JULY 2009 Volume 94, Number 7

FEATURES Stephen J. Regnier Does the U.S. have the best Editor health care system in the world? 8 Linn Meyer Ronald D. Wenger, MD, FACS Director, Division of Integrated Communications ACS promotes the six competencies of the Accreditation Council for Graduate Medical Education 16 Tony Peregrin B. J. Palmer, MD; Victor Stams, MD; Thomas R. Russell, MD, FACS; Associate Editor Alden H. Harken, MD, FACS; and L. D. Britt, MD, FACS Diane S. Schneidman Karen Stein Equipment for ambulances 23 American College of Surgeons Committee on Trauma, American College Contributing Editors of Emergency Physicians, National Association of EMS Physicians, Tina Woelke Pediatric Equipment Guidelines Committee–Emergency Medical Services Graphic Design Specialist for Children Partnership for Children Stakeholder Group, and American Alden H. Harken, Academy of Pediatrics MD, FACS Governors’ Committee on Chapter Activities: An update 30 Charles D. Mabry, Lenworth M. Jacobs, Jr., MD, MPH, FACS MD, FACS Jack W. McAninch, Residents salute their mentors 32 MD, FACS Editorial Advisors My mentor: The persistent calm: Anthony Stallion, MD, FACS 33 Tina Woelke Kaine C. Onwuzulike, MD, PhD Mary Beth Cohen My mentor: Front cover design The ideal surgical mentor: R. Anthony Perez-Tamayo, MD, FACS 34 Daniel Eiferman, MD Future meetings 2009 Clinical Congress Preliminary Program 35 Clinical Congress 2009 Chicago, IL, October 11-15 DEPARTMENTS 2010 Washington, DC, October 3-7 From my perspective 4 2011 San Francisco, CA, Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director October 23-27 What surgeons should know about... 6 The surgical CAHPS survey Letters to the Editor should Elizabeth W. Hoy, MHA be sent with the writer’s name, address, e-mail ad- Socioeconomic tips 52 dress, and daytime tele- ACS Coding Hotline: Operative report questions phone number via e-mail to [email protected], or via mail John T. Preskitt, MD, FACS; Albert Bothe, Jr., MD, FACS; Linda Barney, MD, to Stephen J. Regnier, Editor, FACS; Mark T. Savarise, MD, FACS; and Debra Mariani, CPC Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or On the cover: Program and registration information for the College’s annual clarity. Permission to publish letters is assumed unless the Clinical Congress appears beginning on page 35. This year’s meeting will take author indicates otherwise. place October 11–15 in Chicago, IL. NEWS Bulletin of the American College of Surgeons (ISSN In memoriam: 0002-8045) is published Former ACS Director Paul A. Ebert, MD, FACS 54 monthly by the American Col- Constantine Mavroudis, MD, FACS lege of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It 2009 Health Policy Scholars announced 60 is distributed without charge to Fellows, Associate Fellows, Visit the ACS Web portal’s rural surgeons community 62 Resident and Medical Student Members, Affiliate Members, A look at The Joint Commission: and to medical libraries and al- lied health personnel. Periodi- Improve hand hygiene with free monograph 63 cals postage paid at Chicago, IL, and additional mailing Correction 63 offices. POSTMASTER: Send address changes to Bulletin of Clinical congress sessions to present research in progress 65 the American College of Sur- geons, 633 N. Saint Clair St., New College Web site centers on Chicago, IL 60611-3211. Cana- E-prescribing Incentive Program 65 dian Publications Mail Agree- ment No. 40035010. Canada NTDB® data points: Falling down 67 returns to: Station A, PO Box Richard J. Fantus, MD, FACS 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312/202-5000; toll-free: 800/621-4111; fax: 312/202- 5001; e-mail:postmaster@ facs.org; Web site: www.facs. org. Washington, DC, office is located at 1640 Wisconsin Ave., NW, Washington, DC 20007; tel. 202/337-2701, fax 202/337-4271. Unless specifically stated otherwise, the opinions ex- pressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons.

©2009 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

From my perspective

he Chair of the American College of Sur- geons’ Board of Regents, L.D. Britt, MD,

MPH, FACS, classifies the geographic,

Teconomic, and ethnic disparities in the U.S. health care delivery system as the civil rights issue of this era. I agree wholeheartedly. Too often patients receive lower-quality care, have ’’ greater difficulty accessing medical services, or have to pay more for treatment simply because of demographics. These variances have no place in a humane and just society and are ethically and morally antithetical to the medical and The need to address disparities surgical professions, which are grounded in the principle that all patients deserve to be treated in care—especially ethnic with compassion and respect, regardless of race, location, or income. and racial divides—is growing Persistent problems increasingly urgent. Whereas the U.S. has made some significant strides in eliminating disparities in access to mammograms, smoking cessation counseling, ’’ and appropriately timed antibiotics, many of the most significant disparities persist. For ex- at least twice as unlikely to visit a physician as ample, African-Americans are more likely than insured patients. Furthermore, Hispanics and are Caucasians to be admitted to the hospital African-Americans have differential access to a for lower extremity amputations due to diabetes primary care physician or specific source of care, and are less likely to receive appropriate pre- with Hispanics at particular risk.† natal care during the first trimester of pregnancy. Regardless of race or ethnicity, low-income Native Americans also are less likely to receive people receive less patient-centered, continuous prenatal care, and they are less likely to undergo care. For example, the percentage of patients who colon-rectal cancer screening. Meanwhile, Asian- have their blood under control is significantly Americans are less likely than whites to receive lower for poor than for high-income people, and timely care for an illness or injury, and Hispanics low-income individuals are much less likely to are three times more likely to contract AIDS.* receive recommended care for colon cancer. Low- Under our current system, access to health income Americans also are two to three times as care is largely determined by whether an in- likely as high-income individuals to report prob- dividual has health insurance, and minority lems receiving timely treatment. Furthermore, populations are far more likely to lack coverage. poor Americans are less likely to have a specific Among nonelderly adults, at least 36 percent of source of ongoing care.* Hispanics and 33 percent of Native Americans Geographic variances also are notable. For ex- are uninsured. In addition, 22 percent of African- ample, there was nearly a 20 percent gap in the American, 17 percent of Asian, and 13 percent of proportion of nonelderly Minnesotans and Tex- white adults are uninsured. Adults in all racial/ ans who were uninsured in 2004–2005. There also ethnic groups who lack insurance coverage are is wide variability across state lines in the odds of *Agency for Health Care Quality and Research. National a patient undergoing certain common Medicare Healthcare Disparities Report, 2008. Available at http://www. procedures, such as carotid endarterectomy, cho- ahrq.gov/qual/nhdr08/nhdr08.pdf. Accessed May 13, 2009. lecystectomy, colectomy, aortic aneurysm repair, †The Henry J. Kaiser Family Foundation. Eliminating Racial/ Ethnic Disparities in Health Care: What Are the Options? and back surgery. Available at http://www.kff.org/minorityhealth/h08_7830.cfm. In addition, rural patients have less access to Accessed May 13, 2009. appropriate care than their counterparts in met- 4

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ropolitan areas. Indeed, more than 25 percent of the health care professions, medical schools need Americans live in communities with fewer than to provide opportunities for positive interaction 50,000 residents, but only nine to 12 percent of among individuals from a range of backgrounds. surgeons practice in nonmetropolitan areas.‡ A multicultural environment forces people to challenge their assumptions about individuals Possible solutions from different backgrounds and broadens their The need to address disparities in care— worldview. especially ethnic and racial divides—is growing Most importantly, however, we need to change increasingly urgent. If these variances in care our professional culture. We need to place greater continue unchecked, many more Americans will emphasis on the tenets of our noble calling: to be at needless risk of requiring costly emergency provide the best possible, ethical, and compas- and acute or end-of-life care, thereby threaten- sionate care to all who people who entrust us ing our nation’s economic and moral fabric. So, with their health care. We need to produce what can the surgical profession do to help close physicians and other health care professionals these divides? who are more culturally aware and better able Some experts claim that one mechanism that to communicate with the broad section of people may be useful is the development of patient- needing our services. centered medical homes, where services are The ACS logo indicates that this organization aligned to care for the whole patient. Indeed, calls upon its members to “serve all with skill and evidence already exists to show that racial and fidelity.” We must remain true to this ideal and ethnic differences in getting needed medical work to overcome disparities in care. care are eliminated when patients are part of a medical home. To address the challenges facing rural popula- tions, we should foster training programs that provide surgeons of the future with the skills they need to treat the full range of conditions they are likely to encounter in this environment. We also Thomas R. Russell, MD, FACS need to develop a more regionalized health care system and encourage the federal government to provide incentives to surgeons who opt to practice outside of urban areas. We need to attract more people of all races and creeds to medicine. Diversity within the physician population leads to improved access to services, increased patient satisfaction, and the delivery of culturally competent care. Minority physicians are more likely to treat minority and medically indigent patients and to practice in underserved communities. When given the op- tion, minority patients are more likely to choose a health care professional of their own racial/ ethnic heritage, and relationships between pa- tients and physicians with similar backgrounds are characterized by higher levels of trust and mutual respect. To encourage more minority students to enter ‡Division of Advocacy and Health Policy. A growing crisis in If you have comments or suggestions about this or patient access to emergency surgical care. Bull Am Coll Surg. other issues, please send them to Dr. Russell at fmp@ 2006;91(8):8-19. facs.org. 5

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

The surgical CAHPS® survey by Elizabeth W. Hoy, MHA, Assistant Director, Regulatory Affairs and Quality Improvement Programs, Division of Advocacy and Health Policy

n article in the April Bulletin* focused on been branded as a CAHPS instrument, users have the American College of Surgeons’ efforts full access to the free resources available through Ato develop a survey to measure patient the CAHPS Survey Users Network (https://www. experiences of surgical care. This development cahps.ahrq.gov/default.asp). This network is re- process, which was carried out on behalf of the sponsible for making the survey products avail- Surgical Quality Alliance, took more than a year able, providing technical assistance and education, to complete and followed the most stringent pro- and facilitating networking among users. tocols for questionnaire development. This survey instrument and its supporting documentation I’m in a large, multispecialty faculty prac- were submitted to the Agency for Healthcare Re- tice. Can you give me an example of how search and Quality (AHRQ) in May for review and physician-level CAHPS survey data are be- inclusion in the Consumer Assessment of Health- ing used in this type of practice? care Providers and Systems (CAHPS) family of survey instruments and reporting tools. CAHPS The University of California–Los Angeles develops and supports the use of a comprehen- (UCLA) Faculty Practice Group manages 1.8 mil- sive and evolving family of standardized surveys lion patient encounters a year across 18 clinical that ask consumers and patients to report on departments in more than 65 ambulatory loca- and evaluate their experiences with health care. tions. Patient feedback is an important component These surveys cover topics that are important to of the service and quality metrics they collect consumers, such as their health care profession- throughout the system. They currently use the als’ communication skills and the accessibility of Clinician & Group CAHPS survey instrument to services. collect information about patient experiences, but have expressed interest in also using the surgical Why should surgery have a CAHPS survey survey when it becomes available. instrument? UCLA incorporates the CAHPS data into their ambulatory scorecard, which is distributed to each There are significant advantages to having the ambulatory care location throughout the clinical surgical experience of care survey adopted into departments. CAHPS data also are incorporated the CAHPS portfolio. Medicare, Medicaid, private into standard-setting discussions with departmen- health plans, large multi-specialty group practices, tal and practice leadership and into staff training and other stakeholders recognize CAHPS as the on customer service. national standard for measuring patient experi- Practices in the lower third of CAHPS scores, ence of care. Making a reliable, valid measure based on a simple rank order summary score of surgical patient experiences—one that has across the major domains measured by the survey, been developed by surgical societies for surgical receive targeted practice consultations to help ev- patients and surgical quality improvement— eryone in the group gain a better understanding of available to the health care marketplace assures the root causes of lower performance scores and to that surgeons stay in control of how the quality develop targeted interventions for improvement. of surgical care is evaluated and reported. Some interventions that UCLA has implemented A second advantage is that, once the survey has to date include the following: training for office *Hoy EW. ACS-SQA surgical patient experience of care survey staff; physician communication training; qual- design project: A progress report. Bull Am Coll Surg. 2009; ity improvement collaboratives, where practices 94(4):14-17. share what works and what doesn’t work with 6

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS each other; and the development of standards of the survey when it is administered directly by and guidelines where appropriate (for example, the physician’s office, especially by telephone. Pa- communication of diagnostic test results). tients may also be concerned that their responses will affect the care that they receive. These con- How would a small group practice use the cerns have the potential to reduce response rates CAHPS information? and bias responses.

Greenhouse Internists in Philadelphia, PA, Who should I contact if I have questions tested the assertion that the CAHPS Clinician about the surgical CAHPS? & Group Survey would meet the needs of both small and large practices. With five internists, If you have questions about the surgical ex- they needed to administer the survey to meet perience of care survey developed by the ACS the requirements of the National Committee for and the Surgical Quality Alliance, please contact Quality Assurance physician recognition program Caitlin Burley, Quality Associate, at cburley@ with a limited practice budget. They arranged for facs.org.  an administrative staff person to generate and mail the questionnaires and notification letters (available free through the CAHPS Survey Users Network) as recommended by the CAHPS data collection protocol. They also followed up with respondents by phone in order to reach the needed 45 completed surveys per physician. To generate scores for the individual physicians, Greenhouse Internists received assistance from a health care researcher at the CAHPS User Net- work, which recommends that practices contact local universities for help with the statistical analysis. Because the CAHPS Analysis Programs and instructions are available in the Survey and Reporting Kit, analyzing CAHPS data doesn’t require advanced statistical knowledge—just the ability to run statistical analysis software programs. The results were used to assess how their phy- sicians were performing in comparison to one another, to confirm problem areas of which they were already aware, and to identify opportunities for improvement. As a result, the practice has hired a health educator to improve the way they handle patient education functions within the practice and expects to see improved scores when they conduct another evaluation in a year or two.

What are some potential problems my prac- tice may encounter if we conduct CAHPS studies in the future?

It is worth noting that surveys conducted by practices may raise certain issues. Potential sur- vey respondents may question the confidentiality 7

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS or many years, it was widely believed that national health care systems. National health the U.S. had the best health care system care systems are extremely complex and involved. in the world. Although this assumption Perhaps looking at a somewhat simpler and had been questioned from time to time, unrelated question such as, “What country had itF wasn’t until the World Health Organization the best Olympic record in 2008?” might help (WHO) report of 2000 that this belief was seri- illustrate some of the problems in measuring ously challenged. complex systems. Is it the country that won the In this discussion, “best health care in the most Olympic medals? This would be the U.S., world” will be defined as having the highest qual- followed by China. Is it the country that won the ity of care available anywhere in the world, and most gold Olympic medals? In which case, China the “best health care system in the world” will be would be the best, followed by the U.S. Or, is it defined as including not only the highest quality the country that won the most Olympic medals of care in the world but also access to this care per person? In which case, the winner would be as well as having the underlying infrastructure the Bahamas, followed by Jamaica. Or, would of education and research. it be the country that won the most medals per Unfortunately, there are no agreed upon or square mile? In which case, the winner would be established criteria for measuring the quality of Bahrain, followed by Singapore.1

Does the U.S. have the best health care system in the world?

by Ronald D. Wenger, MD, FACS

8 Why do many people believe that the U.S. formance relative to how well it theoretically has the best health care system in the world? could have performed. Essentially a country’s First of all, the U.S. spends a higher percent- ranking was raised or lowered by the UN officials age of its gross domestic product (GDP) and depending on whether it was believed that, based more per capita on health care than any other on the country’s resources, the country actually country in the world. Secondly, the best health performed better than anticipated or worse than care institutions in the world are in the U.S.; anticipated. By any measure this action unto these include Johns Hopkins, Mayo Clinic, itself was highly subjective. and Massachusetts General Hospital. Thirdly, Table 1 on page 10 shows the OA ranking from physicians from all over the world come to the the WHO study. Note that Japan is ranked as U.S. for advanced training. Finally, patients number 1 and that France is number 6, Italy is from all over the world come to the U.S. for 11, Germany is 14, and the U.S. is number 15. quality care. Table 2 on page 10 shows the OP ranking, in which France and Italy are promoted to number Evaluating national health care systems 1 and number 2 because UN experts believed that they performed better than anticipated; In reviewing the health economics literature, Japan, Germany, and the U.S. are demoted to there are three measures that have been fre- numbers 10, 25, and 37 respectively, because quently applied to national health care systems: they performed less well than UN experts be- • The WHO’s World Health Report of 20002 lieved that they should have. • National life expectancy data The WHO in their report of 2000 used five cri- • National infant mortality data teria for measuring the quality of health care:3 On close examination, however, all three of these • Health level: 25 percent measures have significant flaws. • Health distribution: 25 percent The WHO is a division of the United Nations • Health responsiveness: 12.5 percent (UN). In 2000, the WHO published its first report • Responsiveness distribution: 12.5 percent comparing the health care systems of 191 coun- • Financial fairness: 25 percent tries. These rankings have been widely cited in Only criteria 1 and 3 are clinical measures the public debate over the quality of health care of health care systems. The remaining crite- in the U.S. Although these rankings are typically ria (accounting for 62.5 percent of the health presented as objective measures of the relative systems grade) are nonmedical, socioeconomic performance of national health care systems, the criteria, which are pseudo-objective measures WHO rankings depend on underlying assump- that look at inequality of the distribution of tions which actually predetermine the ranking of health care services within a country. It would the health care systems being measured. These have been more valuable to have examined assumptions are thoroughly vetted in the recent the quality of care received by each country’s article, “WHO’s fooling who?” by G. Whitman.3 poorest citizens. What is not commonly known is that there is more than one WHO ranking. In the World Other measures comparing systems Health Report of 2000, two rankings were actu- ally reported.2 The first ranking was called Over- There are two other measures of health care all Attainment (OA), and in this ranking the U.S. systems that have been used: life expectancy and was internationally ranked as 15th. The second infant mortality. ranking was called Overall Performance (OP) in For each of these statistics to be meaningful, which the U.S. was ranked 37th. Interestingly, there needs to be an actual relationship between in an extensive review of the English language the health care system and the item being mea- literature on this subject, the first ranking (OA) sured. Changes in the health care system must is rarely, if ever, quoted. Both of these rankings be reflected in changes in the measure. Further- are based on the same underlying data, but the more, it is very important that the measure be OP index is adjusted to reflect a country’s per- uniformly used by all nations involved.4 9

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Life expectancy Table 1: Overall health system attainment in all member states, Review of recent literature WHO index estimates for 1997 (rank top 40) suggests that life expectancy is a poor statistic for de- 1 Japan 15 United States 29 Slovenia termining the quality of a 2 Switzerland 16 Iceland 30 Czech Republic health care system because 3 Norway 17 Andorra 31 Malta many people actually die with 4 Sweden 18 Monaco 32 Portugal minimal interaction with the 5 Luxembourg 19 Spain 33 Chile health care system (in auto 6 France 20 Denmark 34 Poland accidents, homicide, and sud- 7 Canada 21 San Marino 35 Republic of Korea den death). Recent research 8 Netherlands 22 Finland 36 Croatia shows that the health care 9 United Kingdom 23 Greece 37 Brunel Darussalam systems have minimal impact 10 Austria 24 Israel 38 Barbados on longevity in the industri- 11 Italy 25 Ireland 39 Slovakia alized world. Studies from 12 Australia 26 New Zealand 40 Cuba multiple countries have found 13 Belgium 27 Singapore that there is no relationship 14 Germany 28 Cyprus between: life expectancy and the number of physicians in the country, life expectancy Table 2: and the number of hospital Overall performance (rank top 40) beds per 100,000 people in a country, and life expectancy 1 France 15 Iceland 29 Morocco and health care expenditures 2 Italy 16 Luxembourg 30 Canada as a percent of national GDP.4,5 3 San Marino 17 Netherlands 31 Finland According to a 2007 article 4 Andorra 18 United Kingdom 32 Australia in the New England Journal 5 Malta 19 Ireland 33 Chile of Medicine, only 10 percent of 6 Singapore 20 Switzerland 34 Denmark premature deaths in the U.S. 7 Spain 21 Belgium 35 Dominica are related to the health care 8 Oman 22 Colombia 36 Costa Rica system. The great majority 9 Austria 23 Sweden 37 United States (85 percent) of premature 10 Japan 24 Cyprus 38 Slovenia deaths are related to human 11 Norway 25 Germany 39 Cuba behavior, genetic predisposi- 12 Portugal 26 Saudi Arabia 40 Brunei Darussalam tion, and social circumstance.6 13 Monaco 27 United Arab Emirates Table 3 on page 11 shows 14 Greece 28 Israel recent life expectancy data in different countries, along with health care expenditures per capita in the respective countries.4 It is noted that most part independent of a nation’s health care the Japanese have the longest life expectancy at system.4 It is also noted that the U.S. spends a 80.6 years, but do not spend the most money on significant percentage of its health care dol- their health care. The U.S. has shorter life expec- lars on screening and treating cancer, which is tancy and spends more on health care. certainly a laudable endeavor. But it has been It is interesting, however, to note that Japanese- calculated that even if all cancer deaths were Americans living in the U.S. have an average life eliminated in the U.S., the life expectancy of the expectancy similar to Japanese living in Japan. average American citizen would only increase by This again confirms recent studies that show that 2.4–3.0 years and this would still be short of the life expectancy in the industrial world is for the Japanese life expectancy.7,8 10

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 3: tries. Japan and Sweden have the lowest infant Life expectancy and health expenditures mortality rate. It should be noted, however, that Life Per capita overall the industrialized world does far better in expectancy health this category than the developing world. at birth expenditure In a number of outcome studies in which the Australia 79.0 $2,513 U.S. trails the industrialized world, the U.S. data for whites is similar to that of Western Austria 78.1 2,191 Europe, suggesting perhaps the problem in Belgium 77.6 2,490 the U.S. may not be quality of health care but Canada 79.0 2,792 distribution of health care. It is also noted Denmark 76.6 2,503 that countries in the industrialized world that frequently have the best outcomes are for the Finland 77.4 1,841 most part quite ethnically homogeneous. Swe- France 78.8 2,561 den, Norway, Iceland, France, Italy, and Japan Germany 77.7 2,808 generally rank very well but all are much more Greece 78.1 1,511 homogeneous than the U.S., which is quite ethnically and culturally diverse. Currently, Iceland 79.6 2,643 whites constitute 66 percent of the U.S. popula- Italy 79.0 2,212 tion. This number is projected to drop below 9 Japan 80.6 2,131 50 percent in the next several decades. Also of significance is the fact that the high Netherlands 77.9 2,626 school dropout rate in the U.S. is well above New Zealand 78.3 1,710 20 percent, which is one of the highest dropout Norway 78.4 2,920 rates in the industrialized world. Students who Spain 78.6 1,600 drop out are more likely to be unemployed, un- able to obtain health insurance, skip prenatal Sweden 79.5 2,270 care when pregnant, and have poor personal United Kingdom 77.4 1,992 health habits (for example, diet and exercise). Non-U.S. average 78.4 2,295 Although this is an extremely important problem, it is not a problem created by the U.S. health United States 76.7 4,887 care system, but nevertheless places tremendous stress on the health care system. In essence, many observers do not believe that Infant mortality the modest ranking of the U.S. in life expectancy and infant mortality statistics is attributable to Theoretically, infant mortality should be a good the performance of the U.S. health care system measure of a health care system. But in spite but to a variety of other factors. of strict UN definitions of what a live birth is, many countries do not follow them. Switzerland, Uninsured Finland, France, Norway, Belgium, and Canada all have idiosyncrasies in their reporting tech- According to the recently published U.S. Cen- niques about live births that significantly affect sus Report 2007, there are 45.7 million uninsured their infant mortality rate.4 It is not known, Americans.9 Interestingly, this number has been for instance, how many countries report babies stable at 14 to 15 percent of the population un- born at 25 weeks gestation or babies weighing der age 65 over the last 20 years. Many of the 1.5 pounds as live births. uninsured are only uninsured for a few months Table 4 on page 12 shows a recent international as they change jobs, 9.7 million of the uninsured report of infant mortality rates.4 Again, note that are illegal immigrants, and 14 million of the unin- the U.S. does not have an outstanding record sured are poor people who are actually eligible for when compared with other industrialized coun- Medicaid but for one reason or another have not 11

