

V103 No 5 BULLETIN American College of Surgeons NEWS

Accreditation/Verification mentioned or were fully Communities Requirements; and the addition focused on bleeding control A total of 2,233 unique discussion of a “Donate” button to the top techniques, with either the contributors posted 18,922 of all pages and ACS NewsScope College, the Committee on messages across all communities to support the ACS Foundation. Trauma (COT), or the Hartford in 2017, a year in which members Usability improvements were Consensus mentioned. These viewed 764,122 community made to the site content search articles provided an estimated web pages. Overall, 3,030 tool to prepopulate suggested total reach of 603.12 million more discussion posts were search terms in the search field. media impressions. logged in 2017 than in 2016. Web traffic increased in 2017 from the previous year. The Social media College’s website logged 9,644,134 The College continued to Division of Research and page views; returning visitors improve its social media Optimal Patient Care represented 43.5 percent of the presence in 2017, with the most The Division of Research and website traffic, and the remaining significant growth happening Optimal Patient Care (DROPC) 56.5 percent were new visitors. on Twitter. In just one year, encompasses the areas of | 89 the number of people who Continuous Quality Improvement Bleedingcontrol.org followed @AmCollSurgeons (CQI) and ACS research and Bleedingcontrol.org recently on Twitter increased by accreditation programs. completed its first full year online. more than 22 percent. The In 2017, the site captured 401,147 Clinical Congress 2017 hashtag Quality and Safety Conference page views. Returning visitors received nearly 110.5 million Following a successful 2017 represented 39.7 percent of the impressions (number of conference, the 2018 Quality and site’s traffic; 60.3 percent were times users potentially saw Safety Conference will take place new visitors. In the last year, the #ACSCC17 on Twitter). New July 21–21 in Orlando, FL. The public profile was substantially hashtags, such as #BulletinACS 2018 conference will include two raised with the national Stop the and #ACSredbook, were additional ACS Quality Program Bleed® campaign, expanding introduced to increase reach and tracks: Cancer and Trauma. awareness among the public usefulness. Launched in 2016, With the theme of Partnering for and press. Extensive media the @bleedingcontrol Twitter Improvement, the program will coverage of bleeding control account now has 3,000 followers. focus on collaborative approaches training and related issues A five-part series of stories, to better understanding how occurred in the aftermath of “Putting the Pieces Together: the fundamentals of quality and shooting tragedies and continued A National Effort to Complete safety apply across all programs. throughout most of 2017. the U.S. Trauma System,” was Stop the Bleed is increasingly developed to draw attention Optimal Resources for Surgical becoming part of the nation’s to gaps in the system and Quality and Safety emergency preparedness proposed solutions. To date, The College officially released consciousness, and the College’s the stories have received 5,500 Optimal Resources for Surgical role in the campaign has been page views on facs.org, as well Quality and Safety in July 2017. The prominently mentioned. In as significant shares on the manual is intended to be a trusted 2017, almost 500 news stories College’s social media sites. resource for surgical leaders