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS applied for it. Of the uninsured, 18 million have a Table 4: household income of more than $50,000/year and Infant mortality rates 9 million have household incomes of more than Infant mortality $75,000/year. Of the uninsured, 11 million have per 1,000 births been offered insurance through their employer but have declined. These individuals are typically Australia 5.0 healthy young people who choose to spend their Austria 4.9 money on things they want rather than on insur- Belgium 6.0 ance they believe they will never need. All in all, Canada 5.5 70 percent of the uninsured actually have access to health insurance but have not taken advantage Denmark 4.7 of it.10 Finland 4.2 What happens to the uninsured in America? France 4.7 Most of them—when they get sick enough—go to emergency rooms, where by law they must be Germany 4.7 appropriately evaluated and treated. In 2001, Japan 3.6 $98.9 billion were spent from public and private Netherlands 5.2 10 sources in providing health care to the uninsured. New Zealand 6.8 Who has the best health care system? Norway 4.0 Spain 5.0 In many ways the U.S. health care system is Sweden 3.6 the best in the world. Cardiac deaths have fallen United Kingdom 5.7 by two-thirds over the past 50 years. Polio has been virtually eradicated from the U.S. Childhood United States 6.8 leukemia has a high cure rate. Eight of the top 10 medical advances of the past 20 years were devel- oped in or had roots in the U.S. The Nobel Prizes in Medicine and Physiology have been awarded to citizens for whom hospital admission had been more Americans than to researchers in all other requested but for whom no beds were available.12 countries combined. Eight of the 10 top-selling As widely reported, the U.S. spends more per drugs in the world are made by U.S. companies. capita for health care and a higher percentage of The U.S. has some of the highest breast, colon, its GDP for health care than any other country. and prostate cancer survival rates in the world.11-12 Currently, 15.2 percent of America’s GDP goes The Figure on page 13 shows that, among a to health care. Although this is widely criticized, select group of top economic powers in the world, some researchers feel this expenditure is simply the U.S. is responsible for more than 53 percent a reflection of the high value American citizens of drug research dollars.13 place on their health care. The U.S. ranks first or second in the world in Interestingly, if one looks at health care expen- kidney transplants, liver transplants, heart trans- ditures as a percentage of GDP in a select group plants, total knee replacements, coronary artery of nations, in the year 1980 the U.S. spent 8.7 bypass, and percutaneous coronary interventions percent of its GDP on health care, which was the per capita. In addition, the U.S. ranks third in bone same percentage as Germany. Twenty-two years marrow transplants per capita.14 According to a later, however, the U.S. health care expenditure Commonwealth Fund report from 2002, the U.S. as a percent of GDP went from 8.7 percent to 14.6 has the shortest waiting time for nonemergency percent, whereas Germany went from 8.7 percent surgery among a select group of industrialized to 10.9 percent. Other industrialized countries countries, with England having the longest wait- showed increases as well, but to a lesser extent.16 ing time.15 A report this past year showed that in One possible explanation for the more rapid a recent period of time there were 750,000 English increase in health care expenditures in the U.S. 12

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure: American pharmaceutical Furthermore, the U.S. by custom and law has research companies lead the world permitted a litigious climate to develop that has in research and development significantly increased the cost of medical care due to the practice of defensive medicine by physicians and the payment of high malpractice premiums. Many health experts believe that health care in the U.S. is expensive because most Americans are isolated from the direct purchase of health care and even the knowledge of many health care costs. Because of this, most Americans seem to consume health care as if it were free. Many health experts believe Americans would have a more realistic approach to health care spending if they were actually aware of how expensive specific health care services were, or if they were responsible for paying a greater portion of their own health care.

International role models for the U.S.? versus other industrialized countries is that in the In reviewing the health care systems of a num- U.S., health care is funded through both private ber of nations, what can one learn? First, the wide as well as public avenues and for the most part variety of systems is surprising. It seems no two does not need to compete with national defense, systems are alike. Each of the major industrialized education, roads, and many other social programs countries’ national health care systems is truly for tax dollars. unique, with major differences from country to country reflecting the history, conditions, politics, Where does the money go? and national character of each country. Careful evaluation of health care systems of the industri- People often ask the question, “Where does the alized world reveals that there may in fact be no money go that the U.S. spends on health care that perfect system. All the major health care systems other countries don’t?” A small percentage may seem to have their own problems.12,16 go for inefficiencies and to insurance company In exploring the wide variety of health care sys- profits and executive salaries, but the majority of tems on the international scene, the only system the excess money pays for a long list of things that one cannot seem to find is the type described by American citizens seem to have come to expect: Michael Moore in his 2007 movie, Sicko—a system • Easy access to sophisticated diagnostic tests, that provides unlimited care with no premiums, including MRIs and CT scans no deductibles, no co-pays, no waiting lists, no • Shortest waiting time for elective surgery in rationing, and from the physician of one’s choice. the world17 This system does not exist. • Widest choice of physicians and hospitals2 • Easy accessibility to joint replacement Lessons learned from other systems • High access to renal dialysis, particularly in older patients and in patients with co-morbidities In reviewing multiple national health care sys- • Easy access to cancer screening and treat- tems, it becomes apparent that universal health ment (although a 50 percent reduction in all insurance does not mean universal health care. In cancer cases would only increase life expectancy most countries with universal health insurance, in the average American by 1.4 years)7 1 to 2 percent of the population falls through the • Greater access to health care provided to cracks. Furthermore, because of evolving tech- elderly Americans and Americans at the end of nology and increasing demand for services, most their lives who may have poor prognoses countries do not have enough money to truly 13

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS provide universal care. Most countries in the in- certainly does have its problems (such as access, dustrialized world are having problems providing cost control, and patient safety), but so does every enough money to pay for the national health care other health care system in the world. demands of their populations. Most countries are beginning to face problems with de facto rationing, Observations waiting lines, and lack of enough hospital beds and CT and MRI scanners.12 The unintended consequences of a handful of As one might suspect, rising health care costs public policies (both legislative and regulatory) and spending is not uniquely an American phe- are partly responsible for many of our problems nomena. In 2004, the average annual per capita today. increase in health care spending was 6.2 percent Although employers can deduct health care in the U.S., followed closely behind by 5.55 per- insurance cost, workers cannot deduct the cost cent in Europe. of the same insurance if they purchase it indi- Single-payor national health care systems vidually, and they cannot deduct out-of-pocket (such as England, Canada, and Norway) are sys- expenses such as co-pays and deductibles. This tems in which the government essentially pays tax policy encourages consumers to seek out low all the health care bills. Multiple-payor national co-pay, low deductible insurance that is the most systems (such as France, The Netherlands, and expensive.11 Switzerland) are systems in which employers, State health insurance regulations increase the insurance companies, and government pay the cost of basic health care insurance by requiring health care bills. Review of recent literature insurance companies to cover certain types of care shows that patients in a single-payor system (chiropractic, autism, psychiatric, acupuncture, seem more likely to face waiting lists and ration- and so on). This means that in most states it is not ing than in multiple-payor national health care possible to buy a basic catastrophic policy. Many systems that have incorporated market reforms, state governments have mandated that basic poli- such as co-pays and deductibles. Surveys of the cies not only include basic insurance but a long list industrialized world show widespread dissatisfac- of other services. Although one cannot question tion and discontent with both single and multiple the value of any one of these add-ons individu- payor systems. ally, the end result is that the cost of buying basic Although no country with universal health health care insurance in many states has become care is contemplating abandoning their universal prohibitive for the average American.11 health care system, the growing trend in coun- There are both federal and state laws that pro- tries with national health care systems is to move hibit selling the same health care insurance policy away from central government control and to across state lines. Such governmental restrictions introduce market-oriented features. Thus, even tend to inhibit competition and result in more as Americans debate adopting a government-run expensive health care insurance policies. system, countries with those systems are now Many health care reformers favor a government- debating how to make their systems look more run system, but it is not at all clear that the like that of the U.S.11 problems of centralized control are any less sig- nificant than the problems of our current system. U.S. system very good, but could be better Competition does spur innovation and lower cost.

In reviewing the pertinent literature on the Suggestions for reform topic, it becomes apparent that many authors critical of the U.S. health care system have care- • Health care tax reform should be passed fully chosen to use only data that support their allowing total deductibility of all health care ex- point of view. If, however, one looks at the litera- penses. Tax credit or vouchers should be provided ture as a whole, one cannot avoid the impression for low-income individuals and families.11 that the U.S. has one of the finest (if not the best) • Health insurance reform needs to be passed health care systems in the world. The U.S. system to reduce the cost of health insurance by creating 14

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS a national market. The laws that limit the sale of It. Washington, DC: Cato Institute; 2005. health care insurance between states should be 6. Schroeder, S. We can do better—Improving the health of the American people. New Eng J Med. eliminated. Health insurance should be individual 2007; 357(12):1221-1228. and portable. The government should subsidize 7. Lai DJ. Measuring the impact of HIV/AIDS, heart private insurance for the chronically ill and for disease and malignant neoplasms on life expec- those individuals who are uninsurable or have tancy in the USA, 1987-2000. Public Health. 2001; 15 120:486-492. pre-existing conditions. 8. Tsai SP. The effect of a reduction in leading cause • Tort reform should become a high priority, of death: Potential gains in life expectancy. Am J establishing a reasonable national cap on non- Pub Health. 1978; 68:966-971. economic damages in medical malpractice suits. 9. U.S. Census Report 2007. Washington, DC: U.S. This action would lower the cost of malpractice Census Bureau. 2007. 10. Gratzer D. The Cure: How Capitalism Can Save insurance and decrease the expensive practice American Health Care. New York, NY: Encounter of defensive medicine. One researcher estimates Books; 2006. such change would reduce the total cost of medical 11. Cogan J, Hubbard RG, Kessler DP. Healthy, expenditure in the U.S. by 5 to 9 percent annu- Wealthy, and Wise: Five Steps to a Better Health 15 Care System. Washington, DC: AEI Press; 2005. ally. 12. Tanner M. The grass is not always greener: A look It should be noted that health care reform can- at national health care systems around the world. not occur in a vacuum. It must occur in concert Policy Analysis. 2008; 613:1-48. with the addressing of social and economic issues. 13. Organization for Economic Cooperation and Devel- The problem of 10 million illegal immigrants with- opment Report. Paris, France: OECD; June 2003. 14. Organization for Economic Cooperation and Devel- out health care insurance cannot be ignored. The opment Report. Paris, France: OECD; 2007. U.S. high school dropout rate is unacceptable and 15. Schoen C; Blendon RJ; DesRoches CM, Osborn must be dealt with. Unhealthy behaviors such as R. Comparison of Health Care System Views and smoking and obesity must be addressed. Experiences in Five Nations, 2001. New York, NY: The Commonwealth Fund; 2001, May 2002. 16. Kling A. Crisis of Abundance: Rethinking How We Final thoughts Pay for Health Care. Washington, DC: Cato Insti- tute; 2006. We must be careful that coverage for all does 17. Ohsfeldt R, Schneider JE. The Business of not come at the price of substandard quality, Health: The Role of Competition, Markets, and Regulation. Washington, DC: AEI Press; 2006. rationing of care, a demoralized health care work- force, and inadequate investment in research, education, public health, and health promotion. The U.S. has a high-quality health care system. We should do all we can to protect it as well as improve it. 

References Dr. Wenger is clinical professor of surgery, 1. Olympics 2008. Sports Illustrated. September 1, University of Wisconsin, 2008, p. 26. and past-chief of sur- 2. World Health Report 2000—Health Systems: Im- gery, Dean–St. Mary’s, proving Performance. Geneva, Switzerland: World Madison, WI, where he Health Organization, 2000. is in the full-time prac- 3. Whitman G. WHO’s fooling who? The World Health tice of general surgery. Organization’s problematic ranking of health care systems. Cato Institute Briefing Papers. Washing- ton, DC: Cato Institute. 2008; 101:1-9. 4. Hogberg D. Don’t fall prey to propaganda: Life expectancy and infant mortality are unreliable measures for comparing the U.S. health care system to others. National Policy Analysis. 2006; 547:1-10. 5. Cannon MF, Tanner MD. Healthy Competition: What’s Holding Back Health Care and How to Free 15

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS I ACS promotes the six competencies II of the Accreditation Council for Graduate III Medical Education

IV by B. J. Palmer, MD; Victor Stams, MD; Thomas R. Russell, MD, FACS; Alden H. Harken, MD, FACS; V and L. D. Britt, MD, FACS

16

VOLUMEVI 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS s a boy, Charles Darwin had everything. and you are done. Daniel Boorstin, in his book, His wealthy, accomplished, and aristo- The Seekers, notes that we will always live in cratic parents not only provided him that dynamic interval between the authoritative with superb genes but also bathed him past and the unknowable future. 1 Historically, inA every conceivable educational opportunity. Yet we have accepted knowledge as derived from Charles famously failed sequentially at medi- a higher authority—the Old Testament, Holy cine, the law, and at religious ministry. By age Writ, a prophet, the department chair, the resi- 19, he was floundering. He and his prodigiously dency program director, or the omniscient chief provident parents were incapable of matching resident. We can, and should, seek our bearing his abilities to any constructively respectable from the vanished past. The static construct of profession or vocation. In 1831, the Electronic the surgery textbook capably sets a descriptive Residency Application Service did not exist. The stage delineating how things are; but Boorstin assessment strategies available to channel prom- distinguishes man—and certainly the surgeon ising youth into productive professions were in and surgical resident—as an “asking animal.” their infancy. We want to know why. We encourage a surgical But in the fall of 1831 Captain Robert FitzRoy resident as residing intellectually within, not an received a commission from the Royal Navy to Old, but a New, Testament of “good news” incor- chart the coastal shoals of South American in porating healthy protest, inquiry, and reform. the HMS Beagle. He was offered the option of We live in an age of molecular medicine. We recruiting an intellectually stimulating com- accept that the genetic recipe within our pa- panion. Captain FitzRoy interviewed several tients’ cells obligates the assembly of proteins applicants. The captain was an enthusiastic that dictatorily conspire to create cellular life. phrenologist. Charles Darwin was not his first We comfortably ignore the idea that purchasing choice. Ultimately, he did select Darwin be- exactly the same trillions of atoms from an inter- cause he approved of the pattern of the bumps net chemistry catalog would result in a desultory on Charles’ head. In retrospect, who among us and frustratingly lifeless mound of chemicals. could or would challenge FitzRoy’s decision? In The lipoproteins that critically establish our the rich panoply of fortuitous scientific events cellular membranes probably don’t even care ultimately shaping the intellectual fabric of our that we exist. So, as physicians and surgeons, we times, FitzRoy’s decision was a successful lunar are looking at patterns. And the truly miniscule landing and a World Series grand slam home differences in the biochemical patterns of happy, run all rolled into one. So, as surgical residency healthy cells versus diseased patients are often program directors, are we doing it wrong? too small to measure. The purposes of this article are to examine the Additionally, the parameters that we have competencies essential to the successful matura- traditionally chosen to measure may not be tion of a surgical resident, to examine the tools reflective of cellular health. For instance, available in assessing these competencies, and 99.9 percent of the genes that encode Mrs. to review potential strategies for enhancing a O’Flaherty with pancreatic cancer are not just resident’s and established surgeon’s (such as similar—they are identical—to the molecular FACS) abilities within these competencies. make-up of Mrs. Wilson with the ankle fracture. The Accreditation Council For Graduate It is easy to conclude that genes don’t count.2 Medical Education (ACGME) has identified six This is where the natural science of surgery essential competencies and we are comfortable morphs into an art. It is undeniable, however, working within this constructive framework. that the patterns presented in a surgical text- book, like the American College of Surgeons’ I. Basic knowledge textbook of surgery,3 fundamentally form the foundation of surgical judgment. As students, we all typically begin with the Strategies to enhance textbook knowledge of assumption that medicine and surgery exist as surgery are appropriately diverse. We all learn a body of knowledge. Acquire that knowledge differently. The admonition to “read more” is 17

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS comparably instructive as mom’s hapless homi- clinically successful and compassionate patient lies to “get rest,” “eat right,” and “be careful.” care. Surgical therapy, when applied at the right Similarly, we have all read a chapter or attended time for the right patient by a skillful practitio- a lecture and come away unscathed. Alterna- ner, can be gratifyingly effective. Unfortunately, tively, it is hard to author a manuscript or give the converse is also true.6 To no one’s surprise, a lecture without learning something. A “cyber a really sick patient tolerates surgical stress less journal club” encourages residents to critique well than a world-class triathlete. To everyone’s a selected surgical study on their own time and surprise, the surgical community never thought online. Surgical residents are sufficiently com- to factor this into preoperative assessment until petitive that they rise to the challenge of present- the American Society of Anesthesiologists (ASA) ing a five-minute “basic science” introduction to developed their practical ASA classification sys- surgical grand rounds. tem 50 years ago.7 Assessment of basic knowledge is harder. The As surgeons, our procedural morbidities and components of the MEN II Syndrome can be mortalities are now being tracked and as “pay for tested—there are correct answers—but the in- performance” evolves, the significance of these formation is frequently not relevant. Conversely, data will soon assume formidable proportions. management of everyday breast lump is too Surgical residents must not only catalog all of controversial to divulge its intricacies following their operative cases, but must learn to risk- an attack by a multiple-choice examination. Sev- stratify their procedures such that a 5 percent eral assessment strategies gratifyingly combine mortality suffered in a series of Supreme Court acquisition and assessment of knowledge. justices may compare favorably to a 2 percent The American Board of Thoracic Surgery mortality with the rugby team who present with re-certification examination presents multiple- identical injury severity scores. Thus, surgical choice questions online.4 After selecting one, the residents must accept the dictum espoused in examinee is referred to a page of instructive text St. Augustine’s City of God8 (Civitas Dei or the and then offered the opportunity to answer the Holy Writ from the textbook and the program initial question again. A correct answer permits director) but this must be filtered through the you to proceed. Most thoracic surgeons require lens of the “earthly city” (Civitas Terrena or the 70 to 100 hours to complete the recertification empirical, risk-stratified, results of direct patient process. But everyone learns—and wins. The care). In other words, the textbook must always American College of Surgeons SESAP (Surgi- be related to the uniqueness of the patient—and cal Education and Self-Assessment Program) it never precisely fits. learning tour successfully accomplishes a simi- lar knowledge acquisition/assessment process.5 III. Interpersonal skills Finally, the American Board of Surgery (ABS) In-Training Examination (ABSITE) serves as There may be some disciplines within medi- a formidable stimulus to study. Some surgical cine that do not obligate teamwork, but surgery residency programs mandate ABSITE success is emphatically not one of them. A surgeon is as a condition of resident progression through absolutely dependent upon everyone from the the training program. The correlation between telephone operators and ward secretary to the ABSITE performance and success on the ABS anesthesiologist and the scrub nurse. It is sur- qualifying examination is frighteningly close. prisingly easy to encourage these people to work together because everyone wants to play on a II. Clinical competence winning team. Unlike the law, or even business, where there are necessarily both winners and Just as the trillions of elemental atoms that to- losers, with surgery, either everyone—most of gether precisely conspire to create Mrs. O’Flaherty all, the patient—wins, or everyone loses. A ma- are nothing but a chaos of chemicals when ture surgeon, almost instinctively, knows that acquired from a chemistry catalog, a rich as- wins must be shared, while the surgeon himself semblage of textbook data does not guarantee or herself must personally shoulder defeat. This 18

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS policy is most effective when the surgeon ac- The “mustering of the forces of humanity” in cepts full responsibility for a misadventure that order to establish a cohesive team is pivotal to was clearly not his or her fault. Perhaps para- the success of a surgeon. An ability to commu- doxically, acceptance of blame will enhance the nicate must be actively nurtured during surgical surgeon’s stature, and will never be forgotten. residency. Opportunities to present ideas persua- Teaching and monitoring interpersonal skills sively at conferences and grand rounds can be is more difficult. The province of Alberta, organized and amplified. The ability to establish Canada, formally practices a 360-degree review “an atmosphere of close understanding and process in which patients, secretaries, nurses, cooperation” routinely trumps basic knowledge and colleagues are encouraged to comment on and is completely subsumed within clinical care. the personal manner of all physicians. More than For a surgeon, interpersonal skills are not 1 million encounters have now been catalogued. simply a matter of life or death, success or fail- Compassionate and sensitive outliers are visited ure, nor just the salvation of your country and to assess strategies for success. Less competent world—they are much more important than that. outliers are also approached with the offer of remediation. In similar fashion, the airlines IV. Professionalism encourage pilots and first officers to identify colleagues with whom they would like to work As professionals, society permits us a mo- or like to avoid in the cockpit. Again, both ends nopoly on a body of knowledge. In return, our of the spectrum are constructively reviewed. community logically mandates that we use our As a junior resident, your primary responsibili- skills altruistically and charges us with the re- ties are data gathering on individual patients. sponsibility of self-regulation.12,13 The imprint of The big jump to senior residency encompasses altruism within the confines of professionalism responsibility for the whole team. These are very appropriately instills an anthropomorphic ring different skills. And, with disturbing frequency, to our activities. Yet, during the 17th and 18th residents thrive at the former and stumble centuries, we ceased our focus on salvation from as seniors. Surgical residency programs that God and began seeking sovereignty over nature. raise team building and interpersonal skills to We continue to worry that we might not grasp the level of senior resident consciousness will the whole picture, however. Hamlet warned more likely succeed. The American College of his skeptical friend: “There are more things in Surgeons runs both an Interpersonal Skills and heaven and earth, Horatio; than are dreamt of Surgeon Leadership Course9 and a Surgeons As in your philosophy.”14 But, by the mid-eighteenth Educators course.10 Both courses have proven to century, Alexander Pope was sufficiently com- be popular and effective. fortable with this domination of the natural On August 9, 1941, U.S. President Franklin sciences that he codified it in verse: Delano Roosevelt arrived off Newfoundland aboard a large Navy cruiser. He met British Know then thyself, presume not God to scan; Prime Minister Winston Churchill, who ap- The proper study of mankind is man.15 proached aboard the HMS Prince of Wales. The purpose of this risky venture was to meet In addition, Dr. Martin Luther King, Jr., personally (for only the second time) and es- fortunately and famously refocused the spirit tablish a friendship. They did. The construct of altruism within professionalism when he of the Second World War and ultimately the observed, “An individual has not started living democratic visions and future of the world hung until he can rise above the narrow confines of his in the balance. Churchill would later observe: individualistic concerns to the broader concerns “Friendship among nations, as among individu- of all humanity.”16 There is huge overlap between als, calls for constructive efforts to muster the “interpersonal skills” and “professionalism.” For forces of humanity in order that an atmosphere the surgeon, the synergy of these competencies of close understanding and cooperation may be is paramount. cultivated.”11 For example, F. Dean Griffen, MD, FACS, re- 19