MAY 2018 BULLETIN American College of Surgeons NEWS

seeking to improve patient care MBSAQIP adult surgery. In recent months, in their institutions, departments, A total of 866 facilities participate the team achieved the following: and practices. Exploratory work is in the Metabolic and Bariatric revised the beta standards, under way to develop adjunct and Surgery Accreditation and created a program compliance integrated resources/standards Quality Improvement Program assessment, and launched the within the manual to ultimately (MBSAQIP), and 63 surgeon beta pilot. The four-year project launch a Surgical Quality surveyors performed 245 site visits will conclude in July 2019. Verification Program. The aim is during 2017. MBSAQIP’s efforts to present a set of standards for continue to focus on data registry ISCR discussion and review by a larger design, training enhancement The Agency for Healthcare group to pilot with a targeted and support for the Metabolic and Research and Quality Improving group of hospitals in 2018. Bariatric Surgery Directors, long- Surgical Care and Recovery term patient follow-up tactics, (ISCR) Program, a collaborative ACS NSQIP and opioid-sparing surgery. effort between the College and A total of 796 hospitals participate the Johns Hopkins Armstrong 90 | in the College’s National Children’s Surgery Institute for Patient Safety and Surgical Quality Improvement Verification Program Quality, is under way. At present, Program® (ACS NSQIP®)—685 In January 2017, the ACS 206 hospitals are participating in the adult option and 111 Children’s Surgery Verification in the first cohort to implement through the pediatric option. Quality Improvement Program the colorectal pathway and An additional 28 hospitals are in officially released its verification establish systems for collecting various stages of the onboarding program with the goal of data in the ISCR platform on process. At present, 87 hospitals ensuring that pediatric surgical compliance with the pathway outside of the U.S. participate patients have access to quality processes and outcomes. The in ACS NSQIP—approximately care. Seven sites have been second cohort, scheduled for 11 percent of all ACS NSQIP verified and 20 sites are involved March 2018, allows hospitals participating hospitals. Interest in the verification process. to focus on orthopaedics (joint from international sites continues Efforts will continue to focus replacement and hip fracture). to build, particularly in Australia, on the framework to develop Chile, Mexico, and Portugal. and bridge the resources of Strong for Surgery Interest in collaboratives verification and the registry. Strong for Surgery, a joint continues to grow. To date, program between the ACS and more than 68 percent of all The Coalition for Quality in the University of Washington, NSQIP hospitals participate in Geriatric Surgery Project Seattle, is a quality initiative at least one of the 56 established The Coalition for Quality in aimed at identifying and collaboratives. In late 2017, the Geriatric Surgery Project, evaluating evidence-based NSQIP Collaborative Leader funded by the John A. practices to optimize the health Quarterly Call Series was Hartford Foundation, aims to of patients before surgery. The launched to aid in engagement systematically improve surgical program empowers hospitals and provide a forum for care of patients older than 65 and clinics to integrate checklists discussion and sharing of years of age by establishing a into the preoperative phase of quality improvement efforts. verification program in older clinical practice for elective

V103 No 5 BULLETIN American College of Surgeons NEWS

operations. The checklists are under way to improve performance measures, which target four areas known the system’s functionality. CMS has approved and are set to be high determinants of for implementation in 2018. surgical outcomes: nutrition, Cancer Programs Attended by 1,800 glycemic control, medication The Commission on Cancer participants, the 2017 TQIP management, and smoking (CoC) has more than 1,500 Annual Scientific Meeting and cessation. An online toolkit accredited programs, and Training took place November launched in July 2017 to aid two 42 new cancer programs 11–13 at the Hilton Chicago, active pilot sites and access was applied for accreditation in IL. The program comprised 26 provided to 178 other sites. 2017. The CoC Accreditation educational sessions, 29 oral Committee is undertaking a abstract presentations, and 102 SSR review of existing standards, posters. The 2018 TQIP Annual The new Surgeon Specific which will lead to publication Scientific Meeting will take place Registry (SSR) platform has an of a new manual in 2019 to November 16–18 in Anaheim, CA. active user base of more than align with the College-wide The COT released the “TQIP 5,000 surgeons. Since its launch standardization of accreditation/ Best Practices Guidelines on | 91 in April 2017, more than 600,000 verification programs. Palliative Care” in November records have been entered in The National Accreditation 2017, and the “TQIP Best the new system. The case data Program for Breast Centers Practices Guidelines on migration from the legacy system (NAPBC) has accredited Imaging for Trauma Patients” was completed in late 2017. nearly 600 U.S. centers and is expected to be released at the The SSR offers several received 62 new applications November 2018 TQIP meeting. regulatory compliance for accreditation in 2017. The This year marks 40 years opportunities for surgeons, NAPBC released a revised of the Advanced Trauma Life including the Merit‐based standards manual in January Support® (ATLS®) Program. Incentive Payment System 2018 and were to begin using Several events and awards are (MIPS) by the Centers for these standards in April 2018 planned throughout the year to Medicare & Medicaid Services following surveyor training. recognize this achievement. (CMS); Maintenance of The National Accreditation The Bleeding Control Certification (MOC) Part 4 by Program for Rectal Cancer is program has experienced rapid the American Board of Surgery launching in 2018 with surveyor and unprecedented growth since (ABS); and submission of cases to training; the first surveys were its inception in January 2017. the ABS during the MOC exam scheduled for March and April. The Stop the Bleed program application. The College worked has a presence in all 50 states, closely with CMS to achieve Trauma Programs with instructor requests from recognition and approval of the The Committee on Trauma’s more than 50 countries. As SSR as a MIPS-Qualified Registry (COT) Trauma Quality of December 31, 2017, the and MIPS-Qualified Clinical Improvement Program (TQIP®) program had been provided to Data Registry, and more than has 754 participating hospitals. more than 100,000 individuals 500 SSR participants registered The TQIP Quality Measures via 17,000 registered classes. for MIPS 2017 participation. Performance Workgroup Integral to the growth of the Continued enhancements developed several new program has been advocacy