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cently reviewed “closed claims” or nonfrivolous V. Patient-based learning malpractice lawsuits in which there probably really was a surgeon-related problem.17 Dr. Surgeons are not very patient. We chose sur- Griffen empaneled six clinically active general gery because we want something to happen. surgeons who meticulously reviewed the charts Surgery is not specific to a skin incision. The and records of 490 cases decided against the sur- distinguishing attribute of a surgeon is that we geon. Over and over again, the panel concluded are capable of proceeding with therapy before that neither “basic knowledge” nor “clinical we are absolutely certain of what is going on. practice” were wanting in the surgeon. In almost We have all encountered the hypotensive trauma 70 percent of instances, “professionalism” was victim who might have a liver laceration, or the the competency that was breached. So, if you septic and dwindling intensive care unit patient want to stay out of trouble—stay professional. who might have an occult intra-abdominal ab- Almost all surgeons cherish their profes- scess. In these instances, the only strategy that sionalism. It is the rewarding and gratifying is wrong is to do nothing. Surgery is a discipline glue that links us to our patients and their of commission—not omission. As surgeons, we families. Transgressions are rare. There are are viscerally capable of proceeding with therapy predictable speed bumps, however. When we before we have all the facts. We understand that are tired, most of us get grumpy, and when waiting is not an alternative. So, we make er- we are grumpy we sometimes act in ways that rors. Mature and appropriately compassionate we wish we hadn’t. As a response, the Profes- analysis of error is “patient-based learning.” sionalism Task Force within the Division of The morbidity and mortality conference is a Education of the American College of Surgeons formidable opportunity to learn. The clinical has produced a professionalism CD (Profession- experiences examined are not sterile and imper- alism in Surgery: Challenges and Choices, 2nd sonal stuff from a textbook—they have familiar Edition). The CD presents clinically relevant faces, names, and families. We all like to think vignettes that exhibit 24 painfully frequent that we practice evidence-based medicine, but the ways to ambush professionalism. These are educational impact of a recent clinical misadven- common hurdles encountered by all surgeons. ture, when analyzed and reviewed thoughtfully, The goal is not to identify and weed out the can burn its way into our memory banks forever. less than 1 percent of surgeons who funda- And this personally painful process is predictably mentally lack professionalism. The purpose of more instructive than a Cochrane analysis. the exercise is to red-flag predictable pressure The morbidity and mortality process is, in points and raise them as warnings to the level itself, a high-risk exercise. Fear and intimida- of consciousness. Individual or group review tion can be formidably undermining of the of these vignettes invariably generates vigor- educational opportunity. Nelson Mandela quotes ous and constructive discussion. The Surgery Marianne Williamson because he knows that she Residency Review Committee now mandates a captured the concept: curriculum in professionalism. Formal review of the ACS CD qualifies as a curriculum. It is our light not our darkness that most Perhaps the most compellingly successful frightens us. strategy for enhancing surgical professionalism, Our deepest fear is not that we are inadequate. however, was devised by one of our colleagues. In Our greatest fear is that we are powerful be- an unpublished study, residents at the Univer- yond measure.18 sity of California-San Francisco, East Bay, were encouraged to record and present instances of We all make errors. Careful analysis of an positive professionalism. During the first week, error is the most effective antidote to a repeat two instances were identified. By the fourth performance. Conversely, misallocation of re- week we were up to 25. We are convinced that sponsibility almost guarantees future trouble. It asking the question constructively amplified is instructive for a senior surgeon—preferably the answer. the residency program director or department 20

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS chair—to present a personal error with regular strategies, not patient care solutions. Again, the frequency. Making an error is acceptable; repeat- senior surgeon can, and must, take the lead in ing that error is not. Senior surgeons still make visibly seeking systems solutions as opposed to errors. By analyzing these errors we continue to individual blame. learn, and we learn how to learn. As surgeons, when we stop learning, we become progressively dangerous. Recurrent themes are that communi- Dr. Palmer is a surgical resident, University cation can always be enhanced, and “calling for of California–San help” is a sign of maturity, not weakness. Again, Francisco–East Bay, Marianne Williamson recognizes this capacity of Oakland, CA. the senior surgeon:

As we let our light shine We unconsciously give other people Permission to do the same18 VI. Systems-based learning

At 30,000 feet, when you respond to the re- quest, “Is there a doctor on this plane?” you rapidly realize and appreciate extraordinary support systems that typically surround us in Dr. Stams is a surgical our hospitals. In the absence of those familiar resident, University of California–San high-tech aids, you abruptly feel technologically Francisco–East Bay, nude. Conversely, when you visit a clinically busy Oakland, CA. surgical team, everyone knows their role and the procedure flows with grace and elegance, almost like a ballet. It is quiet. The resuscitative suc- cess of a Code Blue-CPR event is, for instance, always inversely related to the decibels and to the number of participants in the room. Each of these are “systems” issues. With frightening frequency we tolerate even dangerous systems problems because we fail to recognize them. When the bottles of succinyl choline and Vanco- mycin have the same blue labels and look alike, that is a systems problem. When the surgeon Dr. Russell is marks the operative site with a water-soluble Executive Director of the College. pen that is easily erased with the surgical prep, that is a systems problem. And when the anes- thesiologist who “pre-ops” the patient is differ- ent from the anesthesiologist who conducts the case, that is a systems problem. Some of these hurdles have been solved ingeniously. But these systems issues pop up all the time. It is easy to blame the trauma surgeon or the surgical resident for giving succinyl choline instead of Vancomycin. Blame is rarely a productive edu- cational strategy. A culture of blame promotes the generation of self-preservational defensive 21

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS With the previously mentioned strategies of en- counting, after publication of our ACS “Code couraging, stimulating, and assessing the matu- of Professional Conduct.” J Am Coll Surg. 2004;199:736-740. ration of surgical residents, it might be easy to 14. Shakespeare W. Hamlet. Act I, scene V, line 166. assume an ease of homogeneous surgical resident 15. Pope, A. (1734). An Essay on Man. Address’d production incorporating cookie-cutter technol- to a Friend. Part I. Epistle II. Facsimile Edi- ogy and efficiency. But diversity is paramount.19 tion, Menston: Scolar Press, 1969. Available at: https://tspace.library.utoronto.ca/html/1807/4350/ Like species, disciplines evolve. Whatever we do poem1638.html. Accessed May 29, 2009. and however we practice surgery today, it is a 16. Available at: http://www.brainyquote.com/quotes/ certainty that the discipline of surgery 10 and authors/m/martin_luther_king_jr.html. Accessed 20 years from today will build on similar apti- January 6, 2009. tudes, but very different skills. 99.99 percent 17. Griffen FD. ACS closed claims study reveals criti- cal failures to communicate. Bull Am Coll Surg. of all the species that have existed since life in 2007;92(1):11-16. this world began are now extinct.20 An emerging 18. Williamson M. A Return to Love: Reflections on the surgical resident must be educationally agile. Principles of a Course in Miracles. New York, NY: The most valuable asset a resident can acquire, HarperCollins; 1992. 19. Bernstein, AS, Ludwig, DD. The importance of or faculty can teach, is the capacity to learn how biodiversity in medicine. JAMA. 2008; 300:229. to learn.  20. Bryson W. A Short History of Nearly Everything. New York, NY: Broadway Books; 2003. References 1. Boorstin DJ. The Seekers. The Story of Man’s Con- tinuing Quest to Understand His World. New York: Dr. Harken is profes- Random House; 1998. sor and chair, depart- 2. Shames BD, Selzman CH, Meng X, et al. Genes ment of surgery, Uni- don’t count. Arch Surg. 1998; 133:667-669. versity of California– 3. Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery: Principles & Practice, 6th Edition. New San Francisco–East York, NY: WebMD Inc.; 2007. ACS Surgery Online Bay, Oakland, CA. (2008) www.acssurgery.com. Accessed March 2009. 4. American Board of Thoracic Surgery Web site. Avail- able at: http://www.abts.org/. Accessed March 2009. 5. Surgical Education and Self-Assessment Program (SESAP), 13th edition. Available at: http://www. facs.org/fellows_info/sesap/sesap.html. Accessed March 2009. 6. Harken AH. Enough is enough. Arch Surg. 1999; 134(10):1061-1063. 7. American Society of Anesthesiologists. Physical Status Classification System. Published annually (January 6, 2009). Available at: http://www.asahq. org. Accessed June 4, 2009. Dr. Britt is Brick- 8. O’Daly JP. Augustine’s City of God: A Reader’s house Professor and Guide. New York, NY: Oxford University Press; 1999. chair, department of 9. Surgeons As Leaders: From Operating Room to surgery, Eastern Vir- Boardroom. Available at: http://www.facs.org/ ginia Medical School, education/surgeonsasleaders.html. Accessed Janu- Norfolk, VA, ary 6, 2008. and Chair of the 10. American College of Surgeons, Division of Educa- Board of Regents. tion, 15th Annual Surgeons As Educators Course. Available at: http://www.facs.org/education/sre/ saeintro.html. Accessed January 6, 2008. 11. Meacham J. Franklin and Winston: An Intimate Portrait of an Epic Friendship. New York, NY: Random House; 2003. 12. ACS Task Force on Professionalism. Code of Profes- sional Conduct. J Am Coll Surg. 2003;197:605-608. 22 13. Barry L, Blair P, Cosgrove E, et al. One year, and

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs

Almost four decades ago, the For purposes of this document, the Committee on Trauma (COT) following definitions have been of the American College of used: a neonate is 0–28 days old, Surgeons (ACS) developed a list an infant is 29 days to 1 year old, of standardized equipment for and a child is >1 year through 11 ambulances. Beginning in 1988, the years old with delineation into the American College of Emergency following developmental stages: Physicians (ACEP) published a similar list. The two organizations Toddlers (1–3 years old) collaborated on a joint document Preschoolers (3–5 years old) published in 2000, and the National Middle Childhood (6–11 years old) Association of EMS Physicians Adolescents (12–18 years old) AmEricAn collEgE of surgEons (NAEMSP) participated in the 2005 committEE on trAumA revision. The 2005 revision included These standard definitions are age resources needed on ambulances for based. Length-based systems have appropriate homeland security. All been developed to more accurately three organizations adhere to the estimate the weight of children and AmEricAn collEgE of principle that Emergency Medical predict appropriate equipment sizes, EmErgEncy physiciAns Services (EMS) providers at all medication doses, and guidelines levels must have the appropriate for fluid volume administration. equipment and supplies to optimize prehospital delivery of care. The principles of nAtionAl AssociAtion document was written to serve as a of Ems physiciAns standard for the equipment needs of prehospital care emergency ambulance services both in the United States and Canada. The goal of prehospital care is to minimize further systemic EMS providers care for patients of insult or injury and manage life- pEdiAtric EquipmEnt guidElinEs all ages, who have a wide variety of threatening conditions through committEE—EmErgEncy medical and traumatic conditions. a series of well defined and mEdicAl sErvicEs for childrEn With permission from the ACS COT, appropriate interventions, and to (Emsc) pArtnErship for childrEn ACEP, and NAEMSP, the current embrace principles that ensure stAkEholdEr group revision includes updated pediatric patient safety. High-quality, recommendations developed by consistent emergency care demands members of the federal Emergency continuous quality improvement Medical Services for Children and is directly dependent on the AmEricAn AcAdEmy (EMSC) Stakeholder Group. The effective monitoring, integration, of pEdiAtrics EMSC Program has developed and evaluation of all components several performance measures for of the patient’s care. the Program’s State Partnership grantees. One of the performance Integral to this process is medical measures evaluates the availability oversight of prehospital care by of essential pediatric equipment using preexisting protocols (indirect and supplies for Basic Life Support medical oversight), which are and Advanced Life Support patient evidence-based when possible, or care units. This document will by medical control via voice and/or be used as the standard for this video communication (direct medical performance measure. The American oversight). The protocols that guide Academy of Pediatrics (AAP) has patient care should be established also officially endorsed this list. collaboratively by medical directors

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JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs for ambulance services, adult and required Equipment: 6. Airways pediatric emergency medicine basic life support • Nasopharyngeal (16F–34F; physicians, adult and pediatric trauma adult and child sizes) surgeons, and appropriately trained (bls) Ambulances basic and advanced emergency • Oropharyngeal (sizes 0–5; medical personnel. Current Institute A. ventilation and Airway Equipment adult, child, and infant sizes) of Medicine (IOM) recommendations 1. Portable and fixed suction 7. Pulse oximeter with encourage each EMS agency to have apparatus with a regulator pediatric and adult probes a pediatric coordinator to specifically (per Federal specifications; 8. Saline drops and bulb coordinate the capability of the see Federal Specification suction for infants service to care for nonadult patients. KKK-A-1822F reference) b. monitoring and defibrillation • Wide-bore tubing, rigid Equipment and supplies pharyngeal curved suction All ambulances should be tip; tonsillar and flexible equipped with an automated The guidelines list the supplies and suction catheters, 6F–16F are external defibrillator (AED) equipment that should be stocked on commercially available (have unless staffed by advanced life ambulances to provide the accepted one between 6F and 10F and support personnel who are standards of patient care. Previous one between 12F and 16F) carrying a monitor/defibrillator. documents regarding ambulance The AED should have pediatric equipment referred to essential or 2. Portable oxygen apparatus, capable of metered flow capabilities, including child- minimal equipment necessary to sized pads and cables. adequately equip an ambulance. with adequate tubing Equipment requirements will vary, 3. Portable and fixed oxygen c. immobilization devices depending on the certification levels supply equipment 1. Cervical collars of the providers, population densities, • Variable flow regulator geographic and economic conditions • Rigid for children ages of the region, and other factors. 4. Oxygen administration 2 years or older; child equipment and adult sizes (small, The following list is divided into • Adequate length tubing; medium, large, and equipment for basic life support transparent mask (adult other available sizes) (BLS) and advanced life support and child sizes), both (ALS) ambulances. ALS ambulances 2. Head immobilization non-rebreathing and device (not sandbags) must have all of the equipment valveless; nasal cannulas on the required BLS list as well as (adult, child) • Firm padding or equipment on the required ALS list. commercial device This list represents a consensus of 5. Bag-valve mask (manual resuscitator) 3. Lower extremity (femur) recommendations for equipment and traction devices supplies that will facilitate patient • Hand-operated, self- care in the out-of-hospital setting. reexpanding bag; adult • Lower extremity, limb- (>1000 ml) and child (450– support slings, padded 750 ml) sizes, with oxygen ankle hitch, padded pelvic reservoir/accumulator; support, traction strap valve (clear, disposable, (adult and child sizes) operable in cold weather); and mask (adult, child, infant, and neonate sizes)

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VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs

4. Upper and lower extremity 6. Adhesive tape 7. Sterile saline solution immobilization devices • Various sizes (including 1” for irrigation (1-liter • Joint-above and joint-below and 2”) hypoallergenic bottles or bags) fracture (sizes appropriate • Various sizes (including 8. Flashlights (2) with extra for adults and children), 1” and 2”) adhesive batteries and bulbs rigid-support constructed 9. Blankets with appropriate material 7. Arterial tourniquet (cardboard, metal, (commercial preferred) 10. Sheets (minimum 4), linen or paper, and pillows pneumatic, vacuum, E. communication wood, or plastic) 11. Towels Two-way communication 5. Impervious backboards (long, device between EMS provider, 12. Triage tags short; radiolucent preferred) dispatcher, and medical control 13. Disposable emesis and extrication device bags or basins • Short (extrication, head- f. obstetrical kit (commercially 14. Disposable bedpan to-pelvis length) and long packaged is available) (transport, head-to–feet 15. Disposable urinal 1. Kit (separate sterile kit) length) with at least three 16. Wheeled cot (conforming appropriate restraint • Towels, 4”x4” dressing, to national standard at the straps (chin strap alone umbilical tape, sterile time of manufacture) scissors or other cutting should not be used for 17. Folding stretcher head immobilization) utensil, bulb suction, and with padding for clamps for cord, sterile 18. Stair chair or carry chair children and handholds gloves, blanket 19. Patient care charts/forms for moving patients 2. Thermal absorbent blanket 20. Lubricating jelly and head cover, aluminum (water soluble) d. bandages foil roll, or appropriate 1. Commercially-packaged or heat-reflective material h. infection control* sterile burn sheets (enough to cover newborn) *Latex-free equipment should be available 2. Triangular bandages g. miscellaneous 1. Eye protection (full peripheral • Minimum two 1. Sphygmomanometer glasses or goggles, face shield) safety pins each (pediatric and adult 2. Face protection (for example, 3. Dressings regular and large surgical masks per applicable • Sterile multitrauma size cuffs) local or state guidance) dressings (various large 2. Adult stethoscope 3. Gloves, nonsterile (must meet and small sizes) 3. Length/weight-based tape or NFPA 1999 requirements • ABDs, 10”x12” or larger appropriate reference material found at http://www.nfpa.org/) • 4”x4” gauze sponges for pediatric equipment sizing 4. Coveralls or gowns and drug dosing based on or suitable size 5. Shoe covers estimated or known weight 4. Gauze rolls 6. Waterless hand cleanser, 4. Thermometer with low • Various sizes commercial antimicrobial temperature capability 5. Occlusive dressing (towelette, spray, liquid) 5. Heavy bandage or paramedic or equivalent 7. Disinfectant solution for scissors for cutting clothing, cleaning equipment • Sterile, 3”x8” or larger belts, and boots 8. Standard sharps containers, 6. Cold packs fixed and portable

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JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs 9. Disposable trash required Equipment: b. vascular Access bags for disposing of 1. Crystalloid solutions, such biohazardous waste Advanced life support as Ringer’s lactate or normal 10. Respiratory protection (Als) Ambulances saline solution (1,000-mL (for example, N95 or N100 For EMT-Paramedic services, include bags x 4); fluid must be in mask—per applicable all of the required equipment listed bags, not bottles; type of fluid local or state guidance) for the basic level provider, plus the may vary depending on state following additional equipment and and local requirements i. injury prevention Equipment supplies. For EMT-Intermediate 2. Antiseptic solution (alcohol 1. All individuals in an services (and other nonparamedic wipes and povidone- ambulance need to advanced levels), include all of the iodine wipes preferred) be restrained (there is equipment for the basic level provider 3. IV pole or roof hook currently no national and selected equipment and supplies standard for transport of from the following list, based on local 4. Intravenous catheters 14G–24G uninjured children) need and consideration of prehospital 5. Intraosseous needles or 2. Protective helmet characteristics and budget. devices appropriate for children and adults 3. Fire extinguisher A. Airway and ventilation Equipment 6. Venous tourniquet, 4. Hazardous material 1. Laryngoscope handle with rubber bands reference guide extra batteries and bulbs 7. Syringes of various sizes, 5. Traffic signaling devices 2. Laryngoscope blades, sizes including tuberculin (reflective material 0–4, straight (Miller); sizes 8. Needles, various sizes (one at triangles or other reflective, 2–4, curved, (MacIntosh) nonigniting devices) least 1 ½” for IM injections) 3. Endotracheal tubes, sizes 9. Intravenous administration 6. Reflective safety wear for 2.5–5.5 mm uncuffed and sets (microdrip and each crewmember (must 6–8 mm cuffed (2 each), macrodrip) meet or exceed ANSI/ISEA other sizes optional performance class II or III if 10. Intravenous arm boards, 4. Meconium aspirator adaptor working within the right of adult and pediatric way of any federal-aid highway. 5. 10-mL non-Luerlock syringes c. cardiac Visit http://www.reflectivevest. 6. Stylettes for endotracheal com/federalhighwayruling.html tubes, adult and pediatric 1. Portable, battery-operated for more information.) 7. Magill (Rovenstein) forceps, monitor/defibrillator adult and pediatric • With tape write-out/ 8. Lubricating jelly recorder, defibrillator (water soluble) pads, quick-look paddles or electrode, or hands- 9. End-tidal CO2 detection free patches, ECG leads, capability adult and pediatric chest • Colorimetric (adult and attachment electrodes, adult pediatric) or quantitative and pediatric paddles capnometry 2. Transcutaneous cardiac pacemaker, including pediatric pads and cables • Either stand-alone unit or integrated into monitor/defibrillator

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VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs d. other Advanced Equipment • Analgesics, narcotic approved have been studied in 1. Nebulizer and nonnarcotic children. Those that have been studied, such as the LMA, have 2. Glucometer or blood • Antiepileptic medications, such as diazepam or midazolam not been adequately evaluated glucose measuring device in the prehospital setting). • With reagent strips • Sodium bicarbonate, magnesium sulfate, glucagon, naloxone 9. Neonatal blood pressure cuff 3. Large bore needle (should hydrochloride, calcium chloride 10. Infant blood pressure cuff be at least 3.25” in length for needle chest decompression • Bacteriostatic water and 11. Pediatric stethoscope in large adults) sodium chloride for injection 12. Infant cervical • Additional medications as immobilization device E. medications (pre-loaded per local medical director syringes when available) 13. Pediatric backboard and extremity splints Medications used on advanced optional basic Equipment 14. Topical hemostatic agent level ambulances should be compatible with current guidelines This section is intended to assist EMS 15. Appropriate CBRNE PPE as published by the American providers in choosing equipment (chemical, biological, Heart Association’s Committee that can be used to ensure delivery radiological, nuclear, on Emergency Cardiovascular of quality prehospital care. Use explosive personal Care, as reflected in the should be based on local resources. protective equipment), Advanced Cardiac Life Support The equipment in this section including respiratory and Pediatric Advanced Life is not mandated or required. and body protection Support Courses, or other such A. optional Equipment 16. Applicable chemical antidote organizations and publications autoinjectors (at a minimum (ACEP, ACS, NAEMSP, and so on). 1. Glucometer (per for crew members’ protection; Medications may vary depending state protocol) additional for victim treatment on state requirements. Drug 2. Elastic bandages based on local or regional dosing in children should use protocol; appropriate for • Nonsterile (various sizes) processes minimizing the need adults and children) for calculations, preferably a 3. Cellular phone b. optional Advanced Equipment length-based system. In general, 4. Infant oxygen mask medications may include: 5. Infant self-inflating 1. Respirator • Cardiovascular medication, resuscitation bag • Volume-cycled, on/off such as 1:10,000 epinephrine, 6. Airways operation, 100% oxygen, atropine, antidysrhythmics 40–50 psi pressure (child/ (for example, adenosine and • Nasopharyngeal (12, 14 Fr) infant capabilities) amiodarone), calcium channel • Oropharyngeal (size 00) 2. Blood sample tubes, blockers, beta-blockers, 7. Alternative airway devices adult and pediatric nitroglycerin tablets, aspirin, (for example, a rescue airway vasopressor for infusion 3. Automatic blood device such as the ETDLA pressure device • Cardiopulmonary/respiratory [esophageal-tracheal double medications, such as albuterol lumen airway], laryngeal 4. Nasogastric tubes, pediatric (or other inhaled beta agonist) tube, or laryngeal mask feeding tube sizes 5F and and ipratropium bromide, airway) as approved by 8F, sump tube sizes 8F–16F 1:1,000 epinephrine, furosemide local medical direction. 5. Pediatric laryngoscope handle • 50% dextrose solution (and 8. Alternative airway devices 6. Size 1 curved (MacIntosh) sterile diluent or 25% dextrose for children (few alternative laryngoscope blade solution for pediatrics) airway devices that are FDA

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JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EquipmEnt for AmbulAncEs

7. 3.5–5.5 mm cuffed such as the American Academy of pulling tools/devices endotracheal tubes Pediatrics Guidelines for Air and • Ropes/chains Ground Transport of Neonatal and 8. Needle cricothyrotomy • Come-along capability and/or Pediatric Patients. cricothyrotomy capability • Hydraulic truck jack (surgical cricothyrotomy Appendix • Air bags can be performed in older protective devices children in whom the Extrication Equipment cricothyroid membrane • Reflectors/flares Adequate extrication equipment is easily palpable, usually must be readily available to the • Hard hats by the age of 12 years) emergency medical services • Safety goggles responders, but is more often found • Fireproof blanket optional medications on heavy rescue vehicles than on the • Leather gloves A. optional basic life primary responding ambulance. • Jackets/coats/boots support medications In general, the devices or tools 1. Albuterol used for extrication fall into several patient-related devices broad categories: disassembly, • Stokes basket 2. Epi pens spreading, cutting, pulling, 3. Oral glucose protective, and patient-related. miscellaneous 4. Nitroglycerin (sublingual The following is necessary equipment • Shovel tablet or paste) that should be available either • Lubricating oil on the primary response vehicle b. optional Advanced life or on a heavy rescue vehicle. • Wood/wedges support medications • Generator 1. Anxiolytics disassembly tools • Floodlights 2. Intubation adjuncts including • Wrenches (adjustable) Local extrication needs may neuromuscular blockers • Screwdrivers (flat and Phillips head) necessitate additional equipment for • Pliers water, aerial, or mountain rescue. interfacility transport • Bolt cutter Additional equipment may be needed • Tin snips by ALS and BLS prehospital care providers who transport patients • Hammer between facilities. Transfers may be • Spring-loaded center punch done to a lower or higher level of • Axes (pry, fire) care, depending on the specific need. Specialty transport teams, including • Bars (wrecking, crow) pediatric and neonatal teams, may • Ram (4 ton) include other personnel such as respiratory therapists, nurses, and spreading tools physicians. Training and equipment • Hydraulic jack/spreader/ needs may be different depending cutter combination on the skills needed during transport of these patients. There cutting tools are excellent resources available that • Saws (hacksaw, fire, windshield, provide detailed lists of equipment pruning, reciprocating) needed for interfacility transfer • Air-cutting gun kit

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Orliaguet G, Renaud E, Lejay M, Footnote: The evidence in children selected references et al. Postal survey of cuffed or for selected prehospital care interventions American Academy of Pediatrics Section uncuffed tracheal tubes used for or topics was reviewed in preparation for on Transport Medicine. Guidelines for paediatric tracheal intubation. Paediatr finalizing this ambulance equipment list. Air and Ground Transport of Neonatal and Anaesth. 2001;11(3):277–281. These topics included: (a) child safety Pediatric Patients, 3rd edition. George A. and booster seats approved for EMS Federal Highway Administration, DOT Woodward, MD, MBA, FAAP (ed). 2007. use; (b) alternative airway devices; (c) CFR-634.2 and 634.3 – Worker Visibility spinal immobilization devices including American College of Surgeons Committee Use of High-Visibility Apparel When collars; and (d) prehospital use of cuffed on Trauma, Advanced Trauma Life Support Working on Federal-Aid Highways endotracheal tubes. The results of Student Course Manual (8th Edition). 2008. Available at: http://www.reflectivevest. this evidence evaluation including full com/federalhighwayruling.html. citations will be provided in a companion American Heart Association, article authored by the primary reviewers Pediatric Advanced Life Support Resources for Optimal Care of the topics and the EMSC Stakeholders Provider Manual. 2006. of the Injured Patient Group. The evidence in all ages for use of American College of Surgeons arterial tourniquets and hemostatic agents Brennan JA, Krohmer J (eds), Principles Committee on Trauma was also reviewed and will be provided of EMS Systems. Sudbury, MA: Jones Chicago 1999, 2006. in separate consensus review articles. and Bartlett Publishers, 2005. Rumball CJ, MacDonald D. The PTL, Brown MA, Daya MR, Worley JA. combitube, laryngeal mask, and oral Experience with chitosan dressings airway: a randomized prehospital in a civilian EMS system. J Emerg comparative study of ventilatory device Med. 2007:Nov 14 (doi:10.1016/j. effectiveness and cost-effectiveness in jemermed.2007.05.043). 470 cases of cardiorespiratory arrest. Prehosp Emerg Care. 1997;1(1):1–10. Cervical spine immobilization before admission to the hospital. Salomone JP, Pons PT, McSwain NE. Neurosurgery. 2002;50(3 Suppl):S7–17. Prehospital Trauma Life Support, 6th edition. Saint Louis, MO: Elsevier, 2007. Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals Treloar OJ. Nypaver M. Angulation for expanded prehospital use. Prehosp of the pediatric cervical spine with Emerg Care. 2008;12(2):241–256. and without cervical collar. Prehosp Emerg Care. 1997;13(1):5–8. Equipment for Ambulances ACEP Policy Statement, American College Wedmore I, McManus JG, Pusateri AE, of Emergency Physicians and Medical Holcomb JB. A special report on the Direction of Emergency Medical Services. chitosan-based hemostatic dressing: Available at: http://www.acep.org. experience in current combat operations. J Trauma. 2006;60(3):655–658. Federal Specifications for the Star-of-Life Ambulance KKK-A-1822F. August 1, 2007. Youngquist S, Gausche-Hill M, Burbulys D. Alternative airway devices for use in Future of EMS in the US children requiring prehospital airway Health Care System management: Update and case discussion. Institute of Medicine, May 17, 2007 Pediatr Emerg Care. 2007;23:1–10. Available at: www.iom.edu. James I. Cuffed tubes in children (editorial). Paediatr Anaesth. 2001;11(3):259–263. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53.

REVISED April 2009

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JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Governors’ Committee on Chapter Activities: An update

by Lenworth M. Jacobs, Jr., MD, MPH, FACS

he Board of Governors’ Committee on Chap- Regents was presented. This forum generated ter Activities (GCCA) serves as an advocate numerous questions from the Governors, al- for the chapters of the American College of lowing for a broad discussion of several topics Surgeons. There are 65 U.S. chapters, two in that were included in the Statement on Health Canada,T and 33 international. The College staff Care Reform generated by the College. who work with the GCCA are in the Division of The Statement on Health Care Reform gen- Member Services. erated three critical and interrelated goals for The GCCA has been very interested in bring- health care. They included recommendations ing forward the concerns of the Governors of on quality and safety (the first goal). The the chapters to the Board of Regents in order specific recommendations that the American to assist the leadership in setting policy for College of Surgeons urged the Congress and the American College of Surgeons. An elec- Administration to support, and a series of tronic survey instrument was developed and statements that the American College of Sur- distributed to all Governors of the College. geons committed itself to deliver, are listed in The areas that were of greatest concern to the the document. The second goal was ensuring Governors were identified and an agenda for universal access to affordable, high-quality, discussion, with an open forum with both the safe surgical care. This goal requires that the Governors and the Regents, was established. nation has a well-trained and available surgi- At the College’s 2008 Clinical Congress in San cal workforce to meet the needs of all surgical Francisco, CA, a discussion that allowed the patients. Similar to the first goal, the College Governors to present their views and have urged the Congress and Administration to sup- specific questions answered by the Board of port a number of items and committed to pro- 30

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Members of the Governors’ mental entities, and professional colleagues. Committee on Chapter Activities Another major item that has been of sig- nificant concern for the College and has been discussed extensively by the committee is the Lenworth M. Jacobs, Jr., MD, FACS, Chair fact that the Fellows of the College are getting Maureen T. Kavanah, MD, FACS, Vice-Chair older and there needs to be a major initiative to Gerard V. Aranha, MD, FACS attract younger surgeons to join the American William G. Cioffi, Jr., MD, FACS College of Surgeons. Ernest L. Dunn, MD, FACS The GCCA’s Membership and Diversity Sub- Danielle A. Katz, MD, FACS committee has worked closely with the Division Kevin P. Lally, MD, FACS of Member Services. There are a number of ini- Matthew B. Martin, MD, FACS tiatives that will be promulgated throughout the John D. Nicholson, MD, FACS upcoming year to attract surgeons-in-training E. Phillips Polack, MD, FACS to join the College before completion of their Grace S. Rozycki, MD, FACS residency. It is thought that exposing young Hilary A. Sanfey, MB BCh, FACS surgeons to the full range of services that the Christian Charles Shults, MD College provides and engaging them in the com- Michael E. Stark, MD, FACS mittees of the College, including governance, Gary L. Timmerman, MD, FACS is a fine way to attract the best and brightest Anthony J. Tortolani, MD, FACS young surgeons to join the American College of Jeanette M. Viney, MD, FACS Surgeons. Leopold M. Waldenberg, MD, FACS The GCCA’s electronic survey has shown Lorin D. Whittaker, Jr., MD, FACS that there is a need for more effective commu- nication with the Fellows of the College. This survey finding has led to a series of live Web- based seminars in which topics are presented by the leadership of the College, and Fellows are encouraged to use real-time Web services to viding education programs, focusing research have their questions asked and answered. Par- and advocacy efforts and developing systems ticipation in these seminars has been steadily to eliminate disparities in the availability and increasing. The most recent webinar included delivery of surgical care. questions from Fellows from other continents. The final goal was that of a reduction of The GCCA has a robust International Activi- health care costs. This objective generated an continued on page 68 important series of discussion items, resulting in a strong statement that encourages involve- ment with enhanced participation of patients Dr. Jacobs is Chair of the GCCA and professor in their own health care decision making and of surgery, University of the development of payment mechanisms that Connecticut, Hartford, promote quality and value. The statement also and director, trauma spoke to the appropriate and compassionate program, Hartford palliative care for patients with life-limiting Hospital. illnesses. The College also recognized that pay- ment for a sustainable workforce needed to be accomplished in conjunction with overall health care reforms. The discussion between the Governors and Regents was then reviewed by the Regents and the final document was widely disseminated to surgeons, health policy administrators, govern- 31

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he following articles are the final installment in a series of brief essays theBulletin is publishing under the theme “My mentor.” These essays are the result of efforts made by the Resident and Associate Society (RAS) of the American College of Surgeons in launching its first essay contest asking residents, fellows, and new faculty to describe in 500 wordsT or less the role that a mentor has played in their development. In this series, you will read what several outstanding surgical trainees who responded to the contest have to say about the individuals who have mentored them. Through this series, members of the College and other Bulletin readers will learn about 10 extraordinary men- tors who have provided both personal and professional guidance for their mentees at various stages of their training. The leadership of the RAS believes that these mentors are more than just role models—they are pillars of strength and good examples for future generations of surgeons who are attaining technical and clinical skills, while also advancing their interest in research, education, and out- reach in an increasingly challenging health care environment. The winner of this year’s essay contest will be announced at the 2009 Clinical Congress in Chicago, IL. 32

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS My mentor The persistent calm: Anthony Stallion, MD, FACS by Kaine C. Onwuzulike, MD, PhD

first met Anthony Stallion, MD, FACS, as a first-year medical student at Case Western Reserve University, and I was instinctively Dr. Stallion drawn to him as one of the few in an elite subset ofI minority academic pediatric surgeons in the greater Cleveland area. As an aspiring surgeon, I found great solace in his wisdom, character, and alacrity toward mentorship. Our continued Dr. Onwuzulike interaction throughout my medical training was immeasurable, and his commitment to surgical academia was a propelling force in my own pursuit to remain sedulous in pursuit and equally diligent of a doctoral degree in genetic epidemiology and in the application of the widely accepted core sur- biostatistics. gical values of honesty, respect for patients and Dr. Stallion embodies the key essentials of any colleagues, contribution to the scientific fund of successful mentor, as he is extremely well learned, knowledge, and respect for tradition. poised, and equally skilled in his craft. He is an Dr. Stallion routinely urges his mentees to be effective communicator, exceptional teacher, and punctilious in preoperative and postoperative powerful motivator. As with most great mentors, care of our patients. He has never been hubristic Dr. Stallion has become a role model to emulate in our interactions, and in contradistinction, has as I learn and practice the “surgical way of life” remained humble and honored to serve the greater as described by Edward M. Copeland III, MD, role of surgical educator. I take great pride in our FACS, the Edward R. Woodward Distinguished relationship and aspire to provide the same lead- Professor of Surgery at the University of Florida, ership and direction to subsequent generations. Gainesville, and 87th President of the American In closing, as described by Dr. Copeland in his College of Surgeons.* Incumbent in this role magnificent Presidential Address, “The role of illustrated by Dr. Copeland and practiced by a mentor in creating a surgical way of life,” Dr. Dr. Stallion and great mentors alike is the seam- Stallion has helped establish for me the very less integration of “sound judgment with both core of professional ethics and patient care that influence and patience.” In my junior career, I are indispensable to a successful and enriching have seen no one do it better than Dr. Stallion. career in academic surgery. He continually strives Perhaps most telling of his influence is his par- to make those around him successful, sharing in ticipation and leadership in national academic our triumphs and achievements, and in doing so organizations such as the American College of solidifies his very own legacy. I remain sanguine Surgeons and the American Association of Pe- that I too will instill these very principles into diatric Surgery. He stresses to his mentees the those mentees who seek to learn and practice the importance of doing the same. His selflessness surgical way of life.  and sincere mentorship have been reflected in his unwavering support during my transition from pursuit of a career in pediatric general surgery, for which he himself is renowned, to that of my current application of neurological surgery. His cogent plea to me during this transformation was Dr. Onwuzulike is a first-year postgraduate neu- *Copeland EM III. Presidential Address: The role of a rological surgery resident, Neurological Institute, mentor in creating a surgical way of life. Bull Am Coll Surg. University Hospitals of Cleveland (OH), Case Western 2006;91(12):8-13. Reserve University Medical Center. 33

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS My mentor The idea surgical mentor: R. Anthony Perez-Tamayo, MD, FACS

by Daniel Eiferman, MD

have the greatest mentor a surgical resident can have: R. Anthony Perez-Tamayo, MD, FACS. Dr. Perez-Tamayo I was introduced to Dr. Perez-Tamayo early inI my internship year while rotating on the cardiothoracic service at Cook County Hospital, Chicago, IL. It was immediately obvious to me that he is one of the rare individuals who excel Dr. Eiferman at all three aspects of an academic surgeon: clini- cal, research, and teaching skills. I am extremely privileged to have had the opportunity to learn of my family and has shared his family with me. from and work with Dr. Perez-Tamayo through- He truly is the ideal surgical mentor. He is the out my entire general surgery residency. surgeon you want to take care of your friends Dr. Perez-Tamayo is a graduate of the Duke and family, the teacher you want to educate your University general surgery program, where he children, the researcher you want writing your also completed a critical care fellowship. He si- grants and manuscripts, and the loyal friend you multaneously obtained a doctorate of philosophy want in times of need.  degree from the engineering department for his work on a novel cardiac assist device, research that he continues to conduct currently. He was granted multiple teaching awards during his training and has won the outstanding teacher award from the current cardiothoracic fellows. He truly is a master teacher, making the complex appear simple. There are several unique aspects of the men- torship Dr. Perez-Tamayo provides. Besides the requisite supervision in the laboratory, operating room, and wards, Dr. Perez-Tamayo constantly is looking for ways to promote me and my work. His priority in mentoring me is always how he can advance my career before thinking of any personal gain. He ensures that I am introduced to leaders in the field of thoracic surgery and has ap- proached contacts on my behalf as I interviewed for fellowship positions. He continually pushes me to become a better physician and person by preaching the virtues of loyalty, integrity, and respect. Dr. Perez-Tamayo is an exceptional physician and surgeon as well as close friend. Our relation- ship extends far beyond the walls of the labora- tory and hospital, and I value his guidance and Dr. Eiferman is a surgical resident and cardiac surgery friendship in my personal life as much as his sur- research fellow at Rush University/John H. Stroger, Jr., gical mentorship. He cares deeply for the welfare Hospital of Cook County, Chicago, IL. 34

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AmericAn college of SurgeonS 95th AnnuAl clinical congress ChICAgo, IL  oCtobER 11–15, 2009

PRELIMINARY 35 P R o g R A M

CC 2009 PP COVER-edited for July.indd 1 6/24/2009 1:16:41 PM Dear Colleagues, ACS PROgRAM The Clinical Congress of the American College COMMITTEE of Surgeons continues to remain the premier Chair: annual surgical meeting that provides a vast array of educational and networking opportunities. Barbara L. Bass, MD, FACS Houston, TX Under the leadership of the Program Committee, chaired by Dr. Barbara Bass and the Division of Vice-Chair: Education, the Clinical Congress program has been Robert R. Bahnson, MD, FACS significantly enhanced over the last several years. Columbus, OH This year’s program is especially designed to enhance the care of surgical patients through Members: state-of-the-art education. The broad-ranging William g. Cioffi, Jr., MD, FACS Providence, RI Panel Presentations, which include experts from across the surgical specialties and nonsurgical disciplines, will focus on key clinical and Craig S. Derkay, MD, FACS Norfolk, VA nonclinical topics in surgery and related fields. The Named Lectures Quan-Yang Duh, MD, FACS will be delivered by renowned experts. The Didactic and Skills-Oriented San Francisco, CA Postgraduate Courses will especially focus on important domains and help Henri R. Ford, MD, FACS attendees advance their knowledge and acquire new skills. Experiential, Los Angeles, CA hands-on learning will be used to achieve the course objectives. David R. Jones, MD, FACS Charlottesville, VA The Scientific Program for the Clinical Congress will include a large number of high-quality Scientific Papers, strong Surgical Forum David M. Mahvi, MD, FACS Chicago, IL Sessions, timely Video-Based Education Presentations, and excellent Fabrizio Michelassi, MD, FACS Posters. These sessions will be complemented by Meet the Expert New York, NY Luncheons and Town Hall Meetings. Attendees will be able to obtain Deborah A. Nagle, MD, FACS certificates of verification following their participation in Postgraduate Boston, MA Courses, and additional certificates will be offered to address a Amy B. Reed, MD, FACS variety of requirements for Maintenance of Certification, Maintenance Cincinnati, OH of Licensure, privileging, and credentialing. The Clinical Congress Program has been arranged in thematic tracks that address content Consultants: of interest to all surgical specialties, as well as specialty-based tracks Ronald V. Maier, MD, FACS that address the learning needs of different specialty groups. Seattle, WA William D. Spotnitz, MD, FACS The outstanding educational program, which includes special opportunities Gainesville, FL to address various regulatory requirements and interact with experts as well as the ability to reconnect with professional colleagues, makes Staff: the 2009 Clinical Congress an essential meeting for all practicing Ajit K. Sachdeva, MD, FACS, FRCSC surgeons, surgical residents, and members of the surgical team. On Chicago, IL behalf of the American College of Surgeons, I would like to extend to Julie A. Tribe, MSEd you our warmest invitation to join us in Chicago October 11–15, 2009, Chicago, IL for the 95th Clinical Congress, which will have as its theme The Surgeon Beth C. Brown, MS as a Role Model. I will look forward to seeing you at the meeting. Chicago, IL With best wishes,

L. D. Britt, MD, MPH, FACS Chair, Board of Regents American College of Surgeons

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Meeting Overview

For registration and more information, go to www.facs.org What’s New CME Credit Convocation The American College of Surgeons Sunday, October 11, 6:00–8:00 pm designates this educational activity for McCormick Place West Convention Center in 2009? a maximum of 47.5* AMA PRA Category 1 Credits™. Physicians should only claim Conferral of Fellowship and Response ‹ Program arranged in thematic credit commensurate with the extent on Behalf of New Fellows, Granting of of their participation in the activity. Honorary Fellowships, Installation of and specialty-specific tracks Officers, and Presidential Address *A maximum of 35.5 AMA PRA Category ‹ Enhanced scientific programs 1 Credits™ for nonticketed sessions only, All Initiates of ACS will be automatically ‹ A range of postgraduate including evening video sessions. registered for the Clinical Congress and need only return the registration (Pg) and skills-oriented form if postgraduate course or social (SC) courses addressing CME Certificates program event tickets are desired. contemporary topics in surgery Confirmed ACS Initiates will be On-site claiming of CME Certificates bestowed with Fellowship in the College ‹ Special certificates including will be issued at the My CME Connection during the ceremony regardless of verification levels achieved located in the ACS Registration Area their attendance at the event and may through Pg/SC courses and at McCormick Place Convention begin using the FACS designation upon sessions in ethics, patient Center, October 12–15, 2009. the conclusion of the ceremony. safety, and trauma Physicians are responsible for claiming Family members of Initiates are ‹ Additional Meet the Expert CME credit for Congress. Claims not required to register for the for CME credit for this event will be Clinical Congress program to attend Luncheons and morning accepted until March 31, 2010. the Convocation Ceremony. Town Hall Meetings scheduled

Cancellation Scientific and Annual Business of Sessions Technical Meeting of Members Wednesday, October 14, 4:15–5:15 pm The American College of Surgeons Exhibitions McCormick Place West Convention Center reserves the right to cancel any of the The Scientific Exhibition is a forum scientific sessions listed in this Program of more than 350 exhibits presenting ‹ Reports from the Chair of the Planner. The information presented completed research, research in Board of Regents, the Chair here is preliminary. Check the College’s progress, and case reviews. Innovative of the Board of governors, Web site at www.facs.org for updates. surgical practices and teaching and the Executive Director methods will also be presented. The ‹ Presentation of the Distinguished Scientific Exhibits will be located in Service Award, the Resident Award the West Building of McCormick Place goal for Exemplary Teaching, and the and the hours are Monday through Joan L. and Julius H. Jacobson II The Clinical Congress is designed Wednesday, 9:00 am–4:30 pm. to provide individuals with a wide Promising Investigator Award The Technical Exhibition comprises range of learning opportunities, ‹ Reports of the Nominating more than 200 companies displaying activities, and experiences that Committee of the Fellows and their products and services. The will match their educational and the Nominating Committee of professional development needs. exhibition provides an excellent opportunity to explore the surgical the Board of governors, and marketplace by comparing products introduction of the President-Elect firsthand and planning purchases. The Objective Technical Exhibits will be located in By the conclusion of the Clinical the West Building of McCormick Place Key to Session/ Congress, participants should gain and the hours are Monday through and be able to apply the knowledge Wednesday, 9:00 am–4:30 pm. Course Codes to improve their current practice, ME Meet the Expert Luncheon research, and care of surgical patients. NL Named Lecture PG Postgraduate Course PS Panel Session Accreditation SC Skills Course SE Scientific Exhibit The American College of Surgeons is SF Surgical Forum accredited by the Accreditation Council SP Scientific Paper for Continuing Medical Education TH Town Hall Meeting (ACCME) to provide continuing VE Video-Based Session medical education for physicians.