MAY 2018 BULLETIN American College of Surgeons NEWS

work by the COT. Several states College’s philanthropic and Foundation also offered several have been able to develop and educational efforts. Thanks to new initiatives to broaden its enhance their efforts based the generous support of Fellows outreach to Fellows, including on lobbying and educational and friends of the College, working with each division efforts to formulate legislation contributions for fiscal year 2017 of the College to offer more and increase funding for the increased by 35 percent from defined giving opportunities Bleeding Control program. fiscal year 2016. With the support to donors, as well as using of two major donors, successful 19 strategic projects to assist matching gift opportunities in fundraising goals and ACS Foundation were offered at Clinical Congress streamlining operations. ♦ The ACS Foundation had a 2017 and the 2017 Annual Fund strong year in its mission to fall appeal, raising $100,000 obtain financial support for the and $200,000 respectively. The

92 | Experience the sphere of surgical influence @AmCollSurgeons

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2018_Bulletin_HalfPageAd_Twitter_v01.indd 1 4/6/2018 3:54:37 PM NEWS

Members in the news

Dr. Ford

| 93

Dr. Datta (far right) with South Nassau representatives (from left) Richard J. Murphy, president and chief executive officer; Lori Edelman, RN, director of patient care services and 2017 Cupola Award recipient; and Joe Fennessy, chair, board of directors

Rajiv Datta, MD, FACS, FRCS, and neck surgery, joined will start in his new position chief of surgery, South Nassau South Nassau in 2001 and has June 1. At press time, he was Communities Hospital, since gained an international vice-president and surgeon-in- Oceanside, NY, recently reputation for leadership chief, Children’s Hospital Los received South Nassau’s and surgical innovation. His Angeles, CA; and professor 2017 Mary Pearson Award. leadership allowed Gertrude of surgery and vice-dean The award is presented & Louis Feil Cancer Center for medical education, Keck annually to an individual to be equipped with cutting- School of Medicine, University for extraordinary effort and edge cancer treatment of Southern California. individual contributions that technology, and colleagues and A Haitian immigrant who advance the hospital’s mission patients recognize Dr. Datta moved to the U.S. with his to provide compassionate for his surgical skill and family when he was 13 years old, care and standard-setting compassionate demeanor. Dr. Ford was drawn to the Miller health care services. American College of Surgeons School of Medicine position Dr. Datta, also medical Regent Henri R. Ford, MD, MHA, because of the University of director, Gertrude & Louis Feil FACS, FRCS, FAAP, in March Miami’s dedication to providing Cancer Center, Valley Stream, was named the new dean of medical resources to Haiti after NY, and director, division of University of Miami, FL, Miller the devastating 2010 earthquake. surgical oncology and head School of Medicine. Dr. Ford Dr. Ford regularly visits Haiti