37 Sessions-at-a-glance by Day

deSignated Saturday, OctOber 10 11:30–1:00 PS11 New Technologies in Thyroid GEN  OTO tr ack S and Parathyroid Surgery 9:00–4:30 $ SC01 Surgical Education: Principles EDU 11:30–1:00 PS12 Surgical Forum Redux: Old BTR  GEN and Practices (SEPAP) Tricks for Young Dogs 9:00–4:30 $ PG15 Challenging Surgical Emergencies: What GEN  TRA 11:30–1:00 PS13 The Complicated Hysterectomy OBG to Do in the Middle of the Night 11:30–1:00 PS14 Triage in Disasters: What Is TRA 9:30–4:30 $ PG16 The Business of Health Care: HP It and How to Do It? Understanding the Surgeon’s Role 11:30–1:00 PS15 Who Needs an Operation for Appendicitis? GEN deSignated Sunday, OctOber 11 11:30–1:00 SP02 Geriatric GEN tr ack S 11:30–1:00 SP03 Surgical Education EDU 7:30–11:45 $ SC02 Fundamentals of Breast Imaging GEN for the General Surgeon 11:30–1:00 VE03 Cardiothoracic Surgery CTS 7:30–1:00 $ SC03 Ultrasound Course for Residents RES/MED 1:00–5:15 $ SC10 Breast Ductoscopy for the General Surgeon GEN 8:00–12:30 $ SC04-A Fundamentals of Laparoscopic Surgery GEN 1:15–2:15 $ ME Meet the Expert Luncheons (Lectures Only) 2:30–3:30 NL03 Charles G. Drake History of Surgery Lecture NL 8:00–6:30 $ SC04-B Fundamentals of Laparoscopic Surgery GEN 2:30–4:00 PS16 2009 Initiates Program: Your EDU  GEN  HP (Lecture, Hands-On Workshop, and Test) Practice: Coping with the Stress of 9:00–4:30 $ PG17 Acute Orthopaedic and Neurotrauma GEN  NEU  ORT  TRA Unexpected and Adverse Outcomes Care for General Surgeons 2:30–4:00 PS17 Advances in the Understanding and CRS  GEN 9:00–4:30 $ PG18 Robotic Pelvic Surgery OBG  URO Treatment of Ulcerative Colitis 12:30–5:45 $ SC05 Mammography for the General Surgeon GEN 2:30–4:00 PS18 Controversies in Parathyroid Surgery: Have GEN  OTO deSignated We Made a Simple Operation Complicated? MOnday, OctOber 12 tr ack S 2:30–4:00 PS19 Management of the Axilla in Breast Cancer GEN  ONC 8:30–9:30 NL01 Opening Ceremony/Martin Memorial NL 2:30–4:00 PS20 Minimally Invasive Therapy for GEN Lecture sponsored by the American Complications of Acute Pancreatitis Urological Association 2:30–4:00 PS21 Pregnancy During a Surgical Career: EDU 9:30–6:00 $ PG19 2009 Introduction to CPT, ICD-9-CM, and HP Strategies for Making It Work in Residency, Evaluation and Management Coding Academics, and Private Practice 9:45–10:45 NL02 John H. Gibbon, Jr. Lecture NL 2:30–4:00 PS22 What’s New in Imaging for General Surgeons GEN 9:45–11:15 PS01 Advances in the Treatment of OBG  URO 2:30–4:00 PS23 Laparoscopic Techniques: How GEN  OBG Urinary Incontinence Far Do You Go with a Scope? 9:45–11:15 PS02 Evaluation and Management of Neck Masses GEN  OTO 2:30–4:00 SF04 Geriatric Surgery GEN 9:45–11:15 PS03 Health Policy 2009: How It May Affect You HP 2:30–4:00 SP04 General Surgery I GEN 9:45–11:15 PS04 Periocular Trauma TRA 2:30–5:45 PS24 Current Interventional Treatment CTS 9:45–11:15 SP01 Systems-Based Practice EDU for Heart Valve Disease 9:45–11:15 VE01 Pediatric Surgery PED 2:30–5:45 PS25 Latin American Day 2009: A Surgical INT Debate (Open versus Laparoscopic) on 9:45–1:00 PS05 Current Controversies in GEN Three Common Surgical Conditions Abdominal Wall Herniae 2:30–5:45 PS26 Education Using Simulation: 9:45–1:00 PS06 Humanitarian Surgical Outreach at INT  VOL EDU  GEN What Is Proven, What Is Not? Home and Abroad: Reports of the 2009 ACS/Pfizer Volunteerism and 2:30–5:45 SF01 Critical Care I TRA Humanitarian Award Winners 2:30–5:45 SF02 Surgical Oncology ONC 9:45–1:00 PS07 The Perfect Cholecystectomy for the GEN 2:30–5:45 SF03 Pediatric Surgery PED Patient and Our Health Care System 2:30–5:45 SF05 Urology and Reproductive Surgery I URO 9:45–1:00 VE02 Bariatric Surgery GEN 2:30–5:45 VE04 Subject-Oriented Symposium I: GEN 10:00–1:15 $ SC06-A Flexible GI Endoscopy for General Surgeons GEN Bariatric/Metabolic Surgery (Lecture Only) 2:30–5:45 VE05 General Surgery I GEN 10:00–5:30 $ SC06-B Flexible GI Endoscopy for General Surgeons GEN 4:15–5:45 PS27 Blood Transfusions in Surgery: 2009 GEN (Lectures and Hands-On Workshop) 4:15–5:45 PS28 Changing Paradigms in the CRS  GEN 10:00–5:30 $ SC07-A Laparoscopic Colorectal Surgery GEN Treatment of Diverticulitis (Lectures Only) 4:15–5:45 PS29 Errors and Near Misses in the Operating Room EDU  OTO 10:00–5:30 $ SC07-B Laparoscopic Colorectal Surgery CRS 4:15–5:45 PS30 What Is the Evidence for Antibiotic (Part I–Lectures) CRS  EDU  GEN Prophylaxis in Mesh Inguinal Hernia 10:00–5:00 $ SC08 Surgeons as Effective Communicators: EDU Repair: Let’s Do Journal Club Sharpening Skills for Critical Moments 4:15–5:45 PS31 Multidisciplinary Treatment of Gunshot NEU  TRA 10:00–5:30 $ PG20 General Surgery Review Course (Part 1) GEN Wounds to the Central Nervous System 10:00–5:30 $ PG21 Surgical Safety Course CANCELLED EDU  GEN 4:15–5:45 PS32 Surgical Outcomes and the Aging Surgeon: BTR 10:00–6:15 $ SC09 Basic Breast Ultrasound GEN Navigating the Transition into Retirement 11:30–1:00 PS08 Carcinoma of the Bladder: ONC  URO 4:15–5:45 PS33 The Problem Resident EDU  RES/MED Advances in Management 4:15–5:45 PS34 Update on the Emerging Specialty GEN 11:30–1:00 PS09 Getting From National Priorities to HP of Acute Care Surgery Real Time Quality Improvement 4:15–5:45 PS35 Update on the Treatment of GERD GEN 11:30–1:00 PS10 Inflammatory Bowel Disease in Children PED 6:30–9:30 VE06 Clinical Workshop through Films GEN Sessions-at-a-glance by Day For registration and more information, go to www.facs.org

deSignated tueSday, OctOber 13 11:30–12:15 NL05 Scudder Oration on Trauma NL tr ack S 11:30–1:00 PS55 Advances in Cancer Staging: CRS  CTS  GEN  ONC 7:00–7:45 TH Town Hall Meetings An Interactive Session 8:00–9:30 PS36 Advances in the Surgical CRS  GEN 11:30–1:00 PS56 Managing Information Overload HP Management of Crohn’s Disease 11:30–1:00 PS57 The Canadian Health Care System: HP 8:00–9:30 PS37 Bringing Sex Back to Massive PLA  URO What Is It All About? Weight-Loss Patients 11:30–1:00 PS58 Science of Obesity Surgery BTR  GEN 8:00–9:30 PS38 Childhood Tumors: Unusual ONC  PED 11:30–1:00 PS59 Surgical Workforce Crisis and the IMG Presentations of Unique Diagnoses EDU  INT Solution: Can We Balance National 8:00–9:30 PS39 General Surgery in the Pregnant Patient GEN  OBG Interest and Global Responsibility? 8:00–9:30 PS40 Meshomania GEN 11:30–1:00 PS60 Tapped In: The Continuing Story of ETH 8:00–9:30 PS41 State-of-the-Art: Endoscopic NEU  OTO Diverse Leadership Development Skull Base Surgery in 2009 11:30–1:00 PS61 The Future of Surgical Training EDU 8:00–11:15 PS42 Current Concepts in the Treatment GEN 11:30–1:00 PS62 Cell Transplantation, Tissue Engineering, BTR  GEN of Metastatic Liver Disease and Transplant Organs: Where Are 8:00–11:15 PS43 Changing Resident Training Paradigms: EDU  RES/MED We Today and What Is the Future? New Options for the Medical 11:30–1:00 SP06 Pediatric Surgery PED Student and Surgical Residents 11:30–1:00 VE10 Otolaryngology–Head and Neck Surgery OTO 8:00–11:15 PS44 Palliative Surgery: Surgical ETH  GEN  ONC 11:30–1:00 VE11 Urological Surgery URO Hubris or Beneficial Act? 11:30–1:00 VE12 Plastic Surgery PLA 8:00–11:15 PS45 She’s 92...What Do I DO?: Optimizing GEN  ORT Surgical Care of the Oldest Old 1:00–5:00 PS63 APDS: Surgical Resident Shortages: EDU How We Deal with It 8:00–11:15 PS46 Spectacular Cases from Residents RES/MED 1:15–2:15 $ ME Meet the Expert Luncheons 8:00–11:15 PS47 State Advocacy: What Is It HP and How Do You Do It? 2:45–3:45 NL06 Olga M. Jonasson Lecture NL 2:30–4:00 PS64 Challenging Cases in Surgical Oncology 8:00–11:15 PS48 Evidence-Based Medicine in the BTR  TRA CRS  GEN  OBG ICU: What’s In and What’s Out  ONC  URO 8:00–11:15 SF06 Cardiothoracic Surgery I CTS 2:30–4:00 PS65 Chest Wall Deformities in Children and PED Adults: Results with New Approaches 8:00–11:15 SF07 Vascular Surgery I VAS 2:30–4:00 PS66 Diagnosis and Emergency GEN 8:00–11:15 SF08 Critical Care II TRA Intervention in Sepsis 8:00–11:15 SF09 Alimentary Tract I GEN 2:30–4:00 PS67 Mentoring Under-Represented EDU 8:00–11:15 SF10 Progenitor Cells and Cell-Based Therapies I BTR Surgical Faculty and Residents: 8:00–3:30 $ PG22 Colon and Rectal Cancer CRS Can We Bridge the Gap? 8:00–4:30 $ PG23 2009 Advanced Surgical and Office- HP 2:30–4:00 PS68 The Drive to Teach Residents: An Unintended EDU  RES/MED Based Coding and Reimbursement Casualty of the 80-Hour Workweek? 8:00–5:30 $ SC11 The Minimally Invasive Approach GEN  ONC 2:30–4:00 PS69 Trauma Management for the Rural Surgeon GEN  TRA to Breast Biopsy: Basic Stereotactic 2:30–4:00 PS70 Working Effectively with Your Hospital HP Technique and Application 2:30–4:00 SP07 Vascular Surgery VAS 9:00–4:30 $ SC07-B Laparoscopic Colorectal Surgery (Part II) CRS 2:30–4:00 SP08 General Surgery II GEN 9:00–4:30 $ SC12 Essential Issues in Management VAS 2:30–4:00 VE13 Orthopaedic Surgery ORT of Lower Extremity Ischemia 2:30–5:45 PS71 Critical Issues in Establishing a GEN 9:00–12:00 $ SC13-A Single-Port Laparoscopic Surgery GEN General Surgery Practice (Lectures Only) 2:30–5:45 PS72 Current Therapeutics for High-Risk Patients 9:00–5:00 $ SC13-B Single-Port Laparoscopic Surgery GEN CTS  ONC with Early-Stage Non-Small Cell Lung Cancer (Lectures and Hands-On Lab) 2:30–5:45 PS73 Ethical Considerations and the PS49 Cancelled EDU  ETH Process of Surgical Innovation 9:45–11:15 PS50 Applications of Telemedicine in Surgery EDU 2:30–5:45 SF11 Plastic Surgery I PLA 9:45–11:15 PS51 Bariatric Surgery in Children and Adolescents GEN  PED 2:30–5:45 SF12 Targeted Therapies BTR 9:45–11:15 PS52 Pancreatic Cancer 2009: GEN  ONC 2:30–5:45 SF13 Quality, Outcomes, and Costs I EDU Is Anything Changing? 2:30–5:45 VE14 Cine Clinic: Esophageal Surgery OTO  GEN 9:45–11:15 PS53 Preparing for International INT  VOL Humanitarian Outreach 2:30–5:45 VE15 Highlights of International Video Sessions INT  GEN 9:45–11:15 PS54 What’s New for Treating the GEN  ONC  PLA 4:15–5:45 PS74 Doc! It Hurts Down There: Surgical GEN BRCA-Positive Patient? Groin Pain Evaluation and Treatment 9:45–11:15 SP05 Urology URO 4:15–5:45 PS75 Evolving Concepts in Breast Irradiation GEN 9:45–11:15 VE07 Gynecology and Obstetrics OBG 4:15–5:45 PS76 The Impact of Chemotherapy on Surgical CRS  GEN  ONC 9:45–11:15 VE08 Neurological Surgery NEU Outcomes: Evidence-Based Surgical Strategies 9:45–1:00 VE09 General Surgery II GEN 4:15–5:45 PS77 What’s New in Angioaccess for Hemodialysis GEN  VAS 10:00–11:00 NL04 Excelsior Surgical Society Edward NL 4:15–5:45 SP09 Trauma and Critical Care TRA D. Churchill Lecture 4:15–5:45 SF14 Urology and Reproductive Surgery II URO 10:00–5:30 $ PG20 General Surgery Review Course (Part 2) GEN 6:30–9:30 VE16 Unusual Problems in Surgery GEN Sessions-at-a-glance by Day

deSignated WedneSday, OctOber 14 2:30–3:30 NL10 Herand Abcarian Lecture NL tr ack S 2:30–4:00 PS97 Controversies in the Management of VAS 7:00–7:45 TH Town Hall Meetings Peripheral Arterial Aneurysms 8:00–9:30 PS78 Colonic Emergencies CRS  GEN 2:30–4:00 PS98 Early Hepatocellular Carcinoma: GEN  ONC 8:00–9:30 PS79 Integration of the Fundamentals of Surgery EDU What Is the Optimal Treatment? Curriculum into a Surgical Residency Program 2:30–4:00 PS99 Learning from Bad Outcomes EDU 8:00–9:30 PS80 Multidisciplinary Approach to Chest GEN  ONC  PLA 2:30–4:00 PS100 New Techniques in Interventional GEN Wall Recurrence of Breast Cancer Esophagoscopy 8:00–9:30 PS81 Specialization in the Allied Health Professions EDU  GEN  HP 2:30–4:00 PS101 Surgery for Type II Diabetes GEN 8:00–9:30 SP10 Otolaryngology OTO 2:30–4:00 PS102 Professionalism, Communication, EDU 8:00–9:30 SP11 Surgical Oncology I ONC and Lessons Learned 8:00–9:30 VE17 Vascular Surgery VAS 2:30–4:00 PS103 Treatment of Locally Advanced Rectal Cancer CRS 8:00–11:15 PS82 A Step-by-Step Guide to Maintenance EDU 2:30–4:00 SP15 Cardiac and Thoracic Surgery CTS of ABS Certification 2:30–4:00 VE20 Subject-Oriented Symposium II: PLA  GEN 8:00–11:15 PS83 Future and Futuristic Trauma and Critical EDU  TRA Breast Reconstruction Care Surgery: Techniques, Devices, 2:30–5:45 PS104 Future Directions in Minimal Access Surgery: EDU  GEN Systems that Will Change Our Practice NOTES, Intraluminal Surgery, Hybrid 8:00–11:15 PS84 Surgical Jeopardy RES/MED Procedures, and Single-Port Laparoscopy 8:00–11:15 PS85 The College’s International Travelers, 2009 INT 2:30–5:45 PS105 Update on Management of GEN  NEU  ORT the War-Wounded  TRA  VAS 8:00–11:15 SF15 Cardiothoracic Surgery II CTS 2:30–5:45 PS106 Surgical Innovation: Issues around EDU 8:00–11:15 SF16 Alimentary Tract II GEN Evaluation, Education, Accreditation, 8:00–11:15 SF17 Progenitor Cells and Cell-Based Therapies II BTR and Reimbursement 8:00–11:15 SF18 Plastic Surgery II PLA 2:30–5:45 SF21 Quality, Outcomes, and Costs II EDU 8:00–11:15 SF19 Orthopaedic and Neuro Surgery NEU  ORT 2:30–5:45 SF22 Genetic Determinants of BTR 8:00–11:15 SF20 Surgical Education I EDU Disease and Outcomes 8:00–11:15 VE18 Cine Clinic: Liver Surgery GEN 2:30–5:45 SF23 Surgical Education II EDU 8:00–11:15 VE19 Movie Classics from the Past GEN 2:30–5:45 SF24 Immunity, Transplantation, GEN 8:00–12:15 $ PG24 Medicare Compliance: HP and Tissue Engineering Audit- Proof Documentation 2:30–5:45 VE21 Trauma TRA 8:00–3:30 $ PG25 Review Course in the Essentials of Vascular GEN  VAS 3:00–4:00 NL11 Distinguished Lecture of the NL Surgery for General and Vascular Surgeons International Society of Surgery 9:00–5:30 $ SC14 Thyroid and Parathyroid Ultrasound OTO 4:15–5:45 SP16 Plastic and Maxillofacial Surgery PLA 9:45–10: 45 NL07 Ethics and Philosophy Lecture NL 4:15–5:45 PS107 Getting Your Manuscript Published GEN 9:45–11:15 PS86 Cancer Survivor Follow-Up: Is Your CRS  GEN  ONC 4:15–5:45 PS108 Improving Surgical Outcomes with ACS NSQIP EDU Clinical Practice Evidence-Based? 6:30–9:30 VE22 Film and Video Festival GEN 9:45–11:15 PS87 Coding and Reimbursement Issues for HP  VAS deSignated thurSday, OctOber 15 Catheter-Based Vascular Procedures tr ack S 9:45–11:15 PS88 Pressure Sores: What You and Your Institution GEN  PLA 7:00–7:45 TH Town Hall Meetings Can Do to Comply with the New Regulations 8:00–9:30 PS109 Minimizing Risk in Bedside EDU 9:45–11:15 PS89 The Surgical Management of Sleep Apnea GEN  OTO Surgical Procedures 9:45–11:15 SP12 Transplantation GEN 8:00–9:30 PS110 New Procedures for Anal Fistulas: CRS 11:30 –12:30 NL08 Commission on Cancer Oncology Lecture NL Does Fistulotomy Still Have a Role? 11:30–1:00 PS90 Carotid Stenosis Management: Current NEU  VAS 8:00–9:30 SP17 Surgical Oncology II ONC Practices and Trends for the Future 8:00–9:30 VE23 Subject-Oriented Symposium III: GEN 11:30–1:00 PS91 Effective Patient Education to Improve EDU  HP NOTES and Single-Port Access Quality and Enhance Patient Safety 8:00–11:15 PS111 How to Succeed in the Highly BTR  RES/MED 11:30–1:00 PS92 Hand Transplantation: Lessons, PLA Competitive World of Grant Funding Advances, and Future 8:00–11:15 PS112 Surgeons’ Role in Cancer Diagnostics ONC 11:30–1:00 PS93 Operative Management of GEN  TRA and Novel Procedures Complex Trauma of the Trunk 8:00–11:15 SF25 Critical Care III TRA 11:30–1:00 PS94 Practicing Medicine in the Information Age: EDU  RES/MED 8:00–11:15 SF26 Alimentary Tract III GEN Are You Prepared for What’s on the Internet? 8:00–11:15 SF27 Quality, Outcomes, and Costs III EDU 11:30–1:00 PS95 Preparing the Cardiac Patient CTS  GEN 8:00–11:15 SF28 Plastic Surgery III PLA for Noncardiac Surgery 8:00–11:15 SF29 Vascular Surgery II VAS 11:30–1:00 PS96 Stress and Burn-Out Among Surgeons: EDU  GEN 9:45–11:15 PS113 Bugs Are Winning the Resistance EDU  GEN Understanding and Managing the Syndrome Battle: The Surgeon’s Responsibility 11:30–1:00 SP13 The Surgical Workforce EDU 9:45–1:00 VE24 Colon and Rectal Surgery CRS 11:30–1:00 SP14 Colon and Rectal Surgery CRS 11:30–1:00 PS114 Breast Imaging: Do We Need It? GEN 1:00–5:15 $ PG26 Practice Management for GEN  HP 11:30–1:00 PS115 State-of-the-Art Reconstruction of GEN  PLA  TRA the General Surgeon Traumatic and Acquired Chest Wall Defects 1:15–2:15 $ ME Meet the Expert Luncheons 11:30–1:00 PS116 Update on Venous Disease GEN  VAS 2:30–3:15 NL09 I. S. Ravdin Lecture in Basic Sciences NL $ indicates that additional course fees and registration apply Clinical Congress 2009 Track Schedule For registration and more information, go to www.facs.org

The scientific program, scheduled in discipline- and theme-based tracks, will focus specifically on the needs of various surgical specialties and learner groups.