MAY 2018 BULLETIN American College of Surgeons NEWS

Dr. Greene Dr. Zundel

to assist in procedures and has authored peer-reviewed curriculum development, train surgeons. He performed manuscripts, book chapters, and education research; Haiti’s first separation of and textbooks, and participated have participated in national conjoined twins in 2015. on several editorial boards. educational meetings, In his upcoming role, The SESC noted that educational publications in Dr. Ford aims to make the Dr. Greene earned the peer-review journals, and the University of Miami Health organization’s Distinguished creation of innovative teaching System and the Miller School Service Award for his programs; and contributed to of Medicine a primary location contributions to the the development of Continuing 94 | for those seeking the latest field of surgery, which Medical Education programs. and best in health care and significantly added to the Dr. Zundel, Secretary- biomedical research. SESC’s mission of supporting Treasurer of the American Frederick L. Greene, MD, FACS, professional development and College of Surgeons (ACS) clinical professor of surgery, educational opportunities. South Florida Chapter, is University of North Carolina, Natan Zundel, MD, FACS, a world-renowned expert Chapel Hill, was awarded FASMBS, clinical professor of in minimally invasive and the Southeastern Surgical surgery and vice-chairman, bariatric surgery. He has given Congress (SESC) Distinguished department of surgery, Florida lectures across the world and Service Award in February. International University trained surgeons of all levels The award is the SESC’s Herbert Wertheim College in bariatric and minimally highest honor, awarded to a of Medicine, Miami Beach, invasive procedures. ♦ member for their continued recently was awarded the contributions, commitment, 2017 American Society and service to the Congress. for Metabolic & Bariatric Dr. Greene was a Lieutenant Surgery (ASMBS) Foundation Commander in the U.S. Navy Master Educator Award. Medical Corps, serving as The Master Educator surgeon on the USS Nimitz and Award recognizes an ASMBS at the Naval Regional Medical member who has demonstrated Center in Portsmouth, Virginia. excellence as a master educator He worked on the surgical and mentor in the field of faculty at the University of bariatric surgery. Recipients South Carolina, Columbia, for of this award have made 17 years, and then Carolinas significant contributions in Medical Center, Charlotte, at least one of the following NC, for 15 years. Dr. Greene areas: educational leadership,

V103 No 5 BULLETIN American College of Surgeons NEWS

Dr. Pellegrini receives Seattle Business Leaders in Health Care Lifetime Achievement Award

Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), assigned primary care FRCS(Hon), FRCSEd(Hon), a Past-President of the provider across its American College of Surgeons, has received primary care clinics.” Seattle Business magazine’s 2018 Leaders in He also integrated Health Care Lifetime Achievement Award for clinical services for his committed service to improving the quality key programs and of patient care in the Seattle, WA, area. created a training Dr. Pellegrini has worked in the University program to prepare of Washington (UW), Seattle, department young clinicians for of surgery since 1993, first as chair of the leadership roles. department and then in 1996 as the Henry Dr. Pellegrini said N. Harkins Professor and Chair, until 2015, that his motivation Dr. Pellegrini when he was appointed to serve as UW has always been Medicine’s first chief medical officer (CMO). to help people, as According to the Seattle Business article on his a surgeon, a mentor, or, as he notes about achievement, as CMO Dr. Pellegrini oversees his role as CMO, by “advancing social issues thousands of health care providers and has led a and the care that we provide our patients.” program that has visibly improved patient care Read more about Dr. Pellegrini’s life quality, reduced costs, and “ensured that all of and career in the Seattle Business article on the health care system’s 270,000 patients have an this achievement at goo.gl/MV9iMo. ♦ | 95

It is the surgeon It begins with a surgeon leader patients count on Optimal Resources for Surgical Quality and Safety to lead the team

It begins here facs.org/redbook

2018_CM_QualityManual_Bulletin_6.5x4_v01.indd 4 4/3/2018 1:03:03 PM MAY 2018 BULLETIN American College of Surgeons NEWS