Saturday Sunday Monday tueSday WedneSday thurSday

Basic / Translational Research (BTR)

Cardiothoracic Surgery (CTS)

Colon and Rectal Surgery (CRS)

(EDU) Education / Outcomes & Safety (EDU)

Ethics (ETH)

General Surgery (GEN)

Health Policy : Practice Management / (HP) Reimbursement / Liability Issues (HP)

International (INT)

Neurosurgery (NEU)

Obstetrics and Gynecology (OBG)

(ORT) Orthopaedic Surgery (ORT)

Otolaryngology–Head & Neck Surgery (OTO)

Pediatric Surgery (PED)

Plastic and Maxillofacial Surgery (PLA)

Residents / Medical Students (RES / MED)

Surgical Oncology (ONC)

Trauma / Critical Care (TRA)

Urology (URO)

Vascular Surgery (VAS)

Volunteerism (VOL) Scientific Program

Named Lectures TUESDAY, WEDNESDAY, OCTOBER 13 OCTOBER 14

MONDAY, nL04 10:00–11:00 aM nL07 9:45–10:45 aM OCTOBER 12 excelsior Surgical Society edward ethics and Philosophy Lecture: Can d. Churchill Lecture: the Surgeon General Surgeons and transplant nL01 8:30–9:30 aM Shortage: Constructive Participation Surgeons Work together to Improve during health reform the Supply and ethical Standards the opening Ceremony followed of Living organ donations? by the Martin Memorial Lecture: PRESIDING OFFICER AND INTRODUCER: David V. Feliciano, MD, FACS, Atlanta, GA re-engineering Systems of PRESIDING OFFICER AND INTRODUCER: LECTURER: George F. Sheldon, MD, FACS, John T. Preskitt, MD, FACS, Dallas, TX Care—Surgical Leadership Chapel Hill, NC LECTURER: Mark Siegler, MD, FACP, Chicago, PRESIDING OFFICER: LaMar S. McGinnis, Jr., Sponsored by the IL MD, FACS, ACS President, Atlanta, GA Advisory Council for General Surgery Sponsored by the Committee on Ethics INTRODUCER: (TBD) LECTURER: Glenn D. Steele, Jr., MD, FACS, nL05 11:30 aM–12:15 pM nL08 11:30 aM–12:30 pM Danville, PA Scudder oration on trauma: Sponsored by the Commission on Cancer oncology American Urological Association Wherever the dart Lands: toward Lecture: a Community Cancer Center the Ideal trauma System Introduction of Honorary Fellows, recipient Program: Getting to the next Level of the Distinguished Philanthropist Award, PRESIDING OFFICER AND INTRODUCER: PRESIDING OFFICER AND INTRODUCER: officers, Regents, Past-Presidents, and special John Fildes, MD, FACS, Las Vegas, NV Stephen B. Edge, MD, FACS, Buffalo, NY invited guests. LECTURER: A. Brent Eastman, MD, FACS, LECTURER: Nicholas Petrelli, MD, FACS, Martin Memorial Lecture, established in San Diego, CA Newark, DE 1946 to honor Franklin H. Martin, MD, FACS, Sponsored by the Committee on Trauma Sponsored by the Commission on Cancer founder of the College nL06 2:45–3:45 pM nL09 2:30–3:15 pM nL02 9:45–10:45 aM olga M. Jonasson Lecture: Leadership I. S. ravdin Lecture in Basic John h. Gibbon, Jr. Lecture: development and Mentoring in the Sciences: reparative, replacement, Intraoperative Myocardial age of restricted Work hours and regenerative Medicine Protection: Still Important? PRESIDING OFFICER AND INTRODUCER: PRESIDING OFFICER AND INTRODUCER: PRESIDING OFFICER AND INTRODUCER: M. Margaret Kemeny, MD, FACS, Jamaica, NY William P. Schecter, MD, FACS, San Francisco, Frank W. Sellke, MD, FACS, Providence, RI LECTURER: Karin M. Muraszko, MD, FACS, CA LECTURER: William A. Gay, Jr., MD, FACS, Ann Arbor, MI Lecturer: Michael T. Longaker, MD, MBA, FACS, St. Louis, MO Sponsored by the Women in Surgery Stanford, CA Sponsored by the Advisory Council for Committee Sponsored by the Cardiothoracic Surgery Committee on Perioperative Care nL03 2:30–3:30 pM nL10 2:30–3:30 pM Charles G. drake history of Surgery herand abcarian Lecture: Lecture: Surgery for Congenital the Little engine that did heart disease: Past and Present PRESIDING OFFICER AND INTRODUCER: PRESIDING OFFICER AND INTRODUCER: Clifford L. Simmang, MD, FACS,Coppell, TX Clarence B. Watridge, MD, FACS, Memphis, TN LECTURER: David J. Schoetz, Jr., MD, FACS, LECTURER: Denton A. Cooley, MD, FACS, Burlington, MA Houston, TX Sponsored by the Sponsored by the Advisory Council for Colon Advisory Council for Neurological Surgery and Rectal Surgery nL11 3:00–4:00 pM distinguished Lecture of the International Society of Surgery: health Care reform in the united Kingdom PRESIDING OFFICER AND INTRODUCER: Ronald V. Maier, MD, FACS, Seattle, WA LECTURER: Ara W. Darzi, MB, BCh, FACS, London, UK Sponsored by the International Society of Surgery 42 Scientific Program

For registration and more information, go to www.facs.org

Postgraduate Courses

Postgraduate Courses and Fees Only registered meeting attendees may purchase postgraduate course tickets. Seating capacities are limited, and ticket requests will be filled on a first-come, first-processed basis. Postgraduate course tickets may be purchased on-site in Chicago, subject to availability. All courses require a ticket for admission. Tickets may only be exchanged before the beginning of a course and may only be exchanged for another course. Course materials will be distributed on site in Chicago.

Best Value Package available only with Postgraduate Course registration Best Value Package (BVP) is a discounted subscription to the 2009 webcast Package (includes 2008/2007 webcasts of select Panel Sessions)—for only $89–Member/$104–Nonmember. See the Web site for further information. The BVP is available only for Pg/SC paid registrants.

description of Fee Categories FELLOW: A surgeon who is a Fellow of the College NON-FELLOW: A practicing physician who is not currently a member of the College RAS: Associate Fellows and Resident Members Medical Student Members, and Affiliate Members of the College NON-RAS: A physician-in-training or member of the surgical team who is currently in an accredited training program or working in a surgical-related setting, but has no membership affiliation with the College

aCS System for Verification of Knowledge and Skills The Board of Regents of the American College of Surgeons has approved a five-level model for verification and documentation of knowledge and skills by the Division of Education, following participation in the educational programs of the College. The model provides a framework for designing and implementing educational courses, based on principles of contemporary surgical education, and permits provision of appropriate documentation to the attendees. The postgraduate didactic and skills courses offered at the Clinical Congress have been assigned verification levels based on the requirement of each level. LEVEL I Verification of attendance LEVEL II Verification of satisfactory completion of course objectives LEVEL III Verification of knowledge and skills LEVEL IV Verification of preceptorial experience LEVEL V Verification of demonstration of satisfactory patient outcomes

43 Scientific Program

PoStGraduate CourSeS

Please register online for any of these Postgraduate Didactic or Skills-Oriented Courses. You are then eligible to purchase the 2009 Webcast Package (which includes 2008/2007 webcasts) for only $89–Member/$104–Nonmember. See the Web site to register and for further information.

cOurSe nOn- nOn- cOurSe title FellOW r aS cOde FellOW r aS

SC01 Surgical Education: Principles and Practice $340 $395 $105 $135 SC02 Fundamentals of Breast Imaging for the General Surgeon $290 $335 $90 $115 SC03 Ultrasound Course for Residents n/a n/a $275 $300 SC04–a Fundamentals of Laparoscopic Surgery (Lectures Only) $350 $390 $105 $140 Fundamentals of Laparoscopic Surgery SC04–B $875 $975 $260 $350 (Lectures, Hands-On Workshop, and Test) SC05 Mammography for the General Surgeon $390 $450 $120 $155 SC06–a Flexible GI Endoscopy for General Surgeons (Lectures Only) $260 $300 $80 $105 Flexible GI Endoscopy for General Surgeons SC06–B $550 $630 $165 $220 (Lectures and Hands-On Workshop) SC07–a Laparoscopic Colon and Rectal Surgery (Lectures Only) $490 $565 $150 $195 Laparoscopic Colon and Rectal Surgery SC07–B $1,690 $1,950 $505 $675 (Lectures and Hands-On Lab)* SC08 Surgeons as Effective Communicators: Sharpening Skills for Critical Moments $340 $395 $105 $135 SC09 Basic Breast Ultrasound $1,250 $1,435 $375 $500 SC10 Breast Ductoscopy for the General Surgeon $900 $1,000 $270 $360 The Minimally Invasive Approach to Breast Biopsy: Basic SC11 $1,500 $1,725 $450 $600 Stereotactic Technique and Application SC12 Essential Issues in the Management of Lower Extremity Ischemia $550 $635 $165 $220 SC13–a Single-Port Laparoscopic Surgery (Lectures Only) $350 $390 $105 $140 SC13–B Single-Port Laparoscopic Surgery (Lectures and Hands-On Lab) $1,200 $1,350 $360 $480 SC14 Thyroid and Parathyroid Ultrasound* $1,250 $1,435 $375 $500 PG15 Challenging Surgical Emergencies: What to Do in the Middle of the Night $340 $395 $105 $135 PG16 The Business of Health Care: Understanding the Surgeon’s Role $340 $395 $105 $135 PG17 Acute Orthopaedic and Neurotrauma Care for General Surgeons $340 $395 $105 $135 PG18 Robotic Pelvic Surgery $340 $395 $105 $135 PG19 2009 Introduction to CPT, ICD-9-CM, and Evaluation and Management Coding $390 $450 $120 $155 PG20 General Surgery Review Course $675 $775 $205 $270 PG21 Surgical Safety Course CANCELLED $340 $395 $105 $135 PG22 Colon and Rectal Cancer $340 $395 $105 $135 PG23 2009 Advanced Surgical and Office-Based Coding and Reimbursement $405 $470 $125 $165 PG24 Medicare Compliance: Audit-Proof Documentation $260 $300 $80 $105 PG25 Review Course in the Essentials of Vascular Surgery for General and Vascular Surgeons $390 $450 $120 $155 PG26 Practice Management for the General Surgeon $260 $300 $80 $105 * Requires prerequisite for registration Scientific Program

For registration and more information, go to www.facs.org

Postgraduate Skills- SC04 FundaMentalS OF SC07 laparOScOpic cOlOn laparOScOpic Surgery and rectal Surgery Oriented Courses LECTURES ONLy: 4 credits, Verification Level I LECTURES ONLy: 6 credits, Verification Level I Sunday, October 11, 2009; 8:00 am–12:30 pm Monday, October 12, 2009 SC01 Surgical educatiOn: LECTURES, HANDS-ON WORKSHOP, AND 10:00 am–5:30 pm principleS and practice FLS ExAMINATION: 6 credits, Verification LECTURES AND HANDS-ON LAB: 6 credits, Verification Level I Level III 12 credits, Verification Level II TRACK: EDU Sunday, October 11, 2009 Monday, October 12, 2009; 10:00 am–5:30 pm Saturday, October 10, 2009 8:00 am–6:30 pm Tuesday, October 13, 2009; 9:00 am–4:30 pm (Lab) 9:00 am–4:30 pm TRACK: GEN TRACK: CRS CHAIR: Mary E. Maniscalco-Theberge, MD, CO-CHAIRS: Brent D. Matthews, MD, FACS, CHAIR: Alan J. Herline, MD, FACS, Nashville, FACS, Reston, VA St. Louis, MO TN CO-CHAIR: Anne T. Mancino, MD, FACS, Daniel J. Scott, MD, FACS, Dallas, TX CO-CHAIR: Mark H. Whiteford, MD, FACS, Little Rock, AR Sponsored by the Committee on Portland, OR Sponsored by the Committee on Emerging Surgical Technology Sponsored by the Committee on Continuous Professional Development Emerging Surgical Technology and LeCtureS onLy Education and the Advisory Council FEE  Fellow $340  NoN-Fellow $395 FEE  Fellow $350  NoN-Fellow $390 for Colon and Rectal Surgery  RAS $105  NoN-RAS $135  RAS $105  NoN-RAS $140 PREREqUISITE FOR HANDS-ON LAB: LeCtureS, handS-on WorKShoP, E-mail [email protected] for more SC02 FundaMentalS OF and FLS exaMInatIon information and an application to register for both the lectures and hands-on lab. breaSt iMaging FOr the FEE  Fellow $875  NoN-Fellow $975 general SurgeOn  RAS $260  NoN-RAS $350 LeCtureS onLy 4 credits, Verification Level I FEE  Fellow $490  NoN-Fellow $565 TRACK: GEN SC05 MaMMOgraphy FOr  RAS $150  NoN-RAS $195 Sunday, October 11, 2009 the general SurgeOn LeCtureS and handS-on LaB 7:30–11:45 am 5 credits, Verification Level I FEE  Fellow $1690  NoN-Fellow $1950 CHAIR: Darius S. Francescatti, MD, FACS, TRACK: GEN Chicago, IL  RAS $505  NoN-RAS $675 Sunday, October 11, 2009 Sponsored by the Program Committee 12:30–5:45 pm SC08 SurgeOnS aS eFFective FEE  Fellow $290  NoN-Fellow $335 CHAIR: Edward J. Donahue, MD, FACS,  RAS $90  NoN-RAS $115 Phoenix, AZ cOMMunicatOrS: Sharpening Sponsored by the Program Committee SkillS FOr critical MOMentS 6 credits, Verification Level I SC03 ultraSOund cOurSe FEE  Fellow $390  NoN-Fellow $450 FOr reSidentS  RAS $120  NoN-RAS $155 TRACK: EDU 5 credits, Verification Level II Monday, October 12, 2009 TRACK: RES/MED SC06 Flexible gi endOScOpy 10:00 am–5:00 pm Sunday, October 11, 2009 CO-CHAIRS: L. D. Britt, MD, MPH, FACS, FOr general SurgeOnS Norfolk, VA 7:30 am–1:00 pm LECTURES ONLy: 2.5 credits, Thomas R. Gadacz, MD, FACS, St. Petersburg, CO-CHAIRS: Andrew W. Kirkpatrick, MD, FACS, Verification Level I FL Calgary, AB Monday, October 12, 2009 Sponsored by the Task Force on Amy C. Sisley, MD, FACS, Baltimore, MD 10:00 am–12:30 pm Interpersonal and Communication Skills Sponsored by the National Ultrasound LECTURES AND HANDS-ON WORKSHOP: Faculty and the Program Committee FEE  Fellow $340  NoN-Fellow $395 6 credits, Verification Level II  RAS $105  NoN-RAS $135 FEE  RAS $275  NoN-RAS $300 Monday, October 12, 2009 10:00 am–5:30 pm SC09 baSic breaSt ultraSOund TRACK: GEN 7.5 credits, Verification Level II CO-CHAIRS: Gerald M. Fried, MD, FACS, FRCSC, Montreal, QC TRACK: GEN Jeffrey M. Marks, MD, FACS,Cleveland, OH Monday, October 12, 2009 Sponsored by the Committee on Emerging 10:00 am–6:15 pm Surgical Technology and Education CO-CHAIR: Shawna C. Willey, MD, FACS, Washington, DC LeCtureS onLy CO-CHAIR: Kristin R. Corgan, MD, FACS, FEE  Fellow $260  NoN-Fellow $300 Marietta, GA  RAS $80  NoN-RAS $105 Sponsored by the National Ultrasound LeCtureS and handS-on WorKShoP Faculty and Program Committee

FEE  Fellow $550  NoN-Fellow $630 FEE  Fellow $1250  NoN-Fellow $1435  RAS $165  NoN-RAS $220  RAS $375  NoN-RAS $500 45

Scientific Program

SC10 breaSt ductOScOpy SC12 eSSential iSSueS in SC14 thyrOid and parathyrOid FOr the general SurgeOn the ManageMent OF lOWer ultraSOund 4 credits, Verification Level III extreMity iScheMia 7 credits, Verification Level II TRACK: GEN 6 credits, Verification Level I TRACK: OTO Monday, October 12, 2009 TRACK: VAS Wednesday, October 14, 2009 1:00–5:15 pm Tuesday, October 13, 2009 9:00 am–5:30 pm CHAIR: William C. Dooley, MD, FACS, 9:00 am–4:30 pm CHAIR: Robert A. Sofferman, MD, FACS, Oklahoma City, OK CHAIR: Kim J. Hodgson, MD, FACS, Burlington, VT Sponsored by the Program Committee Springfield, IL Prerequisite: Registrants must have FEE  Fellow $900  NoN-Fellow $1,000 Sponsored by the Advisory completed a course in basic ultrasound  RAS $270  NoN-RAS $360 Council for Vascular Surgery to register for this course. Three options are available to meet the prerequisite: FEE  Fellow $550  NoN-Fellow $635 SC11 the MiniMally invaSive  RAS $165  NoN-RAS $220 1. Completion of the previously offered ACS postgraduate course apprOach tO breaSt titled Ultrasound for Surgeons. biOpSy: baSic StereOtactic 2. Completion of the CD-ROM course, technique and applicatiOn SC13 Single-pOrt Ultrasound for Surgeons: The Basic 8 credits, Verification Level II laparOScOpic Surgery Course. The CD-ROM is available for TRACK: GEN  ONC LECTURES ONLy: 3 credits, Verification Level I purchase online at www.facs.org in the ACS Publications and Services Catalog Tuesday, October 13, 2009 Tuesday, October 13, 2009; 9:00 am–12:00 noon 8:00 am–5:30 pm or by contacting ACS Customer Service LECTURES AND HANDS-ON LAB: at 312-202-5474. CHAIR: Arthur G. Lerner, MD, FACS, 6 credits, Verification Level II White Plains, NY Tuesday, October 13, 2009; 9:00 am–5:00 pm 3. Completion of a comparable course elsewhere. Please include the following It is highly recommended that the TRACK: GEN skills-oriented postgraduate course, documents with your registration CHAIR: Deborah A. Nagle, MD, FACS, form: * CME Certificate * Certificate SC02, Fundamentals of Breast Boston, MA Imaging for the general Surgeon, of Completion * Registration be taken prior to this course. CO-CHAIR: Paul G. Curcillo II, MD, FACS, confirmation/verification. If you do Philadelphia, PA Sponsored by the Program Committee not have one of these documents, Sponsored by the Program Committee please contact the organization   FEE Fellow $1500 NoN-Fellow $1725 that sponsored your course to   LeCtureS onLy RAS $450 NoN-RAS $600 obtain one. Your registration will    FEE Fellow $350 NoN-Fellow $390 RAS not be processed until the National $105  NoN-RAS $140 Ultrasound Faculty has approved LeCtureS and handS-on LaB your accompanying documentation. Sponsored by the National Ultrasound FEE  Fellow $1,200  NoN-Fellow Faculty and Program Committee $1,350  RAS $360  NoN-RAS $480 FEE  Fellow $1250  NoN-Fellow $1440  RAS $375  NoN-RAS $500

Scientific Program

For registration and more information, go to www.facs.org

Postgraduate PG19 2009 intrOductiOn tO PG23 2009 advanced Surgical cpt, icd-9-cM, and evaluatiOn and OFFice-baSed cOding Didactic Courses and ManageMent cOding and reiMburSeMent 7 credits, Verification Level I 7 credits, Verification Level I PG15 challenging Surgical Monday, October 12, 2009 Tuesday, October 13, 2009 eMergencieS: What tO dO in 9:30 am–6:00 pm 8:00 am–4:30 pm the Middle OF the night TRACK: HP TRACK: HP 6 credits, Verification Level I CHAIR: Linda M. Barney, MD, FACS CHAIR: Albert Bothe, Jr., MD, FACS Saturday, October 10, 2009 Sponsored by the General Surgery Coding Sponsored by the General Surgery Coding 9:00 am–4:30 pm and Reimbursement Committee and Reimbursement Committee TRACK: GEN  TRA FEE  Fellow $390  NoN-Fellow $450 FEE  Fellow $405  NoN-Fellow $470 CHAIR: Michael J. Sise, MD, FACS  RAS $120  NoN-RAS $155  RAS $125  NoN-RAS $165 CO-CHAIR: Charles M. Ferguson, MD, FACS Sponsored by the Committee on Trauma and PG20 general Surgery PG24 Medicare cOMpliance: the Advisory Council for General Surgery revieW cOurSe audit-prOOF dOcuMentatiOn FEE  Fellow $340  NoN-Fellow $395 12 credits, Verification Level II 4 credits, Verification Level I   RAS $105 NoN-RAS $135 Part I: Monday, October 12, 2009 Wednesday, October 14, 2009 Part II: Tuesday, October 13, 2009 8:00 am–12:15 pm PG16 the buSineSS OF health 10:00 am–5:30 pm TRACK: HP care: underStanding TRACK: GEN CO-CHAIRS: Guy R. Orangio, MD, FACS the SurgeOn’S rOle CHAIR: John A. Weigelt, MD, FACS Paresh C. Shah, MD, FACS 5.5 credits, Verification Level I VICE-CHAIRS: Eugene F. Foley, MD, FACS Sponsored by the General Surgery Coding Saturday, October 10, 2009 Robert C. McIntyre, Jr., MD, FACS and Reimbursement Committee 9:30 am–4:30 pm Sponsored by the American FEE  Fellow $260  NoN-Fellow $300 TRACK: HP College of Surgeons’ Division of  RAS $80  NoN-RAS $105 CHAIR: Paul A. Taheri, MD, MBA, FACS Education in collaboration with the Sponsored by the Committee Southeastern Surgical Congress and on Perioperative Care Southwestern Surgical Congress PG25 revieW cOurSe in the eSSentialS OF vaScular FEE  Fellow $340  NoN-Fellow $395 FEE  Fellow $675  NoN-Fellow $775  RAS $105  NoN-RAS $135  RAS $205  NoN-RAS $270 Surgery FOr general and vaScular SurgeOnS PG17 acute OrthOpaedic PG21 Surgical SaFety cOurSe 6 credits, Verification Level II and neurOtrauMa care 6 credits, Verification Level I Wednesday, October 14, 2009 FOr general SurgeOnS Monday, October 12, 2009 8:00 am–3:30 pm TRACK: GEN  VAS 6 credits, Verification Level I 10:00 am–5:30 pm CHAIR: Gilbert R. Upchurch, Jr., MD, FACS Sunday, October 11, 2009 TRACK: EDU  GEN 9:00 am–4:30 pm CHAIR: John R. Clarke, MD, FACS Sponsored by the Advisory Council for Vascular Surgery TRACK: GEN  NEU  ORT  TRA CO-CHAIR: Donald W. Moorman, MD, FACS CHAIR: Jeffrey O. Anglen, MD, FACS FEE  Fellow $340  NoN-Fellow $395 FEE  Fellow $390  NoN-Fellow $450 CO-CHAIR: Domenic P. Esposito, MD, FACS  RAS $105  NoN-RAS $135  RAS $120  NoN-RAS $155 Sponsored by the Committee on Trauma CanCeLLed FEE  Fellow $340  NoN-Fellow $395 PG22 cOlOn and rectal cancer PG26 practice ManageMent  RAS $105  NoN-RAS $135 6 credits, Verification Level I FOr the general SurgeOn Tuesday, October 13, 2009 4 credits, Verification Level I PG18 rObOtic pelvic Surgery 8:00 am–3:30 pm Wednesday, October 14, 2009 6 credits, Verification Level I TRACK: CRS 1:00–5:15 pm Sunday, October 11, 2009 CHAIR: Thomas E. Read, MD, FACS TRACK: GEN  HP 9:00 am–4:30 pm CO-CHAIR: Howard M. Ross, MD, FACS CO-CHAIRS: Jay A. Gregory, MD, FACS TRACK: OBG  URO Sponsored by the Advisory Council Charles T. McHugh, MD, FACS CHAIR: Jeffery L. Cornella, MD, FACS for Colon and Rectal Surgery Sponsored by General Surgery Coding CO-CHAIR: Erik P. Castle, MD FEE  Fellow $340  NoN-Fellow $395 and Reimbursement Committee Sponsored by the Advisory Council  RAS $105  NoN-RAS $135 FEE  Fellow $260  NoN-Fellow $300 for Gynecology and Obstetrics and  RAS $80  NoN-RAS $105 the Advisory Council for Urology FEE  Fellow $340  NoN-Fellow $395  RAS $105  NoN-RAS $135

47 Scientific Program

Meet the Expert Luncheons Discuss selected topics with the experts over an informal lunch. Cost for each luncheon is $45. The luncheons will be from 1:15–2:15 pm.

tItLe and FaCILItator Monday, October 12 Changing Paradigms in the Treatment of Diverticulitis with Neil H. Hyman, MD, FACS General Neurosurgery with Particular Emphasis on Brain Tumors with John L. D. Atkinson, MD, FACS Salivary Gland Surgery with David W. Eisele, MD, FACS Thyroid Cancer with Martha A. Zeiger, MD, FACS Treatment of Severe Liver Injuries with Rao R. Ivatury, MD, FACS Current Recommendations for Blood in Trauma Resuscitation with Ernest E. Moore, MD, FACS Prostate Cancer with William J. Catalona, MD, FACS Endograft Repair in the Thoracic Aorta: Current Status Laparoscopic Colectomy with Anthony Senagore, MD, FACS Pilonidal Disease with John U. Bascom, MD, FACS; and Thomas H. Bascom, MD Bariatric Surgery in Children and Adults with Thomas H. Inge, MD, FACS Tuesday, October 13 What Is Involved in an Acute Care Surgery Practice? with Gregory J. Jurkovich, MD, FACS Advances in the Surgical Management of Crohn’s Disease with Walter A. Koltun, MD, FACS Anorectal Disease/Abscess/Fistula with Herand Abcarian, MD, FACS Treatment of Pancreatoduodenal Injuries with Andrew B. Peitzman, MD, FACS Training the Next Generation of Neurosurgeons with A. John Popp, MD, FACS Critical Care Management for the Traumatic Brain Injury Patient with Alex B. Valadka, MD, FACS Workforce Issues in Otolaryngology with Harold C. Pillsbury, MD, FACS Breast Reconstruction with Robert L. Walton, MD, FACS Management of Thoracic Injuries for the General Surgeon with David V. Feliciano, MD, FACS Thoracic Outlet Syndrome—Venous Thrombosis with Julie A. Freischlag, MD, FACS Aortic Graft Infection with G. Patrick Clagett, MD, FACS Chest Wall Deformities in Children and Adults: Results with New Approaches with Donald Nuss, MD, FACS Wednesday, October 14 Goiter Surgery—When and How with Christopher R. McHenry, MD, FACS Diverticulitis with Richard P. Billingham, MD, FACS Damage Control Abdominal Procedures with Frederick A. Moore, MD, FACS Management of Hemorrhagic Cerebrovascular Disease with Charles J. Prestigiacomo, MD, FACS Minimally Invasive Thyroidectomy with David J. Terris, MD, FACS Endovascular Options for Complex Aortic Disease with Gregorio A. Sicard, MD, FACS New Hemostatic Agents to Control Bleeding with Martin A. Schreiber, MD, FACS

Keep checking the ACS Web site at www.facs.org to register and for 48 additional Meet the Expert Luncheons. Scientific Program

For registration and more information, go to www.facs.org

Special Interest Surgery resident Program 2009 excellence in research 9:45 am–4:00 pm award distribution/Surgical Sessions Essential Skills for Surgical Practice: Forum dedication A Primer for Residents 11:30 am–1:00 pm Please note, these are non-CME designated Surgery residents from all postgraduate Science of Obesity Surgery sessions, unless otherwise indicated. year levels are invited by the Division The Committee for the Forum on of Education to participate in a special Fundamental Surgical Problems will program designed to assist surgery distribute 12 awards for excellence SUNDAY, OCTOBER 11 residents with essential nonclinical in research and the 60th volume issues they face during residency of the Owen H. Wangensteen training and the transitional period Medical Student Program Surgical Forum will be dedicated to their posttraining career. Session I: 12:00 noon–6:00 pm to Hiram C. Polk, Jr., MD, FACS. The Division of Education invites For additional information, please students from all four years of medical contact Ms. Cherylnn Sherman at school to attend the Clinical Congress 312-202-5424 or [email protected]. Medical Student Program and to participate in a program Session III: 1:00–6:00 pm designed specifically for medical For a full description of this program, students who may be interested in Medical Student Program please refer to the Sunday schedule. pursuing surgery as a career. Session II: 1:00–6:00 pm For a full description of this program, Additional sessions are scheduled please refer to the Sunday schedule. Meet the expert Luncheons on Monday and Tuesday. 1:15–2:15 pm Students must be enrolled in a LCME- Meet the expert Luncheons accredited medical school in order to Posters of exceptional participate. For additional information, 1:15–2:15 pm Merit Presentation please contact Ms. Laura Meyer at 1:15–2:15 pm 312-202-5335 or [email protected]. Cardiothoracic Surgery in the All attendees are invited to join in a Please register online at www.facs.org. Future: technology overview for lunchtime tour and discussion of the residents and Medical Students Posters of Exceptional Merit, facilitated resident and associate 5:30–9:00 pm  Fee: $25 (includes dinner) by Barbara L. Bass, MD, FACS, Chair Society Symposium COURSE DIRECTORS: Daniel L. Miller, MD, of the Program Committee. More 1:00–4:00 pm FACS, Atlanta, GA than 350 posters will be on display at Congress, but only a select few are RAS to debate “Is the generalist John D. Puskas, MD, FACS, Atlanta, GA designated Posters of Exceptional Surgeon Obsolete?” This course will introduce surgery residents and medical students Merit. Come hear the authors of these The debate will focus on the to minimally invasive procedures distinguished works present their impact that increasing interest in that are available to cardiothoracic research and answer questions, prior specialist practice has on the role surgeons today and will address what to the judges awarding one poster of the generalist practitioner. new technologies will be available in the title of Best Scientific Exhibit. For additional information, please the future. Sponsored by the American This session carries 1 CME credit. contact Ms. Peg Haar at 312-202-5312 College of Surgeons, The Society of or [email protected]. Thoracic Surgeons, and the American Association for Thoracic Surgery. Please Sixth annual rural Surgeons Meeting refer to the registration section of the and oweida Scholarship Presentation MONDAY, OCTOBER 12 ACS Web site at www.facs.org. 4:00–5:30 pm The presentation of the 2009 Nizar N. Oweida, MD, FACS Scholarship to estate Planning & estate tax Issues TUESDAY, OCTOBER 13 Nathan C. Kanning, MD, Sandpoint, for Surgeons and their Spouses ID, will open the session. Sponsored by SA05 (405) town hall Meetings the ACGS Rural Surgery Subcommittee 9:00–10:30 am / $25 7:00–7:45 am This seminar will be presented by Richard Campbell, Attorney, Mayer WEDNESDAY, OCTOBER 14 Brown Rowe & Maw, and will cover residency Program Interviews: the Keys to Success all of the basic topics and principles town hall Meetings of estate planning. Topics that will 8:00–9:45 am 7:00–7:45 am be covered include use of trusts in This workshop will provide third- estate planning, disability planning, and fourth-year medical students an creditor and asset protection planning, overview of the residency program Meet the expert Luncheons charitable planning ideas, and Top interview process. This session 1:15–2:15 pm 10 Estate Tax Planning Ideas. As part will be moderated by Kim Agretto, of the presentation you will receive C-TAgME, ARCS President, Easton, PA. reference material concerning estate THURSDAY, OCTOBER 15 planning. Find out all you need to know about your own personal estate town hall Meetings planning from one of the top estate 49 planning attorneys in the country. 7:00–7:45 am general Information

REgISTRATION VISA INFORMATION AFFILIATE gROUP Registration is open to all physicians and International Fellows, guest physicians, FUNCTIONS individuals in the health care field and and meeting attendees: Please be aware includes a name badge, program, and that the process of obtaining a visa groups planning a social function entrance to the exhibits and all sessions to attend meetings in the U.S. takes or business meeting to be held in other than postgraduate courses. much longer than in the past. You are conjunction with the Clinical Congress Please refer to page 49 for information strongly urged to apply for a visa as will need to make arrangements on registration location, hours, and early as possible, preferably at least 60 through ACS. For more information fees. To review the full registration days before the start of the meeting. and to request function space, please policies and submit your 2009 Clinical contact Carrie Balzer, ACS Convention You may request a letter from the College Congress registration, please visit and Meetings, at [email protected]. welcoming you to the meeting if you our Web site at http://www.facs.org/ feel this will be helpful by contacting clincon2009/registration/index.html. the International Liaison via e-mail at: [email protected] or by fax at: 312- 202-5021. AIR TRANSPORTATION

ACS has arranged special meeting discounts on United Airlines. These special discounts are available by booking with United directly (independently or through a travel agent). Be sure to reference the ACS file number to obtain the special fares. Area/Zone fares based on geographic location are also available with no Saturday night stay required. Minimum stay (two nights); seven- day advance purchase required. Zone fares are not available through online ticket purchase; please call: united airlines 800-521-4041 8:00 am–10:00 pm ET ACS File: 501CR www.united.com Purchase your ticket online and receive a discount off the lowest applicable fares.

CAR RENTAL Avis is designated as the official car rental company for the 2009 Clinical Congress. Special meeting rates and discounts are available on a wide selection of gM and other fine cars. To receive these special rates, be sure to mention your Avis Worldwide Discount (AWD) number when you call. avis reservations 800-331-1600 www.avis.com AWD Number: B169699

Printable registration forms are available on the Web site, 50 but register online to receive instant confirmation.

Registration Information For registration and more information, go to www.facs.org

Registration is open to all physicians and individuals in the health care field and includes a name badge, program, and entrance to the exhibits and all sessions other than postgraduate courses. To review the full registration policies and submit your 2009 Clinical Congress registration, please visit our Web site at http://www. facs.org/clincon2009/registration/index.html.

reGIStratIon LoCatIon and hourS McCormick Place – West Building – 3rd Floor Sunday, October 11 7:00 am–5:00 pm Monday, October 12 7:30 am–5:00 pm Tuesday, October 13 6:30 am–4:30 pm Wednesday, October 14 6:30 am–4:30 pm Thursday, October 15 7:00 am–12:00 noon

reGIStratIon FeeS and CredentIaLS On or Category 9/15–10/10 On Site Before 9/14 ACS Fellow (2009 dues paid) No Fee $50 $125 Commercial Representatives may obtain the commercial Initiate No Fee $50 $125 registration form by faxing a request to 312-202-5003. Associate Fellow No Fee $50 $125 *Nonmembers who pay the applicable registration fees will have their membership application fees waived if Resident Member No Fee No Fee $30 they apply for membership by December 31, 2009. The Medical Student Member No Fee No Fee $15 American College of Surgeons is pleased to offer discounted registration fees for residents and medical students. Please Affiliate Member No Fee $50 $125 submit a letter verifying your educational status with Guest Physician (U.S. & Canada)* $610 $660 $735 the completed registration form to expedite processing. Residents should obtain a letter from their program director; Guest Physician (International)* $610 $660 $735 students should contact their department chairs. Resident Nonmember (U.S. & Canada)† $45 $45 $75 (with verification letter) †Resident and Medical Student Membership Medical Student Nonmember (U.S. & Canada)† $25 $25 $35 The College has membership opportunities for medical (with verification letter) students and residents. Medical students must be Resident Nonmember (International) attending a U.S., Canadian, or international allopathic or $45 $45 $75 (with verification letter) osteopathic medical school. There is a one-time fee of $20, which covers all four years of medical school. Membership Medical Student Nonmember (International)† $25 $25 $35 will expire upon graduation from medical school. (with verification letter) Residents enrolled in a program accredited by the Accreditation Hospital Administrator (nonphysician) $375 $425 $500 Council for Graduate Medical Education (ACGME) or surgeons Hospital Purchasing Agent* $275 $325 $400 in surgical research or fellowship programs acceptable to the American College of Surgeons are eligible for Resident Medical Association Personnel* $275 $325 $400 Membership. The application fee of $20 is waived for first- Nurse Nonmember* $275 $325 $400 year residents. Annual dues thereafter are also $20. Surgical Assistant Nonmember* $275 $325 $400 Nonmember medical students and residents that register for this meeting and meet the appropriate Surgical Technician Nonmember* $275 $325 $400 membership category requirements will be PhD Nonmember* $395 $445 $520 contacted to affirm their membership status. Commercial Press $475 $525 $600 COMPANY NAME ______

Printable registration forms are available on the Web site. Socioeconomic tips

ACS Coding Hotline: Operative report questions by John T. Preskitt, MD, FACS; Albert Bothe, Jr., MD, FACS; Linda Barney, MD, FACS; Mark T. Savarise, MD, FACS; and Debra Mariani, CPC, Division of Advocacy and Health Policy

his column presents questions recently posed to the American College of Surgeons Around the corner TCoding Hotline and their responses. ACS • For dates and locations of the 2009 ACS- Fellows and their staff may consult the hotline five sponsored Coding Workshop schedule, visit http:// times annually without charge. If your office has www.facs.org/ahp/workshops/index.html. Online coding questions, please contact the ACS Coding registration is also available at this Web site. The Hotline at 800-227-7911 between 7:00 am and next coding workshops will take place July 9 and 10 4:00 pm Mountain Time, Monday through Friday, in Chicago, IL. The College is sponsoring another holidays excluded. set of workshops on August 27 and 29 in Los An- geles, CA. Our surgeon had to bring a patient back to • Be sure to catch the practice management the operating room to perform a postopera- webcasts that the College sponsors every other Wednesday. To register and see the schedule tive incision and drainage, complex, for a please go to http://www.facs.org/ahp/workshops/ wound infection. We coded this procedure teleconferences.html. 10180, Incision and drainage, complex, post- • For help with coding, the ACS sponsors “Cod- operative wound infection. Can we bill for ing Today” at http://acs.codingtoday.com/. this service during the global period of the original surgery?

When a return to the operating room is neces- sary during a global surgery period for the incision and drainage of a complex postoperative wound The correct coding is 43644, Laparoscopy, sur- infection, append modifier –78,Unplanned return gical, gastric restrictive procedure; with gastric to the operating/procedure room by the same physi- bypass and Roux-en-Y gastroenterostomy (roux cian following initial procedure for a related pro- limb 150 cm or less). Diagnostic EGD (esopha- cedure during the postoperative period, to 10180. gogastroduodenoscopy) and 43653 (laparoscopic gastrostomy) are both included in the procedure The dictated operative report states that according to Current Procedural Terminology the following procedures were performed: (CPT)* guidelines and National Correct Coding (1) laparoscopic gastric bypass, Roux-en- Initiative (NCCI) edits. Use of robotic equipment Y; (2) laparoscopic tube gastrostomy; (3) is inherent in the procedure. insertion of percutaneous pain pump; and (4) upper gastrointestinal endoscopy with The operative report indicates that the endoscopic retrieval of percutaneous placed surgeon performed a direct laryngoscopy, pull wire. The entire operation was done an esophagoscopy, and a rigid bronchoscopy. with a voice-operated robotic arm to control Can all three of these procedures be coded the laparoscopic movement. What would be separately or should they be bundled? the appropriate codes for these procedures? *All specific references to CPT (Current Procedural Terminology) You can report all three as long as your docu- terminology and phraseology are © 2008 American Medical mentation supports that each procedure was a Association. All rights reserved. distinct and separate procedure. CPT code 31525, 52

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn, is included in 31622, Resources Bronchoscopy, rigid or flexible, with or without Current Procedural Terminology 2009, Profes- fluoroscopic guidance; diagnostic, with or without sional Edition, American Medical Association cell washing (separate procedure). 31525 may be (AMA), Chicago, IL Principles of CPT Coding, 5th unbundled from 31622 if you can justify the use Edition, AMA. of an appropriate modifier (–59—see below). If you are unable to justify the use of a modifier, you may only bill 31622. If you bill both, 31525 should receive the modifier. CPT code 31525 is included in 43200, Esopha- goscopy, rigid or flexible; diagnostic, with or Code as follows: 11423, Excision, benign lesion without collection of specimen(s) by brushing or including margins, except skin tag (unless listed washing (separate procedure). 31525 may be un- elsewhere), scalp, neck, hands, feet, genitalia; bundled from 43200 if you can justify the use of an excised diameter 2.1 to 3.0 cm; 11422–51, Exci- appropriate modifier. If you are unable to justify sion, benign lesion including margins, except the use of a modifier, you may only bill 43200. If skin tag (unless listed elsewhere), scalp, neck, you bill both, 31525 should receive the modifier. hands, feet, genitalia; excised diameter 1.1 to You would have to use the modifier –59, Distinct 2.0 cm; 11421–51, Excision, benign lesion in- procedural service. CPT code 43200 and 31622 cluding margins, except skin tag (unless listed may be reported together using the modifier –51, elsewhere), scalp, neck, hands, feet, genitalia; Multiple procedures. excised diameter 0.6 to 1.0 cm; and 11200–51, Removal of skin tags, multiple fibrocutaneous Our surgeon removed three breast masses tags, any area; up to and including 15 lesions. from the patient’s left breast. The masses The number of skin tags removed determines were excised from two separate sites. How the code assignment. Code 11200 refers to 15 should we code for this operation? or fewer skin tags. When specimens are sent for pathological analysis, coders are advised to wait You would code 19120, Excision of cyst, fibroad- for pathology results before assigning codes. enoma, or other benign or malignant tumor, aber- rant breast tissue, duct lesion, nipple or areolar If a laparoscopic procedure is performed, lesion (except 19300), open, male or female, one or but no codes accurately describe the lapa- more lesions. Report a second procedure 19120–59, roscopic procedure, can the open procedure because it required a separate incision through code be reported? a different excision site. Modifier –59 is used to indicate a separate site was excised. It would be No, an open procedure code should never be re- advisable to include either a clear operative dicta- ported to describe a procedure that was performed tion or a cover letter stating two distinct incisions laparoscopically. If there is not an accurate code were made. descriptor, use the unlisted code, for example, 44238, Unlisted laparoscopy procedure, intestine The operative report indicates that the (except rectum). surgeon excised three nevi involving the right side of the neck, ranging from 0.75 to Can we code for a laparoscopic lysis of adhe- 2.5 cm in size. The surgeon also removed sions when a laparoscopically assisted small approximately 10 skin tags, ranging from bowel resection is performed? 2 to 5 mm in size, from the neck. The three nevi were 0.75 cm, 2 .0 cm, and 2.5 cm. How Do not report laparoscopic lysis of adhesions do you code for multiple excisions of differ- in addition to the laparoscopically assisted small ent sizes? Pathology states that all of the bowel resection, as this service is included.  specimens were benign. 53

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

In memoriam: Former ACS Director Paul A. Ebert, MD, FACS by Constantine Mavroudis, MD, FACS

Paul Allen Ebert, MD, FACS, the eighth Director of the Amer- ican College of Surgeons, died in the early hours of April 21, 2009, in Sacramento, CA, quite unexpectedly of an acute myo- cardial infarction at 76 years of age. His entire life was filled with selfless, virtuous acts, befitting the hero that he was. He was the modest athlete of fairy tales, always eschewing the limelight and giving praise to his teammates. He displayed the equanimity of the thought- ful surgeon, and he always made an effort to relate to his patients. He lived the ethical life and became a beacon of light for those who knew him. He was a towering figure of a man, a vir- tual giant upon whose shoulders stood a generation of trainees, colleagues, admirers, sports fans, philosophers, friends, and family members. He could have done anything, it seemed, which Dr. Ebert made his premature passing all the more poignant and stark.

Academic and on the baseball team. In bas- and wins every year that he athletic excellence ketball, he was first team All played, which earned him con- Dr. Ebert was born August 11, Big Ten and the team’s most sensus All-America selection 1932, in Columbus, OH. He valuable player every year that in his senior year (see center was one of those gifted people he played at Ohio State, a feat photo, page 55). Dr. Ebert was who excelled in everything he that culminated in All-America recruited by the New York Gi- did. As a student at The Ohio honors as a senior (see left ants and Pittsburgh Pirates State University, he was a for- photo, page 55). In baseball, to play professional baseball, ward and center on the school’s he had a career 21–8 record and for a few moments he basketball team and a pitcher leading his team in strikeouts entertained the idea, until it 54

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS LETIC DEPARTMENT LETIC DEPARTMENT TH TH A A TE TE TA TA S S O O HI HI O O COURTESY OF COURTESY OF

Dr. Ebert playing basketball at OSU. Dr. Ebert playing baseball at OSU. Dr. Ebert with Dr. Dunphy (right).

became clear that he could not recommended Dr. Ebert to Center, New York, NY. He was play professional baseball and Alfred Blalock, MD, FACS, the 39 years old at the time; some attend medical school at the 35th President of the American of his residents were older than same time—although he was College of Surgeons, of Johns he was. Yet he was able to form intrigued by the idea. Profes- Hopkins University, where a stellar training program, due sional baseball was put aside he excelled in a program that in large part to his leadership for loftier goals. was to foster some of the great qualities and his commitment Dr. Ebert enrolled at The surgeons and educators of the to surgical education. Ohio State University Medical twentieth century. After two In 1975, Dr. Ebert was named School, during which time he years as a senior assistant chairman at the University married his high school sweet- surgeon at the National Heart of California–San Francisco, heart, Louise Joyce Parks, on Institute, he became associate where he succeeded J. Engle- September 4, 1954. Together professor of surgery at Duke bert Dunphy, MD, FACS, the they were to share the next University where David Sabis- 44th President of the American 55 years in constant compan- ton, MD, FACS, the 66th Presi- College of Surgeons (see right ionship as parents, grandpar- dent of the American College of photo, this page). ents, and adopted family to Surgeons, was establishing his their numerous trainees. Dr. now-famous residency training Service to the College Ebert graduated from The program. In November 1986, he as- Ohio State University Medical Dr. Ebert’s stature as a sur- sumed the Directorship of the School in 1958. geon and virtuous individual American College of Surgeons Robert Zollinger, MD, FACS, grew rapidly. From 1971 to and served in that role until the chair of surgery at Ohio 1975, he served as chairman his retirement at the end of State and 42nd President of the of the department of surgery June 1998. During his tenure American College of Surgeons, at Cornell University Medical as Director of the College, Dr. 55