ABS announces details of new Continuous Certification Program

The American Board of Surgery • Can be taken from personal way our diplomates practice (ABS) has announced details computer at a time within the today, and to support them about its new Continuous given assessment window by providing a high-value Certification Program, designed assessment process that focuses to provide greater value, • Provides immediate feedback, on essential developments in flexibility, and convenience in with two opportunities to surgical practice,” said Mary maintaining ABS certification. answer a question correctly E. Klingensmith, MD, FACS, 96 | The ABS is transitioning ABS chair. “We welcome to a new assessment process • Should be taken and diplomates’ input as this new that will gradually replace passed every two years program continues to evolve.” the traditional secure Read more about the recertification exam. Rather All ABS certificates will Continuous Certification than one recertification remain valid until their Program on the ABS exam every 10 years, ABS expiration date. Diplomates website at www.absurgery. diplomates will use the will not need to begin taking org/default.jsp?exam-moc. ♦ new assessment process to the general surgery assessment continually demonstrate until their certificate is due to their surgical knowledge. expire. The new general surgery The new assessment is assessment will be available this being introduced in 2018 for year for interested surgeons. general surgery, with other ABS Registration for the new specialties launching over the general surgery assessment will next few years. Following are open August 1. The assessment a few of the new details about will be available this fall, the general surgery assessment: September 7 to November 5. This new paradigm is • Consists of a 40-question, open- intended to more accurately book assessment; 20 questions reflect the rapid changes will cover core surgical in surgical knowledge and principles, and the other 20 will practice and better promote cover a practice-related area of high-quality patient care. the diplomate’s choice, including “It was important to all the general surgery, abdomen, ABS directors and staff that alimentary tract, and breast this new program reflect the

V103 No 5 BULLETIN American College of Surgeons NEWS

New oral histories added to the ACS Archives At Clinical Congress 2017, the American FRCSEd(Hon), Seattle, WA; Andrew L. Warshaw, College of Surgeons (ACS) Archives continued MD, FACS, FRCSEd(Hon), Boston, MA; J. David its Past-Presidents Oral History Project. This Richardson, MD, FACS, Louisville, KY; and project is designed to capture an official, Courtney M. Townsend, Jr., MD, FACS, Galveston, historical record of ACS Past-Presidents and TX. These video interviews provide insight into reflections on their careers and time serving their careers, interests, and impressions of the as President of the ACS. The Archives seeks College and its significance to the field of surgery. | 97 to include the voices of all the living Past- These interviews, as well as the entire Presidents in a collection that is intended to be collection of oral histories on the ACS recognized and researched for years to come. Archives Catalog, are available online by The 2017 interviews captured the thoughts and clicking on the “Oral Histories” featured reflections of the four most recent ACS Presidents category at goo.gl/cyDYmM. Send any questions (one-year terms, 2013–2017, respectively): Carlos A. or comments to ACS Archivist Meghan Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), Kennedy at [email protected]. ♦

Coming next month in JACS and online now

Post-discharge opioid prescribing and use after common surgical procedures

Mayo H. Fujii, MD, MS; Ashley C. Hodges; Ruby L. Russell; et al found that median opioid use after surgery was 27 percent of the total prescribed, and only 18 percent of patients reported receiving disposal instructions. Significant variability in opioid prescribing and use after surgery warrants investigation into contributing factors. This article and all other JACS content is available at www.journalacs.org. ♦

MAY 2018 BULLETIN American College of Surgeons NEWS

Making quality stick: Optimal Resources for Surgical Quality and Safety Lifelong learning: A key responsibility of the individual surgeon

Editor’s note: In July 2017, the and mortality conferences; and retool to maintain and American College of Surgeons (ACS) simulation; video review; the advance their performance. released Optimal Resources for American College of Surgeons Be sure to read next month’s Surgical Quality and Safety—a new National Surgical Quality overview of the red book for manual that is intended to serve as a Improvement Program® insights into how disruptive trusted resource for surgical leaders (ACS NSQIP®) Quality In- behavior affects the patient care 98 | seeking to improve patient care in Training Initiative, which team and the value of mentoring their institutions and make quality offers defined training in and coaching. Optimal Resources stick. Each month, the Bulletin quality improvement for for Surgical Quality and Safety is highlights some of the salient points residents; journals; and so on. available for $44.95 per copy for made throughout the “red book.” The pursuit of lifelong orders of nine copies or fewer learning and continuous and $39.95 for orders of 10 or Without lifelong education and professional development is the more copies at facs.org/redbook. ♦ training, there is no quality. responsibility of each surgeon. The groundwork for developing The individual surgeon who is the knowledge and capabilities committed to quality should needed to provide safe, reliable, participate in Continuing quality care is set in medical Medical Education programs, school. In residency, trainees evaluate performance in develop hands-on skills they practice, and engage in self- will apply in practice while assessment activities. Surgeons honing their theoretical and also are obligated to engage practical knowledge. Practicing in quality improvement surgeons learn with each new programs, such as ACS NSQIP case, but also must continually and specialty programs that seek out opportunities to learn benchmark outcomes data; new techniques and procedures. use tools designed to make Many tools are available surgical care more patient- to assist in applying the centered, including the ACS principles of adult learning NSQIP Risk Calculator, Strong to the education and training for Surgery checklists, and of residents and surgeons. patient-reported outcome Examples include morbidity measures; and reeducate

V103 No 5 BULLETIN American College of Surgeons Why wait?

| 99 Get instant access to the Journal of the American College of Surgeons (JACS) by switching to an online-only subscription. JACS, a trusted print resource since 1905, is adapting to meet the needs of surgeon-readers in the 21st century. We are committed to maintaining the high-quality, peer-reviewed, surgical content our readers rely on.

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journalacs.org MAY 2018 BULLETIN American College of Surgeons

2017_Bulletin_JACS-subscription_7.5x10.25in_v03.indd 1 7/12/2017 10:39:47 AM MEETINGS CALENDAR Calendar of events*

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

Missouri Chapter 2018 ACS Coding and MAY May 11–13 Reimbursement Workshop Lake Ozark, MO May 17–19 Chile Chapter Contact: Denise Boland, New York, NY May 6–9 [email protected], Contact: KarenZupko & Associates, Inc., Viña del Mar, Chile www.moacs.org [email protected], Contact: Lorena Lopez, www.karenzupko.com/workshops2/ [email protected], Southern California Chapter gensurg-workshops/ www.acschile.cl May 11–12 Indian Wells, CA Maine Chapter Region 16 Contact: Tracey Dowden, May 18–20 May 7–10 [email protected], Kennebunkport, ME Sydney, Australia www.socalsurgeons.org Contact: Cathy Stratton, Contact: Rowena Bentley, [email protected], [email protected], Metropolitan Washington, www.mainefacs.org asc.surgeons.org DC Chapter May 12 Puerto Rico Chapter Brooklyn-Long Island Chapter Washington, DC May 18–19 100 | May 8 Contact: Ashley Porter, San Juan, Puerto Rico Garden City, NY [email protected], Contact: Aiza Velez-Silva, Contact: Teresa Barzyz, www.dcfacs.org [email protected], [email protected], www.acspuertoricochapter.org www.bliacs.org Metropolitan Philadelphia Chapter Brooklyn-Long Island Chapter Region 17 May 14 Young Surgeons Dinner May 10–12 Philadelphia, PA May 29 Ankara, Turkey Contact: Lauren Newmaster, Garden City, NY Contact: Dr. Mehmet Haberal, [email protected], Contact: Teresa Barzyz, [email protected] www.metrophilasurgeons.org [email protected], www.bliacs.org

West Virginia Chapter San Diego Chapter May 10–12 May 15 White Sulphur Springs, WV San Diego, CA FUTURE CLINICAL Contact: Sharon W. Bartholomew, Contact: Jim Cox, CONGRESSES [email protected] [email protected], www.sdcacs.org 2018 Metropolitan Chicago Chapter October 21–25 May 11 Michigan Chapter Boston, MA Chicago, IL May 16–18 Contact: Nathalia Granger, Acme, MI 2019 [email protected], Contact: Carrie Steffen, October 27–31 www.mccacs.org [email protected], San Francisco, CA www.michiganacs.org 2020 October 4–8 Chicago, IL V103 No 5 BULLETIN American College of Surgeons