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Ebert oversaw an explosion of expanded member services, which served the growing interests of ACS members in education, new technology, and governance. New challenges in health care delivery neces- sitated greater representation in Washington, DC, and inter- action with the U.S. Congress (see photo, this page). As a spokesman for the College, Dr. Ebert effectively advocated for our patients and our profes- sion. His vision for the future re- sulted in a new home for the American College of Surgeons. He led a team that negotiated the terms of a new building, which ensured a permanent W. Gerald Austen, MD, FACS (left), and Dr. Ebert testifying before Congress home for the College and in 1991. made possible the adminis- trative offices for The Society of Thoracic Surgeons, The American Board of Thoracic to clinical cardiothoracic sur- gical challenge. He could give Surgery, the Southern Tho- gery, neonatal and infant open advice without criticism, he racic Surgical Association, the heart surgery, development of could understand the condi- Society for Vascular Surgery, clinical techniques that dra- tions underlying the patient’s the American Association for matically improved survival problem, and he could express the Surgery of Trauma, the for patients with truncus ar- a solution in simple terms with Thoracic Surgery Directors teriosus, and establishing the clear goals. He was a masterful Association, and the Eastern pioneering techniques that teacher whose efforts in the Association for the Surgery led to neonatal application of operating room were aimed of Trauma. His monthly “As I the arterial switch operation at ensuring that the trainee see it” columns for the Bulle- for transposition of the great could perform the operation tin of the American College of arteries. He authored or co- without his help. The success Surgeons were, and continue authored 198 manuscripts in of this teaching style has been to be, thoughtful analyses of peer-reviewed journals, which demonstrated by the success of current events and College are a record of achievement his trainees and subsequently activities, as well as models that speak for his genius and by their trainees. There can for future directions. innovative talents. be no greater testimony to He was a popular visiting his memory than the living A teacher and leader professor, mostly for his mod- manifestation of his teaching Dr. Ebert established surgi- est style and the perspicacious methods learned by present cal laboratories wherever he manner in which he solved and future generations (see went. Some of his most impor- clinical problems. Everyone photo, page 57). tant contributions to surgery wanted to know how Paul Paul Ebert touched a gen- include the initial experiments would approach this clinical eration of colleagues, students, that introduced cardioplegia dilemma or that complex sur- and patients from all parts 56

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Ebert (front row, second from left) and a group of his residents in January 2007, in San Diego, CA, where they met in association with the annual meeting of the Society of Thoracic Surgeons. Dr. Ebert gave an informal talk on his recollections of “the Blalock years” at Johns Hopkins University.

of the world. One was struck Offices and awards Other awardees include Dwight immediately by his humanity, Besides serving as president Eisenhower; Jesse Owens; character, and stature. He was of the American Association George H.W. Bush; Ronald gentle, polite, and firm in his for Thoracic Surgery, Dr. Ebert Reagan; Denton Cooley, MD, convictions. He could and did was elected president of the FACS; and Roger Staubach. Dr. argue effectively, but in the American College of Cardiology, Ebert wasn’t a wallflower. In end, no matter what the out- the Association of Academic his speech to the NCAA com- come, the experience was fruit- Surgery, the Society of Univer- memorating his coveted prize, ful, engaging, and educational. sity Surgeons, and the Western he noted, “Certainly pressures It was amazing that one with Thoracic Surgical Association. today on our entire society so many strong ideas and com- In 1989, he was the recipi- have made many fantasize life mitted visions could be loved ent of the Theodore Roosevelt with the use of drugs—and by so many people. Perhaps his Award, the highest honor that athletes have not been immune most noble of traits was that the National Collegiate Athletic to these temptations. Stresses he could “get out of himself” Association (NCAA) may con- and strains on the college ath- to recognize the needs and fer on an individual, awarded lete may well be greater than concerns of others. He was a to a distinguished citizen of on the ordinary student and very unselfish man, and he led national reputation based on the temptations greater and by example. outstanding life achievement. the feeling of indestructibility 57

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS by the athlete perpetuated. Joyce Parks, his spouse of 55 don’t get into the right atrium Combine this with the more years; his children, Leslie Ebert at least once during a redo recent and more common use of Buhlman, Michael Ebert, and dissection, you are moving too steroid compounds to increase Julie Ebert-McQuillan; and slow (sic)” or “You could have performance and body size and his grandchildren, Holly, Rudy, done that better” never die. His the pressures upon this orga- Claire, and Paul Buhlman, and family will remember him for nization [NCAA] have further Danyon Ebert-McQuillan. his love, affection, candor, and amplified. Yet through these In the end, history will re- unconditional devotion. Those unpleasant and certainly ad- member Paul Ebert for the individuals who worked with verse types of events, the NCAA Renaissance man that he was: him will remember his virtues, continues to strengthen the scholar, quintessential sur- humanity, humor, and sensitiv- bonds between academia and geon, investigator, athlete of ity. We will all miss him. athletics.” This speech took legendary proportions, and place in 1989, years before the committed teacher. His legacy Dr. Mavroudis is Ross Professor drug problem became overt in will be recreated every day by of Surgery and chairman, pediat- professional and college sports. the scores of “Ebertisms” that ric and congenital heart surgery, have been propagated over the Cleveland Clinic/Lerner School of A natural years. Anecdotes like, “If you Medicine, Cleveland, OH. Everyone loved to talk to Paul. It seemed like he had a solution for everything. Some people who knew him recom- mended that he run for the U.S. Senate or President of the U.S. ACS Career Opportunities These were not idle or ground- less suggestions. He didn’t take these comments seriously, The American College of Surgeons’ online job bank however, and in fact spurned A unique interactive online recruitment tool provided by the the ideas until someone men- tioned sports. He then became American College of Surgeons. animated—almost as if he were playing again. One could see An integrated network of dozens of the most prestigious the excitement, subtle as it was, health care associations. in his eyes. He was concentrat- ing on striking out the batter. Residents: He was about to drive for a lay up. It was easy to see why • View national, regional, and local job listings 24 hours he was such an accomplished a day, 7 days a week-—free of charge. surgeon—he had the hand-eye • Post your resume, free of charge, where it will coordination of a two-sport All-American. He didn’t have be visible to thousands of health care employers a favorite pitch in baseball or a nationwide. You can post confidentially or openly— preferential shot in basketball. depending on your preference. He could beat the opposing • Receive e-mail notification of new job postings. team with whatever pitch or • Track your current and past activity, with toll-free shot that was necessary. It was access to personal assistance. like that in surgery. He was just a natural, the likes of which Contact [email protected] for more information. will not come again soon. He is survived by Louise 58

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS We proudly announce our 2009 member dividend. We set a higher standard. We ensure that members benefit from our strength. We embrace opportunities to recognize and reward physicians. We exceed expectations. We offer tangible benefits to those who join us. We stand behind the promises we make. We are The Doctors Company. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

We are on a mission to relentlessly defend, protect, and reward doctors who advance the practice of good medicine. We act with single-minded determination to reward our members and to ensure that they share in the company’s financial strength. In 2007 and 2008, our members received a dividend of between 5 and 7.5 percent. For 2009, eligible members will receive a dividend distribution at the same level. That’s approximately $60 million returned to members in three years. ACS has sponsored our medical professional liability program since 2002. To learn more about our program for ACS members, call (800) 352-0320 or visit us at www.thedoctors.com.

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American College of Surgeons

A2686_ACS Bulletin_final.indd 1 6/4/09 1:46:17 PM 2009 Health Policy Scholars announced

Fourteen surgeons attend- participation in the weeklong in- • AC S Health Policy ed the Leadership Program in tensive course, to be followed by Scholar for General Sur- Health Policy and Management a year’s service in a health policy- gery: John Maa, MD, FACS, that took place last month at related capacity to the College University of California San Brandeis University, Waltham, and the surgical specialty society Francisco, San Francisco, CA. MA. Each scholarship included co-sponsoring the awardee. • A C S H e a l t h Po l i c y

Dr. Maa Dr. Wyrzykowski Dr. Moore

Dr. Ratliff Dr. Block Dr. Lund

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VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Scholar for General Sur- • ACS/American Asso- MD, MBA, FACS, Orlando gery: Amy Wyrzykowski, MD, ciation of Neurological Regional Medical Center, Or- FACS, Emory University, At- Surgeons Health Policy lando, FL. lanta, GA. Scholar: John K. Ratliff, MD, • ACS/American Pedi- • ACS/American Academy FACS, Thomas Jefferson Uni- atric Surgery Association of Otolaryngology–Head & versity, Philadelphia, PA. Health Policy Scholar: Den- Neck Surgery Health Policy • ACS/American Asso- nis P. Lund, MD, FACS, Univer- Scholar: Brian A. Moore, MD, ciation for the Surgery sity of Wisconsin-Madison. FACS, Eglin Air Force Base Re- of Trauma Health Policy • ACS/American Sur- gional Hospital, Pensacola, FL. Scholar: Ernest F.J. Block, gical Association Health

Dr. Spain Dr. Kurtzman Dr. Sentovich

Dr. Tufaro Dr. Lazarou Dr. Saigal

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JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • ACS/American Society of Plastic Surgeons Health Policy Scholar: Anthony P. Tufaro, MD, DDS, FACS, Johns Hopkins University, Baltimore, MD. • ACS/American Urogy- necologic Society Health Policy Scholar: George Laz- arou, MD, Albert Einstein Col- lege of Medicine, Bronx, NY. • ACS/American Uro- logical Association Health Policy Scholar: Christopher S. Saigal, MD, FACS, Univer- sity of California Los Angeles. • ACS/Society of Thorac- Dr. Ellis Dr. Shanley ic Surgeons Health Policy Scholar: Jennifer L. Ellis, MD, FACS, Washington Hos- pital Center, Washington, DC. Policy Scholar: David A. bury Hospital, Waterbury, CT. • ACS/Society for Vascu- Spain, MD, FACS, Stanford • ACS/American Society lar Surgery Health Policy University, Stanford, CA. of Colon and Rectal Sur- Scholar: Charles J. Shanley, • ACS/American Society geons Health Policy Schol- MD, FACS, Beaumont Hospi- of Breast Surgeons Health ar: Stephen M. Sentovich, MD, tal, Royal Oak, MI. Policy Scholar: Scott H. FACS, Boston Medical Center, Kurtzman, MD, FACS, Water- Boston, MA.

Visit the ACS Web portal’s rural surgeons community

Are you a rural surgeon look- have time to read it right tor, Rural Surgeons), has cre- ing for an easier way to stay away? Just click the “Add to ated the rural surgeons’ net- current on topics of interest? Bookmarks” button to save the work for those who wish to be If so, look no further than the item to the portal’s “My Book- alerted to postings and events Rural Surgeons Community marks” page for later reading. on rural surgery. The alerts on e-FACS.org, the College’s The community also includes are noncommercial, brief, and members-only Web portal, a link to the rural surgeons dis- transmitted only when a new where you will find many use- cussion forum, where members subject of interest is posted. ful features and resources. of the College can share ideas For information on how to For starters, the “Latest from or ask questions—you can even join the network or to submit PubMed” feature provides subscribe to the forum to re- material, photos, or ideas, visit scrolling links to the most ceive an e-mail when new post- the Rural Surgeons Community recent journal articles related ings are added. As an extension at http://efacs.org/rural. to surgery in rural areas. See of this forum, Tyler G. Hughes, something you like but don’t MD, FACS (co-community edi- 62

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS A look at The Joint Commission Improve hand hygiene with free monograph

Preventing infections is crit- Measuring hand hygiene per- organizations through the ical to patient safety. A mono- formance has long been com- Consensus Measurement in graph from The Joint Com- plicated because of the need Hand Hygiene Project. The mission offers surgeons and to monitor the practices of project was supported by an their team members a new way many different care providers unrestricted educational grant to focus on an important as- in numerous locations for suf- from GOJO Industries, Akron, pect of infection prevention— ficient periods of time. With- OH. compliance with recommended out standardized approaches Electronic copies of the hand hygiene practices. for measuring hand hygiene monograph are available Effective hand hygiene prac- performance, it is impossible on The Joint Commission’s tices have long been recognized to determine whether overall Web site at http://www.joint as the most important way performance is improving, commission.org/Patient to reduce the transmission of deteriorating, or unchanged Safety/InfectionControl/hh_ potentially deadly germs in as new strategic interventions monograph.htm. One free health care settings, including are introduced. printed copy is available by the surgical suite. The new The Joint Commission’s calling The Joint Commis- monograph, Measuring Hand National Patient Safety Goals sion’s Customer Service Cen- Hygiene Adherence: Overcom- require accredited organiza- ter at 630-792-5800, option ing the Challenges, is the result tions to follow recognized hand 5, or sending an e-mail to of a two-year collaboration with hygiene guidelines; however, customerservice@joint major infection prevention and studies continue to show that commission.org. control leadership organiza- adherence to these guidelines tions in the U.S. and abroad to is lacking. This finding is due, identify effective approaches in part, to the variation in for measuring adherence to approaches to measurement, hand hygiene guidelines in which makes rates of adher- health care organizations. ence difficult to compare. In addition to The Joint The monograph provides a Correction Commission, the participat- framework to help health care ing organizations include the workers make necessary deci- In the memorial for David Association for Profession- sions about when, why, and Coston Sabiston, Jr., MD, als in Infection Control and how to measure compliance FACS, which appeared in the Epidemiology Inc., the Cen- with hand hygiene. The mono- May Bulletin (page 39), it ters for Disease Control and graph systematically reviews was stated that Dr. Sabiston Prevention, the Society for the strengths and weaknesses accepted the James B. Duke Healthcare Epidemiology of of commonly used approaches. Professorship of Surgery at America, the World Health Or- Examples of measurement Duke University in 1963. Dr. ganization World Alliance for methods and tools in the mono- Sabiston accepted the profes- sorship in 1964. The editors Patient Safety, the Institute graph, which also includes regret the error. for Healthcare Improvement, references to evidence-based and the National Foundation guidelines and published lit- for Infectious Diseases. erature, were submitted by 63

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION • LEARNING AT YOUR FINGERTIPS

 NEW! ACS MULTIMEDIA ATLAS OF SURGERY Colorectal Volume. This DVD and accompanying book provide an interactive demonstration of 26 colorectal surgery procedures, both laparoscopic and open. Especially designed to address the cognitive element of surgical procedures, each procedure is presented in a step-wise fashion, offering expert commentaries that highlight specific nuances and actions to be taken to prevent errors. Upcoming volumes include Pancreas Surgery and Hernia Surgery.

 NEW! PROFESSIONALISM IN SURGERY, 2nd Edi- tion: This DVD presents an additional 12 new vignettes that depict professionalism challenges faced by surgeons in everyday practice, as well as possible courses of action in the context of the core competency of professionalism. The vignettes are ideal for teaching purposes and CME credit is available.

 NEW! ACS SURGERY RESIDENT OSCE: This pro- gram provides a tool to assess the entry-level knowledge and skills of PGY-1 surgery residents to deliver safe care to surgery patients with critical and life-threatening conditions. It includes a CD-ROM manual with all the materials needed to administer the OSCE, and a DVD that provides a gold standard performance of each clinical scenario. This project was supported by grant number U18 HS12021 from the Agency for Healthcare Research and Quality.

 NEW! PATIENT SAFETY 2008 CD. This CD features patient safety sessions from the 2008 Clinical Congress.

 BASIC ULTRASOUND COURSE CD: This CD provides a basic core of education and training in ultrasound imaging as a foundation for specific clinical applications and is available for CME credit.

 PRACTICE MANAGEMENT for Residents and Young Surgeons: This series of three CDs covers important topics such as mechanics of setting up or running a private practice, essen- tials of an academic practice and career pathways, and basics of surgical coding. CME credit is available.

 ADDITIONAL CDs, including the Bariatric Surgery Primer and Personal Financial Planning and Management for Residents and Young Surgeons.  NEW! Selected Clinical Congress 2008/2007 sessions available as webcasts and audio CD/MP3  DVDs AVAILABLE AT NO CHARGE, including downloads through ACS E-Learning Resource Disclosing Surgical Errors: Vignettes for Discussion, and Center. The online webcast sessions contain audio fully Communicating with Patients About Surgical Errors synchronized to each speaker’s PowerPoint presentation, and Adverse Outcomes, each supported by a grant of the providing users with a true multimedia recreation of the Agency for Healthcare Research and Quality. event. CME credit is available.  VIDEO-BASED EDUCATION SESSIONS: Select video sessions from the Clinical Congress are available on CD/ DVD. The ACS Video Library contains narrated videos, donated by the authors.

For purchase and pricing information, call ACS Customer Service at 312/202-5474 or visit our E-LEARNING RESOURCE CENTER at www.acs-resource.org

For more information, contact Olivier Petinaux, MS, at [email protected], or 866/475-4696.

All Prod Ad-Bulletin (rev 03-09).indd 1 5/8/2009 1:24:12 PM Clinical congress sessions to present research in progress

More than 300 presentations lowing the award distribution, West Building of McCormick will take place during the Owen the 2009 Surgical Forum Vol- Place. Attendees are especially H. Wangensteen Surgical Forum ume will be dedicated to Hiram encouraged to visit the exhibits and the Scientific Exhibition C. Polk, Jr., MD, FACS. Tien C. during the lunch break, when forums at the 2009 American Ko, MD, FACS, will make the authors will be at their booths to College of Surgeons Clinical introductory remarks, with discuss their work and answer Congress in Chicago this Octo- comments from Dr. Polk to fol- questions. A lunchtime tour ber. Awards will also be distrib- low. Medical students, surgical and discussion of the Posters of uted during each forum. residents, and their mentors are Exceptional Merit will be facili- More than 300 abstracts have encouraged to attend the award tated on Tuesday, October 13, by been selected for presentation in distribution and dedication, as Barbara L. Bass, MD, FACS, a the 29 sessions that make up the well as the abstract sessions Regent of the College and Chair Owen H. Wangensteen Surgical taking place throughout the du- of the College’s Program Com- Forum. Twelve authors have ration of the Clinical Congress. mittee. The authors will present been selected for Excellence The Scientific Exhibition is a each distinguished work, and an in Research Awards. Award forum during which more than award will be given to the best distribution will take place at 350 posters are used to present poster of the exhibition. the beginning of the Surgical completed research, research For more information, Forum-sponsored panel session, in progress, and case reviews. visit http://www.facs.org/ Science of Obesity Surgery, on Each poster will be on display clincon2009/. Tuesday, October 13, from 11:30 for one day only—Monday, am to 1:00 pm. Immediately fol- Tuesday, or Wednesday—in the

New College Web site centers on E-prescribing Incentive Program

The American College of E-prescribing Incentive Program. tions, and resources for sur- Surgeons has created a Web The Web site includes an geons who want to participate. site to educate members about introduction to the electronic The Web site can be accessed the Centers for Medicare prescribing program, a discus- at http://www.facs.org/ahp/ & Medicaid Services’ 2009 sion of frequently asked ques- pqri/2009eprescribing.html.

Change your address online! Go to the College’s “members only” Web portal at www.e-facs.org

65

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This organization receives financial support for allowing Liberty Mutual to offer this auto and home insurance program. *Discounts and savings are available where state laws and regulations allow, and may vary by state. To the extent permitted by law, applicants are individually underwritten; not all applicants may qualify. **Coverage provided and underwritten by Liberty Mutual Insurance Company and its affiliates, 175 Berkeley Street, Boston, MA. A consumer report from a consumer reporting agency and/or a motor vehicle report, on all drivers listed on your policy, may be obtained where state laws and regulations allow. Please consult a Liberty Mutual specialist for specific details. ©2008 Liberty Mutual Insurance Company. All Rights Reserved. NTDB® data points Falling down by Richard J. Fantus, MD, FACS

Over the millennia, Earth’s climate has changed many times, with periods ranging Percentage by summer months vs. non-summer months from the ice age all the way to long periods of heat. In the past, these climate changes occurred only from natural factors—including volcanic eruptions, alterations in the amount of energy released by the sun, and changes in the Earth’s orbit. It was not until the Industrial Revolu- tion began in the late 18th century that human activities very likely started to affect the composition of the atmosphere and the Earth’s climate. More than 200 years of de- forestation and the burning of fossil fuels such as coal and oil have led to the increase of heat-trapping greenhouse gasses. Acting somewhat like the panels of a greenhouse, these gases prevent heat from escaping into space (for more information on climate change, v i s i t http://www.epa.gov/ perature over the past 50 years the equator or large bodies of climatechange). Global warm- comes a new finding that the water. As seasons change and ing is a well-known phenom- hottest day of the year has the temperatures go up dur- enon that has achieved world- shifted nearly two days earlier ing the summer, there is an wide focus and attention. (Thomson DJ. Climate change: accompanying increase in the Many initiatives to combat Shifts in season. Nature. 2009; trauma volume seen at trauma global warming are under way 457:391-392). centers.This seasonal trend or in the planning process Global warming may ul- held true for all four census at the local, state, national, timately have an impact on regions and was reported in a and international levels. A trauma. Average temperatures September 2006 Bulletin ar- hot news item was reported tend to increase from winter to ticle, “Trauma season” (2006; earlier this year pointing out summer. This seasonal varia- 91(9):58-59). that along with the well-known tion is more pronounced the Increased trauma in the sum- rise in the average global tem- farther one gets away from mer months is most likely due 67

JULY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to a variety of factors that may records had discharge status the environment, on the gen- include the temperature. recorded, including 96,174 dis- eration of greenhouse gasses, Many individuals can per- charged to home, and 15,682 and on global warming and its sonally relate to the deterio- to acute care/rehabilitation; impact on “falling down.” ration of their coping skills in 8,511 were sent to nursing The full NTDB Annual Re- challenging situations on the homes, and 5,499 died. These port Version 8.0 is available on hottest day of the year, when patients were 65.2 percent the ACS Web site as a PDF and the heat and humidity are roll- male and on average 38.4 years a PowerPoint presentation at ing down one’s forehead, as of age; they had an average http://www.ntdb.org. dramatized in the 1993 movie length of stay of 5.6 days, and If you are interested in sub- Falling Down, starring Mi- an average injury severity mitting your trauma center’s chael Douglas. Along with the score of 9.2. data, contact Melanie L. Neal, warmer weather of summer, When comparing the sum- Manager, NTDB, at mneal@ there are more recreational mer group with the remain- facs.org. activities and family vacations ing nine-month group (non- with their related risks. summer months), there were Acknowledgment In order to examine the oc- statistically significant in- currence of summer-related creases in penetrating trauma, The author acknowledges trauma in the National Trau- alcohol confirmed by test posi- the assistance of Sandra Goble, ma Data Bank Research data- tive, location of injury as recre- MS, in the preparation of this set 2007 admissions (formerly ation, and assaults (these data column. called research dataset 8.0), are displayed in the graph on records were searched for page 67). Dr. Fantus is director, trauma admission dates occurring Summer should be a time services, and chief, section of surgical critical care, Advocate in the months of June, July, to kick back and enjoy the Illinois Masonic Medical Center, and August (representing the outdoors. Spend time with and clinical professor of surgery, three-month peak seasonal family and friends. Take a University of Illinois College of increase demonstrated in the vacation, enjoy time on fos- Medicine, Chicago, IL. He is Chair 2006 Bulletin analysis). sil fuel-propelled boats, all- of the ad hoc Trauma Registry Ad- Of the 507,262 incidents, terrain vehicles, planes, and visory Committee of the Committee there were 140,888 occur- trains.However, while one is on Trauma. ring during the three summer relaxing and trying to beat the months. Of these, 125,866 heat, take time to reflect on

GOVERNORS’ COMMITTEE ON CHAPTER ACTIVITIES, from page 31 ties Subcommittee that has addressed the issue be extremely important, as the educational of- of modifying the criteria to become a Fellow of ferings of the College are widely recognized as the American College of Surgeons. There was being of excellent quality and are thought to give widespread agreement that the highest clini- great benefit to surgeons throughout the world. cal, ethical, and professional standards should The College is also working to increase the abil- be maintained while identifying and reducing ity to provide ongoing education in an electronic administrative barriers that have made it a chal- format that can be accessed through the Web. lenge for surgeons elsewhere in the world to join The GCCA aggressively advocates for the broad the College and participate in the educational range of members in all chapters nationally and offerings presented at the Clinical Congress and internationally.  at other forums. This initiative was thought to 68

VOLUME 94, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS