JULY 2007 Volume 92, Number 7

FEATURES Stephen J. Regnier From the Chair of RAS-ACS: Editor The voices of young surgeons 8 Gregory S. Cherr, MD Linn Meyer Removing our loupes: Encouraging surgeons to develop Director of a broader perspective for the future 11 Communications C. Suzanne Cutter, MD The future of the American College of Surgeons: Karen Stein Uniting two perspectives 14 Associate Editor Ted A. James, MD, and Thomas R. Russell, MD, FACS Diane S. Schneidman The road to innovation: Emerging technologies in surgery 19 Carlos M. Mery, MD, MPH; David T. Cooke, MD; Venita Chandra, MD; Contributing Editor Bilal M. Shafi, MD, MSE; Ali Tavakkolizadeh, MD; and Thomas K. Varghese, Jr., MD (edited by Dr. Mery and Dr. Cooke) Tina Woelke Graphic Design Specialist The globalization of surgery: Surpassing the frontiers 34 Mecker G. Möller, MD; John Karamichalis, MD; and C. Suzanne Cutter, MD Alden H. Harken, International medical graduates in American surgery: MD, FACS Past, present, future 39 Charles D. Mabry, Dean R. Cerio, MD; and Cyrus F. Loghmanee, MD MD, FACS New trends and developments in fellowship training 43 Jack W. McAninch, MD, Heena Santry, MD; and C. Suzanne Cutter, MD FACS New ways of practicing surgery: Alternatives and challenges 51 Editorial Advisors Mecker G. Möller, MD; Luis A. Santiago, MD; John Karamichalis, MD; and Joshua M. V. Mammen, MD Tina Woelke Front cover design Congressman Michael Burgess, MD: The necessity of physician involvement in the political process 59 Shawn Friesen

College recognizes ACS NSQIP hospitals 65 Future meetings 2007 Clinical Congress preliminary program 67 Clinical Congress DEPARTMENTS 2007 New Orleans, LA, October 7-11 From my perspective 4 Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director 2008 San Francisco, CA, October 12-16 Dateline: Washington 6 Division of Advocacy and Health Policy 2009 Chicago, IL, October 11-15

On the cover: The Resident and Associate Society of the American College of Surgeons addresses issues pertinent to residents in a series of articles on pages 8-58. Photo courtesy of Punchstock. NEWS Bulletin of the American College of Surgeons (ISSN Dr. Pierce receives Jacobson Award 84 0002-8045) is published monthly by the American Col- Resident Research Scholarships for 2007 awarded 87 lege of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It 2007 Health Policy Scholars announced 89 is distributed without charge to Fellows, to Associate Fellows, The Clowes/ACS/AAST/NIGMS to participants in the Candi- Mentored Clinical Scientist Development Award available 90 date Group of the American College of Surgeons, and to ACOSOG news: medical libraries. Periodicals postage paid at Chicago, IL, ACOSOG Z9001 completed 91 and additional mailing offices. David Ota, MD, FACS; and Heidi Nelson, MD, FACS POSTMASTER: Send address changes to Bulletin of the Operation Giving Back: American College of Surgeons, Volunteer opportunities available 92 633 N. Saint Clair St., Chicago, IL 60611-3211. Canadian Pub- A look at The Joint Commission: lications Mail Agreement No. Low health literacy puts patients at risk 94 40035010. Canada returns to: Station A, PO Box 54, Windsor, NTDB® data points: ON N9A 6J5. The rockets’ red glare 95 The American College of Richard J. Fantus, MD, FACS, and Joshua Fantus 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 endorse- ment by nor official policy of the American College of Sur- geons.

©2007 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.

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION •

 SYLLABI SELECT: The content of select ACS Clinical Congress postgraduate courses is available on CD-ROM.

 BASIC ULTRASOUND COURSE: This course has been developed on CD-ROM to provide the practicing surgeon and surgical resident with a basic core of education and train- ing in ultrasound imaging as a foundation for specific clinical applications. It replaces the basic course offered at the Clinical Congress and is available for CME credit.

 PROFESSIONALISM IN SURGERY: CHAL- LENGES AND CHOICES: This CD presents 12 case vignettes, each including a scenario followed by multiple-choice questions related to professional responsibilities of the surgeon within the context of the case. The program provides a printable CME certificate upon successful completion.

 PERSONAL FINANCIAL PLANNING AND MANAGEMENT for Residents and Young Sur- geons: This CD uses an interactive/lecture format to equip residents and young surgeons with the knowledge to manage their personal financial future, including debt management and financial planning for surgical practice. This program provides a printable CME certificate upon successful completion.

 PRACTICE MANAGEMENT for Residents and Young Surgeons: This CD uses an interactive/lecture format to equip residents and young surgeons with the knowledge to manage their surgical future, including how to select a practice type and location, the mechanics of setting up or running a pri- vate practice, the essentials of an academic practice and career pathways, and surgical coding basics. This program provides a printable CME certificate upon successful completion.

 BARIATRIC SURGERY PRIMER: This CD addresses various aspects of bariatric surgery, including the biochemistry and physiology of obesity, appropriate candidates, basic bariatric procedures, comorbidity and outcomes, and surgical training, as well as facilities, managed care, liability  NEW: DISCLOSING SURGICAL ERROR: issues, and ethics. VIGNETTES FOR DISCUSSION: This DVD demonstrates two approaches used by a surgeon to disclose to the patient’s  ONLINE CME: Courses from the ACS’ Clinical Con- family a major technical error that occurred in the operating room. gresses are available online for surgeons. Each online course The vignettes demonstrate effective disclosure techniques, as well features a video introduction, slideshow presentations with as approaches that need improvement. This project was supported synchronized audio of session, printable written transcripts, by a grant from the Agency for Healthcare Research and Quality and printable CME certificate upon successful completion. The and is available at no cost. courses are accessible at www.acs-resource.org.

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 tel. 866/475-4696.

All-Products-Ad-Bulletin-(revise1 1 3/15/2007 3:50:16 PM From my perspective

any surgeons and other medical pro- fessionals apparently are getting the

message: Our nation’s health care sys-

Mtem is on the verge of historic reform, and either we contribute to efforts to stimulate the delivery of value-based care, or we will suffer the repercussions of regressive thinking. In light ’’ of recent developments, I thought it worthwhile to review some of the innovative approaches to patient care that surgeons and other stakehold- ers are testing and bringing to the negotiating table. Key concepts under discussion are intended I thought it worthwhile to to improve efficacy and efficiency in health care through better-coordinated care; pay for compli- review some of the innovative ance with evidence-based guidelines; and fewer costly, unsupported medical treatments. approaches to patient care that Continuous, coordinated care surgeons and other stakeholders Most patients and their physicians would agree that medical care today lacks continuity—that are testing and bringing to patients too often see subspecialist after subspe- cialist and receive little guidance in their attempts the negotiating table. to navigate our fragmented health care system. Some experts believe that more coordinated and comprehensive care aimed at treating the whole ’’ patient will reduce the complications associated Physicians, the American Academy of Family Phy- with hand-offs and poor cross-specialty commu- sicians, and the American Osteopathic Association nication. Under a model that accommodates more have recently proposed the development of the continuous care, surgeons and other physicians “advanced medical home.” Under this proposal, would lead teams of high-performance health patients would secure the services of “personal care professionals. These teams would function physicians,” who would be responsible for ensur- within multidisciplinary centers, where medical ing that patients have access to a coordinated team professionals work together to provide consistent, of specialists. Other aspects of this plan deal with cost-effective patient care. pay for performance and related reimbursement The Mayo Clinic’s Gonda Vascular Center is issues. Although certain elements of the plan are successfully applying this philosophy. Here, physi- controversial, the idea of patients having a core cians, surgeons, and allied health personnel work medical professional who can help them to make cooperatively to provide comprehensive care to informed decisions merits further consideration. vascular patients. Physical resources include all of As other medical institutions adopt a team- the imaging, laboratory, interventional, and other based approach to care, it will be interesting to equipment necessary to provide patients with the see how their outcomes compare with those at full spectrum of vascular care, including tests; facilities following a more traditional path. The interventional radiology; and surgical, ultrasound, College’s National Surgical Quality Improvement medical, and rehabilitative services. Furthermore, Program (ACS NSQIP) should prove useful in the health care professionals at the center receive generating these types of data. integrated training and credentialing and are sub- ject to uniform quality controls. Pay for compliance Other medical professionals anticipate bring- Some health networks are experimenting with ing similar concepts into the larger health care programs that reward surgical teams for adher- schematic. For example, the American College of ing to professionally crafted, evidence-based 

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS treatment guidelines. For instance, the Geisinger normal activities and avoid bed rest; using X rays Health System in Pennsylvania charges coronary and computed tomography scans only when appro- bypass patients a flat fee that includes 90 days priate; administering epidural steroid injections of follow-up treatment, thereby providing physi- judiciously; and holding off on operating until at cians with an incentive to consistently apply best least six weeks after pain onset. practices and lead teams to positive outcomes Sponsoring the California Pacific program is the and otherwise avert costly follow-up visits. Since National Committee for Quality Assurance, which Geisinger instituted this policy in February 2006, monitors health care quality and accredits health patients have been less likely to return to inten- plans. We can anticipate that in the near future sive care, have spent fewer days in the hospital, this organization will encourage other specialists and have more frequently returned home to re- to find ways to reduce waste and that Medicare cuperate, rather than going to expensive nursing and other payors will provide financial incentives centers. to physicians who do so. Geisinger attributes these successes to physician adherence to “ProvenCare” standards for bypass Moving ahead operations. Network surgeons developed a set of All of these efforts represent the bold, forward 40 guidelines for preoperative, intraoperative, and thinking that is needed to build a more efficient postoperative team members and devised proce- and effective health care system for the future. dures to ensure compliance. When the experiment Of course, these are just first steps, and we need began, all 40 steps were completed only 59 percent to closely track their effects through the sort of of the time. Now, operations are canceled when- solid outcomes research and analysis that the ever any preoperative activity is skipped. College’s scholars in residence and our Health One reason Geisinger has been able to imple- Policy Institute will be conducting. As long as ment this plan is that it maintains sophisticated surgical and medical professionals continue to electronic health records, which allow network develop these programs, conduct the studies, physicians to closely monitor both services pro- and generate the standards, the odds of arriving vided and outcomes. The College anticipates that at a system that treats surgeons fairly and that ACS NSQIP and our cancer and trauma databases provides patients with a better quality of life will could facilitate similar, more global efforts in the be much improved. future.

Reduced futility To limit waste in the future, surgeons need to do less and do it right. We need to show restraint in performing unnecessary, unproven, or futile procedures. When we engage in heroics, we some- Thomas R. Russell, MD, FACS times do more for our egos than for our patients’ health. The back pain specialists at California Pacific Medical Center, for example, are discovering the benefits of following standards that result in a more conservative course of care. California Pacific’s Back Pain Recognition Program seeks to reduce superfluous tests and procedures and to encourage physicians, surgeons, and chiro- practors to adopt treatments that have proven beneficial. More specifically, the new program urges these professionals to follow 16 evidence- If you have comments or suggestions about this or based guidelines, including helping patients to other issues, please send them to Dr. Russell at fmp@ quit smoking; encouraging patients to maintain facs.org. 

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dateline Washington prepared by the Division of Advocacy and Health Policy

On April 23, the Medicare trustees released their 2007 report re- Trustees project garding the Medicare program’s fiscal outlook. The report estimates 9.9 percent pay cut that the Medicare conversion factor used to calculate physician pay- ments will be cut 9.9 percent in 2008 and 4.8 percent to 5.4 percent each subsequent year through 2016. These cuts stem from Medicare’s use of the flawed sustainable growth rate (SGR) to calculate the conversion factor. Last December, Congress stopped a 5 percent re- duction in 2007 by freezing the conversion factor at the 2006 level. This marked the fourth piece of legislation that Congress has passed to preempt five years of cuts prompted by the SGR’s application in determining the conversion factor. (One bill prevented cuts over two years.) Congress must act again to prevent further reductions from going into effect in 2008 and in future years. In addition, the trustees’ report indicates that in 2013, general revenues are expected to exceed 45 percent of the dollars used to pay Medicare benefits. This finding demonstrates that funds generated through Medicare taxes and premiums are insufficient to keep pace with the program’s rising costs. The 2013 date is significant because the Medicare Modernization Act of 2003 requires the President to submit a proposal to Congress to preserve Medicare solvency when, in two consecutive reports, the trustees project that general revenues will exceed 45 percent of Medicare spending within the next seven years. Because this report marked the second year in a row that this projection has occurred, the President will be required to submit a proposal to Congress for containing Medicare spending. As many Fellows know, in spite of congressional action in December, payments for some services were reduced in January because of other regulatory changes that the Centers for Medicare & Medicaid Services (CMS) issued last year. The College is deeply concerned that these cuts and the pending reductions will significantly challenge the ability of surgeons to maintain financially viable practices and of patients to access the surgical care they need. The College continues to be ac- tively engaged with members of Congress and their staff in calling for measures that would base Medicare physician payments on the rising costs of practicing medicine. For a copy of the trustees’ report, go to http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2007.pdf.

Reps. Kendrick Meek (D-FL) and Wally Herger (R-CA), recently College supports introduced H.R. 1823, the Ambulatory Surgical Center Payment ASC legislation Modernization Act of 2007. The College has lent its support to the bill, which would provide a more equitable payment system for am- bulatory surgery centers (ASCs) and responds to a Medicare Payment Advisory Commission recommendation that CMS modify the ASC procedures list. More specifically, the legislation would counteract a proposed rule from CMS that calls for capping ASC payments at 62 percent of the 2008 Hospital Outpatient Prospective Payment System (HOPPS) proposed rate. H.R. 1823 would provide a more reasonable pay- ment level of 75 percent of the HOPPS. In addition, the bill would 

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS allow ASCs to receive reimbursement for any surgical services they provide, unless (1) the Secretary of the U.S. Department of Health and Human Services (HHS) identifies a specific risk associated with performing a procedure in the ambulatory setting, or (2) an overnight stay is required. Under the current rules, CMS arbitrarily adds to and deletes procedures from the ASC list, and Medicare beneficiaries are routinely denied the option of selecting an ASC as the site of service for hundreds of procedures commonly provided safely and effectively in ASCs to private-pay patients. For a copy of the College’s letter of support for H.R. 1823, go to http://www.facs.org/ahp/views/ meekletterhr1823.pdf.

On May 9, HHS Secretary Mike Leavitt announced that health HHS reports plans committed to providing patients with quality and cost infor- movement to mation now provide coverage to more than 100 million Americans. The announcement came less than a year after Secretary Leavitt value-driven care announced his Value-Driven Health Care Initiative, calling upon the nation’s insurers to make information about the quality and cost of care more transparent to patients. Soon thereafter, in August 2006, President Bush issued an Executive Order, mandating that the fed- eral government take steps to put in place the “four cornerstones” of value-driven care: health information technology, public reporting of provider quality information, public reporting of cost information, and incentives for value comparison. According to Secretary Leavitt, the steady progress toward value- driven health care is attributable to actions taken across the spec- trum of stakeholders: the federal government; half of the states; approximately 775 employers, including nearly half of the top 200 U.S. corporations; and numerous unions, communities, and physician and hospital coalitions. For more information on efforts to establish a value-driven health care system, go to www.hhs.gov/valuedriven.

On April 13, CMS announced that it had revised the interpretive Informed consent guidelines for conditions of participation related to hospital informed rules revised consent. The requirement that informed consent forms give the name of a resident participating in an operation and the tasks he or she will perform has been eliminated. Instead, the new guidelines require that the informed consent document state that the participating resident will be chosen at the time of the surgery and that the specific tasks assigned to the resident will be compatible with his or her skills. The revisions became effective immediately. For more information, including the revised guideline language, go to http://www.cms.hhs. gov/SurveyCertificationGenInfo/downloads/SCLetter07-17.pdf.



JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From the Chair of RAS-ACS: The voices of young surgeons

by Gregory S. Cherr, MD, Buffalo, NY

t was only a few years ago that I attended the first meeting of the Resident and Associate Society of the American College of Surgeons (RAS-ACS), then known as the Candidate and As- sociate Society. I clearly remember the sense of excitement as Iwe residents realized that this new committee would be a means for the voices of young surgeons to be heard by the leadership of the College. Over the ensuing years, this has proven to be true, as RAS members have joined ACS committees and advisory councils, attended Board of Regents meetings, moderated Clinical Congress plenary sessions, published an e-newsletter, and made regular con- tributions to ACS publications like Surgery News and the Bulletin. Given the opportunity by the leadership of the ACS, members of the RAS committees have worked tirelessly to address issues of concern to young surgeons. The July issue of the Bulletin—which, since 2004, has been devoted to issues of importance to young surgeons—is an excellent illustration of the contributions that young surgeons can make when given the opportunity. 

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The RAS has a Council of Representatives second-year residents and enlisted liaisons to (with members from each local ACS chapter), an help with retention of these young surgeons. The Executive Committee, and officers (determined Membership Committee is also exploring ways to by vote of the Council). A majority of the RAS’ recruit medical students into the ACS. work is done by the four standing committees, composed of volunteer members from the U.S. Issues Committee and Canada. (On a related note, the RAS is always looking for interested new members to join our The primary focus of the Issues Committee is committees.) the annual RAS symposium at the Clinical Con- gress. Last year’s very successful topic was acute Update on the RAS Committee activities care surgery and included speakers from multiple surgical specialties. This year’s symposium—ten- Education Committee tatively entitled Pay for Performance and Surgical Quality Initiatives: Will the “Generalist” and Sur- The Education Committee is charged with gical Training Survive in the New Paradigm?—will identifying educational areas of need for young explore the impact of quality initiatives on surgical surgeons. The committee, led by Anathea Powell, training and the future practice of surgery. Led MD, and Joshua Mammen, MD, has many ongo- by Hari Nathan, MD, and Mindy Williams, MD, ing projects. To help interested residents find ap- the committee has recruited a prominent panel of propriate research positions, the committee has speakers to explore this timely issue. The program developed an online database of available resident is followed by a question-and-answer session. research fellowships. Before implementation of Based on the response to previous symposia, I’m the 80-hour workweek, the committee published sure that this session will prove to be provocative the results of a resident survey regarding their and stimulating. opinions of restricted duty hours. The committee is now developing a follow-up survey to gauge Communications Committee the impact of the 80-hour workweek on resident education. The committee has also partnered with The Communications Committee, led by C. the Committee on Resident Education to develop Suzanne Cutter, MD, remains very busy and the Residents As Teachers and Leaders course, productive. This issue of the Bulletin is a shining offered for the first time in June 2007. example of the accomplishments of the committee. The RAS e-newsletter, edited by Carlos Mery, MD, Membership Committee and Wesley Francis, MD, is regularly distributed and addresses the issues and activities of young The Membership Committee of the RAS is surgeons. Because of the rapid turnover time for charged with recruiting and retaining young the e-newsletter, we are able to focus on timely members. This committee, led by Luke Brewster, topics of concern to our membership. Unsolicited MD, and Adil Haider, MD, has recruited more contributions to the e-newsletter are welcomed than 100 young surgeons to serve in the new RAS and encouraged—young surgeons are invited to liaison program. The liaisons will serve as lead- write about an issue of interest to them. The com- ers at a local level to engage young surgeons and mittee is also pursuing alternative online methods further the goals of the RAS. The committee has of interaction, such as RAS discussion groups and developed a recruiting package for the liaisons, Web logs. including a comprehensive list of ACS member- ship benefits. Our goal is to enlist two liaisons Ad-hoc committees from each surgical residency program in North America. Surgical interns continue to receive free The RAS also has ad-hoc committees to ad- first-year membership in the ACS. However, there dress other topics of interest to young surgeons. is attrition after the first year of free membership. This year we have a new committee, the Inter- The committee sent letters to all nonrenewing national Medical Graduate (IMG) Committee. 

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The ACS has many exciting activities devel- Resident and Associate Society oped by and targeted to young surgeons. The Executive Committee leadership of the ACS is committed to hearing and responding to the voices of young surgeons. chair: Gregory S. Cherr, MD With the rapid changes in the practice of surgery vice-chair: Ted A. James, MD (and training of surgical residents), the ACS has secretary: Jacob Moalem, MD engaged young surgeons to become involved in the College. With energy and enthusiasm, the  Members-at-large: RAS-ACS has responded to this call. Glenn Thomas Ault, MD Katherine Ann Barsness, MD Joshua Alan Broghammer, MD Andrew Richard Evans, MD Scott Lee Hansen, MD Joshua M. V. Mammen, MD Deepak Gopalan Nair, MD Teimour A Nasirov, MD Joshua Michael Rosenow, MD Erin Johnson Saunders, MD Neil Tanna, MD

ex-officio: Michael J. Sutherland, MD, FACS

IMGs comprise a significant proportion of sur- gical residents, practicing surgeons, and ACS Fellows. This committee is exploring methods to acclimate IMGs into surgical training as well as recruit them as RAS members. Many young sur- geons are also enthusiastic advocates of surgical volunteerism and we are working with Operation Giving Back to encourage the development of international rotations for surgical residents. The Web Portal Committee has been working to improve the appearance and content of the Dr. Cherr is assistant RAS-ACS Community on e-FACS. professor of surgery Finally, the Leadership Award Committee iden- and research assistant professor of social and tified four worthy recipients of the second annual preventive medicine, RAS-ACS Leadership Award: Gerald S. Lipshutz, State University of New MD, DDS, Los Angeles, CA; Neal Barshes, MD, York at Buffalo. Houston, TX; Awori Hayanga, MD, Ann Arbor, MI; and Arezou Tory Yaghoubian, MD, Los Ange- les, CA. We received more than 80 applications for the scholarships (which are funded by an anony- mous donor). Two recipients will attend the ACS Clinical Trials Course and two will participate in the Committee on Young Surgeons Leadership Conference in Washington, DC. 10

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS hen I was an intern, a great vascular is happening within the field. We have kept our surgeon advised me to start using my heads down, worked hard, and looked up peri- loupes. He wanted me to get used to odically to find another agency or governmental operating with them in preparation for body has restricted our practice and is trying to Wthe major vascular cases I would perform as a tell us how best to care for our patients. There is senior resident. Having completed a two-year no shame in focusing on our craft, working hard, research fellowship after postgraduate year and caring for our patients. It has become quite two, I returned to residency to find that a new clear, however, that we can no longer afford to vascular/endovascular surgeon had joined our trust in the good nature of entities outside our staff. He works without loupes and suggested field to make things fair, just, or commensurate I remove mine in order to maintain a broader with our effort. We need to remove our loupes, perspective on the surgical field. take a look around the field, and take action to improve the environment. Operating with loupes Many surgeons have been traversing their careers with the type of focus on operating that Traditionally, surgeons have pursued their ca- is at the expense of everything else. We believe reers with a loupe-like view: So focused on what that someone else will take care of the details that they are doing, they get distracted from what do not interest us and, in the end, our patients

Removing our loupes: Encouraging surgeons to develop a broader perspective for the future

by C. Suzanne Cutter, MD, New York, NY

11

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS will be well and our practices will thrive. It is Training our eyes clear that this type of thinking led to affronts to patient care, including managed care organiza- Focus on where you want to go, not on what you tions, capitated reimbursements, and exponential fear. increases in medical liability costs. —Anthony Robbins†

What do you see? When I removed my loupes, I had to train my eyes to see the fine detail enough to complete I never see what has been done; I only see what the vascular anastomosis while maintaining an remains to be done. awareness of the patient’s condition. Likewise, —Marie Curie* as each of us takes care of our patients, we need to remain abreast of current issues and, I dare As we face our future in surgery, we are expect- say, get involved either on an institutional, lo- ed to do things differently. First, we must demon- cal, regional, national, or international level. strate skills outside of the operating room such as Although the level of involvement may vary, all negotiation, public speaking, coalition-building, of our efforts combine to make us stronger and and the art of persuasion (not coercion). In the more effective as a field. future, we will be expected to be highly skilled • Get the training. When attending confer- in the endoscopy suite, at the interventional- ences, take a course on the new technology, ists’ table, and perhaps at the robotics console. spend some time on the exhibition floor, or visit Second, we must know more about government. a local or regional hospital that is already using For example, pay for performance (P4P) stands the technology. to radically change the way we care for patients • Get the facts. If everyone is talking about and the way the public interacts with surgeons. IOM reports, pay for performance, or the Com- There may be a silver lining to P4P, but accord- mission on Cancer, take a moment to research ing to most authorities, the current trajectory is it while you are waiting for the operating room not favorable. Now is the time to realize that our to turn over. work extends beyond the operating room. • Get involved. Decide how much time and It was challenging to adjust to working with effort you are willing to devote and be active. If loupes and it was also difficult to work without you cannot be active, be supportive. If you cannot them. Loupes provide a view of the field that is be supportive, be constructive. If you cannot be dazzling. Fine detail, subtle elements of anatomy, constructive, be reflective. precision…oh, the wonder of it. This view is quite a distraction from the fact that the patient’s Optimism in action systolic blood pressure is in the 80s, and the an- esthesiologist has started a little vasopressor drip The pessimist sees difficulty in every opportu- to keep things moving while he catches up with nity. The optimist sees the opportunity in every fluids, measures the hematocrit, and orders more difficulty. packed red blood cells. Likewise, when we focus —Winston Churchill‡ only on our work, we develop ill-advised tunnel vision. We become enamored with our explanation It profits none of us to allow the challenges of a recent misadventure during the morbidity and we face to become paralyzing. Contrary to mortality conference, the invitation we received popular belief, it is not too late to effect change. to be visiting professor, or the next paper we are Following are just a few examples of ways you planning to write on our impressive series of pa- can remove your loupes and take a broader tients. We have not noticed the recent Institute perspective. of Medicine (IOM) report, new Leapfrog Group †Robbins A. Awaken the Giant Within. New York: Simon & recommendations, or pending legislation. Schuster; 1992. *Goldsmith B. Obsessive Genius: The Inner World of Marie ‡Churchill W [Intro by Keegan J]. The Second World War. Curie. London: W.W. Norton & Co.; 2004. London: Warner Books; 1986. 12

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS On the front line • Participate in surgical volunteerism To respond to the call to serve on the front lines, If you cannot do any of these things, be reflective you might do the following: and do the following: • Testify before Congress • Temper the expression of your frustrations, • Join a national committee especially in the presence of medical students and • Take a national office in the College residents • Attend the ACS Leadership Conference • Set a good example through your hard work • Donate at least $1,000 ($100 for residents) • Be diligent with your duties to the American College of Surgeons Professional • Maintain good relationships with your pa- Association Political Action Committee (ACSPA- tients, colleagues, and administration SurgeonsPAC) • Donate at least $1,000 ($100 for residents) to ACSPA-SurgeonsPAC Supporting the front line For more information, visit the College’s Web If you cannot be on the front line, support those site at www.facs.org or the Web portal at www. who are by doing the following: efacs.org. Then, take the time to identify and • Donate at least $1,000 ($100 for residents) to contact your state representative. You may also ACSPA-SurgeonsPAC e-mail, call, or visit your congressional repre- • Attend national meetings sentative or senator. Now is a good time to join • Write letters to the Senate, House of Repre- your local ACS chapter and participate in the sentatives, and your state legislature meetings.  • Respond to College surveys and write in com- ments • Attend local ACS chapter meetings and broach topics of concern to surgeons

The next generation If you cannot support the front line, groom the next generation by doing the following: • Mentor a new faculty member (regardless of gender or ethnicity) • Take a resident or young surgeon to a local or regional meeting • Maintain currency on health policy and share the information with residents and young surgeons • Donate at least $1,000 ($100 for residents) to ACSPA-SurgeonsPAC • Encourage residents and young surgeons in Dr. Cutter is a general their writing and presentation skills surgery chief resident at New York Hospital Queens, Chair of the Managing yourself RAS-ACS Communica- If you cannot groom the next generation, groom tions Committee, and yourself by doing the following: Representative to the • Understand and develop an opinion on health ACS Advisory Council policy issues for General Surgery. • Work with a mentor to expand your skills and knowledge base • Treat your patients and colleagues with re- spect and professionalism • Donate at least $1,000 ($100 for residents) to ACSPA-SurgeonsPAC 13

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The future of the American College of Surgeons: Uniting two perspectives

by Ted A. James, MD, Burlington, VT; and Thomas R. Russell, MD, FACS, Chicago, IL

14

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS …The great thing in the world is not so much tinuing threats of Medicare reimbursement cuts. where we stand, as in what direction we are Given the ever-changing environment of modern moving. medicine, one wonders how the noble mission of —Oliver Wendell Holmes* the American College of Surgeons—to improve the care of the surgical patient and to safeguard Authors’ note: In this article, the authors standards of care in an optimal and ethical prac- attempt to provide insights into the future of the tice environment—will be achieved. nation’s health care system and the American Like any good leader, the College must provide College of Surgeons’ role in shaping it from two vision and direction, set new standards, and perspectives—that of a young, practicing surgeon empower its members. The challenge facing and that of an older surgeon responsible for ad- the future of the American College of Surgeons ministering the operations of this organization. is how to reach surgeons who are experiencing Dr. James has been a member of the American difficulties in their practices and provide them College of Surgeons since joining as an intern in with the tools and resources needed to assist general surgery. During this time, he has served them in addressing their concerns. Although the on various committees and worked with some of task may be daunting, we believe the current and the leaders of this Fellowship. Dr. Russell became imminent challenges that the evolving health a Fellow of the College as a young colorectal sur- care system presents offer vast new opportuni- geon and, after serving on various committees ties for the College to play a leadership role and and the Board of Regents, filled the position of to develop practical resources for young surgeons ACS Executive Director in January 2000. and surgeons-in-training.

ince its inception in 1913, the College has Leadership in quality enjoyed many proud achievements. It was a leader in the hospital standardization Quality has become the buzzword in health movement. In fact, The Joint Commission care policymaking. Readers are no doubt familiar (previouslyS known as the Joint Commission on with how both private sector and national advi- the Accreditation of Healthcare Organizations) sory organizations, such as the Leapfrog Group has its origins in the ACS’ Hospital Standards and the Institute of Medicine, respectively, have Program. had major influence in the determining the The College also pioneered the innovative course of health system reform. The issues of technique of using medical motion pictures to quality assurance and public reporting of out- educate surgeons-in-training. The organization comes are no longer matters of discussion but played a major role in the development of the rather imminent realities heavily supported by American Board of Surgery and its Residency third-party payors and public interest groups. Review Committee and set the standards for the Cardiac surgeons in New York have had their administration of surgical education research, outcomes aired in the public forum since 1991 using cancer and trauma as its model.† Many of when the Supreme Court of New York State the College’s early initiatives are still critical ruled that Newsday could print cardiac bypass and relevant today. mortality data.‡ Similar “report cards” for in- However, today’s surgeon faces new chal- dividual surgeons and treatment facilities are lenges and harsh realities, such as the possible certain to become increasingly commonplace. implementation of pay for performance, new re- Voluntary outcomes reporting programs, such as quirements for maintenance of certification, the the Physician Quality Reporting Initiative that nation’s ongoing medical liability crisis, and con- the Centers for Medicare & Medicaid Services launched this month, and pay for performance *Respectfully Quoted: A Dictionary of Quotations. Available at: are likely to be cornerstones of the future value- www.bartleby.com/73/5.html. Accessed June 12, 2007. †American College of Surgeons Archival Collections: History based health care system. of The American College of Surgeons. Available at www.facs. ‡ Zinman D. State takes docs’ list to heart. New York Newsday. org. Accessed June 4, 2007. December 18, 1991:7. 15

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Despite the many controversies concerning As we move forward in the realm of public the reliability of outcomes data and review and reporting, the College seeks to position itself not debate over whether they are accurate measures only as a resource for verifying the credentials of quality, the reality is that surgery and medi- of individual surgeons but as an accrediting cine as a whole will be much more regulated in organization of educational programs and cen- the near future. What individual surgeons are ters of care. Last year, the College launched the allowed to do in the operating room will be predi- ACS Program for the Accreditation of Education cated on their previous training, outcomes data, Institutes to verify regional skills-development and ongoing analysis of their performance. In centers. In addition, the College accredits order for surgeons to practice in such an envi- trauma, cancer, and bariatric surgery centers. ronment, they are going to need lots of “tickets” There will be more in the future. documenting what they have learned and what they can deliver. The College can be a wonderful Leadership in health policy place to obtain those tickets. The College will need to continue to develop The future of surgery will be determined educational courses that allow surgeons to at- largely through the health system reforms that tain certification at certain levels of expertise. national policymakers and leaders are crafting The College has the potential to emerge as the now. The College, therefore, cannot afford to central organization for collecting outcomes sit on the sidelines and be a passive observer of data on individual surgeons’ practices and pro- these changes. Rather, the College must grasp cesses of care. In this way, the data can be easily the mantle of leadership and assume an active and seamlessly transferred to the state licensing role in shaping the changes in our health care boards, national specialty boards, hospital privi- system. To this end, the College is in the process leging bodies, and so on. Also included on the of establishing a Health Policy Institute. This list of entities wanting access to this information think tank will be run by a surgeon and will would be third-party payors who would want to be responsible for monitoring, analyzing, and know that Dr. X provides value-based care. Sur- issuing statements on health policies that af- geons will need to support their claims of being fect our ability to provide patients with optimal providers of value-based care with high-level surgical care. data, the relevance and accuracy of which have In addition, plans are in the works to move been verified through research. We are obviously the College’s Washington Office to a new loca- moving into an era of increasingly greater ac- tion, closer to Capitol Hill. This building also countability in surgery and away from the past will be significantly larger than the current practice of judging surgeons’ skills and abilities structure, and the College anticipates being on the basis of empirical information. able to house the Washington staffs of several The surgical community will need to play an surgical specialty societies in order to facilitate active role in ensuring the veracity of the qual- collaborative efforts in surgical advocacy. The ity metrics so that appropriate benchmarks College anticipates that, by developing the and guidelines can be developed. If surgeons Health Policy Institute and improving outreach don’t help to develop and promote these qual- to the specialty societies, the organization will ity initiatives, legislators and policymakers in improve its visibility as an organization dedi- Washington, most of whom have no medical cated to and effective in surgical advocacy and background, will force their measures on us. In the political process. The College leadership light of this reality, the College is thoroughly is particularly interested in learning how the engaged in quality and outcomes research organization can become a leading contributor through the ACS National Surgical Quality to making the health system more patient- Improvement Program and the data-collection centered—that is, more focused on safety and and analysis capabilities afforded through the quality. National Cancer Data Base and the National The College has the unique opportunity to act Trauma Data Bank®. as the main representative body for all surgi- 16

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cal specialties and all surgeons, regardless of cerns about reimbursement, liability reform, whether they are in academics, private practice, and access to care. Hence, the authors encour- research, or administration. There is strength in age all practicing surgeons to make financial numbers, and it will be important for the College contributions to the ACSPA-SurgeonsPAC. to work harder to include all surgical special- It is equally important that the College reach ties and break out of the general surgery silo. out to and support the local surgical community We must realize that in order to advance into to achieve reforms at the state and local level. the future, we have to start thinking about the Former Speaker of the House Thomas “Tip” whole system, rather than what is best for the O’Neill (D-MA) is perhaps best remembered general surgeon versus the orthopaedic surgeon for coining the phrase “all politics is local,” and versus the urology surgeon and so on. grassroots activism certainly has a long his- The College must renew its commitment to tory of bringing about successful change in our building a strong, active organization working country. In the coming years, the College will on behalf of the needs of all surgeons and their need to further its commitment to working with patients. A unified surgical voice is likely to local surgical societies and state ACS chapters have a tremendous ability to influence health in dealing with local issues and struggles with policy. The simple reality is that in Washington, health care and health care reform. lobbying is a numbers game, and the squeakiest wheel gets the most oil. Community outreach Greater collaboration with our nonsurgical colleagues will also be an important step in the As important as it certainly is to have pres- future. To this end, the College has continued to ence on Capitol Hill and in the state legisla- reestablish the line of communication with the tures, the College must also rebuild surgery’s American Medical Association and has opened image within the patient community. The its membership to nonsurgeon health care pro- College needs to forge new partnerships with fessionals who are part of the operative team. patient groups and will need to be seen as an Again, when it comes to lobbying, it’s all about advocate for patient rights and a champion for power in numbers. excellence in care. Furthering patient educa- Furthermore, the College anticipates the contin- tion activities, addressing the surgical needs of ued growth and influence of the American College local communities, and ensuring patient safety of Surgeons Professional Association Political Ac- all need to be future mandates of the College. tion Committee (ACSPA-SurgeonsPAC). Lobbying This increased public visibility will be instru- strength must improve before Congress can be mental in improving and maintaining a healthy expected to pass legislation that addresses con- relationship between the surgical and patient communities in an increasingly untrusting and litigious environment. Dr. James is assistant Surgeons need to expand their patient com- professor of surgery, munications skills and attempt to better address University of Vermont our patients’ unique needs. As we improve our division of surgical oncology, Fletcher Allen outreach to patients, we can educate them about Health Care, Burling- the problems and limitations of the current ton, VT. He is Vice- medical system and how patients and surgeons Chair of the RAS-ACS. can work together to restore and improve our nation’s health care. The College has already made strides in this direction by launching a patient education Web site (http://www.facs.org/ patienteducation/index.html), as well as through the activities of Operation Giving Back, the volunteerism branch of the College (http://www. operationgivingback.facs.org/). 17

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Mentoring new leaders tance of active membership in the College, and Of course, the next generation of young sur- for those so inclined, this organization provides geons and surgeons-in-training ultimately will many avenues for participation. Let us ensure determine the future of the American College our future by taking action in the present.  of Surgeons. The College has demonstrated its dedication to identifying and mentoring new leaders through its continued support of the Resident and Associate Society and the Com- mittee on Young Surgeons. It is important to continue the development of young surgeons to act as future leaders in health care decision- making. To this end, the College presently spon- sors a scholarship in Health Policy and Manage- ment through Brandeis University (http://www. facs.org/memberservices/acshealthpolicy.html), and the Division of Education has started a new resident leadership program (http://www.facs. org/education/residentsasteachersandleaders. html). Further training opportunities for resi- dents, either during their residency or after they enter practice, will need to be made available. We also anticipate that the American College of Surgeons will be a wonderful training ground for future surgical leaders. This organization will continue to provide young surgeons with oppor- tunities to learn about the activities and affairs of the College, to develop a greater understand- ing of the intricacies of health care policy, and to help generate the metrics that will be used to further promote quality and optimize the ef- ficiency and the effectiveness of surgical care.

Conclusion

In the future, the American College of Sur- geons will continue to carry out its mission to ensure the best quality of care for surgical pa- Dr. Russell is tients. The College must work hard to achieve Executive Director of this goal and to avoid becoming irrelevant in the the College. emerging era of modern medicine. This organi- zation must continue to develop new strategies and novel approaches to quality assurance, edu- cation, outreach, and advocacy. The College has the opportunity and responsibility to affect the future of health care leadership and to become the representing body for all of surgery. But also, each individual surgeon has an im- portant role to play in shaping the future of the College and helping it succeed in its mission. The authors cannot overly emphasize the impor- 18

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The road to innovation: Emerging technologies in surgery

by Carlos M. Mery, MD, MPH, Palo Alto, CA; David T. Cooke, MD, Ann Arbor, MI; Venita Chandra, MD, San Francisco, CA; Bilal M. Shafi, MD, MSE, Palo Alto, CA; Ali Tavakkolizadeh, MD, Boston, MA; and Thomas K. Varghese, Jr., MD, Elmhurst, IL

• Edited by Dr. Mery and Dr. Cooke 19

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS hroughout the centuries, the advancement surgeons to become involved in surgical innova- of surgery has been synonymous with in- tion, and showcase some of the technical and novation or, as journalist Harold Evans technological advances currently taking place says, “inventiveness put to use.”1 Surgical in our field at large. Tinnovators have dared to challenge the “stan- dards of care” and explore alternative ways Redefining surgery to treat surgical disease. A mere look into the second half of the 20th century is all it takes As technology is allowing us to perform the to appreciate how much surgery has advanced, same procedures through smaller and smaller thanks to a few of these visionaries. Examples incisions, there is a growing concern among include John Gibbon, MD, FACS (creator of the some that the field of surgery will shrink or first cardiopulmonary bypass machine); Thomas even disappear. This obviously depends on how Fogarty, MD, FACS (developer of the vascular we define surgery. thrombectomy catheter and pioneer of the field In his editorial “What is surgery?”, Tom Krum- of vascular interventions); Joseph Murray, MD, mel, MD, FACS, analyzes how the definition of FACS (performer of the first successful human “surgery” can have an impact on the scope of organ transplant); and Mark Ravitch, MD, FACS our field. Based on his conversations with Dr. (creator of multiple pediatric surgery procedures Ravitch, he concludes that rather than a place, and developer of the modern surgical stapler). an event, or a particular procedure, surgery The last two decades have also seen the develop- is “fundamentally an intellectual discipline, ment of laparoscopy, now commonplace through- frequently involving a surgical procedure, but out the world, and the progressive development most importantly characterized by an attitude of minimally invasive surgery. of responsibility toward the care of the sick.”2 Technology is advancing at an outstanding According to this definition, shock lithotripsy is pace. At the same time, the surgeon’s view is part of urological surgery just as endovascular narrowing because of increased specialization stent graft placement for aneurysms is within and higher clinical workload. The complexity the scope of vascular and cardiothoracic surgery. of technology, combined with this narrowing The definition of surgery goes beyond perform- view, is leading to an expanding gap between ing a particular operation on a patient. Instead, surgeons and surgical technologies. Surgeons are it implies the delivery of integral care to a patient becoming less involved in the early development with the use of the most appropriate methods. of technology and leaving innovation to indus- Krummel then goes on to define a surgical try or nonsurgical clinicians. Lack of surgical operation as an act that entails two components: involvement in medical innovation may lead to an image and a manipulation. In conventional the development of ineffectual answers to the surgical procedures, the image is provided by clinical problems that afflict our patients. direct visualization of the operative field by the Surgeons, being at the forefront of patient surgeon and the manipulation is performed by care, have a vantage point that allows them to the hands and conventional instruments of the identify unmet clinical needs, characterize them, surgeon. However, both image and manipulation and conceptualize techniques and technologies to can take different forms without altering the address those needs. No one is better poised than principles and goals of the procedure. For exam- the surgeon to recognize the clinical problems ple, the image could be the one magnified by the that afflict surgical patients and to do something loupes of the surgeon, digitally transmitted from about them. It is therefore imperative for sur- a laparoscopic or endoscopic camera to a monitor, geons to be at the core of innovation, oversee the or captured by a computed tomography (CT) or ethical integration, and direct the implementa- an ultrasound and sent to a digital display. Simi- tion of effective new techniques and technologies larly, a manipulation may be performed by way of into current practice in our field. conventional surgical instruments, laparoscopic The purpose of this article is to briefly ana- or endoscopic devices, instruments connected lyze the process of innovation, explore ways for to a robotic arm, or energy sources capable of 20

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS crossing the skin without any incisions. and, particularly for medical devices, money. It is not uncommon for surgeons to stay away Who provides each of these components will from new technology as it is adapted into areas vary in every single case. Surgeons, because of that perform procedures that are very differ- their direct role in the care of patients, should ent from the procedures that they currently undoubtedly play a pivotal role in different perform. As technology advances, imaging and parts of the development. Engineers, design- manipulation techniques will certainly change; ers, and other people with technical skills will however, regardless of the type of image or ma- likely participate in the actual development of nipulation used, the principle will still be the the concept. The government may help by way same. All of the technologies being showcased of grants. Private investors and industry (such in this article—robotic surgery, natural orifice as large corporations, small startups, and so transluminal endoscopic surgery, implantable forth) will assist in translating that technology one-way bronchial valves, stereotactic radio- back to the bedside. The details of the interac- surgery, and radiofrequency ablation of lung tion between physician-innovators and industry tumors—abide by this same principle of an image have been the subject of recent debate and are and a manipulation. As such, these technologies beyond the scope of this article. Suffice it to say should be considered part of the armamentarium that physicians and industry are both essential of surgical procedures that the surgeon has in pieces of the innovation process. order to care for patients. Innovation is a discipline sand, a such, it can be learned, stimulated, and enhanced. The fol- The process of innovation lowing sections of this article describe a process by Carlos M. Mery, MD, MPH of innovation that has been followed by several serial innovators in the surgical field, albeit with Innovation is the process by which creative some differences between them.3 This process is ideas are successfully implemented. Innovation described in order to provide an overall frame- is not only about creating a new widget, devel- work to help surgeons engage more actively in oping a new process, or coming up with a new the innovation of our field. Independent of the procedure, and it is more than mere creativ- surgeon’s entry point in the development cycle ity or idea generation. Innovation entails the or the duration of his or her involvement, as identification of a problem, the generation and an inventor, he or she must have a good under- development of an idea, and the translation of standing of the entire innovation process. This that idea back to the bedside to have an impact understanding leads to optimal development. on patient care. Innovation is about creating An important characteristic of this particular value—value for patients, health care providers, process is that it starts with the identification and society. of a clinical need rather than with a particular There is a common misconception that the technology looking for an application. A good most difficult part of the process of innovation a priori characterization of the need to be solved is the creative “eureka” moment when the idea will increase the possibilities of working on first occurs to the innovator. On the contrary, it something with a significant impact. is just the beginning. A drawing on a napkin may represent the foundation for a great innovation. Step 1: Needs identification However, unless that idea is fully developed and Identification of a legitimate, yet unmet clini- physicians and patients can use it and benefit cal need is the single most important step in de- from it, it will remain just that: an idea on a veloping a successful innovation. A good solution napkin. It is the responsibility of the innovator for a suboptimal need will yield an imperfect to translate that idea into a tangible product innovation, independent of how good the solu- or procedure that can really have an impact on tion may be. Unmet clinical needs are ubiquitous patients and health care providers. in our environment, but it takes an open and Transforming an idea into a useful innova- perceptive state of mind to be able to identify tion requires time, perseverance, commitment, those needs. Stop and think throughout the day 21

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS about those clinical conundrums that bother you the most and impede the optimal care of your Suggested resource guide patients. These are usually latent problems in need of someone to solve them. The references listed in the series of resource The natural tendency after identifying a guides are presented as additional sources for the problem is to immediately think of potential reader interested in learning more about each solutions. This approach, although successful topic. sometimes, may hinder innovation. At this stage of the process, you haven’t studied the problem Innovation well enough and you may overlook better ways Books of solving it. • Evans H. They Made America. New York: After identifying a need, try to specify it in a Little, Brown and Company; 2004. single sentence that concisely summarizes what • Grossman JS. Innovative Doctoring: Solutions you are trying to accomplish. A needs state- Lie Within Us. Atlanta: Innovative Doctoring; ment—such as, “A less invasive method to reduce 2006. the pain in patients with compression fractures • Kelley T. The Art of Innovation. New York: of the spine”—is a powerful tool that delineates Currency Doubleday; 2000. the characteristics of the problem at hand and helps you generate possible solutions. Article Gertner, M. You have an idea, now what? Semin Pediatr Surg. 2006;15:302-8. Step 2: Need validation and specification Once a need has been identified and a need Web sites statement created, perform extensive research • BME Source. www.bmesource.org. (Organized in order to fully understand the problem. Talk and edited Web portal with links to medical, to people who may face the same issue but engineering, and business resources related to might have different perspectives (for example, biomedical engineering). patients, nurses, and so on). Read the literature. • FreePatentsOnline. http://www.freepatents Talk to other colleagues. Become an expert. You online.com. (Free site for searching U.S. and Eu- will find that this process will give you a differ- ropean patents and patent applications). • USPTO. www.uspto.gov. (Official site of the ent insight and allow you to rephrase the need U.S. Patent and Trademarks Office). statement in a more specific way. Create a list of “requirements” that your solu- tion must have in order to fully solve the problem identified. Which of those requirements does your solution have to have (musts) and which of those items on the list would be advantageous as some of the most innovative ideas in medicine for your solution to have (desirables)? have come from the application of concepts that previously had been used to solve nonmedical Step 3: Idea generation problems. Once the clinical need is well characterized, Idea generation is an iterative process that try to generate possible solutions. Most innova- may require several brainstorming sessions, tors in the field have formal or informal “brain- going back to experts in different areas (for ex- storming” sessions.4 In general, three to five ample, clinical, technical, and product develop- creative and open-minded people get together ment), or answering questions that arise from for one or two hours to find as many solutions the previous sessions. The need statement and as possible to the problem being studied. A mix the solutions being generated may change as of people with some clinical depth and people the process evolves. Once a series of concepts with some technical expertise (in any area) is have been generated, these concepts are as- adequate for a brainstorming session.5 Try to sessed in terms of feasibility, novelty, possible get people with different experience than you, efficacy, regulatory burden, and how well these 22

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS concepts fulfill those items previously specified find people interested in continuing with its as requirements. development.

Step 4: Prototyping Step 6: Development plan Prototyping, or creating a visual demonstra- The development pathway of an idea after tion of a concept, is a useful tool to help the initial prototyping varies depending on the par- inventors better conceptualize their ideas and, ticulars of the project. Usually the next step after most importantly, to answer some simple ques- initial development is to find the right people tions about that idea. For example, will magnets to help with development—that is, to create a be strong enough to pull apart the tissue? Will multidisciplinary team. It is impossible for a an endoscope allow for adequate visualization single inventor to transform an invention into when placed inside a balloon? A prototype does a product ready for patient care. Different team not need to be an elaborate device that performs profiles are required at different stages of the the function that the final device will accomplish. development. The initial team may require a set On the contrary, the simpler the prototype, the of people with deep clinical and technical exper- better. Simple prototypes will enhance creativity tise, whereas a later team may need experts in and may prompt the inventors to change their regulatory affairs, clinical trials, manufacturing, concept in unexpected ways. As the idea evolves, and administration. more complicated prototypes can be created in Once the team is assembled, a development order to provide some “proof of principle” that plan is designed based on different milestones. the concept is likely to indeed solve the particu- The particular milestones will depend on the proj- lar need. ect itself but may likely include project financing, acute and chronic animal testing, human testing, Step 5: Intellectual property regulatory process, and commercialization. A patent gives the inventors the right to “ex- Funding is one of the most important aspects of clude others from making, using, offering for the project because without funding, an innova- sale, or selling” the claimed invention.6 A good tion will never be realized.5 The most common patent gives significant value to a concept, mak- forms of funding are government-sponsored (in ing it more likely for a company to try to trans- the form of research grants, development grants, late that particular technology in the future. or small business grants), angel or venture Submitting a patent can be an expensive and capital investments, or corporate sponsorship complicated feat and the details of this process from major corporations. The type of funding are beyond the scope of this discussion. Suffice sought out will obviously depend on the scope of it to say that the U.S. Patent and Trademarks the project and on the ultimate intention of the Office (USPTO) offers a fast and efficient way to innovators. obtain initial protection for your idea. For $100, An important decision that the physician- an inventor can send a “provisional patent” that inventor will face is how far he or she wants to can be as simple as a drawing on a napkin or go with the idea. Some inventors accompany as complicated as a formal document specifying the product throughout the process, up to the all the details of the invention. This provisional first use in patients or even commercialization. patent serves as a 12-month “placeholder” for Other inventors start the project and take it to a formal patent application and sets a priority varying points before transferring the project to date, that is, the date when the rights of a pat- others willing to take it forward. The extent of ent would begin if a patent is eventually filed involvement is essentially a matter of personal and approved. If a formal patent application is preference. Regardless of the ultimate decision not sent to the USPTO within 12 months, the and direction of the project, surgeon involvement priority date of the provisional patent is lost. will undoubtedly help with the development of These 12 months provide a window of time to the concept and, ultimately, with the ethical and allow the inventors to talk to people about their responsible incorporation of effective technology idea, define if an idea is feasible to pursue, or into patient care. 23

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In the following sections, five emerging tech- nologies that are the products of the careful Suggested resource guide application of the process of innovation will be presented. Robotic surgery Emerging technologies Book Gomez G. Emerging technology in surgery: I. Robotic surgery Informatics, electronics, robotics. In: Townsend by Venita Chandra, MD CM, Beauchamp RD, Evers BM, Mattox K, eds. Sabiston Textbook of Surgery. 17th ed. Philadel- Decades ago, computer-enhanced robotic phia: Elsevier Saunders; 2004. surgical systems were originally conceived as a military tool for remote surgical care of the Articles injured soldier on the battlefield. By the late • Camarillo DB, Krummel TM, Salisbury JK Jr. 1990s, rapid advances in computer science and Robotic technology in surgery: Past, present, and future. Am J Surg. 2004;188:2S-15S. robotics technology have helped bring a num- • Satava RM. The future of surgical simula- ber of surgical robotic systems into the modern tion and surgical robotics. Bull Am Coll Surg. operating room. These systems come in a wide 2007;92(3):13-19. variety, ranging from simple adjustable arms supporting instruments or cameras to automat- Product information ed fixed-path robots with programmed motion Intuitive Surgical da Vinci Surgical System of- planning based on preoperative imaging studies. ficial Web site. http://www.intuitivesurgical.com/ The most frequently used surgical robot today products/davinci_surgicalsystem/index.aspx. is a tele-operating system called the da Vinci Surgical System® (Intuitive Surgical, Sunnyvale, NOTES CA), a sophisticated, multi-armed machine that Article enables complex endoscopic procedures. What Baron TH. Natural orifice transluminal endo- makes this type of robotic system attractive scopic surgery. Br J Surg. 2007;94:1-2. (Overview stems from its ability to overcome many of the of the history, current status, and challenges of limitations of conventional endoscopic tech- NOTES). niques such as difficulties with dexterity and 7 Web site challenges of two-dimensional optics. Official Web site of the Natural Orifice Surgery The da Vinci Surgical System is composed of Consortium for Assessment and Research. www. two major components. The first component is noscar.org. the surgeon’s console, which can be placed up to 10 m away from the operating table and contains the following: (1) the surgeon’s control handles that direct movements of the robotic arms inside the patient’s body, (2) the visual display, and (3) the user interface panels. The second com- would otherwise be nearly impossible using ponent is the patient’s side cart, which consists standard techniques. In addition, one of the of two or three arms that contain the operative innovative features of this device is that the instruments and another arm that controls instruments are “wristed,” thus providing up to the video endoscope.8 Highly magnified three- seven degrees of freedom. This enhances dexter- dimensional stereoscopic images, in combination ity compared with standard minimally invasive with improved hand-eye coordination, tremor surgical instruments, which allow for only five filtration, and motion scaling are features of the degrees of freedom.9 da Vinci Surgical System, which allow delicate There are a number of limitations with robotic motions in small areas, thus enabling surgeons surgical systems, which restrict their widespread to perform minimally invasive procedures that adoption. Current teleoperating systems such 24

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS as the da Vinci lack the ability to provide force II. Natural orifice transluminal endoscopic feedback or “haptic” input. Instead, the operat- surgery (NOTES) ing surgeon must rely on visual cues such as by Ali Tavakkolizadeh, MD tissue compression and blanching, and suture stretch (such as knot deformation) to determine The definition of minimal access surgery is con- the tensile strength of tissue and sutures. In tinuously expanding. In the field of gastrointesti- addition, robotic surgical systems generally are nal surgery, minimal access surgery has become substantially more expensive and more complex synonymous with laparoscopic surgery, where an than conventional techniques, often resulting in increasing body of data has documented the safety longer operating room times as well as increased and superiority of laparoscopic approaches over total costs.9,10 open surgery. The key question is not how success- To date, the majority of published clinical ex- ful laparoscopy is today, but rather how the field of perience using robotic technology has consisted minimal access surgery will develop in the future primarily of retrospective case reports and case with key interest in developing new concepts that series. Robotic surgical systems have been used will lead to even less invasive procedures. in many different surgical disciplines including A developing field is endoluminal therapy, general surgery, urology, cardiac surgery, gyne- which allows endoscopists to perform procedures cology, and pediatric surgery. Initially, robotic previously in the domain of open or laparoscopic technology was used primarily in procedures surgeons. More recently, endoluminal therapy that were already performed laparoscopically, has been taken a step further with investigators such as cholecystectomy, splenectomy, and breaching the luminal barrier to access the peri- Nissen fundoplication. With these procedures, toneal space and performing procedures translu- robotic and standard approaches yield similar minally. This approach avoids the need for any clinical results; however, given the longer abdominal incisions and has been referred to as preparation and operating room times, using a “scarless surgery,” or natural orifice transluminal robot for routine cases does not appear to offer endoscopic surgery (NOTES). a significant advantage. Nonetheless, there is Anthony Kalloo, MD, from Johns Hopkins literature that supports the adoption of robotic Hospital, published the first paper on a NOTES technology to enable surgeons to perform more procedure using a porcine survival model.13 After complex reconstructive procedures, such as the lavaging the stomach with antibiotic solution, Kasai procedure, coronary revascularization, gastrotomies were made with a needle-knife and especially transpubic radical prostatec- puncture. The peritoneal cavity was insufflated tomy. Robot-assisted prostatectomies have with air using the endoscopic air channel and ex- been shown to be associated with significantly ploratory peritoneoscopy and liver biopsies were reduced blood loss and similar if not decreased performed. risks of incontinence and impotence. These An expanding body of the literature has con- benefits have resulted in a substantial increase firmed the feasibility of a variety of transluminal in patient and urologist demand for robotic procedures, including tubal ligation, gastroje- technology.9-12 junostomy, nephrectomy, pancreatectomy, and The future of robotic surgery lies in its ability splenectomy. Transluminal access for gallbladder to extend the boundaries of a surgeon’s skill. Al- surgery has been evaluated by a number of stud- ready, procedures once thought to be impossible ies, using both transgastric and transcolonic ap- to perform with minimal access are now done proaches. Although transgastric and transcolonic routinely. Exciting prospects for robotic technol- have been the most reported routes, other natural ogy in the future include development of high- orifices, namely the vagina and urethra (transvesi- fidelity force sensors to improve tactile sensa- cal), have also been used.14 These animal studies, tion, device miniaturization to allow surgeons all performed in pigs, have proved the feasibility to access increasingly remote anatomy, and and short-term safety of NOTES. increasingly sophisticated graphic interfaces The reported, but as yet unpublished, case involved in image-guided procedures. of a transgastric appendectomy performed by 25

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS N. Nageshwar Reddy, MD, FRCP, DSC, and G. it will likely take some time for NOTES to gain Venkat Rao, MS, MAMS, from Hyderabad, India, professional acceptance. However, hopefully we, is regarded as the first case of a NOTES proce- as a profession, are prepared to evaluate this dure in humans.15 There are currently multiple concept without bias and get involved in its approved or pending institutional review board evolution. protocols for NOTES procedures in humans in Many have asked who will be performing the U.S. Although a true, completely translu- NOTES procedures: surgeons or gastroenterolo- minal endoscopic NOTES procedure has not gists? The answer is unclear at this time and may yet been performed in this country, some have require “hybrid training” for those interested. reported on laparoscopic-assisted transvaginal Going beyond the “natural” boundaries of medi- cholecystectomy. Such hybrid procedures are cal specialties may enrich all sides. An interdisci- likely to be the next step in the human applica- plinary and collaborative effort will be the most tion of this concept. beneficial approach in this field. Surgeons are Recognizing the potential impact of this new well positioned to be actively involved in this technology, a meeting of the expert representa- field, and ultimately perform new and innovative tives from the Society of American Gastroin- procedures with potential benefits to patients. testinal Endoscopic Surgeons (SAGES) and the American Society of Gastrointestinal Endoscopy III. Minimally invasive treatment of emphysema (ASGE) was organized in 2005 to identify the with implantable bronchial valves potential applications and the challenges facing by David T. Cooke, MD this novel field. During their meeting, the panel identified eight fundamental barriers to clinical Chronic obstructive pulmonary disease (COPD) application of NOTES and proposed guidelines is a devastating disease that significantly affects and a road map to the development of this field the U.S. health care system. COPD is the fourth and its eventual human application. Their rec- leading cause of death in this country, with ommendations have been published in a white 123,884 deaths in 2004.16 Among patients with paper.15 A joint subcommittee between the two COPD, emphysema affects 2 million patients and societies, NOSCAR (Natural Orifice Surgery is characterized by alveolar wall destruction and Consortium for Assessment and Research), was coalescence of alveolar units. Loss of elastic recoil also set up. NOSCAR has a dedicated Web site results in hyperinflation of emphysematous lung (www.noscar.org), a useful resource for those and impairs the function of spared lung. interested in this field. NOSCAR is gaining The surgical approaches for emphysema in- increasing momentum with recent funding op- clude lung transplantation and lung volume portunities through the society in the area of reduction surgery (LVRS). LVRS, by resection transluminal surgery. NOSCAR will likely take of hyperinflated nonfunctional lung tissue, on an increasingly important role in coordinat- improves the mechanics of the remaining lung, ing NOTES research and developing a NOTES respiratory muscles, and diaphragm. LVRS was patient registry as human studies begin. first described in the 1950s with limited success, NOTES is an exciting new concept and holds and because of high mortality, the procedure promise to become a useful technique in some was abandoned until the 1990s when Cooper clinical settings. To fulfill this potential, however, et al described LVRS via a median sternotomy there is a need for extensive research into the and use of reinforced stapling techniques.17 LVRS physiological changes and potential complica- can also be performed by video-assisted thoracic tions of this technology. There is also a critical surgery. need for new devices that will allow reliable The National Emphysema Treatment Trial closure of enterotomies, as well as endoscopic identified specific subgroups of emphysema suturing and visualization. As demonstrated patients who benefit from LVRS; patients with through the advent of laparoscopy, surgeons are primarily upper lobe disease and poor exercise slow in adopting new technology, and therefore, tolerance demonstrate improved quality of life even after overcoming the technological hurdles, and survival, and patients with primarily upper 26

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Intrabronchial Valve (Spiration IBV®, Spiration Suggested resource guide Inc., Redmond, WA) is a nitinol umbrella-shaped implant covered with a synthetic polymer. The device can be delivered through the working Bronchial valves channel of a flexible fiber-optic bronchoscope, Articles and the umbrella opens to conform to the tar- • Fishman A, Martinez F, Naunheim K, et al. geted airway. The device can be removed via the A randomized trial comparing lung-volume re- bronchoscope by grasping the central bar. The duction surgery with medical therapy for severe second-generation Emphasys Endobronchial emphysema. N Engl J Med. 2003;348:2059-2073. Valve (EmphasysTM EBV, Emphasys Medical, (Classic multi-institutional randomized study Redwood City, CA) is composed of a nitinol identifying patient subpopulations that would framework with a silicone seal, and a silicone benefit from LVRS) internal one-way valve. Unlike the Spiration • Wan IY, Toma TP, Geddes DM, et al. Bron- IBV, the device does not expand when deployed. choscopic lung volume reduction for end-stage emphysema: Report on the first 98 patients. Fine placement is achieved with the use of the Chest. 2006;129:518-526. (The largest multi- bronchoscope and a guidewire-based delivery institutional trial evaluating the use of implant- system. The third-generation Emphasis Zephyr able valves) EBV is a self-expanding nitrol valve similar to the • Wood DE, McKenna RJ Jr, Yusen RD, et al. Spiration IBV. The umbrella-like device is passed A multicenter trial of an intrabronchial valve down the working channel of the bronchoscope for treatment of severe emphysema. J Thorac and self-expands in the appropriate bronchus, Cardiovasc Surg. 2007;133:65-73. (First multi- facilitating its placement into the airway. The instutional trial evaluating the Spiration im- device can be removed if needed. plantable bronchial valve) Wood and colleagues have published a phase I multicenter clinical trial evaluating the Spiration IBV.21 In this study, 30 patients with primary upper lobe emphysema were treated on average with six implantable devices. Minimum follow-up lobe disease and high exercise tolerance demon- was six months. There were no adverse events strate improved quality of life but no significant that the authors definitively associated with increase in survival.18 Despite the benefits of the valves, and there was no evidence of valve LVRS, it is an invasive procedure with a number migration, erosion or valve-induced hemopty- of potential complications. Morbidity includes, sis, or death. Patients demonstrated significant but is not limited to, persistent air leak (~40%) improvement in quality of life as measured by and pneumonia (~11%), and mortality is between the St. George’s Respiratory Questionnaire, but 5 percent and 16 percent.18-20 there were no significant quantitative improve- Because of these drawbacks of LVRS, mini- ments in functional benchmarks such as forced mally invasive approaches to the treatment of expiratory volume in one second (FEV1), lung emphysema are being developed. One of these volume, diffusing capacity for carbon monoxide innovations is the bronchoscopic treatment of (DLCO), and six-minute walk distance (6MWD). emphysema with implantable one-way bronchial A broader, randomized, blinded clinical trial, valves. These valves are implanted in the seg- the planned IBV Valve Trial, will compare the mental bronchi of hyperinflated lung and allow treatment group receiving Spiration IBV valves air and secretions to egress but do not allow with a control group not receiving valves.22 The air to enter the target airway. The objective is treatment cohort will be monitored up to five to allow passive atelectasis of emphysematous years. segments and redistribute ventilation to normal There are numerous studies evaluating the lung segments. Emphasys EBV. Wan et al recently reported the Three current bronchial valves have been first multicenter study using the Emphasys extensively studied. The Spiration Implantable EBV.23 In this study, 98 patients were treated 27

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS with an average of four valves per patient and as X rays,25 is now known to be part of the electro- follow-up was 90 days. There was one death (a magnetic spectrum that includes light and con- patient who developed pneumonia in a treated sists of photons or packets of energy. The ionizing lobe). Despite variations in target lobes (up- radiation is either produced in the form of X rays, per and lower lobe emphysema), and patient generated by the destabilization and restabiliza- selection between institutions, the study dem- tion of a stable atom, or gamma rays, produced onstrated significant improvements in forced by the radioactive decay of radioactive substances vital capacity (FVC), residual volume, FEV1, and such as Cobalt-60. Initially, the amount of energy 6MWD. The Endobronchial Valve for Emphy- that could be produced by radiation sources was sema Palliation Trial will evaluate the Emphasys small, subsequently limiting the use of radiation Zephyr EBV.24 This trial will randomize patients to diagnostic applications or treatment of super- with heterogeneous emphysema to either treat- ficial pathological lesions such as skin cancer. As ment with the Emphasys Zephyr EBV, or medical technology advanced, radiation sources produced management. higher doses of ionizing radiation, allowing for Treatment of emphysema with implantable deeper tissue penetration. Most recently, modern one-way bronchial valves shows promise. Studies linear accelerators, or LINACs, have allowed the including the reports mentioned in this section production of very high amounts of energy that and others demonstrate both qualitative and can be manipulated through various filters and functional improvements in patients with em- beam-conforming collimators to accurately target physema. It is interesting to note that all studies deep-seated diseased tissue. have achieved their results without demonstrat- Radiation affects biological tissue in a complex ing consistent atelectasis of hyperinflated seg- manner.26 Photons—whose energy is character- ments targeted by implanted bronchial valves. ized by the rad (radiation-absorbed dose) or, This suggests that bronchial valves may improve more recently, the Gray (energy deposited per lung function in a different manner than classic kilogram of tissue)—destabilize the atoms of LVRS without definitively eliminating hyperin- biological tissue at a specified depth depending flated tissue. In addition to emphysema, one can on the initial energy. This destabilization leads imagine other indications for bronchial valves, to an energy release that can affect the cells ei- such as bronchopleural fistulas or hyperinflation ther directly by damaging the deoxyribonucleic syndromes. acid (DNA) or indirectly through the creation of oxygen free radicals that can then damage the IV. Stereotactic radiosurgery DNA. The resulting DNA damage can lead to by Bilal M. Shafi, MD, MSE permanent injury, apoptosis, genetic mutation, or repair depending on the sensitivity of the Stereotactic radiosurgery (SRS) has emerged cells to radiation and the stage of the cell cycle. as a novel technique to eliminate pathological Ultimately, the lethality of ionizing radiation tissue with minimal effects to the surrounding depends on the extent of DNA damage and the normal tissue. This technology employs two main cell’s capacity for repair. concepts to achieve this goal. First, it localizes Radiation therapy was used as early as 1899 the diseased tissue with a combination of imag- to treat basal cell cancer but its use was lim- ing techniques and both artificial and anatomical ited because of the collateral damage to nor- landmarks. Then, it delivers a high dose of ioniz- mal skin.27 In 1932, Claude Regaud and Henri ing radiation to ablate the pathological tissue. To Coutard found that delivering a number of ensure that surrounding tissue is not damaged, smaller doses of radiation in multiple sessions multiple low energy beams of ionizing radiation over a longer period of time eliminated the are fired from multiple directions. At their point pathological tissue while sparing the surround- of intersection, which happens to be the location ing normal tissue. Later, it was determined of the diseased tissue, the level of ionizing radia- that these advantages were based on the four tion increases to ablative levels. principles of radiobiology: repair, redistribu- Radiation, first discovered by Roentgen in 1895 tion, repopulation, and reoxygenation. Smaller 28

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS multiple doses (that is, fractionation) limit the disease without exacting collateral damage. damage to normal tissue and allow the cells to Because this therapy should be seen as within repair themselves before the next dose. At the the scope of “surgical treatment” of disease, same time, fractionation allows pathological it is imperative for all general surgeons to un- cells to redistribute themselves into more radio- derstand and consider incorporating this new sensitive cell cycle phases and previously less- technique into their tool arsenal for treating perfused tumor cells to reoxygenate so that more surgical disease. oxygen free radicals can be generated. Overall, this promotes the eradication of some rapidly V. Radiofrequency and radiosurgical proliferating cancer cells while relatively sparing ablation of thoracic tumors normal and slowly proliferating tissue. by Thomas K. Varghese, Jr., MD Unfortunately, fractionated radiotherapy is ineffective against some slowly proliferating Lung cancer is the leading cause of cancer- cancer tissues. In 1951, Lars Leksell, MD, PhD, related mortality in U.S. men and women. It a Swedish neurosurgeon, developed the concept was estimated that 174,470 new cases of lung of SRS. Using a rigid frame attached to the cancer (92,700 in men, and 81,770 in women) patient’s skull, he was able to deliver multiple would be diagnosed in 2006 and that the disease low-energy beams fired from different directions would lead to 162,460 deaths (90,330 in men, to converge on a specified target in the cranium 72,130 in women).28 Only 15 percent of all lung with minimal damage to surrounding tissue. cancer patients are alive five years or more This ultimately resulted in the Gamma Knife™ after their diagnosis. Surgical resection offers (Elekta, Stockholm, Sweden), which is still in the best chance for cure in early stages, with use today. This device was limited to intracranial five-year survival rates of 67 percent for stage I targets because it required a rigid frame to be and 57 percent for stage II. Unfortunately, only attached to the patient. With the development 10 percent of patients will have stage I disease of the LINAC, a number of systems, including and 20 percent will have stage II disease. Cyberknife™ (Accuray, Sunnyvale, CA) and Early-stage patients with multiple comor- ExacTrac X-ray 6D™ (BrainLAB AG, Munich, bidities who are not surgical candidates are Germany), have allowed the delivery of targeted typically offered conventional external beam radiation without the use of rigid frames. In- radiotherapy as treatment, with reported five- stead, these systems use radiological imaging year survival rates of 10 percent to 20 percent.29 and a combination of anatomical landmarks Chemotherapy in this patient population is and markers placed in the body to target the palliative in nature. The lung is also the sec- lesion. The Cyberknife uses a LINAC attached ond most frequent site of metastatic disease, to a robotic arm to deliver the radiation from and several studies have reported surgical multiple directions while the Exactrac rotates resection of pulmonary metastasis as a viable the patient around a fixed beam. Both systems option for treatment. However, often the num- open up the possibility of fractionated radio- ber and location of the lesions would require surgery and radiation therapy to extracranial a sacrifice of too much functional lung tissue. targets. These systems also allow more accurate Surgical resection in patients with widespread delivery of radiation to nonuniform lesions and metastatic disease often compromises quality of lesions located next to critical structures. life. As a result of these dismal outcomes, newer The development of SRS has allowed the treatment modalities have been used in thoracic expansion of delivering radiation to previously surgery, such as CT-guided radiofrequency abla- overlooked targets. With the help of various tion (RFA) and SRS. tracking devices to account for respiratory motion, lesions in the lung, liver, and kidney RFA can now be treated. Ultimately, SRS provides RFA is a thermal energy delivery system, patients with unresectable disease another op- where a probe is introduced percutaneously tion that could potentially help palliate their under ultrasound or CT-guidance into the tumor, 29

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS with deployment of multiple tines. The tines al- low for maximal distribution of energy. Radiofre- quency energy is then applied in order to achieve Suggested resource guide a temperature greater than 60°C (in most cases 90°C). Thus, coagulative necrosis of the tumor Stereotactic radiosurgery/ is induced in a controlled manner. This method Radiofrequency and radiosurgical has been successfully used for the treatment of ablation of thoracic tumors hepatocellular carcinoma, hepatic metastases, osteoid osteoma, and other solid tumors. The Book Smith RP, McKenna WG. The basics of ra- first percutaneous RFA of a lung tumor was 30 diation therapy. In: Abeloff MD, et al. Clinical reported by Dupuy et al in 2000. They treated Oncology. Philadelphia: Elsevier Churchill three patients for whom the main purpose of Livingstone; 2004. (Overview of the physics and RFA was palliation, with results that were tech- biology of radiation therapy) nically successful and uneventful. Others have applied the technique to pulmonary tumors with Articles promising preliminary results.31 These studies • Dupuy DE, Zagoria RJ, Akerley W, et al. have reported a good local response, tolerability, Percutaneous radiofrequency ablation of malig- and a very low rate of complications. However, nancies in the lung. AJR. 2000;174:57-59. (First they have a short follow-up period and little is description of radiofrequency ablation of lung tumors) yet understood about the efficacy of RFA in the • Kavanagh BD, McGarry RC, Timmerman mid- to long-term. Initial experience suggests RD. Extracranial radiosurgery (stereotactic body that RFA is most effective for lesions smaller radiation therapy) for oligometastases. Semin than 3 cm and for metastases. When compared Rad Oncol. 2006;16:77-84. with surgery, as expected, there is a higher re- • Pennathur A, Luketich JD, Burton S, et al. currence rate locally and in the mediastinum. Stereotactic radiosurgery for the treatment of Caution for use of RFA is needed in those pa- lung neoplasm: Initial experience. Ann Thorac tients with high pulmonary arterial pressures Surg. 2007;83:1820-1824. (Study that reports and central lesions, as there have been reports some early results with stereotactic radiosurgery of increased risk of hemoptysis. for lung tumors and provides a background of the technology) SRS for lung cancer Failure to attain local control has been one of the biggest obstacles blocking the success of ra- diotherapy for many common epithelial cancers, including lung cancer and a variety of metasta- has become standard treatment for intracranial ses in solid organs. Higher radiation doses will tumors in many centers. However, unlike the enhance local control. However, increased doses brain, respiratory motion creates difficulties in of radiation will also result in increased toxicity the delivery of precise radiation to lung tumors. and damage to surrounding lung parenchyma. These respiratory displacements are greatest SRS was developed in response to a clearly identi- near the diaphragm and least near the lung fied need in oncology to improve local control of apex and adjacent to the carina. One option is deep-seated tumors. the use of breath-holding techniques, sometimes SRS provides selective delivery of an intense in combination with an abdominal compression dose of high-energy radiation to destroy a tumor device, to limit the ability of the diaphragm to with precision targeting (see the “Stereotac- move caudally. tic radiosurgery” section of this article). The Another option is the use of a frameless improved accuracy is achieved by very precise system such as the Cyberknife Stereotactic Ra- spatial localization of the tumor and the deliv- diosurgery System. The Cyberknife system con- ery of multiple cross-fired beams of radiation sists of a 6-MV linear accelerator mounted on a to converge upon the tumor. This technology computer-controlled robotic arm. Before 30

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS initiating treatment, fiducials (small tumor Conclusion markers that are seated percutaneously with CT-guidance for precise localization) are placed The involvement of surgeons in the develop- adjacent to the tumor. The addition of the ment, testing, and adoption of new techniques Synchrony™ option enables dynamic radio- and technology is of paramount importance for surgery during respiration. The Synchrony the future growth of our field. Surgeons, with option records the breathing movements of a their unique perspective in terms of patient care, patient’s chest and combines that information should actively engage in identifying unmet with sequential X-ray pictures of the fiducials clinical needs and in developing adequate solu- to facilitate delivery of radiation during any tions for these needs. point in the respiratory cycle. This allows fur- Emerging technologies such as bronchoscopic ther precision with radiation delivery (reduc- valves for emphysema, robotic surgery, SRS, ing normal tissue exposure) and is also more transluminal endoscopic surgery, and RFA comfortable for patients because of the shorter of tumors are examples of new tools that the treatment times compared with breath-holding surgeon now has to enhance the treatment techniques. of his or her patients. It is only with an open Whyte and colleagues provided the first re- and a flexible mind that we, as surgeons, will port from the U.S. using a similar system for rise above the usual definition of surgery as a frameless SRS in 23 patients treated with a particular procedure and embrace the variety single fraction of 15Gy.32 The mean follow-up of tools that are now (and will be in the future) was seven months and the reported response at our disposal.  rates were complete in two patients, partial in 15, stable in four, and progressive in two. References Pennathur and colleagues at the University of Pittsburgh recently reported their results 1. Evans H. They Made America. 1st ed. New York: Little, Brown and Company; 2004. in 32 high-risk patients treated with SRS for 2. Krummel TM. What is surgery? Semin Pediatr lung neoplasms.33 A median dose of 20 Gy Surg. 2006;15:237-241 was administered in a single fraction. This is 3. Stanford Biodesign Surgical Innovation Program. equivalent to a biologically effective dose (BED) Biomedical Innovation, Surgical Innovation, and Beyond. Available at: http://surgery.stanford. of 60 Gy to 70 Gy. A total of 32 patients, 27 edu/innovation/BeyondInnovation.pdf. Accessed with nonsmall cell lung cancer and five with April 28, 2007. pulmonary metastases, underwent SRS over a 4. Kelley T. The Art of Innovation. New York: Cur- two-year period. The median overall survival for rency Doubleday; 2000. the entire group was 26 months. Onishi evalu- 5. Gertner M. You have an idea, now what? Semin Pediatr Surg. 2006;15:302-308. ated the clinical outcomes in 245 patients with 6. U.S. Patent and Trademarks Office. Gen- stage I non-small cell lung cancer from 13 Japa- eral information concerning patents. Available nese institutions.34 The overall response rate at: http://www.uspto.gov/web/offices/pac/doc/ was 13.5 percent. A lower recurrence rate was general/index.html#ptsc. Accessed April 28, 2007. seen when BED greater than 100 Gy was used. 7. Camarillo DB, Krummel TM, Salisbury JK Jr. Overall three-year survival was 56 percent. Robotic technology in surgery: Past, present, and Caution is needed when using high-dose radia- future. Am J Surg. 2004;188:2S-15S. tion, as there have been reports of peribronchial 8. Intuitive Surgical. The da Vinci Surgical System. abscesses and hemoptysis.33 Available at: http://www.intuitivesurgical.com/ products/davinci_surgicalsystem/index.aspx. Ac- Surgery clearly remains the best treatment cessed April 27, 2007. for resectable lung cancer. However, newer 9. Gomez G. Emerging technology in surgery: Infor- modalities such as RFA and SRS may play a matics, electronics, robotics. In: Townsend CM, role in medically inoperable patients. Well-de- Beauchamp RD, Evers BM, et al, eds. Sabiston Textbook of Surgery. Philadelphia: Elsevier Saun- signed clinical trials with a long-term follow-up ders; 2004. are required to confirm the initial promising 10. Murphy D, Challacombe B, Khan MS, et al. results. Robotic technology in urology. Postgrad Med J. 31

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Mery is a gen- 2006;82:743-747. 11. Hazey JW, Melvin WS. Robot-assisted general eral surgery resident at surgery. Semin Laparosc Surg. 2004;11:107- Brigham and Women’s 112. Hospital, Boston, MA, 12. Chandra V, Dutta S, Albanese CT. Surgical ro- and a biodesign surgi- botics and image guided therapy in pediatric cal innovation fellow surgery: Emerging and converging minimal at Stanford University, access technologies. Semin Pediatr Surg. 2006; Stanford, CA. He is a 15:267-275. member of the RAS- 13. Kalloo AN, Singh VK, Jagannath SB, et al. ACS Communications Flexible transgastric peritoneoscopy: A novel approach to diagnostic and therapeutic inter- Committee. ventions in the peritoneal cavity. Gastrointest Endosc. 2004;60:114-117. 14. Baron TH. Natural orifice transluminal endo- scopic surgery. Br J Surg. 2007;94:1-2. 15. Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Transluminal En- doscopic Surgery, October 2005. Surg Endosc. 2006;20:329-333. 16. National Cancer for Health Statistics. Report of Final Mortality Statistics, 2004. Available at: Dr. Cooke is a cardio- www.cdc.gov/nchs/fastats/deahts.htm. Accessed thoracic surgery fellow April 28, 2007. at University of Michi- 17. Cooper JD, Trulock EP, Triantafillou AN, et al. gan, Ann Arbor, MI. He Bilateral pneumectomy (volume reduction) for is a member of the RAS- chronic obstructive pulmonary disease. J Thorac ACS Communications Cardiovasc Surg. 1995;109:106-116. Committee. 18. Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume- reduction surgery with medical therapy for se- vere emphysema. N Engl J Med. 2003;348:2059- 2073. 19. Cooper JD, Patterson GA, Sundaresan RS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg. 1996;112:1319-1329. 20. Geddes D, Davies M, Koyama H, et al. Effect of lung-volume-reduction surgery in patients with severe emphysema. N Engl J Med. 2000;343:239- 245. 21. Wood DE, McKenna RJ Jr., Yusen RD, et al. A Dr. Chandra is a multicenter trial of an intrabronchial valve for general surgery resident treatment of severe emphysema. J Thorac Car- and a biodesign surgi- diovasc Surg. 2007;133:65-73. cal innovation fellow 22. Spiration Inc. IBV Valve Trial. Available at: www. at Stanford University, spiration.com/us_clinical_trial.asp. Accessed Stanford, CA. April 28, 2007. 23. Wan IY, Toma TP, Geddes DM, et al. Broncho- scopic lung volume reduction for end-stage em- physema: report on the first 98 patients. Chest. 2006;129:518-526. 24. Emphasys Medical Inc. Endobronchial Valve for Emphysema Palliation Trial. www.emphasys medical.com/wt/emp/clinical_trials. Accessed April 28, 2007. 25. Roentgen W. On a new kind of ray (translation). Br J Radiol. 1933;1:32. 26. Smith RP, McKenna WG. The basics of radiation therapy. In: Abeloff MD, Armitage JO, Nieder- 32

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS huber JE, et al, eds. Clinical Oncology. Phila- Dr. Shafi is a general delphia: Elsevier Churchill Livingstone; 2004. 27. Chang SD, Steinberg GK. General and historical surgery resident at Uni- considerations of radiotherapy and radiosurgery. versity of Pennsylvania, In: Winn HR, ed. Youman’s Neurological Surgery. Philadelphia, PA, and Philadelphia: Saunders; 2004:3991-3998. a biodesign surgical 28. Jemal A, Siegel R, Ward E, et al. Cancer statistics, innovation fellow at 2006. CA Cancer J Clin. 2006;56:106-130. Stanford University, 29. Sibley GS, Jamieson TA, Marks LB, et al. Radio- Stanford, CA. therapy alone for medically inoperable stage I non-small-cell lung cancer: The Duke experience. Int J Radiat Oncol Biol Phys. 1998;40:149-154. 30. Dupuy DE, Zagoria RJ, Akerley W, et al. Percu- taneous radiofrequency ablation of malignancies in the lung. AJR Am J Roentgenol. 2000;174:57- 59. 31. Herrera LJ, Fernando HC, Perry Y, et al. Radiofre- quency ablation of pulmonary malignant tumors in nonsurgical candidates. J Thorac Cardiovasc Surg. 2003;125:929-937. 32. Whyte RI, Crownover R, Murphy MJ, et al. Ste- reotactic radiosurgery for lung tumors: Prelimi- nary report of a phase I trial. Ann Thorac Surg. Dr. Tavakkolizadeh 2003;75:1097-1101. is a minimally invasive 33. Pennathur A, Luketich JD, Burton S, et al. Ste- surgeon at Brigham reotactic radiosurgery for the treatment of lung and Women’s Hospital neoplasm: Initial experience. Ann Thorac Surg. and an instructor in 2007;83:1820-1824. surgery at Harvard 34. Onishi H, Araki T, Shirato H, et al. Stereotactic Medical School, Boston, hypofractionated high-dose irradiation for stage I MA. nonsmall cell lung carcinoma: Clinical outcomes in 245 subjects in a Japanese multiinstitutional study. Cancer. 2004;101:1623-1631.

Dr. Varghese is a cardiothoracic surgery fellow at University of Michigan, Ann Arbor, MI.

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JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The globalization of surgery: Surpassing the frontiers

by Mecker G. Möller, MD, Tampa, FL; John Karamichalis, MD, London, UK; and C. Suzanne Cutter, MD, New York, NY

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VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Our loyalties must transcend our race, our in the U.S.5 The Educational Commission for tribe, our class, and our nation; and this means Foreign Medical Graduates currently hosts a we must develop a world perspective. formal program of classes to teach new IMGs —Martin Luther King, Jr.1 American-style medicine. There are residen- cies seeking ways to ease the transition of egardless of the motivations that bring these individuals.5 In fact, Memorial Sloan- one to become a surgeon, at the end of Kettering Cancer Center in New York, NY, has the day, there is one thing in common an international fellowship program that allows among all of us, the young and old war- physicians to participate in a three- or four-week riRors. It is not the color of our scrubs, the white observership rotation.4 The American College of coat, or the blood spatter on our surgical shoes. Surgeons has long recognized the importance Behind each surgical mask, irrespective of the of the academic contributions of surgeons from language spoken, a silent light shines through other countries in research and clinical practice. the surgeon’s eyes, reflecting the long journey of The College has international chapters in 32 a soul that carries with it the responsibility for countries around the world, including North and the life of the unconscious human on the table, South America, Europe, Asia, and Australia and at the mercy of his or her hands. has been sponsoring International Guest Schol- Knowledge and skills would be empty without arships since 1968. Since then, surgeons from the love and passion for surgery. The high expec- 64 countries have come to the U.S. to augment tations and demands of our profession obligate their knowledge in varied surgical disciplines. no less than a true passion for learning. A mere Some of the IMG surgeons return to practice fondness for surgery without appropriate and to their home country, whereas others become dedicated training will not suffice. These core liaisons with their former medical schools and values are shared by surgeons across the globe, professors, expanding the principles of surgery motivating the exchange of ideas, knowledge, learned in the U.S. technology, and advanced surgical skills. Collaborations among universities have made it possible for surgeons to visit and learn new Global educational exchange emerging surgical technologies and concepts. The International Society of Surgery hosts its A professor of one of the authors once said, annual World Congress of Surgery in August. “You are a surgeon in training since the first Here, acclaimed surgeons and leaders in their day of your residency until the day you are field share their latest research results and taken to the grave.” One way a surgeon may discoveries on issues we all face in our daily expand on training is through travel to foreign practices. universities. Seeking additional surgical training U.S. surgeons and surgical trainees are also abroad seems to be pursued by individuals from traveling abroad for clinical experiences. The all countries.2 Medical education in general has College also awards funding for American sur- maintained its international scope. In the 18th, geons to travel to surgical institutions in Ger- 19th, and early 20th centuries, U.S. medical many, Japan, Australia, and New Zealand, and students opted for higher education in London, the Society for Surgery of the Alimentary Tract Germany, and Paris.3 Nowadays, talented stu- has a Traveling Fellowship Award for Surgeons dents and surgeons around the world admire in Academic Practice. and respect the U.S. surgical residency system. The increased access to air travel has short- It may not be perfect, but its high standards for ened the distances for physicians to attend surgical proficiency and ethics make it desirable conferences and meetings around the world. for domestic and international students to fulfill Similarly, patients are able to look for surgi- their dreams and to become the best surgeons cal care far beyond their home countries and possible.4 continents. International medical graduates (IMGs) com- In a recent article published in the Journal of prise 14 percent of current practicing surgeons the American College of Surgeons, Dr. Itani and 35

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS colleagues summarize the exchange of ideas and experiences expressed by a panel of experts from diverse educational and social systems invited Preparation for global surgery: by the International Relations Committee of A case study the American College of Surgeons.2 Underscored in Dr. Itani’s report and in a recent article by The New York Hospital Queens (NYHQ) is a Dr. Galandiuk et al is that surgeons in today’s strong training ground for the global surgeon. The world share similar educational issues and social hospital is located in Flushing, Queens, which is challenges irrespective of where they live and 11 miles from Midtown Manhattan. Of the five work.6 New York City boroughs, Queens is known for having the most ethnically diverse communities. According to the New York state comptroller, 138 The pursuit of global health languages are spoken in Queens. With each patient encounter, language and cul- The University of California, San Francisco tural issues must be considered. Although there (UCSF), has already implemented a pilot pro- are robust translation services, many residents gram for surgery residents to be exposed to the learn to accommodate language differences. They multifaceted disparities of global health in coun- learn enough of the languages to communicate tries with fewer resources than the U.S. This effectively with patients for brief encounters that interaction has created reciprocally beneficial augment the more comprehensive interview with opportunities for educational programs.7 The translators. Skills are honed in communicating new generation of surgeons understands that with family and extended family while still re- professional growth is impaired if we ignore and specting the guidelines of the Health Insurance maintain a distance from the changes occurring Portability and Accountability Act. In fact, many in the international medical community. A fine of the residents and attending staff are bilingual. example is that of surgery residents at the New Health care proxies have a greater importance York Hospital Queens, who learn to interact since the decision maker may be the one person in with a highly diverse cultural population (see the patient’s support system who speaks English sidebar, this page). but is not necessarily related to the patient. The Pan American Health Organization James Turner, MD, FACS, is the chair of the (PAHO) has recognized the political, social, NYHQ department of surgery and President of the economic, and cultural changes that have taken Brooklyn-Long Island Chapter of the American place during the last decades at an accelerated College of Surgeons. He makes an annual sojourn to India to act as a visiting professor. The trip rate. These changes have intensified the process immerses him in a different culture and allows of globalization in a society where the access to him to interact with a world population in their community of origin. Residents are encouraged to Dr. Möller is a surgi- participate in similar pursuits and there is elective cal oncology fellow at time in the postgraduate year two to accommodate Moffitt Cancer Center such an interest. at the University of NYHQ is a 457-bed facility and level I trauma South Florida, Tampa. center serving the 2 million individuals living in She is Co-Chair of the Queens as well as a subset of individuals living RAS-ACS Communica- in Manhattan and Long Island. Surgical services tions Committee and the include general, cardiac, thoracic, otolaryngol- International Medical ogy, neurosurgery, plastic and reconstructive, Graduate Committee. endocrine, orthopaedic, colorectal, and minimally invasive surgery. Residents in training rotate through all these departments and, through NYHQ affiliations, rotate through hospitals in the New York-Presbyterian Healthcare System.

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VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS information continues to escalate. These trends ticle, “New ways of practicing surgery: Alterna- present new challenges from an international tives and challenges,” on page 51 of this issue. medical perspective. To address these challenges, PAHO has created a training program in inter- Global technology revolution national health to facilitate the collaboration among nations.8 Eric Muhe, MD, performed the first laparo- Other organizations—such as the Foundation scopic cholecystectomy 21 years ago in Germany, for Advancement of International Medical Edu- using the “galloscope.” This technique spread cation and Research, the Association of American rapidly among surgeons interested in innovation, Medical Colleges (AAMC), and the Global Health and, 10 years after its introduction, most elective Education Consortium—provide scholarships for cholecystectomies were already performed using physicians and students interested in pursuing laparoscopy in the U.S.9 research or postgraduate training abroad. These Nevertheless, new technologies have not opportunities are available to the upcoming only affected the operating room but have also generation of surgeons. Trainees become lead- changed the way surgical residents learn, re- ers in the expansion of surgical knowledge while search, and communicate with staff and patients. serving a vital role in the international medical Computer simulations allow global education and surgical community. in surgery without the need for travel. Tele- conferencing and e-mail allow surgeons in dif- Missionary and academic traveling surgeons ferent locations throughout the world to share, discuss, and challenge current knowledge and U.S. academic and missionary surgeons travel opinions. Robots, personal digital assistants, to other countries to share their knowledge and and discussion forums (for example, www.e-facs. skills while learning from invaluable experiences org) facilitate communication with patients and about the surgical lifestyle and how surgery is colleagues around the globe. practiced by colleagues around the globe. The Advances in technology and educational tools strong ties they build with other institutions and have radically changed the expectations of educa- surgeons have become a legacy for the coming tors, trainees, patients, and society in general.10 generation of surgeons in the U.S. and abroad. Medical Web sites, such as the ACS Web portal, With recent technological advances and the not only provide a space for information sharing availability of the Internet, the borders between and discussion but also provide access to books, surgeons across the world have faded and the journals, and videos that can be instantly down- distances have been minimized. We all belong to loaded worldwide. In addition, physicians now the same group—surgeons—regardless of where have remote access to patient medical records, we live, and we all face the same challenges in treating diseases. We have come to realize this connection by visiting different countries and Dr. Karamichalis is a creating links with our colleagues across the cardiothoracic surgeon world. We learn and expand our vision by doing at Royal Brompton Hospital, London, UK, so and we benefit by seeing how surgery is prac- and a member of the ticed in places where the system is not burdened RAS-ACS Advisory as much by all the medico-legal restraints we Committee. face in the U.S. International missions and volunteer work are other ways to become more versatile and expand our horizons. This work also serves a noble goal that binds all surgeons across the world to help our people in need. The subject of volunteer and missionary sur- geons is addressed at greater length in the ar- 37

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS laboratory results, and imaging studies wherever 7. Schecter WP, Farmer D. Surgery and global health: the Internet is available. This type of technology A mandate for training, research and service: A faculty perspective from the UCSF. Bull Am Coll allows international consultations on clinical Surg. 2006;91(5):36-38. decision making. 8. The Pan American Health Organization. Promot- In some U.S. hospitals, a Web camera and lap- ing health in the Americas. Training program in top computer can be connected to an electronic international health. Available at: http://www. paho.org/english/DPM/SHD/HR/pfsiabout.htm. stethoscope, electrocardiogram, and sphygmo- Accessed May 24, 2007. manometer, thus becoming the eyes and ears of 9. C i r o c c o WC. F i r s t l a p cholecystectomy physicians who cannot be readily available to a seems like just the other day. Contemp Surg. patient’s bedside to give a diagnosis. This pos- 2007;63(4):166. sibility is of particular importance to patients 10. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: A new in rural or remote areas when a consultation paradigm. Surgery. 2004;136(5):953-965. is required and tests need to be ordered for the 11. Satava RM. How the future of surgery is chang- workup of a patient. Telemonitoring, wherein a ing: Robotics, telesurgery, simulators, and other robot accompanied by a nurse allows the surgeon advanced technologies. Telesurg Surg Sim. 2006. Available at http://depts.washington.edu/surg/ to see patients from a remote location, is now biointel/Future-of-Surgery-0606.pdf. Accessed available.11 Early studies suggest that patients May 24, 2007. have adapted well to this modality since surgeons spend more time with the patient and eye contact is improved. As the well-known aphorism says, “The only thing constant is change.” This statement con- veys accurately the reality of surgery, and we have been privileged to witness its evolution in the globalization of surgery. Now, more than ever, surgeons are called on to be generous in their interactions with international colleagues and open to participating in the emerging global environment. By participating in this revolution, we will become part of an important part of the evolving history of our profession. 

References 1. Martin Luther King Memorial Web site. http:// www.mlkmemorial.org/site/apps/nl/content2.as p?c=hkIUL9MVJxE&b=1601381&ct=3560637. Dr. Cutter is a chief Accessed May 24, 2007. 2. Itani KMF, Morris PJ, Macias FC, et al. Training resident in general sur- of a surgeon: An international perspective. J Am gery at New York Hos- Coll Surg. 2007;204:478-485. pital Queens, Chair of 3. Sheldon GF. Globalization and the health work- the RAS-ACS Commu- force shortage. Surgery. 2006;140:354-358. nications Committee, 4. Brennan MF. The international medical graduate and Representative in the US surgical training system: Perspectives of to the ACS Advisory an aging warrior. Surgery. 2006;140(3):362-366. Council for General 5. Croasdale M. Classes teach new IMGs Ameri- Surgery. can-style medicine. American Medical News. December 11, 2006. Available at: www.ama-assn. org/amednews/site/free/prl21211.htm. Accessed June 12, 2007. 6. Galandiuk S. An international perspective on surgical health care and education. J Am Coll 38 Surg. 2007;204:148-157.

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS International medical graduates in American surgery: Past, present, future

by Dean R. Cerio, MD, Buffalo, NY and Cyrus F. Loghmanee, MD, Buffalo, NY

39 ccording to the National Residency Match- accepting an IMG to a program would diminish ing Program’s 2007 match statistics, 22 the institution’s reputation. percent of general surgery positions were This topic is undoubtedly difficult, as the filled by medical graduates who are not points of view being questioned are rooted in Afrom the U.S., a 5 percent increase from the overwhelmingly anecdotal accounts. The opin- previous year’s results.1 Even in surgical special- ions have not been objectively studied and are ties considered to be more competitive, such as biased concerning their significance (that is, the orthopaedics and plastic surgery, international idea that the issue is more significant to IMGs). medical graduates (IMGs) constitute 6 percent Regardless, we encourage readers to pay atten- of the positions filled in each field. In 2006, tion to their own feelings and emotions conjured IMGs composed 15 percent (8,399 of 55,142) of the next time they hear the term “IMG.” This the Fellows of the American College of Surgeons brief period of introspection will not only serve practicing in the U.S. (personal communication, to provide some degree of external validity to this Peg Haar, Administrator, Division of Member discourse but will also set the stage for a rational Services, July 24, 2006). and provocative debate by arming each individual with an opinion regarding the matter. Response to the term “IMG” Comparison of training In the August 2006 issue of the RAS-ACS news- letter, the authors briefly reviewed the topic of But the question remains: Are IMGs inferior IMGs in U.S. surgery2 and, to our surprise, the when comparing their training with that of U.S. article generated a substantial amount of positive graduates? feedback. The general thrust of the article was The plight of IMGs in their efforts to attain a to bring to center stage the negative reaction to position within the world-renowned U.S. surgical the term “IMG” that is common among students, training system was briefly outlined in our article residents, program directors, and laypeople, and in the RAS-ACS newsletter, and several questions to question the validity of this response. At the were posed to readers in an attempt to provoke same time as our article, other publications and rational thought about the matter—namely, organizations addressed the role of IMGs in U.S. should the decision to accept a graduating medicine, especially in light of an anticipated medical student into a U.S. residency be based on physician shortage in the near future.3,4 hard-earned scores on the U.S. Medical Licensing The NRMP also reported an increase of 9 per- Examination (USMLE) and personal attributes cent in overall IMG participation in the match or rather on where he or she attended medical for all residency positions.1 In light of the cur- school? In their article, Leon and colleagues rent important role of IMGs in U.S. medicine and outline the process of medical certification and surgery, the authors believe that the perceived or review the immigration issues faced by IMGs as real bias against IMGs should be addressed. they seek eligibility for U.S. residency positions. For instance, a common argument is that foreign- One will quickly deduce from this article that the trained medical students are inadequately trained bureaucratic whirlwind of paperwork could only to function in the rigorous and demanding cur- be endured by those individuals truly committed riculum of a U.S. residency program because of to the notion of receiving U.S. training and to their inferior understanding of the U.S. medical becoming physicians. Keep in mind, this process system, or because there is a language barrier, or occurs during an international student’s years of perhaps they were not held to the same standards academic medical training, where testing profi- as U.S. programs during their academic train- ciently is not an option—it is an imperative. Some ing in their own countries (and are, therefore, students may not test well because of personal not of the same objective intellectual caliber). struggles or hardships at the time of the test. Add Furthermore, anecdotal evidence suggests that to this pressure several government forms, dead- during review of candidates’ applications to resi- lines, and visa applications and the challenges to dency programs, there is a pervasive belief that studying efficiently quickly amass. 40

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS An outstanding medical school record and top to accept one student over the other should only USMLE scores are often the keys that open the then be based on supplemental application ma- door to a U.S. residency position for many IMGs. terials and the interview process. This approach is appropriate, though, as the same For argument’s sake, at this time assume there applies to all candidates. The USMLE is a stan- is widespread agreement that similar scores dardized exam, able to provide accurate measures imply similar training. What else, then, could of each individual’s respective knowledge base. explain the purported divergence and disparity Therefore, IMGs who score as high on the exam in U.S. versus foreign medical training? Do medi- as their U.S. counterparts should be deemed as cal students trained in the U.S. receive superior having been trained equally. Admittedly, an objec- training in the clinical years on the wards? tive analysis and subsequent comparison of U.S. The medical student who engages himself or and international medical training using medical herself in the third and fourth years of ward school transcripts and USMLE scores would be training by learning about the patient and a monolithic undertaking, certain to be fraught supplementing the clinical experience with ad- with confounding factors and biases. However, junctive textbook and article review will always if we accept the USMLE as a fair representation be better trained, despite regional or even global of knowledge base and as an adequate tool for differences in disease prevalence. These profes- the standardization and normalization of scores, sional habits can be learned in even the smallest then what is the source of this perspective of in- clinics of Timbuktu. Conversely, consider the ferior training, given a U.S. student and an IMG medical student who arrives late, leaves early, with equal scores? takes a quick history, performs a mediocre physi- Does this idea come from the issue of a lan- cal exam, and depends on the resident to fill in guage barrier or of communicating with a promi- the blanks—this medical student will always nent accent? be inferior in training, regardless of his or her Communication is paramount in medicine. In USMLE scores, how many cholecystenteric fis- the communication among physicians with other tula patients he or she had rounded on at Mass physicians, physicians and nurses, residents and General Hospital, or how many gastric cancer students, physicians and patients, and physicians patients in Japan he or she has operated on. and patients’ families, every word counts. English proficiency for IMGs is a prerequisite for applica- International influence on U.S. surgery tion to U.S. residencies. Much like our faith in the USMLEs, we must equally entrust our nation’s There exists a multitude of examples of foreign- testing centers with the ability to adequately set born or foreign-trained physicians who have for- standards for English language proficiency. ever changed the face of modern-day U.S. surgery. By logical reasoning, therefore, after having established proficiency in the English language (either by examination or being granted citizen- Dr. Cerio will be serv- ship)—and considering that the biochemical ing as administrative equations of glucose metabolism are the same chief surgical resident at the University of Buf- across the world, that the flexor digitorum falo in the 2007–2008 profundii of the human hand all have the same acdemic year. He is a origins and insertions regardless of where in member of the RAS- the world they are dissected, and that deductive ACS Education reasoning on a clinical question posed during an Committee. exam occurs through similar neural pathways regardless of that brain’s ethnicity—it could be fair to assert that two medical students with equal scores on the USMLE have been trained at equivalent levels and should be considered equally for a residency program. The decision 41

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS How many can you name? One prominent example Statistics 2007. Available at: www.nrmp.org/ is William S. Halsted, MD, commonly referred to res_match/data. Accessed May 23, 2007. 2. Cerio DR, Loghmanee CF. IMGs in American as the father of modern American surgery. The surgery. Available at: http://www.facs.org/ authors propose that if he were alive today, he ras-acs/resources/rasnews0806.pdf. Accessed would be shocked and alarmed to learn of the May 23, 2007. scrutiny currently endured by foreign-trained 3. Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med. 2004;141:705- medical graduates in their pursuit of American 714. surgical training. Dr. Halsted graduated from 4. Leon LR Jr, Villar H, Leon CR, et al. The journey Yale University and then enrolled at the presti- of a foreign-trained physician to a United States gious Columbia University College of Physicians residency. 2007;204(3):486-493. and Surgeons. Of note, however, is that he then pursued advanced training with German-born sur- geon Theodore Billroth, MD, in Vienna, Austria. Dr. Halsted then continued his studies in Germany before returning to the U.S. and establishing the first formal surgical residency training program at Johns Hopkins University in 1889. Would his prolific contributions to medicine and surgery and the establishment of Johns Hopkins University have occurred without his foreign training? To many, the United States of America, the land of opportunity, represents a mecca of medi- cal education. We are, in fact, a nation of pioneers and inventors, constantly pushing the envelope of medical technology and biomedical engineering, devotedly pursuing unanswered questions about tragic illnesses. This is a world of nations, not of individual units, and the U.S. could not sustain the level of medical advancement that has been achieved without some help from other nations— be it from funding; the sharing of information through medical journals; or the bright minds that by one circumstance or another land in the U.S., remain here to train, and stay long enough for the U.S. to claim their inevitable discoveries as American. The medical arena is quickly becoming a world stage. We need to embrace this progres- Dr. Loghmanee will sion by dismantling the unfounded prejudices be administrative chief surgical resident at the toward IMGs that many have constructed from University of Buffalo in hearsay and anecdotal offerings from colleagues. the 2007–2008 acdemic Let us not show the world our naiveté toward year. He is a member the globalization of medicine and surgery. Let us of the RAS-ACS Issues accept into the privileged ranks of a U.S. surgical Committee. residency and train only those who are the best, both academically and personally, and not just those who are from the U.S. 

References 1. National Residency Matching Program. Match 42

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS New trends and developments in fellowship training by Heena Santry, MD, Chicago, IL, and C. Suzanne Cutter, MD, New York, NY

pecialization has been driven by tech- With all these advances have come additional nologic developments, increasing so- fellowships and modifications to previously phistication, and the complexity of established fellowships. To better understand operations.1 planned changes in fellowship training, a brief SFellowship training in surgical specialties is questionnaire was distributed to a chosen small thriving as never before. There are many factors group of surgical specialists. Their responses that influence this situation. One such influ- are included in the discussion that follows. The ence is the pursuit of an academic career. Many specialists include the following: graduating general surgery residents are reluc- • Surgical oncology fellowship: Steve Curley, tant to face the trials of owning and managing a MD, FACS private-practice business. They seek the shelter • Open surgery fellowship: Simon Fink, MD, of a salaried academic practice where they have FACS no responsibilities for managing the practice. • Pediatric surgery: Henri Ford, MD, FACS These individuals have found that fellowship • Orthopaedic surgery: Cato Laurencin, MD training is a way to distinguish themselves in • Rural surgery fellowship: Ken Olson, MD, order to obtain these coveted positions. FACS Another factor that affects the popularity of • Geriatric surgery fellowship: Kenneth Rif- fellowship training is the career model presented kind, MD, FACS, and Michael Zenilman, MD, by the faculty at universities and large centers. FACS These institutions are staffed by an army of • Neurosurgery: John Atkinson, MD, FACS specialists and superspecialists, role models who send a clear message to residents that fellowship New specialties training is essential to an academic career. An additional factor that may be somewhat implicit As recently as January 2005, the American is the residents’ perceived need for further train- Board of Surgery recognized three new disciplines ing. In the current residency environment, many within the field of general surgery as distinct, residents do not feel well prepared for indepen- evolving specialties: gastrointestinal surgery, dent clinical practice. Fellowship is viewed as surgical critical care–trauma-burn-emergency an extension of residency training wherein their surgery, and transplantation surgery. Each was responsibilities continue to increase while they afforded Advisory Council status.2 remain in the shelter of a large center. Previously, fellowship training was based on Technology also influences the state of fellow- a field of surgery that was related to the care of ship training. New tools, techniques, and thera- an organ system or patient population by demo- pies have become integrated into general surgery graphics. However, specialties such as minimally practice. Understanding and mastering these invasive surgery (MIS) and endovascular surgery technological advances has been challenging. have originated with the surgical techniques. 43

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS According to Barbara Bass, MD, FACS, in an and participation of surgeons in end-of-life care. article in Annals of Surgery: Balancing curative versus palliative care in every age group will become absolutely essential. We do not need to create new surgical specialties Clinical skills include a multidisciplinary ap- based on techniques; we need to allow surgical sci- proach to care. Although many surgeons consider ence and disease management to drive the develop- themselves to have a geriatric focus by nature of ment of specialization. At the present time, these their patient population, very few understand the fellowships are filling a procedural training void (a unique problems the geriatric group face—not void created initially by a now rapidly disappearing only physiologic changes but topics such as the faculty gap in expertise) but now more importantly following: a gap created by the simple fact there is not enough • Effect of comorbid disease on survival time to acquire technical mastery in these skills in • Dementia and delirium the current training structure.2 • Polypharmacy • Alcoholism Geriatric surgery fellowship • Abuse • End-of-life care Persons older than 65 years represent the fastest- Eventually, focused care plans will be developed growing segment of the U.S. population. As in- for elderly patients based on their presenting dividuals age, their risk of complications from comorbidities. Residents and medical students chronic disease and affliction by advanced disease interested in geriatric surgery training may increases. With aging, baseline functions of almost prepare themselves by pursuing interests in every organ system undergo progressive decline, elderly patients, the differences occurring when resulting in a decreased physiologic reserve and patients are hospitalized versus institutionalized, ability to compensate for stress. Pain control, post- maintenance care (for example, enterostomy operative cognitive dysfunction, end-of-life issues, tubes, stomas), and the elements of the home and realistic expectations after surgery are para- care setting. There are no current fellowships mount throughout the perioperative period.3 The in geriatric surgery at U.S. schools but such a special needs of this growing population provide curriculum should include the following: an argument in favor of establishing a geriatric • MIS surgery fellowship. • Palliative care Representatives from an increasing number of • Geriatric training surgical specialties are publishing more data on • Communication skills training for interact- their experiences with this population as it repre- ing with family members sents the fastest-growing segment of many of their Until a fellowship-training program is devel- practices. These specialties include orthopaedics, oped, referrals to surgeons with an interest in the breast cancer4, gynecology5, neurosurgery6, and elderly population and leading a multidisciplinary cardiothoracic surgery.7 Surprisingly, in addition team will be the best practice for these patients. to the major contributions to the literature by the There are also grant monies available from the cardiothoracic and orthopaedic surgeons, many of American Geriatric Society to surgical subspe- the contributions to the literature have been from cialties to study issues particular to the geriatric our anesthesiology colleagues. patients. New topics include focused care for the There is now increased awareness of geriatric nursing home patient, integrated care for frail surgery issues by residents and faculty. Likewise, elderly with geriatricians, specialized nursing, there is increased emphasis from the Residency Re- and specialized units. view Commission (RRC) and the American Board of Surgery (ABS) as well as inclusion of questions Acute care surgery fellowship in the surgical boards. Technical skills are really focused on the use of MIS to decrease the stress of With improvements in nonoperative manage- surgery for elderly patients. Finally, palliative care ment of trauma and with overall reduction in is a hot topic and includes a focus for education crime rates in major cities across the U.S., the 44

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS viability of trauma surgery as a specialty has practice but 88 percent thought their work come into question over the last two decades. was undervalued by representatives within the Decreasing surgical volume in favor of nonopera- field of surgery in general and by society. The tive management had decreased reimbursements respondents also reiterated earlier findings that for trauma care but trauma surgeons still faced poor reimbursement, irregular work schedules the lifestyle challenges of frequent in-house call including in-house call, and diminished oppor- and practice challenges of providing care in un- tunities to operate discouraged the practice of derserved environments. trauma. A majority of respondents indicated that Beginning in the 1990s, in order to increase a new model of trauma surgery that included operative volume, trauma services at a num- emergency general surgery and surgical critical ber of major academic level I trauma centers care and might be amenable to shift-based work became integrated trauma–emergency general would assuage many of their concerns. surgery services. Then the Future of Trauma After extensive deliberation, a two-year cur- Surgery–Trauma Specialization Committee was riculum was proposed for the acute care surgery first convened by the American Association for specialty.11 The proposed curriculum would begin the Surgery of Trauma (AAST) in 2002 with the after four years of general surgery residency goal of developing “a specialty that would best training and includes six months of trauma/ serve the needs of our patients; offer an attrac- surgical critical care, three months of critical tive, viable, and sustainable career and lifestyle; care electives, and 15 months of emergency and and be recognized by the public and profession elective surgery. Orthopaedic surgery, neurosur- as a valuable specialty.”8 After careful consider- gery, and vascular surgery are included in the 15 ation, this committee envisioned a new surgical months of surgery. specialty: Acute care surgery: Trauma, critical At present, the majority of acute care surgery care, and emergency surgery (hereafter referred fellowships are slated to start in July 2008. All to as acute care surgery). This surgical specialist require board certification or eligibility in gen- would “be responsible for managing acute gen- eral surgery and will lead to board certification eral surgical problems, covering general surgical in surgical critical care. and specialty services, providing surgical critical care and managing acute trauma…[including] Rural surgery fellowship ‘general trauma’ (neck, thoracic, and abdominal injuries)…[and] limited neurosurgical and ortho- Dr. Olson, a general surgeon on the west coast, pedic [trauma].”9 The committee also suggested came to a crossroads in life and decided to actually that the new specialty might be compatible with take a leave of absence to begin an “experiment” shift work similar to that of emergency room in modern American frontier general surgery, physicians, thus possibly reducing the lifestyle- the premise being that there is no natural law based deterrents to the choice of trauma as a that says that (a) modern high-quality surgery surgical specialty. cannot be accomplished in a marginal, extreme, In 2003, the AAST conferred with the American rural, inner city, international, or disaster en- College of Surgeons’ Committee on Trauma, the vironment, or (b) there is an absolute limit on Eastern Association for the Surgery of Trauma what the appropriately selected, trained, and (EAST), and the Western Trauma Association equipped person can learn to accomplish in his (WTA) and began the process that would ulti- or her life. mately transform the practice of trauma surgery Through a “needs assessment,” Dr. Olson de- into the practice of acute care surgery. A 2004 termined that this type of experience requires survey of AAST, EAST, and WTA members (60% the best general surgical residency available. response rate, n=379), confirmed that 88 percent The motivated surgical resident within a busy of respondents agreed with national leadership residency—particularly one with few or no fel- that a fundamental change in trauma as a surgi- lows and with a faculty amenable to promoting cal specialty was needed.10 Among respondents, individual career development—could probably 72 percent were satisfied with their trauma get enough didactic training to start a practice in 45

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS a rural setting without a fellowship experience. for other rural surgery fellowship programs. Such programs are rare. The amount that can be Their fellows rotate among a network of hospitals mastered within a five-year residency under 80- in remote areas to obtain such experiences. hour workweek restrictions is finite. There are Critically, rural surgery as a true broad-based few, if any, mentors/role models in rural residency practice could be an option currently not per- programs who actually practice rural surgery. ceived by students and residents when selecting There are even fewer academic surgeons who a career. It is always challenging. A rural sur- believe that there is any need to train surgeons gery fellowship provides a basis for many rural for rural environments. hospitals to develop established surgical services The current gold standard of surgical education that would very naturally and gradually be able obviously is for all residents to go to “finishing to attract the specialists themselves into those school” so they can be competitive. Imposing fel- communities to do more complex cases with the lowship training standards on rural surgical prac- general surgeon there to assist and care for the tices is somewhat controversial, yet the concept patients postoperatively. Such a partnership seems to have support by the public, the health would be beneficial to the patient, rural surgeon, and malpractice insurance industry, students, and specialist. Patients would be pleased to avoid residents, and professors throughout the world’s leaving their homes, families, and jobs to travel academic medical community. Government seems to obtain the routine specialty care they need if to also be in favor of supporting this approach they had even more advanced, modern surgical to training. Therefore, the need to use this ac- care near their home. cepted methodology to train board-eligible and The availability of surgeons with such skills board-certified general surgeons in the specialty in these remote settings would help thousands of rural surgery has become clear. of patients nationwide, relieve the overwhelmed As the experiment continued, the pattern of specialty surgeons of the more routine proce- experiences for rural surgery became more clear: dures that take time from their busy practices, approximately 50 percent endoscopy, 25 percent and provide an incredible economic boost to local open general surgery, and 10 percent to 15 per- hospitals. cent laparoscopy (the remainder is a variety of procedures). Through the experience of provid- Open surgery fellowship ing care in the rural settings, inadequacies that Dr. Olson discovered in general surgery training MIS will be the gold standard as the years were illustrated: basic plastic surgery, basic or- progress. It seems that general surgery residency thopaedics (especially hand surgery), emergent graduates are increasingly becoming more com- operative obstetrics, elective basic gynecology, fortable with the MIS cases versus the open pro- therapeutic endoscopy, advanced laparoscopy, cedures. As surgeons become more skilled, there basic urology, and basic otolaryngology. Skills will be fewer indications for conversion to an in these areas would be helpful for acute care of open procedure as, for example, the skilled sur- hand infections or tendon lacerations, z-plasties geon may now control bleeding with laparoscopic and Limburgh flaps for facial reconstructions suturing, clips, cautery, or other techniques. on elderly women, functional blepharoplasties An aging population has led to a cohort of pa- on ranchers, cystoscopies for hematuria and tients who are beyond an age included in clinical emergent ureteral stents, endoscopic control of a practice guidelines and the evidence for evidence- bleeding duodenal ulcer or snare polypectomy on based medicine. Treating these individuals often a colonic adenoma, emergent cesarean sections, requires a level of skill seen in “master surgeons” and closed reductions for simple fractures. (surgeons with extensive experience obtained The type of experience that fellowship training through decades of practice) or highly specialized could provide includes outpatient clinic, basic surgeons who are able to address a narrow aspect and advanced surgical techniques, and inpatient of the patient’s overall care. rounds. The Oregon Health and Sciences Univer- However, there will continue to be indications sity’s rural fellowship program serves as a model for celiotomy. The complexities of an open proce- 46

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS dure differ from those of MIS procedures. Gain- the importance of multidisciplinary care and fa- ing abdominal entry, arranging retractors and miliarity with all aspects of modern cancer care, laparoscopic pads for exposure, and manipulating including their impact on surgical care, to our tissue digitally are all areas that, when performed trainees. We must find ways to increase the clinic properly, determine the overall success and pace experience of fellows to better understand new of the procedure. Lack of exposure to these and patient evaluation and decision making and to ap- other skill sets will eventually make it unsafe preciate the importance of longitudinal follow-up for certain surgeons to proceed with celiotomies. of our patients. As oncologic therapy becomes more Thus, just as MIS required a separate fellowship sophisticated, fellows are expected to develop an in order to fully develop technical and judgment understanding of molecular diagnostic techniques skills in surgeons, an open surgery fellowship and targeted therapies, as well as familiarity with likewise will be needed to hone the skills of what potential toxicities of the burgeoning array of may become a lost art. In the future, these spe- neoadjuvant therapies and their impact on surgi- cialists trained in open surgical procedures will cal care. It is also likely that the development of either join a group practice and take referrals educational and hands-on simulation tools will from their partners or practice as solo practi- be needed to enhance the surgical experience and tioners who receive referrals from a variety of improve the technical skills of trainees coming surgeon groups within a hospital. from residency programs in the 80-hour work era. It is likely that in the next 20 years, the surgical Enhancements to established fellowships oncology curriculum will switch to a three-year general surgery core training program followed Surgical oncology fellowship by a four- to five-year training period in surgical oncology. Given the complexity and breadth of Surgical oncologists will be much busier in the disease processes evaluated and treated, a longer future because as the population increases in period of immersion in surgical oncology topics will number and in average age, cancer cases diagnosed be needed. This extended period of training will be annually will continue to increase. New diagnostic particularly beneficial as it will allow the inclusion and therapeutic modalities will make the specialty of clinical research and essential competency in the both challenging and exciting. multidisciplinary management of patients with There will also be an increased emphasis on the malignant disease. role and indications for laparoscopic approaches to treat colorectal, pancreatic, gastric, hepatobiliary, Neurosurgery training and fellowships and adrenal malignancies. However, a complete understanding of the open surgical techniques Technology is an important aspect of neuro- required to treat these patients is a critical com- surgical care, and when provided through imag- ponent of fellowship training. Robotics is still ing, technology is most useful. More than other too new to draw comments on a role in surgical surgical specialties, imaging is essential to the oncology. However, it will likely find a niche for intraoperative care of the neurosurgical patient. some operations as it has with prostate resections. These procedures are performed through small At M.D. Anderson Cancer Center, the number of apertures. As the field progresses, the aperture radiofrequency ablation procedures is dropping as will become smaller. CT imaging continues to be we become more aggressive with resections and important for both diagnosis and treatment. The neoadjuvant therapies. The issue that must be roles for positron emission tomography and mag- included in discussions of thermal tumor ablation netic resonance imaging technologies are expand- techniques is an adequate training experience ing, and intraoperative studies will be beneficial. in open and laparoscopic intraoperative ultra- Applications for robotics in neurosurgery are not sonography, which is essential to these techniques yet promising, however. This trend is not expected and in performing state-of-the-art hepatobiliary to change. Thus far, simulation training has had a and pancreatic surgery for neoplasia. limited role. Neurosurgical procedures do not ben- Most cancer centers continue to emphasize efit as much from simulators because the apertures 47

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS are so small. However, simulators are useful for Vascular surgery fellowship problem solving, especially for handling surgical emergencies such as high-oxygen-content fires. As the variety of minimally invasive approaches This technology will also be useful for procedures to treating vascular problems grew over the last in spinal surgery. decade, the rationale for two years of vascular Fellowship training programs in neurosurgery surgery training after completing general surgery subspecialties are primarily provided by certifi- training versus one year was rapidly embraced. cate programs. They are not ACGME approved. In 1995, there was great discrepancy in the type Only pediatric neurosurgery has regulation close and volume of endovascular procedures required to the level of the ACGME standards. In order of vascular surgery trainees (50 procedures as to prepare neurosurgery residents for general suggested by the Society for Vascular Surgery practice and fellowship training, it is likely that [SVS]) compared with trainees in interventional all residencies will become seven years in length. radiology (500 procedures as specified by the This time frame will allow for successful train- ACGME) who were in theory training to gain the ing in the environment of resident work hour same endovascular skills. Importantly, despite restrictions and will allow residents time for any formal or informal endovascular training electives in their area of practice or fellowship requirements, in 1995, 49 percent of 77 vascular interest. With so many residents progressing to surgery training programs had no specific endo- fellowship, the necessity for fellowship training is vascular training component.12 questionable. Those who pursue academic careers It became increasingly apparent in the later will need to be fellowship trained. Otherwise, 1990s that interventional radiologists and cardi- the benefit of fellowship training is related to ologists were poised to treat a substantial num- personal preference. ber of patients traditionally treated by vascular Approximately 70 percent of neurosurgery surgeons. It was apparent that an additional residents obtain fellowship training. Over the year of training in endovascular approaches course of residency, most individuals change would complement training in the full spectrum their mind about which fellowship they pursue. of open approaches that had previously occupied Nevertheless, interested residents may incorpo- an entire year’s worth of training. Thus, in 2005, rate as much of their area of interest into their the ABS declared that the 2006–2007 academic residency training through the following: year would be the last term that vascular surgery • Research fellowship certification after only a one-year vascular sur- • Elective rotations gery fellowship following general surgery would • Off-campus rotations be permitted. Pursuing rotations off-campus has two key One year before this declaration, another benefits: It demonstrates that the resident has major change in vascular surgery training was a broad perspective and is not inbred, and it is already developing, led by the SVS, the APDVS, an effective approach to gaining entry into an and the Vascular Surgery Board of the ABS. The institution, practice, or fellowship. effort toward primary certification in vascular Neurosurgery training is very demanding. The surgery was to eliminate the five-year general ideal fellowship candidate is someone who has surgery prerequisite. This approach was a major maintained his or her energy level and is not departure for the field of vascular surgery—a “burned out.” The successful fellow is enthusi- field in which many surgeons, in particular in astic, shows up, and works hard. There will be community hospital settings, have maintained a broadening of the front lines for the delivery practices in both general and vascular surgery of neurosurgical care. Over time, a systems ap- over the years. proach will evolve. Patients will find there is a National leaders in vascular surgery sought pri- group of individuals with similar interests who all mary certification and increased training options have the skills to provide care. The hope is that for vascular surgery in order to “enhance vascu- these individuals will work more in cooperation lar surgery’s attractiveness as a career option.”13 than in competition. The new options would also increase trainees’ 48

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS overall experience in vascular procedures by of the orthopaedic surgeon. It is essential that providing more exposure to vascular surgery these areas receive sufficient emphasis during than the traditional five years of general surgery fellowship training. followed by vascular surgery fellowship. Although the apprenticeship model has some The American Board of Medical Specialties advantages, some leaders would like to see a approved the proposal for primary certifica- greater emphasis on those fellowship programs tion in March 2005; the RRC and the APDVS that expose orthopaedic surgeons to a variety of subsequently specified the requirements for clinical viewpoints. Orthopaedics is a very inven- this new training paradigm in vascular surgery tive specialty. The orthopaedic surgeon must be during the following year. The certificate was able to consider different perspectives and ad- officially available to trainees as of July 2006. judicate them in making clinical decisions. This As of April 2007, the ACGME had approved four approach is similar to the geometry and physics integrated programs: at Dartmouth-Hitchcock, of a planned repair. All the different dimensions, University of Michigan, University of Pitts- configurations, and forces must be resolved for a burgh, and University of South Florida.14 With successful repair. Fellowship training presents a increased exposure to endovascular surgery great opportunity to hone such skills. techniques, the field is likely to become more The scientific basis of the specialty will become aggressive. There will likely be more overlap even greater with greater use of evidence-based with interventional radiology, cardiology, and medicine in clinical decision making and with perhaps cardiothoracic surgery in the future. biologic and engineering technology playing a Robotics may increase the feasibility of vascular greater role in treatment. Orthopaedic surgeons microsurgery, which would revolutionize areas have been selective in the technologies adopted such as lower extremity bypasses. Technology into training programs. Surprisingly, simulation and new tools will remain essential to vascular training has not been widely embraced, in spite surgery. of the availability of software such as the Virtual Bone-Setter (under development by the Moscow Orthopaedic surgery training, fellowships Institute of Physics and Technology). Robotics is a growing area of influence as orthopaedists For the first time, a subspecialization examina- seek and hone applications for this burgeoning tion in sports medicine/orthopaedic surgery will technology. As with other surgical areas, MIS is be administered this year. Since sports medicine big. It is clear that commercial companies have an is the most popular of the orthopaedic fellow- influence on this area of orthopaedics. Growth in ships, one may expect curricula to be designed MIS and robotics may lead to advanced develop- to ensure success of fellows trained in sports ments in intraoperative imaging and video. medicine. Unlike trends in general surgery fellowships such as MIS, orthopaedic fellowships are moving Dr. Santry is a fellow away from a match system. Many of the fellow- in trauma surgery at ship positions in orthopaedic surgery previously Cook County Hospital, Chicago, IL. She is a were enrolled in a match system. Over the past member of the RAS few years, a number of matched fellowship areas Communications Com- (sports and spine, for example) have dissolved. mittee. Orthopaedic surgeons are waiting to see if this trend continues. The competencies as taught in residency pro- grams will achieve even more importance over the next 10 to 20 years. In our view, the devel- opment of professionalism and the development of a thorough understanding of systems-based practices will assume a central role in the success 49

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Pediatric surgery fellowship 3. Loran DB, Hyde BR, Zwischenberger JB. Periopera- tive management of special populations: The geriat- ric patient. Surg Clin North Am. 2005;85(6):1259- The biggest change in recent years has been a 1266. stronger emphasis on MIS training during the 4. Passage KJ, McCarthy NJ. Critical review of the fellowship training. Most institutions have taken management of early-stage breast cancer in elderly steps to ensure that the trainees are proficient in women. Int Med J. 2007;37(3):181-189. 5. Susini T, Amunni G, Busi E, et al. Ovarian cancer this area by adding special equipment or building in the elderly: Feasibility of surgery and chemo- integrated operating rooms outfitted with the latest therapy in 899 geriatric patients. Int J Gynecol technology to support MIS. Cancer. 2007;17(3):581-588. As the current trend suggests, there will be great- 6. Roser F, Ebner FH, Ritz R, et al. Management of er emphasis on MIS in the future. Skilled adult skull based meningiomas in the elderly patient. J Clin Neurosci. 2007;14(3):224-228. general surgeons trained in MIS may be asked to 7. Outcome of heart surgery procedures in octoge- perform laparoscopic surgical procedures where a narians: Is age really not an issue? Expert Rev pediatric surgeon is not available to do so. Pediatric Cardiovasc Ther. 2007;5(2):243-250. surgeons need to remain vigilant to prevent other 8. Spain DA, Miller FB. Education and training of future trauma surgeon in acute care surgery. Am subspecialties from eroding their patient base as J Surg. 2005;190:212-217. we have seen in adult general surgery. 9. Cryer HM. The future of trauma care: At the cross- It is anticipated that many of the operations that roads. J Trauma. 2005;58:614-616 pediatric surgeons currently perform will be done 10. Esposito TJ, Leon L, Jurkovich GJ. The shape of using minimally invasive techniques. In addition, things to come: Results from a national survey of trauma surgeons on issues concerning their future pediatric surgeons who have a special competency (presented, AAST, September 2005). J Trauma. in the area of trauma and critical care will be at a 2006;60(1):8-16. premium. They are likely to play leadership roles 11. The Committee on Acute Care Surgery of the AAST. in shaping the future of the discipline. The acute care surgery curriculum. J Trauma. 2007;62(3):553-556. The match process for pediatric surgery will 12. Claggett GP, Silver D, Veith FJ, White RA. Impact likely undergo a revision. The successful candi- of new technology on vascular surgery training. J dates typically have spent time doing research Endovasc Surg. 1995;2:133-135. to prove themselves. Yet, many others who have 13. Vascular Surgery Board of the American Board of committed time to research are not successful in Surgery. The meaning of the Primary Care certifi- cate. VSB of the ABS. Spring 2006:204. the match. Furthermore, many of the successful 14. Society for Vascular Surgery VascularWeb. Avail- candidates who match in pediatric surgery are not able at: http://www.vascularweb.org/. Accessed committed to doing research. Perhaps the research April 8, 2007 option should be offered at the end of the fellow- ship. Training programs would then select among candidates who are committed to doing research at the end of their training. Those who are not in- terested in research would match in places where Dr. Cutter is a chief research is not required. Interested residents need resident in general sur- to enter a productive lab where they will get strong gery at New York Hos- pital Queens, Chair of mentoring and will be nurtured. In addition, they the RAS-ACS Commu- must excel clinically throughout their training in nications Committee, general surgery.  and Representative to the ACS Advisory References Council for General Surgery. 1. Cheadle WG, Franklin GA, Richardson JD, Polk HC Jr. Broad-based general surgery training is a model of continued utility for the future. Ann Surg. 2004;239(5):627-636. 2. Bass BL. Matching training to practice. Ann Surg. 2006;243(4):436-438. 50

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS New ways of practicing surgery: Alternatives and challenges

by Mecker G. Möller, MD, Tampa, FL; Luis A. Santiago, MD, Tampa, FL; John Karamichalis, MD, London UK; and Joshua M.V. Mammen, MD, Cincinnati, OH

hroughout history, the field of surgery has been shaped by social, cul- tural, and economic forces. However, in recent years, its evolution has been aimed at expanding service access, improving patient outcomes, and reducing cost. In an era of global competitiveness and rapid flux Tof information, physician groups and training programs must mold their organizational models and curricula, respectively, to the demands of today’s surgical practice. Volunteer surgeons The U.S. Census Bureau has estimated that some 44.8 million Americans are currently uninsured.1 Despite great technological advances in medicine, lack of access to health care continues to have calamitous implications for underserved populations, especially in developing countries. Many active and retired American surgeons have committed to volunteer- ing as part of their practice of surgery. These brave surgeons and residents deal anonymously with the myriad logistics of missionary work and often travel at their own expense. The noble crusade of Keith Harmon, MD, comes to mind. As a third-year surgery resident at Michigan State University in Grand Rapids, he spent his vacation time in Viet Nam in collaboration with a local surgeon. Dr. Harmon dedicated many weekends to raising money for the purchase of wheelchairs for Vietnamese amputees. He continues to be an inspiration for young residents who are enlightened by the stories of his missionary trip. Not surprisingly, surgery residents involved in volunteer work often contin- ue this practice throughout their careers. Surgical residents at the University of California at San Francisco (UCSF) may already enroll in an elective vol- unteerism rotation in a developing country. In fact, an overwhelming majority of participants claim a satisfactory experience.2 Similarly, residents at New York University may choose a training track in international surgery.3 Volunteerism demonstrates its value as an essential building block in the formation of future surgeons across international boundaries.2,4,5 It comple- 51

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ments the resident’s training by exposing him or with the mere intent of performing hundreds of her to a broad pathology spectrum, sometimes surgical procedures.8 It is also extremely impor- necessitating innovative surgical approaches in tant to share knowledge with those local physi- the absence of sophisticated technology. Working cians who will ultimately care for patients once the in the context of limited resources nurtures the missionary surgeons leave. Operation Smile is one volunteer’s intellectual growth, compassion, and example of cross-integration of knowledge. Each understanding of surgical practice worldwide. year, this program invites surgeons from develop- In his “From my perspective” editorial in the ing countries to the U.S. for surgical training. March 2007 Bulletin, Thomas R. Russell, MD, Policies and legislation across the nation are FACS, Executive Director of the American College being proposed to legally protect surgeons who of Surgeons, shares his experience during a medical are involved in volunteer work. In 1997, Congress mission in Haiti.6 Dr. Russell reminds us eloquently passed the Volunteer Protection Act, legislation of why we chose a career in surgery and urges us that provides immunity from tort claims that to honor the noble roots of our profession. might be filed against volunteers with not-for- The ACS recognizes and supports volunteer profit organizations, contingent on the organiza- surgeons who offer their services to underserved tions carrying adequate levels of general liability communities around the world. In this spirit, it insurance.9 In this regard, Volunteers in Health, has created Operation Giving Back (OGB). This a not-for-profit organization, has created a guide organization manages a Web site that has become for volunteer physicians to better understand the a valuable resource for surgeons interested in intricacies of this legislation.10 volunteer work.7 It currently lists 34 American Notwithstanding the possibility of malpractice organizations offering international volunteer lawsuits, surgeons continue to step up, volunteer- opportunities for U.S. surgical residents and 20 ing their skills and knowledge in caring for dis- organizations with domestic volunteer opportuni- tressed patients in all corners of the world. Recent ties. The experience gained in these appointments examples include the rescue and treatment efforts promotes an enhanced understanding of the following the catastrophes of Hurricane Katrina disparities and similarities of the daily practice in 2005 and the Asian tsunami in 2004. among surgeons domestic and abroad. Kathryn Anderson, MD, FACS, FRCS, during The OGB Web site also contains links to several her 2005 Presidential Address, “Crises in human- university programs and organizations such as ity,” to the Fellows of the American College of Robert Wood Johnson Medical School, University Surgeons, encouraged physicians to get involved of Arizona, University of Massachusetts, Univer- in volunteer works, especially in the wake of sity of Washington, University of Wisconsin, the medicine’s recent industrial revolution. In her Association of American Medical Colleges, the lecture, she pointed out that by giving of ourselves, Global Health Education Consortium, and sev- we are not only giving of our time and heart, but eral other foundations that provide scholarships, we are also receiving the rewards of the greatest fellowships, and information about funding for humanitarian profession.11 students, residents, and physicians interested in volunteerism and global health. In a recent sur- Surgeons as innovators vey, OGB asked about the types of volunteer work that are most interesting to surgeons. Among New approaches and technologies continue respondents, 55 percent indicated an interest in to push the envelope in what can be achieved international clinical surgery; 20 percent in inter- in surgery. For instance, mini-laparotomies national teaching, and the remainder in domestic have managed to substitute for large, painful, volunteer opportunities.7 and disfiguring incisions, while advanced lapa- In a 2006 article in the New England Journal roscopy and robotics have further minimized of Medicine, Adam Wolfberg, MD, MPH, Fellow of the need for mini-laparotomies. Likewise, Maternal-Fetal Medicine at Tufts-New England endovascular and angiographic tools and a Medical Center, comments that it does not suffice new generation of medications are putting the for a surgeon to visit a foreign country once a year scalpel to rest.12 52

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgeons are active contributors to emerg- Surgeons as constant educators ing technologies, as some of them dedicate time away from their regular practice to collaborate Fundamental to the existence of any discipline is in designing new surgical tools. Other surgeons the ability to transmit both time-tested traditions get involved in research to improve the current and new innovations to a new group of pupils. The technology. model advocated by William S. Halsted, MD, has One example of recent surgical innovation been the basis for surgical education as well as is natural orifice transendoluminal endoscopic education in other medical disciplines. However, surgery (NOTES). The Natural Orifice Sur- a host of scientific and educational changes have gery Consortium for Assessment and Research led to a reevaluation of the current model, which (NOSCAR) is a collaboration of the American has retained some of the original Halsted elements Society for Gastrointestinal Endoscopy and the but has lost others as well. In the particular, the Society of American Gastrointestinal and Endo- ideal of graduated responsibility based on readi- scopic Surgeons (SAGES), dedicated to the devel- ness or competence of the trainee (that Dr. Halsted opment of NOTES. The interest in this minimally initially advocated) is being resurrected. invasive technology was so great that the 2007 Several surgical societies have taken the lead NOSCAR conference was fully booked a few days in creating a competency-based surgical model. after registration opened. Even though endoscopic SAGES developed the fundamentals of laparo- approaches have been used for years, the report scopic surgery program, a prime example of a of a transoral appendectomy by D. Nageshwar competency-based model.16 The organization con- Reddy, MD, FRCP, DSC, and G. Venkat Rao, MS, tinues to devote efforts not only in the implemen- MAMS, at the Asian Institute of Gastroenterol- tation, but also in validation of this educational ogy in Hyderabad, India, drew the attention of model. surgeons and journalists alike. The media storm The academic study of surgical education has was even greater when Marc Bessler, MD, at the truly grown over the last several years. Surgical College of Physicians and Surgeons of Columbia Education Week—a collaboration of the Associa- University in New York reported a transvaginal tion for Surgical Education, the Association of cholecystectomy on a 66-year-old woman. The Program Directors in Surgery, and the Association NOTES field continues to progress with surgeons of Residency Coordinators in Surgery—brings at the forefront. together a variety of disciplines to address the Scientific and technological advances continue challenges of surgical education. The number of to shape medical decision making. For example, publications focused on surgical education con- anti-peptic ulcer procedures have become second- tinues to climb with nearly twice as many articles line therapy after medical treatment. Likewise, published in the last five years as were published the maze procedure has revolutionized the treat- a decade ago. Furthermore, another sign of the ment of atrial fibrillation and is preferred over current times may be the name change of the medical therapy for a group of selected patients. journal Current Surgery to The Journal of Surgi- Furthermore, more patients are undergoing Roux- cal Education. en-Y gastric bypass procedures for treatment of morbid obesity. In California, for example, the Telepresence and telementoring number of Roux-en-Y gastric bypass procedures alone increased from 887 in 1995 to 13,637 in Advances in digital communication, especially 2003.13 Other advances have improved patient the progress made in the transmission of real- outcomes in areas where surgery was once thought time media, have facilitated the implementation to be contraindicated. For example, a combination of training sessions for novice surgeons in remote of chemotherapy with debulking is now consid- areas.17,18 Thus, telepresence and telemonitoring ered standard of care for mucinous appendiceal permit the instruction of nouvelle surgical proce- cancer.14 More commonly, colon adenocarcinoma dures by an expert surgeon while guaranteeing the metastatic to lung or liver is considered for surgi- highest level of care and safety for patients. The cal resection.15 National Aeronautics and Space Administration 53

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS and the U.S. Department of Defense continue to Surgeons, the written word, and the media invest financial resources in technology, which would allow a surgeon in a base station to oper- Writer surgeons ate on an astronaut in outer space or a wounded soldier in the battlefield. The same technology Although surgeons have historically demon- potentially could be imported to civilian life in strated talent as writers, nowadays more surgeons order to assist surgeons in remote locations or write about subjects beyond the scope of clinical underprivileged countries with emergent or practice. Some are also novelists, storytellers, and complex surgical procedures. It is arguable that social and political commentators. Their books “remote preceptoring has always been difficult to and opinions have traditionally had a significant implement due to the inefficient use of the expert impact on how society perceives the surgeon’s surgeon’s time.”19 However, an experienced sur- arduous vocation and strong sense of mission. geon may choose a career in real-time consulta- However, most recent writings depart from the tion services from a remote site. Meanwhile, the portrayal of the stoic surgeon with nerves of steel novice surgeon may benefit from these services by to that of a sensible physician who shows height- receiving immediate, needs-based training from ened respect for life. In turn, this new attitude experienced surgeons without having to travel allows the public to identify with the courage, hu- long distances. maneness, and sensibility that have characterized It is foreseeable that telesurgery, assisted by a surgeons in many difficult historical scenarios. remote interface, will not only foster long-distance Many of us recall H. Richard Hornberger, MD, training but will also facilitate direct intervention an Army surgeon who served as a war correspon- by surgeons who are not physically located at the dent during World War II (who also wrote under patient’s bedside. In fact, the use of telesurgery the names W. C. Heinz and Richard Hooker). His is already supported by multiple feasibility stud- collection of experiences was published in When ies. Results show that total anesthesia time in We Were One: Stories of World War II (Cambridge, robot-assisted procedures is either comparable or MA: Da Capo; 2007 [reprint edition]) and MASH: slightly shorter than in conventional procedures. A Novel About Three Army Doctors (New York: Furthermore, complication rates and outcomes Harper Perennial; 1997 [reprint edition]). The are similar in both approaches; however, in ro- latter was adapted for a movie and the popular botic surgery, there is the added benefit of a stable television series and became part of America’s camera platform, three-dimensional imaging sys- culture and heart. tems, increased degrees of freedom, and improved Richard Karl, MD, FACS, chairman of the de- ergonomics for the surgeon.19 Nonetheless, as partment of surgery at University of South Florida more capabilities are added to robotic arms for College of Medicine, has delighted and inspired us increased dexterity and haptic feedback, greater with his book, Across the Red Line: Stories from data transmission rates will be required to make the Surgical Life. Dr. Karl has also written for the surgical procedures appear fully virtual. St. Petersburg Times and is a contributing editor The use of telepresence and telemonitoring and monthly columnist (“Gear Up”) to Flying. breaches the gap between the uniform surgical Richard E. Sall, MD, a general surgeon special- training of yesteryear and the ever-evolving needs izing in occupational medicine, has published a of a served population. This problem becomes tan- fictional novel Straightjacket, and other nonfic- gible in the case of remote communities that have tion books of social impact such as Strategies on limited access to health care and that are served Workers Compensation and Behind the Union by surgeons who have not retrained in the latest Curtain: The Battle between Union Workers and therapeutic modalities. In this sense, exploiting Company Doctors. media communications may improve the surgeon’s Atul Gawande, MD, FACS, has published a few technical skills and ultimately facilitate service fascinating books, Complications: A Surgeon’s access. Unfortunately, the high cost of a reliable Notes on an Imperfect Science and Better: A Sur- communication infrastructure remains a handicap geons’ Notes on Performance. He also writes for for many underprivileged regions. Slate and The New Yorker. 54

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Other fine examples of current publications surgery and their potential outcomes, especially by surgeons include The Making of a Surgeon in in an era of heightened expectations of the medi- the 21st Century, by Craig A. Miller, MD, a board- cal profession. Most importantly, the way a case certified vascular surgeon; Mortal Lessons: Notes is presented through the media may alter public on the Art of Surgery, by Richard Selzer, MD, a opinion overnight. retired assistant clinical professor of surgery at Broadcasting accurate, evidence-based medical Yale University; When the Air Hits Your Brain, information to the general public in lay terms has by Frank T. Vertosick, Jr., MD, a neurosurgeon; been incorporated into surgical practice and is wel- Hot Lights, Cold Steel: Life, Death, and Sleepless comed by patients. Discussing the available treat- Nights in a Surgeon’s First Years, by Michael J. ment options and their potential risks and benefits Collins, MD, an orthopaedic surgeon; and Daktari: empowers patients to choose the treatment that A Surgeon’s Adventures With the Flying Doctors better suits them. In this manner, keeping patients of East Africa, by Thomas D. Rees, MD. well informed avoids false expectations, improves patient satisfaction, and protects physician trust- Embracing the media worthiness even in the face of complications.

Surgeons working as media consultants are in- Surgical practice and legislation creasing public awareness about important health care issues such as malpractice reform. For in- American surgeons live in a litigious society that stance, recall the restrictions placed on residency demands rigorous technical standards and mini- work hours after the Libby Zion malpractice case mal margin for error.21 In view of the ever-present was made public in New York.20 Following the fatal risk of perioperative complications, surgeons are outcome of this 18-year-old Bennington College forced to disburse considerable amounts of money undergraduate, allegedly after a surgical intern in malpractice insurance in order to protect their failed to diagnose a sepsis syndrome and pneu- ability to practice. monia secondary to a tooth extraction and/or a Some surgeons may be reluctant to abandon drug-to-drug interaction, training programs were high-risk procedures, but the possibility of a law- compelled to reevaluate the level of supervision of suit and its catastrophic consequences may deter surgical residents and to limit work hours. Even them from helping the sickest of patients. It is though lawyers and mainstream media were the likely that adopting such a defensive attitude may first to present this case for public scrutiny, it was take some of the joy away from surgery. physician reporters who brought insight into how It is imperative that surgeons become knowl- close expert supervision of medical residents is edgeable of their state and federal laws regarding crucial in arriving at a timely diagnosis, especially health care. Not only should they be aware of in potentially life-threatening scenarios where patient histories and clinical findings are clouded by inconclusive information. Dr. Möller is a surgi- Several surgeons and physicians contribute to cal oncology fellow at newspapers and provide televised interviews in Moffitt Cancer Center at the University of their areas of expertise. A well-known example is South Florida, Tampa. Sanjay Gupta, MD, a neurosurgeon and medical She is Co-Chair of the correspondent for CNN who reports on medical RAS-ACS Communica- news worldwide. In the midst of today’s hype and tions Committee and the sensationalism over glamorous surgical makeovers International Medical performed on television, it is extremely important Graduate Committee. that the public receives objective information about the risks and benefits of surgical procedures from qualified medical advisors, especially from surgeons themselves. In this sense, public aware- ness must be raised about recent developments in 55

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS liability issues but also of national health policy implement health care policy. Even though the issues such as Medicare reform, managed care surgeon’s time is primarily dedicated to patient policies, and service reimbursements. The latter care, a surgeon working as a full-time representa- elements potentially affect career satisfaction, fi- tive ensures that the guild’s needs and point of nancial solvency, and, ultimately, service availabil- view are always considered. ity. Medicare fee reimbursements have declined In some private settings, the board of directors consistently for the past 20 years despite inflation includes all the partnering doctors in addition to and rising costs of surgical practice. Caring for the other administrative staff. Although this inclu- Medicare population and the uninsured popula- sion strategy may seem a bit extreme, the point tion has become a financial burden for many sur- is made that appointing surgeons with a master’s geons. As a result, some surgeons have relocated degree in business administration to key positions their practice, and whole communities have been inside the hospital administration makes sure the left without surgical services. The ACS has already surgeons’ collective voice is heard. presented this problem to Congress. In September At a national level, there are 11 physicians who 2006, Dr. Russell addressed the House Energy and are members of the 110th U.S. Congress. Of those Commerce Committee Subcommittee on Health elected physicians, two are Fellows of the College: regarding Medicare physician payments.22 Charles Boustany, MD, FACS (R-LA); and Tom Surgeons must be aware of the restrictions im- Price, MD, FACS (R-GA). And in the 109th Con- posed by the managed care model in order to have gress, the Senate majority leader was Sen. Bill a successful practice. Unfortunately, some restric- Frist, MD, FACS, a cardiothoracic surgeon, and tions jeopardize the traditional surgeon-patient Joe Schwarz, MD, FACS, an ear, nose, and throat relationship by limiting the amount of diagnostic surgeon, was a representative. studies, procedures, and referrals that a patient is Now more than ever, members of the College approved for. Consequently, it has become crucial are becoming a strong and active force in the to hire staff that is knowledgeable of the potential legislation of malpractice reform. For instance, pitfalls and perils of this business model. the College has supported legislation such as the Medical Liability Reform; the Help Efficient, Ac- Surgeons as policy consultants cessible, Low-Cost, Timely Healthcare Act of 2005; the Medicare Physician Payment-Medicare Value- Alternatively, some surgeons have made a career Based Purchasing for Physicians’ Services Act of out of representing the interests of other fellow 2005; the Preserving Patient Access to Physicians surgeons. These guardians keep a watchful eye on Act of 2005; and the Medicare Coverage Screening how hospital budgets are allocated, how insurance Abdominal Aortic Aneurysms Very Efficiently Act reimbursements are processed, and how hospitals of 2005. Most recently, members have been urged to sign the petition for Mitigating the Impact of Uncompensated Service and Time Act of 2007.23 Dr. Santiago is a first- The latter legislation has been introduced in the year general surgery U.S. House of Representatives to help physicians resident at University of recoup some of the financial losses they incur South Florida, Tampa. while taking emergency department call. The College’s Division of Advocacy and Health Policy helps the College to lobby draft legislation at the state and federal levels, to prepare legislative and issue briefings, and to provide testimony for committee hearings. Furthermore, it has sponsored a complimentary consultation for practice manage- ment during the Clinical Congress for issues such as coding and reimbursement, compliance with the Health Information Portability and Accountability Act, group mergers, and contract negotiations. 56

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The era of hour limitations Hospital directors, medical managers, and human resource personnel are proposing and implement- In the ideal health care system, patients are ing business models to deliver competitive and offered affordable, effective, sensible, and close-to- comprehensive services to their served popula- home surgical services by experienced physicians. tions. Great emphasis continues to be put on Medical errors, complication rates, and length of innovative ways for reducing cost, improving hospital stays are kept to a minimum through return on capital investment, improving service continued hands-on training and the application quality, and promoting new services. Nevertheless, of the latest medical and surgical technologies. In hospital managers are refocusing their attention such a system, surgeons are delighted to improve on the liabilities produced by medical error and patients’ lives as long as they are also able to stay on how these may affect patient safety, service abreast of the latest medical knowledge, they are availability, institution trustworthiness, and, of not subject to frivolous defamation and lawsuits, course, profit. It is noteworthy that hospitals have and their practice remains profitable. Neverthe- invested heavily in information technology and less, the reality of surgery is far from ideal because new business processes (for example, medication it is influenced by complex cultural, societal, and reconciliation, pain scales, and so on) in order to market forces. expedite care and increase patient safety. How- It has been proposed that implementing work- ever, even though physician workload, fatigue, hour restrictions on attending physicians may be and inexperience have long been recognized as beneficial in surgical practice. However, such a policy potential sources of medical error, these human has potential advantages and disadvantages. On one matters have not been addressed as aggressively hand, it may help reduce specialized manpower cost, as financial and organizational ones. improve patient safety by reducing case load and In this sense, the hiring of surgeons as locum fatigue, reduce medical error liability and malprac- tenems presumably serves multiple purposes— tice insurance cost, foster academic activities such namely, to relieve the workload and improve the as medical research and education, and enable the quality of life of the permanent staff, to meet hiring of junior attending physicians for a fraction work hour regulations, and to make available a of the cost. On the other hand, it is arguable that broader offering of services to patients without it may jeopardize client satisfaction by limiting the assuming the cost of recurring employment ben- amount of time physicians dedicate to their patients. efits. Furthermore, the novice surgeon benefits It is also worrisome that more patients could be from this modality as some hospitals agree to pay referred to surgeons with less operative experience for malpractice insurance and ancillary services. in an effort to reduce cost, which may then result, Nevertheless, it is arguable that the outsourcing ironically, in increased morbidity and mortality, of medical services may be detrimental to patient inefficient resource use, unacceptable medical li- ability, and, ultimately, fewer referrals. Moreover, the more experienced surgeons may opt to relocate Dr. Karamichalis is a to geographical areas where overhead and medical cardiothoracic surgeon insurance costs are not prohibitive and that allow at Royal Brompton Hospital, London, UK, for higher incomes. This exodus of experts could and a member of the be detrimental to medical education and may even RAS-ACS Advisory leave entire towns without basic surgical services, Committee. thus necessitating long-distance transport to already congested tertiary hospitals in neighboring cities. Locum tenems

The general surgery enterprise has experienced changes similar to those seen in the management consulting, banking, and engineering industries. 57

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS care because locum tenems may not have the manity. Bull Am Coll Surg. 2005;90(12):10-16. same sense of ownership as permanent staff. For 12. Farley DR, Van Heerden J. Can you pass this mock oral examination? Today’s correct answers may instance, a patient may present to the emergency not be tomorrow’s. Contemp Surg. 2007;63(4):158- room with an acute condition, and the physician 160. on-call may limit his or her duty to the initial 13. Zingmond DS, McGory ML, Ko CL. Hospitalizations work-up without a greater sense of urgency. before and after gastric bypass surgery. JAMA. 2005;294(15):1918-1924. Moreover, patients may misinterpret the lack of 14. Sugarbaker PH. New standard of care for appen- continuity of care as gross inattention. Of most diceal epithelial neoplasms and pseudomyxoma concern, nonetheless, is the possibility that a tem- peritonei syndrome? Lancet. 2006;7(1):69-76. porary physician may lose the ability to empathize 15. LaFreniere R. What’s new in general surgery: Surgi- with patients if he or she is unable to enjoy patient cal oncology. J Am Coll Surg. 2004;198(6):966-988. 16. Peters JH, Gried GM, Swanstrom LL, et al. Develop- recuperation in the long term. ment and validation of a program of education and As the new generation of surgeons, residents assessment of the basic fundamentals of laparoscopic share the responsibility of standing up for our surgery. Surgery. 2004;135(1):21-27. profession and of being proactive in matters 17. Whitten P, Mair F. Telesurgery versus telemedicine in surgery: An overview. Surg Tech Int. 2004;12:68- regarding national health policy and surgical 72. education and practice. Most importantly, we 18. Satava RM. Robotics in colorectal surgery: Tele- should strive to meet today’s demands without monitoring and telerobotics. Surg Clin North Am. comprising patient care.  2006;86(4):927-936. 19. Ballantyne GH. Robotic surgery, telerobotic surgery, telepresence, and telementoring. Surg Endosc. References 2002;16:1389-1402. 20. Robins N. The Girl Who Died Twice: The Libby Zion 1. Center on Budget and Policy Priorities. The num- Case and the Hidden Hazards of Hospitals. New ber of uninsured Americans is at an all-time high. York, NY: Delacorte Press; 1995. August 29, 2006. Available at: http://www.cbpp. 21. Mueller LP. Manpower issues: A golden opportunity. org/8-29-06health.htm. Accessed May 24, 2007. Advocacy blog. Available at: http://efacs.org/forum/ 2. Ozgediz D, Roayaie K, Wang J. Surgery and global viewpost_171_1.html. Accessed May 24, 2007. health: The perspective of UCSF residents on 22. Statement of the American College of Surgeons to training, research, and service. Bull Am Coll Surg. House Energy and Commerce Committee Subcom- 2006;91(5):26-35. mittee on Health by Thomas Russell, MD, FACS, 3. Lovinget SP. Volunteers hone skills while helping on Medicare Physician Payments: 2007 and beyond. the needy. Surgery News. March 2007:16. September 28, 2006. Available at: http://www.facs. 4. Karamichalis JM, Möller MG. Surgery residents and org/ahp/testimony/russell0906.html. Accessed May volunteerism. Bull Am Coll Surg. 2005;90(7):23- 24, 2007. 26. 23. ACS advocacy Web portal link. Available at: 5. Schecter WP, Farmer D. Surgery and global health: http://www.capitolconnect.com/acspa/alert_detail. A mandate for training, research, and service—A aspx?AlertID=42. Accessed May 24, 2007. faculty perspective from the UCSF. Bull Am Coll Surg. 2006;91(5):36-38. 6. Russell TR. From my perspective. Bull Am Coll Dr. Mammen is chief Surg. 2007;92(3):4-7. resident of general 7. Operation Giving Back. Available at: www.operation surgery at University of givingback.facs.org. Accessed May 24, 2007. Cincinnati, OH. 8. Wolfberg AJ. Volunteering overseas—Lessons from Surgical Brigades. N Engl J Med. 2006;354(5):443- 445. 9. Public Law 105-19. 105th Congress. Volunteer Protection Act of 1997. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=105_cong_pub- lic_laws&docid=f:publ19.105.pdf Accessed May 25, 2007. 10. Hattis PA, Walton J. Understanding Charitable Im- munity Legislation. A Volunteers in Health Care Guide. 2004. Volunteers in Health. Available at: www. volunteersinhealthcare.org. Accessed May 24, 2007. 11. Anderson KD. Presidential Address: Crises in hu- 58

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Congressman Michael Burgess, MD:

The necessity of physician involvement in the political process

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

59

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Author’s note: In 2001, Rep. Richard Armey When the position became open, I seriously (R-TX), then the Majority Leader of the U.S. looked at whether or not I should run. I talked to House of Representatives, announced that he my wife. I talked to my partners. I think everyone would not seek reelection. Having personally sort of good-naturedly said, “You go ahead and experienced the effects of congressional decisions do that.” No one expected me to win, but I did in his medical practice, Michael Burgess, MD, seek out the advice and counsel of those closest decided to seek election to the seat and filed to run to me before I actually filed. for the Republican nomination. In a competitive primary that included Representative Armey’s How did you first become involved in politics? son as one of the candidates, Dr. Burgess won the nomination in a run-off election. I had some marginal involvement with the Tex- as Medical Association (TMA) and the American efore his election to Congress in 2002, Rep. Medical Association (AMA). I was an alternate Michael Burgess spent more than two de- delegate to the AMA, but that was really the sum cades as a respected obstetrician-gynecolo- total of my political experience. Bgist in Lewisville, TX. During his medical ca- When people ask me what I would recommend reer, Dr. Burgess delivered more than 3,000 babies, for someone who wants to run for Congress, the including the son of the Democratic challenger he logical response is that obviously you start at faced in his first general election campaign. a local level, then work up to a state level, and Since taking office, Dr. Burgess has established then up to the federal level. But I did not do himself as a leading voice on health policy. In that, so I cannot very well tell someone that his first term, he chaired the House Republi- is the right trajectory. A lot of things worked can Policy Committee’s Health Subcommittee; out for me, and it is important for people to he currently serves as the Policy Committee understand that an election bid does not always Vice-Chairman. Since 2005, he has served as a work out. There have been a lot of disappointed member of the powerful Energy and Commerce people who have tried to do what I have done. Committee and as a member of its Subcommittee To the extent that I made it look easy, it was on Health, which has jurisdiction over Medicare not, and people should not mistake the fact payment policy.* that there were a lot of factors beyond my In April, Dr. Burgess and I sat for an interview control that broke in my favor for me to win in which he discussed how he became involved my first race. in politics, his decision to run for Congress, and the importance of surgeon involvement in the As you said, when you ran for Congress, it was your first political process. The following summarizes that race. Had you ever before considered running for public interview. office at any level?

Why did you decide to run for office? At sort of the same level that people think about being an astronaut or a fireman. There Well, I can’t say that running for office had were days when I said, “There has got to be some always been a burning ambition of mine, but the other profession that I can do other than deliver- position became open at a time in my professional ing babies.” That was usually at three o’clock in life where it appeared to me that Congress was the morning. But, no, it was not one of the things making many decisions that were affecting my on my to-do list. ability to provide care to my patients. You first ran in a very competitive primary that resulted *Information regarding Dr. Burgess’ background was obtained in a run-off election. What was the hardest part of that from the following Web sites: first campaign? • http://burgess.house.gov/Biography/. Accessed May 23, 2007. • http://nationaljournal.com/pubs/almanac/2006/people/tx/ Well, number one, I had not planned on enter- rep_tx26.htm. Accessed May 23, 2007. ing the campaign. The seat opened during our 60

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS filing period in Texas, which was in December The TMA was pretty involved in that effort. that year. Of course, at that time, with the George W. Bush was Governor of Texas at that Christmas and New Year holidays, a lot of people time. State Sen. Jane Nelson had been very in- were out of town—people whose counsel I would volved in that effort. Her committee held a lot of have liked to get before filing, but that was not the hearings—very compelling hearings. It was a available to me. little bit of a different time. Health maintenance The other thing was that I was very fortunate organizations were just making their incursion to have a very busy medical practice. My ap- into the Texas market. There were times when pointment schedule was booked and my surgery some restraint was needed, and it wasn’t avail- schedule was already set through March. These able. We as physicians were looking for tools to were people whom I felt I could not disappoint. help our patients, and the Patients’ Bill of Rights So, I had to run a campaign—which I had never did work out to be a very reasonable solution. The done before—and keep up a fairly busy medical U.S. Supreme Court never issued a favorable rul- practice at the same time. There were some times ing on our provision that a company that strictly where I was able to reschedule some things to did business in the state would have to abide by make important dates. the Texas statute. Nonetheless, the issue did Now, from the time of the primary to the run- change over time so that when I took office, the off, that was a very intense four weeks. I had most compelling issue on the front burner for never been through anything quite like it in my most physicians was the liability crisis. life. I did really scale back the operations of the Now the most compelling issue is cuts in Medi- medical office during that time. Fortunately, I care reimbursement to physicians. Certainly had the sense that the primary might go to a when I talk to my doctor friends back home, that run-off and that scaling back was important so is one of the problems they are concentrating I would have the time to actually devote to the on. Of course, the other issue that has become campaign. important to me is making sure we have enough doctors to take care of people 30 years from now, Tougher than residency? and whether we are doing things today with our policies that will lead us to a place where young It’s a different kind of tough. people decide that they do not want to go into medicine. That would be a tragedy. A different kind of tough? Please explain. What lessons from your experience in the TMA’s efforts At least when you’re in residency, there is to pass the Texas Patients’ Bill of Rights legislation have some point when you can turn off the light and you used during your tenure in Congress? go home. You may have a 24-hour shift, so it may seem like you are never getting home but eventu- The TMA is a very cohesive, collegial organiza- ally you do. When you are running a campaign tion. When I transitioned from being a delegate like the one I was, you cannot put all the issues to the TMA to being an alternate delegate to the to bed for a while and have a little quiet time. AMA, I was suddenly in a much larger group in It doesn’t happen. During a campaign, the next which the interests are not so closely aligned, thing you know, a reporter is on the phone ask- and that was a bit of an eye-opener for me. It ing you about this, that, or the other. It’s not as is much the same in Congress where I have though you can just brush off the question, and the Texas delegation—Republicans and Demo- you have to be pretty in-depth when giving your crats—who may be pretty aligned on Texas is- answer. sues; but when the issues are extrapolated out to the whole country, it becomes a different set Before running for this seat, you were very active in of circumstances. Going from the TMA to the health care policy in Texas and were one of the leaders AMA was one experience that I can very easily of the successful effort to get the Patients’ Bill of Rights say helped me prepare for what I was going to passed in Texas. face at the national level in Congress. Obviously, 61

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the issues are much more varied, but it is the process, and you have already touched on this topic some same concept. The Texans do tend to look at in our conversation. Why do you think it is so important things a little differently and do tend to be more for physicians to be politically involved? cohesive—even when you would not think they necessarily would be aligned. Again, because the rank-and-file member of Congress just does not have a good understand- In recent years, it seems that an increasing number of ing of the health care issues. Bear in mind, too, physicians are not just running for public office but winning that when we are up here in Washington, we are as well. Since 2000, we have seen the election, on both working, and we are stuck in the mode of deter- sides of the aisle, of several new members of Congress mining how to craft the best policy. We are also who are physicians. Why do think this is the case? constantly stuck in the financial mode of consider- ing how much things are going to cost now and in I do not think it has happened as much as I the future. The typical member of Congress does would have liked. The year that I won election, not bring to the legislative process knowledge of another doctor, Phil Gingrey (R-GA), MD, also what goes on in the treatment room, the emer- was elected, but we also lost two doctors in the gency room, and in the operating room. So, that is House of Representatives when they unsuccess- where doctors, I think, need to become involved. fully ran for the Senate. So in 2002, we had a It is as if you need to mentor your member of net gain of zero as far as physicians in Congress. Congress—if you cannot afford the time away At that time, there were about 11 physicians in from your practice to run, then be sure you are a the House. In 2004, we picked up ACS Fellows mentor to your member of Congress. Charles Boustany (R-LA), Joe Schwarz (R-MI), and Tom Price (R-GA) (all MD, FACS). In 2006, Some physicians have continued to practice medicine we lost Joe Schwarz, but we picked up Steve Ka- after being elected to Congress. Have you continued to gen, MD (D-WI). So there just has not been a big practice? influx of physicians. When you stop and consider that the nation spends roughly 17 percent of the By law, we as representatives can earn no more gross domestic product on health care, arguably than $22,000 outside our congressional salary, you could say that 15 percent to 17 percent of the which would not pay for the average liability members of the House of Representatives should policy—even with all the improvements that we be doctors. That has been my mantra. That is have had in Texas. So, I am licensed, I keep my still what I believe. license active, and I keep up with all my continu- I encourage people to think about either run- ing medical education requirements, but I don’t ning for office themselves or getting to know their carry insurance. member of Congress very well, being supportive, [The day before this interview] there was the and making sure he or she knows them. Honestly, national tragedy of the shooting at Virginia Tech. the rank-and-file member of Congress does not I did call the House physician’s office to see if have a good resource that he or she can turn to they had received any calls from the National back in the district to get good, solid medical in- Health Service Corps or if they needed help in formation. Not every physician can take the time that relatively rural part of Virginia. The answer away from practice to run for office, but everyone was “no.” So, your physician identity never can take some time away from practice to get to leaves you, I promise you. As a physician, you know his or her member of Congress a little bit see something like that happen on television, better and be certain that the member knows and you want to respond. who to go to back home when the top health care issues come up—because they will come up, over What advice would you give to surgeons who are and over again. considering a run for public office?

Earlier this year, you wrote in AMA News about the Every set of circumstances is going to be dif- importance of physician involvement in the political ferent. If it is a run for Congress and you do not 62

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS live right next door to Washington, you need to pulled away for a vote and needing to leave in the think about travel considerations and setting middle of your elevator speech. Do not discount up a separate household. If you have young the possibility of taking an afternoon off and children, time away from home obviously has going to sit and visit with your legislator. Also, to be a consideration. For all of the complaining avoid making all your visits about some problem that we in medicine do about payment, I will tell that you are having. Sometimes it’s good to talk you that the average member of Congress earns about something positive—to say something like, less than the average physician in private prac- “Hey, here’s something that I have thought of tice—at least that has been my observation. So that would really improve the delivery of health you do have to be able and willing to put up with care for the uninsured in our area, and I would that type of financial cut. As you know, doctors like to share it with you,” or, “A group of us has are busy people, but this is an extremely time- decided on something we can do for our Medicaid consuming job. I do not know if I was quite pre- population, and we are doing it locally, and we pared for how much time it does take—even more wanted you to know about it and be a part of it.” so than medicine. Again, there is no time for you Those sorts of discussions are helpful as well. to check out and go somewhere else. There is no time when you can take a weekend off and hand What have you enjoyed most about your service in the someone else the beeper. You are always it. You House, and what has been your biggest challenge as a are always on. member of Congress since your first election in 2002?

You touched on this a little bit when you talked about the You certainly have a chance to affect things idea of mentorship, but what are some other ways that on a much larger scale. Obviously as doctors we surgeons who are uninterested in running for public are used to helping people, but in that capac- office can be involved and affect the political debate in a ity, we are affecting the lives of our individual positive way? patients or maybe a family. In this business, you have the ability to affect thousands of lives over Of course, every representative runs every two a relatively short period of time. An instance in years, and most state legislators in the lower which that point came home to me was when I state houses run every two years. In Texas, state was participating in the talks that kept a large senators run every four years, and, of course, airline in my district from going into bankruptcy. nationally, U.S. senators run every six years. So Having an impact on such a broad scale is like you are never far away from a political campaign being able to cure 90,000 cases of pneumonia where you can be helpful, whether it’s serving in with one shot. It is really unlike anything I have an advisory role or just getting out and working ever been involved in before. The downside is the nuts and bolts of a campaign to see if that that you are dealing with so many people and sort of activity is something that might suit so many lives and that the decisions you make you. Working on a campaign is a good exercise today may, in years to come, come back in ways and you can make it a family exercise as well, that you never intended. Witness what we’ve particularly if there’s an issue—a local issue or seen with implementing the Health Insur- a national issue—that you really believe in and ance Portability and Accountability Act or the want to get behind. Resource-Based Relative Value Scale to set It’s also important to remember that every Medicare reimbursement or any number of representative and senator spends time at home other proposals that seemed like good ideas at every year. They are not always in Washington. the time. In the end, they have affected the way Lobbying trips to Washington are important, that medicine is practiced—and not always in a but it is also worth the effort to catch someone positive way—for years to come. The whole sus- during their down time—during the August tainable growth rate formula (SGR) [for setting recess or the Memorial Day recess. When they the conversion factor in the Medicare physician are in their home offices, they can spend a little fee schedule] was thought to be a good idea at more time with you because they are not being one point; now it is a travesty that we have to 63

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS fight against day after day. pan came and talked to the Congress last year My biggest disappointment would be how long before he finished up his term [as Chairman] it takes to get anything done—how long it takes at the Federal Reserve, and he said, “Yes, I am to build a consensus, how many terms you just concerned about Medicare, and I am concerned have to keep chipping away at the same problem about how we’re going to pay for it. But I am and building those coalitions and getting the more concerned about if there is going to be right people involved and bringing it to the at- anyone there to provide the services you want.” tention of enough other members of Congress. He was talking about doctors and nurses. He is Surgeons learn to never let the sun set twice on quite correct. If we do not pay attention, there a bowel obstruction. I promise you, many ses- may be a Medicare program but no one around to sions of Congress will set before we get some of provide the services. We have to make sure that these problems solved. On the other hand, once does not happen.  the changes start moving, be ready, because if you are not ready for action when the train starts moving, you can completely miss it, and it may not be around for a long time again. So even though things move so slowly, and you ask yourself, “Why do I need to be prepared? Why do I need to read this memo? Why do I need to reread this committee testimony?”—it’s because when [something] happens, you have to have all your ducks in a row. Is there anything that we have not touched on that surgeons should know about Congress and the American political process?

One thing that I had not considered when I started up here was the value of some of the young people who work on Capitol Hill for low salaries, just like we did when we were residents. I have a health care fellow working in the office now, and she is a recent graduate of Southwest- ern Medical School. Hearing her perspective—her concerns about the future—has been so helpful to me. I know what has happened for the past 30 years, what has been good and what has been bad. She’s thinking about what things going are to be like 30 years from now and why it is im- portant that we get some things done and how certain policies would affect the lives of doctors practicing decades into the future when I, quite frankly, might not still be around, but she will be around to live with the consequences. So having that “legacy aspect” has been important. That is why in these past couple of weeks, I have been focusing on bills that will protect the workforce we have now, add some fairness to the SGR formula, and make certain that we have a medical workforce in the future. Alan Greens- 64

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College recognizes ACS NSQIP hospitals

he American College of Surgeons would participating in ACS NSQIP, these hospitals like to recognize the first 150 hospitals have committed to improving surgical care at Tenrolled in the ACS National Surgical their institutions and sharing best practices with Quality Improvement Program (NSQIP). By other ACS NSQIP hospitals across the nation.

Pa r t i c i pat i n g S i t e Pa r t i c i pat i n g S i t e Hospital City Hospital City A l a s k a I o wa Alaska Native Medical Center Anchorage Grinnell Regional Medical Center Grinnell A l a b a m a University of Iowa Hospitals and Clinics Iowa City Decatur General Hospital Decatur I d a h o University of Alabama Birmingham Kootenai Medical Center Coeur d’Alene at Birmingham Hospital I l l i n o i s B r i tish Columbi a Advocate Good Samaritan Hospital Downers Grove Royal Columbian Hospital New Westminster Advocate Lutheran General Hospital Park Ridge Surrey Memorial Hospital Surrey Central DuPage Hospital Winfield C a l i f o r n i a Memorial Medical Center Springfield California Pacific Medical Center San Francisco Mercy Hospital and Medical Center Chicago Cedars-Sinai Medical Center Los Angeles Northwest Community Hospital Arlington Heights Contra Costa Regional Medical Center Martinez Northwestern Memorial Hospital Chicago David Grant Medical Center Travis AFB OSF Saint Francis Medical Center Peoria Fountain Valley Regional Hospital Fountain Valley Rush University Medical Center Chicago Fresno Community Hospital Fresno St. John’s Hospital Springfield and Medical Center I n d i a n a Kaiser Foundation Hospital San Diego Clarian Methodist Hospital Indianapolis Kaiser Medical Center Walnut Creek Walnut Creek Clarian University Hospital Indianapolis Kaiser Permanente, Santa Clara Columbus Regional Hospital Columbus Santa Clara Medical Center K a n s a s Mills Peninsula Health Services Burlingame Stormont-Vail Healthcare, Inc. Topeka Scripps Green Hospital La Jolla K e n t u c k y Sharp Memorial Hospital San Diego University of Kentucky Hospital Lexington Stanford Hospital and Clinics Stanford M a s s ac h u s e t t s Beth Israel Deaconess Medical Center Boston University of California San Diego Brigham & Women’s Hospital Boston San Diego Medical Center Faulkner Hospital Boston University of Southern California Los Angeles C o l o r a d o Lahey Clinic Burlington Exempla Saint Joseph Hospital Denver Lowell General Hospital Lowell Parkview Medical Center Pueblo Massachusetts General Hospital Boston C o n n e c t i c u t Newton-Wellesley Hospital Newton Danbury Hospital Danbury North Shore Medical Center Salem Middlesex Hospital Middletown South Shore Hospital South Weymouth M a ry l a n d Yale New Haven Hospital New Haven Greater Baltimore Medical Center Baltimore D e l awa r e Johns Hopkins Hospital Baltimore Christiana Care Health System Newark Sinai Hospital of Baltimore Baltimore F l o r i d a University of Maryland Medical Center Baltimore Baptist Hospital of Miami Miami M a i n e Cleveland Clinic Hospital Weston Eastern Maine Medical Center Bangor Doctors Hospital Coral Gables M i c h i g a n Shands Hospital Gainesville Foote Hospital Jackson South Miami Hospital Miami Genesys Regional Medical Center Grand Blanc G e o r g i a Henry Ford Hospital Detroit Atlanta Medical Center Atlanta Hurley Medical Center Flint Memorial Health University Medical Center Savannah 65

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS “Quality Improvement Through Quality Data”

Pa r t i c i pat i n g S i t e Pa r t i c i pat i n g S i t e Hospital City Hospital City M i c h i ga n ( c o n t i n u e d ) University Hospitals of Cleveland Cleveland McLaren Regional Medical Center Flint O r e g o n Mercy General Health Partners Muskegon Kaiser Sunnyside Medical Center Clackamas Northern Michigan Hospital Petoskey Oregon Health Science University Portland Oakwood Hospital Medical Center Dearborn Providence St. Vincent Medical Center Portland Providence Hospital and Medical Centers Southfield Sacred Heart Medical Center Eugene Saint John Hospital and Medical Center Detroit P e n n s y lva n i a Saint Joseph Mercy Hospital Ann Arbor Hahnemann University Hospital Philadelphia Saint Mary’s Health Care Grand Rapids Hospital of the University of Pennsylvania Philadelphia Spectrum Health Hospitals Grand Rapids Lehigh Valley Hospital and Health Network Allentown University of Michigan Hospitals Ann Arbor Penn State Milton S. Hershey Medical Center Hershey and Health Center Robert Packer Hospital Sayre William Beaumont Hospital–Troy Troy Thomas Jefferson University Hospital Philadelphia William Beaumont Hospital Royal Oak York Hospital York M i n n e s o ta R h o d e I s l a n d Cuyuna Regional Medical Center Crosby The Miriam Hospital Providence Mayo Clinic Rochester Methodist Hospital Rochester S o u t h C a r o l i n a Mayo Clinic Saint Mary’s Hospital Rochester Medical University Hospital Authority Charleston M i s s o u r i S o u t h d A ko ta Barnes-Jewish Hospital St. Louis Sioux Valley Hospital Sioux Falls Saint Louis University Hospital St. Louis T e n n e s s e e Saint Luke’s Hospital of Kansas City Kansas City Erlanger Health System Chattanooga N o rt h C a r o l i n a Saint Francis Hospital Memphis Duke University Medical Center Durham Vanderbilt University Hospital Nashville Moses Cone Memorial Hospital Greensboro T e x a s Baylor University Medical Center Dallas North Carolina Baptist Hospital, Inc. Winston-Salem Doctors Hospital at Renaissance Edinburg Presbyterian Hospital Charlotte Providence Memorial Hospital El Paso Southeastern Regional Medical Center Lumberton Scott & White Hospital Temple N e b r a s k a Sierra Medical Center El Paso Creighton St. Joseph Omaha Tarrant County Hospital District Fort Worth Regional Healthcare System JPS Health Network Nebraska Methodist Hospital Omaha The Methodist Hospital Houston N e w J e r s e y University of Texas Medical Branch Galveston Hackensack University Medical Center Hackensack USMD Hospital at Arlington Arlington Morristown Memorial Hospital Morristown William Beaumont Army Medical Center El Paso N e w Yo r k U ta h Albany Medical Center Albany LDS Hospital Salt Lake City Highland Hospital Rochester University of Utah Hospitals and Clinics Salt Lake City Mary Imogene Bassett Hospital Cooperstown New York Hospital Queens Flushing V i r ginia New York-Presbyterian–Columbia New York Inova Fairfax Hospital Falls Church New York-Presbyterian–Cornell New York Sentara Hospitals–Norfolk Norfolk Saint Peter’s Hospital Albany University of Virginia Health System Charlottesville SUNY at Stony Brook University Hospital Stony Brook Wa s h i n g t o n SUNY Upstate Medical University Hospital Syracuse University of Washington Medical Center Seattle University of Rochester Medical Center Rochester W i s c o n s i n O h i o Gundersen Lutheran Medical Center La Crosse Cleveland Clinic Foundation Cleveland Saint Joseph’s Hospital Marshfield Hillcrest Hospital Mayfield Heights University of Wisconsin Hospital & Clinics Madison Medical University of Ohio Toledo Waukesha Memorial Hospital Waukesha Miami Valley Hospital Dayton W yo m i n g Ohio State University Medical Center Columbus Campbell County Memorial Hospital Gillette 66

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AmericAn college of SurgeonS 93rd AnnuAl clinical congress

The role of a menTor in creaTing a surgical way of life

E r n E s t n . M o r i a l ConvEntion CEntEr nEw orlEans, la oCtobEr 7–11, 2007

preliminary Program

CC Preliminary Program cover-edi1 1 5/31/2007 11:15:12 AM • •

Dear Colleague, Premier hands-on learning. Leading-edge surgical research. Exceptional peer access. These are the hallmarks of the American College of Surgeons annual Clinical Congress. For surgeons dedicated to improving the care of the surgical patient and safeguarding standards of care, there is no better learning opportunity. On behalf of the College, I extend our warmest invitation to join us October 7–11, 2007, for the 93rd annual Clinical Congress, “The Role of a Mentor in Creating a Surgical Way of Life.” Programs at the Clinical Congress are designed to advance our ongoing quest to achieve the best clinical outcomes for patients. Regardless of your specialty area, you will find unique programs among our lectures, skills- oriented and didactic postgraduate courses, panels, Surgical Forum sessions, specialty and multidisciplinary sessions, and video-based education sessions. Attendees will be able to obtain special certificates including those enabling recipients to meet requirements for maintenance of certification, maintenance of licensure, and hospital reprivileging. In addition to advancing quality and innovation in the surgical field for our patients, the College is making significant strides to improve the practice environment for surgeons. This year we will expand the American College of Surgeons National Surgical Quality Improvement Program; launch the Health Policy Institute in Washington, DC, with the goal of enhancing our ability to shape the future direction of health policy; and partner with the Harvard School of Public Health to build awareness of the surgeon’s role in advancing the health of the population. We will discuss these new initiatives and how the College is working to become the leading and most trusted medical organization in the country. With outstanding educational programming and networking opportunities, this is the most important surgical conference of the year. I look forward to seeing you in New Orleans. With best wishes,

68

Josef E. Fischer, MD, FACS • Chair, Board of Regents •

2007 CC prelim program-edited ve1 1 6/14/2007 9:50:13 AM • • A Brief Scientific and Technical Overview American College Exhibitions of Surgeons The Scientific Exhibit is a forum of more than 150 exhibits 633 N. Saint Clair St. Goal presenting completed research, research in progress, and case Chicago, IL 60611-3211 The Clinical Congress is designed reviews. Innovative surgical 312/202-5000 to provide individuals with a wide practices and teaching methods 800/621-4111 range of learning opportunities, will also be presented. www.facs.org activities, and experiences that will match their educational and The Technical Exhibition professional development needs. comprises more than 250 companies displaying their Objective products and services. The exhibition provides an excellent By the conclusion of the Clinical ACS Program opportunity to explore the Congress, participants should Committee surgical marketplace by gain and be able to apply comparing products firsthand Chair: knowledge to improve their and planning purchases. Barbara L. Bass, MD, FACS current practice, research, and Houston, TX care of surgical patients. Scientific and Technical Exhibit hours are: Monday through ViCe-Chair: Accreditation Wednesday, 9:30 am-3:30 pm; Layton F. Rikkers, MD, FACS and Thursday, 9:30 am-12:00 The American College of Madison, WI noon. The exhibits are located in Surgeons is accredited by the Ernest N. Morial Convention MeMbers: the Accreditation Council for Center, Halls H through J. Robert R. Bahnson, MD, FACS Continuing Medical Education Columbus, OH to provide continuing medical education for physicians. Convocation Timothy R. Billiar, MD, FACS Pittsburgh, PA CME Credit Sunday, OctOber 7, 6:00–8:00 pm Julie A. Freischlag, MD, FACS cOnvOcatiOn ceremOny The American College of HiltOn new OrleanS riverSide Baltimore, MD Surgeons designates this Rene Lafreniere, MD, FACS educational activity for a Initiates of the ACS will be Calgary, AB maximum of 42.75* AMA PRA automatically registered for the Clinical Congress and need only Ronald V. Maier, MD, FACS Category 1 Credits™. Physicians to return the registration form Seattle, WA should only claim credit commensurate with the extent of if postgraduate course or Social Deborah A. Nagle, MD, FACS their participation in the activity. Program event tickets are desired. Boston, MA *Maximum of 28.25 credits Family members of Initiates do William D. Spotnitz, MD, FACS for attendance at morning and not need to register to attend the Charlottesville, VA afternoon general sessions. Convocation Ceremony only. Ronald G. Tompkins, MD, FACS *Maximum 35.75 credits including Boston, MA evening video sessions. Annual Business staff: Meeting of CME Certificates Ajit K. Sachdeva, MD, FACS, FRCSC Members Chicago, IL CME certificates will be issued tHurSday, OctOber 11, 2007 at the My CME Connection Julie Aikins Tribe, MSEd 7:30–8:30 am Chicago, IL located in the ACS Registration Area at the Ernest N. Morial erneSt n. mOrial

Beth Cherry, MS Convention Center, beginning on cOnventiOn center 69

Chicago, IL Monday, October 8, at 1:00 pm. • •

2007 CC prelim program-edited ve2 2 6/14/2007 9:50:14 AM • • Controversies in Trauma Surgical Management Scientific Triage and Resuscitation of Facial Trauma General Session sponsored by Multidisciplinary Session Program the Committee on Trauma sponsored by the Advisory Council Highlights Ductal Carcinoma In Situ: for the Surgical Specialties Evolving Strategies for Optimal Ablation and Reconstruction Diagnosis in Management Techniques for Skin Cancers The Clinical Congress is General Session sponsored by Multidisciplinary Session sponsored the Program Committee by the Advisory Council for Plastic designed to provide a range The Future of Open versus and Maxillofacial Surgery of educational experiences Laparoscopic Surgery ICU Management of Increased on a variety of topics—from During Residency Training: Intracranial Pressure contemporary issues, How Much Is Enough? Multidisciplinary Session leading-edge research, and General Session sponsored by the sponsored by the Advisory Council Committee on Perioperative Care advances in technology to for Neurological Surgery professional competence and Tools for Minimally Invasive Evidence-Based Guidelines for Abdominal Surgery: Optimizing the Care of Chronic Wounds clinical applications of new Safety and Efficacy Multidisciplinary Session sponsored developments in the basic General Session sponsored by by the Advisory Council for Plastic sciences. Some of the special the Program Committee and Maxillofacial Surgery topics being offered during Familial Cancer Syndromes Challenging Vascular Access this year’s Clinical Congress General Session sponsored by Problems in Infants and Children: include the following: the Program Committee Strategies and Options Multidisciplinary Session Advances in Stem Cell Biology: Management of Acute sponsored by the Advisory Translation Implications Council for Pediatric Surgery Colonic Diverticulitis for Surgeons (Excellence in General Session sponsored by Research Award Presentations/ Reconstruction Following Severe Abdominal Trauma the Program Committee Surgical Forum Dedication) Multidisciplinary Session sponsored Incisional Hernia Conundrum General Session sponsored by by the Advisory Council for Plastic General Session sponsored by the the Committee for the Forum on and Maxillofacial Surgery Advisory Council for General Surgery Fundamental Surgical Problems Response of an Academic Surgical Controversies in Breast NOTES Forum: Frontier for Specialty to a Natural Disaster Cancer Management Intervention or Just Another General Session sponsored by Pathway to Mischief? Multidisciplinary Session sponsored by the Advisory Council for Urology the Program Committee Multidisciplinary Session sponsored Occult Gastrointestinal Bleeding by the Program Committee Minimally Invasive Colorectal Surgery General Session sponsored by the Fertility-Sparing Surgery Postgraduate Course sponsored Advisory Council for General Surgery for the General Surgeon by the Committee on Emerging Multidisciplinary Session Treatment of GERD: Pharmacologic, Surgical Technology and Education sponsored by the Advisory Council Endoscopic, or Surgical? and the Advisory Council for for Gynecology and Obstetrics General Session sponsored by Colon and Rectal Surgery the Program Committee Recent Advances in Fundamentals of Evidence-Based Care for the Management of Cerebrovascular Disease Laparoscopic Surgery Patients with Acute Upper Postgraduate Course sponsored by Gastrointestinal Hemorrhage Multidisciplinary Session sponsored by the Advisory Council the Committee on Emerging Surgical General Session sponsored by Technology and Education the Program Committee for Neurological Surgery Accelerated Partial Inguinal Hernia Repair: When Evaluation and Management of the Mangled Lower Extremity Breast Irradiation and Which Operation? Postgraduate Course sponsored by General Session sponsored by Multidisciplinary Session

sponsored by the Advisory Council the Committee on Emerging Surgical

70 the Program Committee

for Surgical Specialties Technology and Education

• •

2007 CC prelim program-edited ve3 3 6/14/2007 9:50:14 AM • • Ultrasound Course for Residents Vascular Surgery: Open Postgraduate Course sponsored by and Endovascular, CanCellation of sessions: the Committee on Emerging Surgical Controversies and Results Technology and Education and Postgraduate Course sponsored by the The American College of the National Ultrasound Faculty Advisory Council for Vascular Surgery Surgeons reserves the right Team Training in Surgery: Subject-Oriented to cancel any of the scientific Lessons from Aviation Symposium II: Robotics Postgraduate Course sponsored by Video Session sponsored by the sessions listed in this Preliminary the Committee on Emerging Surgical Committee on Video-Based Education Program. Check the College’s Technology and Education Laparoscopic Colectomy: Web site www.facs.org for updates. Ultrasound in the Surgical ICU Ascending the Learning Curve Postgraduate Course sponsored by Video Session sponsored by the Committee on Emerging Surgical Committee on Video-Based Education Technology and Education and the National Ultrasound Faculty General Surgery Review Course Postgraduate Course sponsored by the Program Committee Meeting the Requirements for the Maintenance of Certification in General Surgery Postgraduate Course sponsored by the Program Committee Review Course in Cardiac and Thoracic Surgery for Certification and Maintenance of Certification Candidates Postgraduate Course sponsored by the Advisory Council for Cardiothoracic Surgery Urology Review for Recertification Candidates Postgraduate Course sponsored by the Advisory Council for Urology Benign Anorectal Disease Postgraduate Course sponsored by the Advisory Council for Colon and Rectal Surgery Medical Malpractice: Understanding the Relevant Issues and Potential Risk Mitigation Strategies for the Practitioner Postgraduate Course sponsored by the Committee on Perioperative Care Accreditation of Education Institutes by the American College of Surgeons: A New Program to Support Acquisition and Verification of New Surgical Skills

Postgraduate Course sponsored 71

by the Program Committee • •

2007 CC prelim program-edited ve4 4 6/14/2007 9:50:15 AM Scientific Program • • NAMED Tuesday, NL08 • 1:30–2:15 pm October 9, 2007 I. S. Ravdin Lecture in Basic LECTURES Sciences: Tissue Engineering NL04 • 1:30–2:15 pm and Regenerative Medicine— Scudder Oration on Trauma: Building Living Replacements Trauma: A Social and for Surgical Reconstruction Medical Challenge and Transplantation Monday, Lecturer: Dario Birolini, MD, FACS, Lecturers: October 8, 2007 Sao Paolo, Brazil John P. Vacanti, MD, FACS, Sponsored by the Committee Boston, MA NL01 8:30–9:30 am • on Trauma Charles A. Vacanti, MD, Boston, MA American Urological Association Sponsored by the Committee Lecture: The Coming Era of Too NL05 • 3:00–4:00 pm on Perioperative Care Few Physicians Olga M. Jonasson Lecture: TBD Lecturer: Richard A. Cooper, MD, Lecturer: TBD NL09 • 2:00–3:00 pm Philadelphia, PA Sponsored by the Committee Herand Abcarian Lecture: Sponsored by the American on Women’s Issues Surgical Mentoring Urological Association Lecturer: Thomas R. Russell, MD, FACS, Chicago, IL NL02 • 11:00 am–12:00 noon Wednesday, Sponsored by the Advisory Council John H. Gibbon, Jr., Lecture: October 10, 2007 for Colon and Rectal Surgery Esophageal Mythology Lecturer: Mark B. Orringer, MD, NL06 • 9:00–10:00 am NL10 • 3:00–4:00 pm FACS, Ann Arbor, MI Ethics and Philosophy Lecture: Distinguished Lecture of Sponsored by the Advisory Council Mind Wars: Brain Research and the International Society for Cardiothoracic Surgery National Defense of Surgery: What Can the Academic Community Offer NL03 • 1:30–2:30 pm Lecturer: Jonathan D. Moreno, PhD, Philadelphia, PA the Third-World Surgeon? Charles G. Drake History of Sponsored by the Committee on Ethics Lecturer: Michael G. Sarr, MD, FACS, Surgery Lecture: Joseph Lovell: Rochester, MN First-Generation American, First NL07 • 11:00 am–12:00 noon Sponsored by the International Surgeon General Surgical Society Lecturer: David L. Nahrwold, MD, Commission on Cancer FACS, Chicago, IL Oncology Lecture: The Excitement of Cancer Research Sponsored by the Advisory Council in the Next Decade Thursday, for Neurological Surgery Lecturer: John E. Niederhuber, MD, October 11, 2007 FACS, Bethesda, MD NL11 8:30–9:15 am Sponsored by the • Commission on Cancer Martin Memorial Lecture: Fighting the Great Pandemics— Challenges and Opportunities Lecturer: Richard G.A. Feachem, KBE, FREng, DSc(Med), Geneva, Switzerland Sponsored by the Honors Committee

72

• •

2007 CC prelim program-edited ve5 5 6/14/2007 10:13:59 AM Scientific Program • • Postgraduate Description of ACS System for Fee Categories Verification Skills Courses of Knowledge FellOw and Skills A surgeon who is a The Board of Regents of the Fellow of the College American College of Surgeons has Postgraduate approved a five-level model for Courses and Fees verification and documentation nOn-FellOw of knowledge and skills by Only registered meeting A practicing physician the Division of Education, attendees may purchase who is not currently a following participation in the member of the College postgraduate course tickets. educational programs of the Seating capacities are limited, College. The model provides a framework for designing and and ticket requests will be filled RAS implementing cutting-edge on a first-come, first-processed Associate Fellow, Resident educational courses, based on basis. Postgraduate course Member, and Affiliate principles of contemporary tickets may be purchased on- Member of the College surgical education and permits site in New Orleans, subject to provision of appropriate documentation to the attendees. availability. All courses require nOn-RAS LeveL I a ticket for admission. Tickets A physician in training or Verification of attendance may only be exchanged before member of the surgical the beginning of a course team who is currently in an LeveL II Verification of satisfactory and may only be exchanged accredited training program or working in a surgical- completion of course objectives for another course. Course related setting, but has no LeveL III syllabi will be distributed affiliation with the College Verification of satisfactory on site in New Orleans. completion of course objectives and verification of knowledge and skills LeveL Iv Verification of satisfactory completion of the course objectives, verification of knowledge and skills, and verification of subsequent preceptorial experience LeveL v Verification of satisfactory completion of the entire education and training program, including satisfactory completion of course objectives, verification of knowledge and skills, verification of subsequent preceptorial experience, and demonstration of satisfactory patient outcomes

73

• •

2007 CC prelim program-edited ve6 6 6/14/2007 9:50:17 AM Scientific Program • • Sunday, Co-Chairs: your course to obtain one. October 7, 2007 Mary E. Maniscalco-Theberge, MD, Your registration and payment FACS, Reston, VA will not be processed until Anne Thompson Mancino, MD, FACS, the National Ultrasound SC01: Fundamentals of Little Rock, AR Faculty has approved your Breast Imaging for the Sponsored by the Committee on accompanying documentation. General Surgeon Continuous Professional Development E-mail Uriah Melchizedek at umelchizedek@ 4 credits, Verification Level I facs.org for more information. FellOw RAS Sunday, October 7 $275 $80 FellOw RAS 7:30–11:45 am $775 $235 FEE nOn-FellOw nOn-RAS Chair: Edward J. Donahue, MD, $315 $110 FEE nOn-FellOw nOn-RAS FACS, Phoenix, AZ $890 $310 Sponsored by the Committee on Emerging Surgical SC04: Thyroid and Technology and Education Parathyroid Ultrasound SC05: Mammography for 7 credits, Verification Level II the General Surgeon FellOw RAS 5 credits, Verification Level I $250 $75 Sunday, October 7 9:00 am–5:30 pm Sunday, October 7

FEE nOn-FellOw nOn-RAS $290 $100 Chair: Robert Sofferman, MD, FACS, 12:15–5:30 pm Burlington, VT Chair: Darius Francescatti, MD, FACS, Sponsored by the Committee on Chicago, IL SC02: Fundamentals of Emerging Surgical Technology Sponsored by the Committee Laparoscopic Surgery (FLS) and Education and the on Emerging Surgical No FLS Examination: 6 credits, National Ultrasound Faculty Technology and Education Verification Level I Prerequisite: Registrants must FellOw RAS With FLS Examination: 6 credits, have completed a course in $355 $130 Verification Level III basic ultrasound to register for FEE nOn-FellOw nOn-RAS Sunday, October 7 this course. Three options are $405 $160 9:00 am–4:30 pm available to meet the prerequisite: Co-Chairs: 1. Completion of the previously E. Matthew Ritter, MD, FACS, offered ACS postgraduate Monday, Gaithersburg, MD course Ultrasound for Surgeons. October 8, 2007 Daniel Scott, MD, FACS, Dallas, TX 2. Completion of the CD- Sponsored by the Committee ROM course, Ultrasound for on Emerging Surgical Surgeons: The Basic Course. The SC06: Minimally Invasive Technology and Education CD-ROM is available for Colorectal Surgery purchase online at www.facs. Part I, Lectures: 6 credits, FellOw RAS org in the ACS Publications Verification Level I $425 $295 and Services Catalog or by Part II, Hands-On: 8 credits, FEE nOn-FellOw nOn-RAS contacting ACS Customer Verification Level II $490 $345 Service at 312/202-5474. NO FLS ExAMINATION Monday, October 8 3. Completion of a comparable 9:45 am–4:15 pm (Lectures) FellOw RAS course elsewhere. Please include $625 $495 the following documents Tuesday, October 9 8:00 am–5:00 pm (Hands-On)

FEE nOn-FellOw nOn-RAS with your registration form: Co-Chairs: $690 $545 • CME certificate WITH FLS ExAMINATION Peter Marcello, MD, FACS, • Certificate of completion Burlington, MA • Registration confirmation/ Matthew Mutch, MD, FACS, SC03: Surgical Education: verification St. Louis, MO Principles and Practices If you do not have one of these Sponsored by the Committee on 6 credits, Verification Level I

74 documents, please contact the Emerging Surgical Technology and

Sunday, October 7 organization that sponsored Education and the Advisory Council • 9:00 am–5:00 pm for• Colon and Rectal Surgery

2007 CC prelim program-edited ve7 7 6/14/2007 9:50:18 AM Scientific Program • • Prerequisite for the hands- 1. Completion of the previously 1. Completion of the previously on session: Application for offered ACS postgraduate offered ACS postgraduate Part II and registration for course Ultrasound for Surgeons. course Ultrasound for Surgeons. Part I required. E-mail Uriah 2. Completion of the CD- 2. Completion of the CD- Melchizedek at umelchizedek@ ROM course, Ultrasound for ROM course, Ultrasound for facs.org for more information Surgeons: The Basic Course. The Surgeons: The Basic Course. The and an application for Part II. CD-ROM is available for CD-ROM is available for purchase online at www.facs. purchase online at www.facs. Part i, LeCtures org in the ACS Publications org in the ACS Publications and Services Catalog or by and Services Catalog or by FellOw RAS contacting ACS Customer contacting ACS Customer $375 $115 Service at 312/202-5474. Service at 312/202-5474. FEE nOn-FellOw nOn-RAS 3. Completion of a comparable $430 $150 3. Completion of a comparable course elsewhere. Please include course elsewhere. Please include Part ii, hands-on the following documents the following documents with your registration form: with your registration form: FellOw RAS CME certificate • CME certificate $825 $250 • Certificate of completion •

FEE nOn-FellOw nOn-RAS • Registration confirmation/ • Certificate of completion $950 $330 verification • Registration confirmation/ If you do not have one of these verification documents, please contact the SC07: Using Advanced organization that sponsored If you do not have one of these Multimedia in PowerPoint your course to obtain one. documents, please contact the Presentations Your registration and payment organization that sponsored your course to obtain one. 6 credits, Verification Level I will not be processed until the National Ultrasound Your registration and payment Monday, October 8 Faculty has approved your will not be processed until 9:45 am–5:15 pm accompanying documentation. the National Ultrasound Chair: William D. Hardin, MD, FACS, E-mail Uriah Melchizedek at umelchizedek@ Faculty has approved your Birmingham, AL facs.org for more information. accompanying documentation. Sponsored by the Committee FellOw RAS E-mail Uriah Melchizedek at umelchizedek@ on Informatics $850 $255 facs.org for more information. FellOw RAS FellOw RAS FEE nOn-FellOw nOn-RAS $415 $125 $975 $340 $775 $235

FEE nOn-FellOw nOn-RAS

FEE nOn-FellOw nOn-RAS $890 $310 $480 $165 SC09: Vascular Ultrasound: New Applications and SC08: Breast Ultrasound Laboratory Management SC10: Safe Operating 7.5 credits, Verification Level II 7 credits, Verification Level II Room Practices 6 credits, Verification Level I Monday, October 8 Monday, October 8 9:45 am–5:45 pm 9:45 am–5:45 pm Monday, October 8 Co-Chairs: Chair: R. Eugene Zierler, MD, FACS, 10:00 am–5:30 pm Jay Harness, MD, FACS, Orange, CA Seattle, WA Chair: John R. Clarke, MD, FACS, Philadelphia, PA Howard Snider, MD, FACS, Sponsored by the Committee on Montgomery, AL Emerging Surgical Technology Co-Chair: Donald W. Moorman, MD, and Education and the FACS, Boston, MA Sponsored by the Committee on National Ultrasound Faculty Sponsored by the Board of Governors Emerging Surgical Technology Committee on Surgical Practice in and Education and the Prerequisite: Registrants must Hospitals and Ambulatory Settings National Ultrasound Faculty have completed a course in basic ultrasound to register for FellOw RAS Prerequisite: Registrants must $325 $95 have completed a course in this course. Three options are available to meet the prerequisite: FEE nOn-FellOw nOn-RAS

basic ultrasound to register for $370 $130 75

this course. Three options are

• available to meet the prerequisite: •

2007 CC prelim program-edited ve8 8 6/14/2007 9:50:18 AM Scientific Program • • SC11: Accelerated Partial Prerequisite: Registrants must Sponsored by the Committee Breast Irradiation have completed a course in on Emerging Surgical 4 credits, Verification Level I basic ultrasound to register for Technology and Education this course. Three options are Monday, October 8 FellOw RAS available to meet the prerequisite: 1:00–5:30 pm $795 $255

Chair: Peter Beitsch, MD, FACS, 1. Completion of the previously FEE nOn-FellOw nOn-RAS Dallas, TX offered ACS postgraduate $910 $330 course Ultrasound for Surgeons. Sponsored by the Committee Completion of the CD- on Emerging Surgical 2. SC15: Computers and Technology and Education ROM course, Ultrasound for Surgeons: The Basic Course. The the Internet for the FellOw RAS CD-ROM is available for Practicing Surgeon $275 $100 purchase online at www.facs. 6 credits, Verification Level I

FEE nOn-FellOw nOn-RAS org in the ACS Publications Tuesday, October 9 $315 $125 and Services Catalog or by 9:00 am–4:30 pm contacting ACS Customer Chair: Ronald Hirschl, MD, FACS, Service at 312/202-5474. Ann Arbor, MI Tuesday, 3. Completion of a comparable October 9, 2007 course elsewhere. Please include Sponsored by the Committee the following documents on Informatics with your registration form: FellOw RAS SC12: Lymphatic Mapping • CME certificate $425 $125

and the Significance of FEE nOn-FellOw nOn-RAS Certificate of completion Sentinel Node Biopsy • $490 $170 7 credits, Verification Level I • Registration confirmation/ verification Tuesday, October 9 If you do not have one of these SC16: Ultrasound 8:00 am–4:30 pm Course for Residents Chair: Armando Giuliano, MD, documents, please contact the FACS, Santa Monica, CA organization that sponsored 5 credits, Verification Level II your course to obtain one. Tuesday, October 9 Sponsored by the Committee Your registration and payment 12:00 noon–5:30 pm on Emerging Surgical will not be processed until Chair: Amy Sisley, MD, FACS, Technology and Education the National Ultrasound Baltimore, MD FellOw RAS Faculty has approved your Sponsored by the Committee on $395 $115 accompanying documentation. Emerging Surgical Technology

FEE nOn-FellOw nOn-RAS and Education and the $455 $160 E-mail Uriah Melchizedek at umelchizedek@ facs.org for more information. National Ultrasound Faculty Note: Although this course FellOw RAS SC13: Laparoscopic and Open has no prerequisite, enrollment Intraoperative Ultrasound $850 $255 is limited, and we encourage

FEE nOn-FellOw nOn-RAS in Abdominal Surgery residents to enroll early as we $975 $340 8 credits, Verification Level II expect the course to sell out. Tuesday, October 9 FellOw RAS 8:00 am–5:30 pm SC14: The Minimally Invasive N/A $105

Chair: Junji Machi, MD, FACS, Approach to Breast Biopsy: FEE nOn-FellOw nOn-RAS Honolulu, HI Stereotactic Technique N/A $140 Sponsored by the Committee on and Application (Basic) Emerging Surgical Technology 8 credits, Verification Level II and Education and the National Tuesday, October 9 Ultrasound Faculty 8:00 am–5:30 pm

Chair: Darius Francescatti, MD, FACS,

76 Chicago, IL

• •

2007 CC prelim program-edited ve9 9 6/14/2007 9:50:18 AM Scientific Program • • Wednesday, Wednesday, October 10 FellOw RAS October 10, 2007 8:00 am–12:30 pm $350 $105 Chair: Reid Adams, MD, FACS, FEE nOn-FellOw nOn-RAS Charlottesville, VA $410 $140 SC17a: Maintenance of Sponsored by the Committee on Certification Part IV: Emerging Surgical Technology SC21: Bariatric Surgery Individualized Education and Education and the Linked to Patient National Ultrasound Faculty for All Surgeons 8 credits, Verification Level I Outcomes (Part A) Prerequisite: Application 4 credits, Verification Level II must be approved by the Wednesday, October 10 National Ultrasound Faculty 8:00 am–5:00 pm Wednesday, October 10 Chair: Henry Buchwald, MD, FACS, Module Director before 8:00 am–12:00 noon Minneapolis, MN Chair: Ajit K. Sachdeva, MD, FACS, registration or payment can FRCSC, Chicago, IL be processed. E-mail Uriah Sponsored by the Committee Melchizedek at umelchizedek@ on Emerging Surgical Enrollment in SC17b is not facs.org for the application Technology and Education a prerequisite to take this and additional information. course, but it is encouraged. FellOw RAS $430 $130 Sponsored by the Program Committee FellOw RAS

$125 N/A FEE nOn-FellOw nOn-RAS FellOw RAS $495 $170 FEE nOn-FellOw nOn-RAS $195 $75 N/A N/A

FEE nOn-FellOw nOn-RAS $225 $85 SC22: Advanced Technology SC19: Team Training in Image-Guided Diagnosis in Surgery: Lessons and Treatment of the Breast SC17b: Hands-On Training: from Aviation 8 credits, Verification Level II Using the ACS Case Log 6 credits, Verification Level I Wednesday, October 10 System to Support Practice- Wednesday, October 10 8:00 am–5:30 pm Based Learning and 8:00 am–3:30 pm Co-Chairs: Improvement and Maintenance Co-Chairs: Eric Whitacre, MD, FACS, Tucson, AZ of Certification (Part B) Donald Moorman, MD, FACS, Victor Zannis, MD, FACS, Phoenix, AZ 4 credits, Verification Level II Boston, MA Sponsored by the Committee on Wednesday, October 10 Jack Barker, PhD, Miami, FL Emerging Surgical Technology 1:30–5:30 pm Sponsored by the Committee and Education and the Chair: M. Michael Shabot, MD, FACS, on Emerging Surgical National Ultrasound Faculty Houston, TX Technology and Education Prerequisite: Approval by Enrollment in SC17a is not FellOw RAS course chair; application required. a prerequisite to take this $325 $95 course, but it is encouraged. E-mail Uriah Melchizedek at umelchizedek@

FEE nOn-FellOw nOn-RAS Sponsored by the Committee $370 $130 facs.org for more information. on Informatics FellOw RAS $775 $235 FellOw RAS SC20: Disaster Management $195 $75 FEE nOn-FellOw nOn-RAS and Emergency Preparedness $890 $310 FEE nOn-FellOw nOn-RAS 7.5 credits, Verification Level I $225 $85 Wednesday, October 10 8:00 am–5:00 pm SC23: Ultrasound in SC18: Ultrasound Chair: John H. Armstrong, MD, FACS, the Surgical ICU Instructors Course Ocala, FL 8 credits, Verification Level II 4 credits, Verification Level III Sponsored by the Committee on Trauma Wednesday, October 10 8:00 am–5:30 pm

Chair: Heidi Frankel, MD, FACS, 77

Dallas, TX • •

2007 CC prelim program-edited ve10 10 6/14/2007 9:50:19 AM Scientific Program • • Sponsored by the Committee on Postgraduate Monday, Emerging Surgical Technology October 8, 2007 and Education and the National Ultrasound Faculty Didactic PG03: General Surgery Prerequisite: Registrants must Courses Review Course have completed a course in 12 credits, Verification Level III basic ultrasound to register for this course. Three options are Sunday, Monday, October 8 available to meet the prerequisite: October 7, 2007 10:00 am–5:30 pm 1. Completion of the previously Tuesday, October 9 offered ACS postgraduate 10:00 am–5:30 pm course Ultrasound for Surgeons. Chair: John A. Weigelt, MD, FACS, Milwaukee, WI 2. Completion of the CD- PG01: Medical Malpractice: Vice-Chairs: ROM course, Ultrasound for Understanding the Relevant Surgeons: The Basic Course. The Robert C. McIntyre, MD, FACS, CD-ROM is available for Issues and Potential Risk Denver, CO purchase online at www.facs. Mitigation Strategies Eugene F. Foley, MD, FACS, org in the ACS Publications for the Practitioner Charlottesville, VA and Services Catalog or by 4 credits, Verification Level I Sponsored by the Program Committee contacting ACS Customer Sunday, October 7 in collaboration with the Southeastern Service at 312/202-5474. 1:00–5:00 pm and Southwestern Surgical Congresses 3. Completion of a comparable Chair: Lewis M. Flint, MD, FACS, course elsewhere. Please include Tampa, FL FellOw RAS the following documents $575 $170 Co-Chair: Michael S. Nussbaum, MD, with your registration form: FEE nOn-FellOw nOn-RAS FACS, Cincinnati, OH $660 $230 • CME certificate Sponsored by the Committee • Certificate of completion on Perioperative Care PG04: Urology Review for • Registration confirmation/ verification FellOw RAS Recertification Candidates $195 $75 6 credits, Verification Level II If you do not have one of these

FEE nOn-FellOw nOn-RAS documents, please contact the Monday, October 8 organization that sponsored $225 $85 10:00 am–5:30 pm your course to obtain one. Co-Chairs: Judd W. Moul, MD, FACS, Durham, NC Your registration and payment PG02: Meeting the will not be processed until Requirements for the Robert R. Bahnson, MD, FACS, Columbus, OH the National Ultrasound Maintenance of Certification in Faculty has approved your General Surgery Sponsored by the Advisory accompanying documentation. 4 credits, Verification Level I Council for Urology E-mail Uriah Melchizedek at umelchizedek@ Sunday, October 7 FellOw RAS facs.org for more information. 1:00–5:00 pm $375 $110

FEE nOn-FellOw nOn-RAS FellOw RAS Co-Moderators: $850 $255 James C. Hebert, MD, FACS, $430 $150 Burlington, VT

FEE nOn-FellOw nOn-RAS $975 $340 Michael S. Nussbaum, MD, FACS, Cincinnati, OH Tuesday, Sponsored by the Committee on October 9, 2007 Continuous Professional Development FellOw RAS PG05: Prevention and $195 $75 Treatment of Complications

FEE nOn-FellOw nOn-RAS in the Trauma Patient

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$225 $85 5 credits, Verification Level I

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2007 CC prelim program-edited ve11 11 6/14/2007 9:50:19 AM Scientific Program • • Tuesday, October 9 Chair: Theodore J. Saclarides, MD, 8:00 am–1:15 pm FACS, Chicago, IL Co-Chairs: Sponsored by the Advisory Council Lawrence M. Gentilello, MD, FACS, for Colon and Rectal Surgery Dallas, TX Joseph P. Minei, MD, FACS, FellOw RAS Dallas, TX $325 $95

FEE nOn-FellOw nOn-RAS Sponsored by the Committee $370 $130 on Trauma

FellOw RAS PG08: Review Course $325 $95 in Cardiac and Thoracic

FEE nOn-FellOw nOn-RAS $370 $130 Surgery for Certification and Maintenance of Certification Candidates PG06: Introduction to CPT, 13 credits, Verification Level II ICD-9-CM, and Evaluation and Tuesday, October 9 Management Coding (Basic) 9:30 am–5:00 pm 7 credits, Verification Level I Wednesday, October 10 Tuesday, October 9 8:30 am–5:00 pm 8:30 am–5:00 pm Co-Chairs: Chair: Linda M. Barney, MD, FACS, Robert J. Cerfolio, MD, FACS, Dayton, OH Birmingham, AL Sponsored by the General Surgery Glenn J.R. Whitman, MD, FACS, Coding and Reimbursement Committee Philadelphia, PA

FellOw RAS Sponsored by the Advisory Council $350 $105 for Cardiothoracic Surgery

FEE nOn-FellOw nOn-RAS FellOw RAS $405 $140 $560 $160

FEE nOn-FellOw nOn-RAS PG07: Benign $645 $220 Anorectal Disease 6 Credits, Verification Level I Tuesday, October 9 9:30 am–5:00 pm

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2007 CC prelim program-edited ve12 12 6/14/2007 9:50:21 AM Scientific Program • • PG09: Accreditation of FellOw RAS FellOw RAS Education Institutes by the $350 $105 $325 $95

American College of Surgeons: FEE nOn-FellOw nOn-RAS FEE nOn-FellOw nOn-RAS A New Program to Support $405 $140 $370 $130 Acquisition and Verification of New Surgical Skills PG12: Innovations in PG15: Vascular Surgery: 4 credits, Verification Level I the Management of Open and Endovascular, Tuesday, October 9 Maxillofacial Trauma Controversies and Results 1:00–5:00 pm 6 credits, Verification Level I 6 credits, Verification Level I Chair: Carlos A. Pellegrini, MD, FACS, Seattle, WA Wednesday, October 10 Wednesday, October 10 9:00 am–4:30 pm 9:30 am–5:00 pm Sponsored by the Program Committee Chair: Seth R. Thaller, MD, FACS, Chair: Bruce A. Perler, MD, FACS, Miami, FL Baltimore, MD FellOw RAS $150 $45 Sponsored by the Advisory Council for Sponsored by the Advisory

FEE nOn-FellOw nOn-RAS Plastic and Maxillofacial Surgery Council for Vascular Surgery $170 $60 FellOw RAS FellOw RAS $325 $95 $325 $95

PG10: Personal Digital FEE nOn-FellOw nOn-RAS FEE nOn-FellOw nOn-RAS Assistant (PDA) $370 $130 $370 $130 6.5 credits, Verification Level I Tuesday, October 9 PG13: Minimally Invasive 1:30–4:30 pm Surgery: The Next Steps Wednesday, October 10 6 credits, Verification Level I 8:30 am–12:00 noon Wednesday, October 10 Chair: David A. Krusch, MD, FACS, 9:00 am–4:30 pm Rochester, NY Chair: Sponsored by the Committee Bruce D. Schirmer, MD, FACS, on Informatics Charlottesville, VA

FellOw RAS Co-Chair: $425 $130 B. Todd Heniford, MD, FACS, Charlotte, NC

FEE nOn-FellOw nOn-RAS $490 $170 Sponsored by the Committee on Emerging Surgical Technology and Education Wednesday, FellOw RAS October 10, 2007 $325 $95

FEE nOn-FellOw nOn-RAS PG11: 2007 Surgical and $370 $130 Office-Based Coding and Reimbursement (Advanced) PG14: The Business Aspects of 7 credits, Verification Level I Health System Management: Wednesday, October 10 The Surgeon’s Role in Health 8:30 am–5:00 pm System Leadership Chair: John T. Preskitt, MD, FACS, 6.5 credits, Verification Level I Dallas, TX Wednesday, October 10 Sponsored by the General Surgery 9:00 am–5:00 pm Coding and Reimbursement Committee Chair: Paul A. Taheri, MD, MBA, FACS, Burlington, VT

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Sponsored by the Committee

• on Perioperative Care •

2007 CC prelim program-edited ve13 13 6/14/2007 9:50:21 AM SPECIAL INTEREST • • Sessions Special Program for Special Program for Medical Students Surgery Residents The Division of Education invites of Special Monday, October 8, students from all four years of Interest medical school to attend the Clinical 9:45 am–2:30 pm Congress and to participate in Surgery residents from all PGY a program designed specifically levels are invited by the Division of for medical students who may be Education to participate in a special interested in pursuing surgery as program designed to assist with Resident and Associate a career. Sessions with leading planning for posttraining careers Society Symposium: Pay for surgeon faculty members and and making the transition from Performance and Surgical residents will include topics such as training to practice. This special deciding if surgery is the best career program is specifically designed Quality Initiatives: Will choice, taking the appropriate steps to assist surgery residents with the Generalist and in each year of medical school to be essential nonclinical issues they Surgical Training Survive competitive for surgical residency face during residency training and in the New Paradigm? programs, identifying the qualities the transitional period to their that program directors want in posttraining career. The program Sunday, October 7, applicants, asking for letters for will feature sessions on personal 1:00–4:00 pm recommendation, interviewing financial planning and debt successfully, choosing residency management, job-seeking strategies Each year, the RAS-ACS sponsors programs, preparing to optimize the and negotiation skills, reduction of a symposium during the Clinical resident experiences, and beginning liability risks, practice management, Congress on a topic targeted to consider various surgical and stress management in personal at surgical residents, young specialties and settings in which to and professional relationships. Join surgeons, and Fellows. This year’s practice. Be sure to take advantage residents from other programs presentation will focus on surgical of this unique opportunity to interact and interact with experts who can quality initiatives and the future of with other students interested in share techniques for managing surgery. The goal of this session is to surgery, residents, program directors, the residency experience more examine surgical quality initiatives faculty, and surgeons practicing in effectively and being better and their potential impact on both academe and the community. Early prepared for life after residency. resident training and the practice registration is encouraged, as space For additional information, of surgery in the future. The is limited. Students must be enrolled contact Ms. Cherylnn Sherman symposium will review the data to in a LCME-accredited medical at 312/202-5424 or csherman@ support pay-for-performance and school in order to participate. For facs.org. Residents must be surgical quality initiatives, as well additional information, contact enrolled in an ACGME-accredited as the effect of these changes on Ms. Emily Bakken at 312/202- program in order to participate. surgical training and the practice 5119 or [email protected]. of surgery. The impact on both To register, find the Scientific general surgery training and surgical To register, find the Scientific Program registration form specialties will be examined. Program registration form online at www.facs.org. online at www.facs.org. Attendance is open to all ACS Resident Members, as well as James IV Association of students and Fellows. An open Convocation microphone discussion will Surgeons Inc. promote audience participation Sunday, October 7, 50th Anniversary Symposium in the symposium. 6:00–8:00 pm Monday, October 8, We hope to see you there. Convocation Ceremony 3:30–5:30 pm Please use the online Scientific Hilton New Orleans Riverside The James IV Association of Program registration form to sign up. Initiates of the ACS will Surgeons was founded 50 years ago automatically be registered for the by Sir John Bruce of Edinburgh, Clinical Congress and need only Professor Ian Aird of London, and to return the registration form Dr. William Hinton of New York if postgraduate course or Social on the occasion of the American Program event tickets are desired. College of Surgeons Meeting Family members of Initiates do on October 17, 1957, in Atlantic not need to register to attend the City, NJ. At that time, both John

Convocation Ceremony only. Bruce and Ian Aird had received 81 Honorary Fellowships from the

• College• and were convinced of the

2007 CC prelim program-edited ve14 14 6/14/2007 9:50:22 AM SPECIAL INTEREST • • need for close ties among surgeons Fourth annual Rural Financial Sessions of different countries. They formed Surgeons Meeting and Oweida the James IV Association to promote Scholarship Presentation international exchange. The 2007 Improve Your Financial symposium celebrates 50 years of Tuesday, October 9, Health: Surgeons Diversified the Association with presentations provided by distinguished members 4:00–5:30 pm Investment Fund Sessions and travelers of the organization To accomplish its mission “To on Prudent Investing summarizing the changes that improve the patient’s access to have taken place in their field. quality surgical care in the rural Planning, Investing, and Saving setting by identifying and addressing for Your Future: Beginners the needs of surgeons in this unique Monday, October 8, Latin America Day: environment,” the Rural Surgery 9:45–10:45 am Cancer in Latin America Subcommittee of the Advisory Council for General Surgery needs Tuesday, October 9, your input. This meeting of the rural Planning, Investing, and Saving 1:30–4:30 pm surgeons will focus on the topic, for Your Future: Advanced How General Surgeons Survive in Tuesday, October 9, Co-Moderators: the Era of Surgical Subspecialization. 1:30–2:30 pm Eduardo Barboza, MD, FACS, The presentation of the 2007 Nizar Lima, Peru N. Oweida, MD, FACS, Scholarship Please join us in reviewing the Jorge A. Ortiz De La Pena R, MD, to Michael C. Gynn, MD, from importance of sound financial Dublin, CA, will open the session. planning, understanding investment FACS, Mexico City, Mexico principles, and the need to plan Thereafter, a panel of well- Hugo V. Villar, MD, FACS, Tucson, AZ for your financial future. recognized surgical leaders eager Cervical, gastric, breast, colon, and to hear from rural general surgeons gallbladder cancer are major health will be introduced. Many of the issues in Latin America. Thyroid issues and challenges traditionally Estate Planning and Estate cancer also seems to be on the faced by rural surgeons and their Tax Issues for Surgeons increase. Speakers from a variety of patients are becoming progressively and Their Spouses countries will address five cancer more relevant to all general surgeons. sites. There will be an update While we face similar challenges, Monday, October 8, SP05 (405) from the College and a report we prioritize and address them 9:00–10:30 am /$20 on the first SLAGO symposium differently, often with remarkably This seminar will be presented by (Simposio Latinoamericano de different outcomes. The leadership Richard Campbell, an attorney Gastroenterologia Oncologica) of our College wants to learn with Mayer Brown Rowe & Maw, on gastrointestinal maligancies. how rural general surgeons have and it will cover all of the basic Additionally, a report on the prioritized and dealt with the major topics and principles of estate triennial meeting in Brazil will take impediments they face in delivering planning, including use of trusts in place and an international medical quality surgical care. Come estate planning, disability planning, graduate surgeon will present a prepared to share your experiences. summary of an article published creditor and asset protection Please use the online Scientific recently in the Journal of the American planning, charitable planning ideas, Program registration form to sign up. College of Surgeons, entitled “The and top ten estate tax planning Journey of a Foreign-Trained ideas. As part of the presentation, Physician to a U.S. Residency.” you will receive reference material Annual Business concerning estate planning. Find In addition, we will recognize the Meeting of Members out all you need to know about Latin American Fellows chosen as your own personal estate planning honorary members of the College. Thursday, October 11, from one of the top estate planning Please use the online Scientific 7:30–8:30 am attorneys in the country. Program registration form to sign up. Ernest N. Morial Convention Center To register, please use the Social Sponsored by the Program Committee Program registration form, available online at www.facs.org.

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2007 CC prelim program-edited ve15 15 6/14/2007 9:50:22 AM GeneraL information • • Registration Deadline for Cancellation Registration is open to all Registration Refunds will be issued if written physicians and individuals The registration deadline for requests are postmarked no later in the health care field. international registrants is August than August 6 for international Registration includes a name 6, 2007. The deadline for U.S. registrants and August 20 for badge, program, and entrances and Canadian registrants is U.S. and Canadian registrants. to the exhibits and all sessions August 20, 2007. Registrations A $50 handling fee will be other than postgraduate courses. received and postmarked after retained from all refunds. Registered attendees may the deadlines will be billed Cancellations and registrations purchase postgraduate course according to the pricing structure postmarked after the deadline tickets based on availability. published on the registration form. will not be eligible for refunds. Advance registration is Conference attendee substitution strongly encouraged. Visa Information from one individual to another is not permitted. Please use one of the following International Fellows, guest The American College of registration options: physicians, and meeting Surgeons reserves the right to attendees: Please be aware that cancel any regularly scheduled Internet: Register online at www. the process of obtaining a visa to session prior to the start of facs.org. attend meetings in the U.S. takes the meeting and assumes no much longer than in the past. responsibility for nonrefundable You are strongly urged to apply By mail: Complete and mail the airline tickets or other travel for a visa as early as possible, registration form (form available costs. ACS will make every preferably at least 60 days from Program Planner or Web effort to immediately notify before the start of the meeting. site) to: registrants of a cancellation. American College of Surgeons You may request a letter from Attn: Registration Services the College welcoming you to PO Box 92340 the meeting if you believe this This preliminary program Chicago, IL 60675-2340 will be helpful by contacting the is subject to change. By fax (Credit card payments only): International Liaison Section via e-mail at postmaster@facs. Complete the registration org or by fax at 312/202-5021. form and fax to: 800/682-0252 or 800/202-5003

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2007 CC prelim program-edited ve16 16 6/14/2007 9:50:23 AM College news

Dr. Pierce receives Jacobson Award

William Schuler Pierce, MD, he also served as lieutenant FACS, a thoracic surgeon and commander in the U.S. Public chemical engineer from Her- Health Service Commissioned shey, PA, has received the Corps. thirteenth Jacobson Innovation In 1970, Dr. Pierce initiated a Award of the American College collaborative effort between the of Surgeons. The award was Penn State Colleges of Medi- presented during a dinner cer- cine and Engineering, Univer- emony held June 8 in Chicago, sity Park and Hershey, PA, and IL, at the College’s newly reno- started an artificial heart and vated John B. Murphy Memo- circulatory assist program. He rial Auditorium. led an interdisciplinary team Inaugurated in 1994, the of surgeons, physicians, engi- Jacobson Award honors living neers, materials scientists, fab- surgeons or surgical teams who rication specialists and machin- have been innovative in the de- ists, veterinarians, and animal velopment of a new technique care technicians to design a in any field of surgery. The mechanical circulatory assist award is made possible through pump for use in patients. a donation from Julius H. Ja- Dr. Pierce Their groundbreaking re- cobson II, MD, FACS, a general search led to the development vascular surgeon known for his of the Penn State Heart-Assist pioneering work in the devel- Pump. The pump is the first opment of microsurgery. Dr. high University in Bethlehem, extremely smooth, surgically Jacobson is director emeritus PA, with highest honors in implantable, seam-free, pul- and the Distinguished Service chemical engineering in 1958. satile blood pump to receive Professor of Surgery at the Dr. Pierce graduated with a widespread clinical use with Mount Sinai School of Medicine medical degree from the Uni- excellent results. of the City University of New versity of Pennsylvania School The heart-assist pump that York. of Medicine, Philadelphia, in Dr. Pierce helped develop re- Dr. Pierce received this re- 1962. Dr. Pierce interned at mains today the only device ward in recognition of his pio- the Hospital of the University that can be used to support neering work in the conception of Pennsylvania (1962–1963), the main pumping cham- and development of mechanical where he continued his resi- ber (left ventricle) or lung- circulatory support and the to- dency first as assistant resident pumping chamber (right ven- tal artificial mechanical heart in surgery (1963–1965, then tricle) or both in heart trans- and his contributions to surgi- 1967–1968), then resident in plant candidates who develop cal bioengineering and patient surgery (1968–1969), and then severe ventricular failure be- care. His major contributions as resident in thoracic surgery fore a suitable donor heart is to science, medicine, and educa- (1969–1970). For a couple of found. The heart-assist pump tion through these efforts have years in between his residency, has become a valuable adjuvant benefited countless surgical Dr. Pierce took leave to serve to cardiac transplantation pro- patients with heart failure. as clinical associate at the Na- grams. The pumps also benefit Dr. Pierce was born and grew tional Heart Institute of the open-heart surgery patients. up in Northeastern Pennsyl- National Institutes of Health Before the development of vania. He graduated from Le- (1965–1967). During that time, successful heart-assist pumps, 84

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS open-heart surgery patients signs. In addition, the pump of Medicine. He continues to who could not be weaned from pioneered the application of contribute personally to the the heart-lung machine would fluid-mechanics principles in research activities of the divi- die. Versions of the pump are blood-pump development and sion of artificial organs at the now used worldwide as both a the use of segmented polyure- Penn State Milton S. Hershey bridge to transplant and a per- thane as the blood-contacting Medical Center and to scholarly manent therapeutic device. material. activities on a national level. The Penn State heart-assist Currently Dr. Pierce is the A Fellow of the College since pump design and operating Evan Pugh Emeritus Profes- 1972, Dr. Pierce has served as principles are now applied to sor of Surgery at Pennsylva- Surgical Forum Representa- many current blood-pump de- nia State University College tive to the Advisory Council on Cardiothoracic Surgery (1989–1994) and as a member of the ACS Committee for the Forum on Fundamental Surgi- Jacobson Innovation Award recipients cal Problems (1989–1994). Throughout his distinguished 1994, Professor Francois Dubois, Paris, France: Laparoscopic career, Dr. Pierce has remained actively involved as a member cholecystectomy. of many prominent academic, 1995, Thomas Starzl, MD, FACS, Pittsburgh, PA: Liver trans- medical, surgical, and scientific plantation. societies. Major surgical organi- 1996, Joel D. Cooper, MD, FACS, St. Louis, MO: Lung transplan- zation memberships include the tation and lung volume reduction surgery. American College of Surgeons, 1998, Juan Carlos Parodi, MD, Buenos Aires, Argentina: Treat- Association for Academic Sur- ment of arterial aneurysms, occlusive disease, and vascular injuries by gery, International Federation using endovascular stented graphs. of Surgical Colleges, Society for 1999, John F. Burke, MD, FACS, Boston, MA: Development and Vascular Surgery, and Society implementation of a number of innovative techniques in burn care, of University Surgeons. including the codevelopment of an artificial skin (IntegraTM). The organizations in which 2000, Paul L. Tessier, MD, FACS (Hon), Boulogne, France: Dr. Pierce has held leadership Development of a new surgical specialty (craniofacial surgery). roles include the American As- 2001, Thomas J. Fogarty, MD, FACS, Portola Valley, CA: Design sociation for Thoracic Surgery; and development of industry standard minimally invasive surgical American Society for Artificial instrumentation, especially for cardiovascular surgery. Internal Organs; American 2002, Michael R. Harrison, MD, FACS, San Francisco, CA: Surgical Association; National Creator of the specialty of fetal surgery and developing techniques of Heart, Lung, and Blood Insti- fetoscopy for minimally invasive fetal technology. tute; Pennsylvania Association 2003, Robert H. Bartlett, MD, FACS, Ann Arbor, MI: Pioneer in for Thoracic Surgery; Society of the development and establishment of the first extracorporeal mem- Thoracic Surgeons; and Society brane oxygenation (ECMO) program. of Clinical Surgery. For his pioneering research in 2004, Harry J. Buncke, MD, FACS, San Francisco, CA: Micro- circulatory assist and artificial surgery and replantation. heart pumps, Dr. Pierce has 2005, Stanley J. Dudrick, MD, FACS, Waterbury, CT: Research been the recipient of numer- in nutritional support for surgical patients. ous awards and honorary de- 2006, Judah Folkman, MD, FACS, Boston, MA: Founder of the grees, including the Dr. Barney field of angiogenesis research. Clark Exemplary Humanitar- ian Award (2005), Wilkes-Barre Distinguished Service Award 85

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS (1995), Monroe J. Rathbone more than 90 book chapters, heart; two for heart valves; and Chemical Engineering Alumni and authored two books. In one for a blood pump. He also Award (1992), International addition, he has served on shares patents in 16 countries Historic Mechanical Engi- the editorial boards of nu- for a right ventricular assist neering Landmark (1990), an merous journals, including device. honorary doctor of science The International Journal of The Jacobson Innovation degree from Lehigh Univer- Artificial Organs, Journal of Award is administered by sity (1988), Clemson Award for Surgical Research, Journal of the Honors Committee of the Applied Research (1985), Fac- Thoracic and Cardiothoracic American College of Surgeons. ulty Scholars Medal in Life and Surgery, Journal of Heart & Original thought combined Health Sciences (1983), and the Lung Transplantation, Journal with first presentation of work AAMI Becton Dickinson Career of Cardiothoracic and Vascular that has led to a milestone in Achievement Award (1977). Anesthesia, and ASAIO Jour- the advancement of surgical Dr. Pierce has authored or nal. care is the main criterion for coauthored approximately 300 Dr. Pierce holds nine pat- choosing a recipient of the Ja- publications, published more ents, including two for surgi- cobson Innovation Award. than 150 abstracts, written cal gloves; one for an artificial

The Residency Assist Page of the American College of Surgeons offers a medium for program directors to acquire updates and advice on topics relevant to their needs as administrators and teachers. Our goals are to offer practical information and approaches from summaries of published articles, invited editorials, and specific descriptions of lessons learned from program directors’ successful and not-so-successful strategies. Through the development of the Residency Assist Page, the ACS intends to support program directors and faculty by providing succinctly presented information helpful in addressing the challenges associated with administering state-of-art residency education. www.facs.org/education/rap For additional information, please contact Olivier Petinaux, MS, at [email protected], or tel. 866/475-4696

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VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Resident Research Scholarships for 2007 awarded

Six American College of beginning July 1, 2007. Unless Research project: The role of Surgeons Resident Research otherwise noted, scholarships mesenchymal stem cells in Scholarships for 2007 were are sponsored by the Scholar- endothelial progenitor cell awarded by the Board of Re- ship Endowment Fund of the formation and adult vasculo- gents in February. College. genesis. The scholarships are of- The recipients are as fol- Rebecca Edmonds, MD, fered to encourage residents lows: resident in surgery, University to pursue careers in academic Hariharan Thangarajah, of Pittsburgh, Pittsburgh, PA. surgery and carry awards of MD, resident in surgery, Stan- Research project: Evaluation $30,000 for each of two years, ford University, Palo Alto, CA. of systemic inflammation and

Dr. Thangarajah Dr. Edmonds Dr. Kohler

Dr. Pitt Dr. Farhadi Dr. Ham

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JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS end organ damage mediated H. Francis Farhadi, MD, fund scholarship and fellow- by toll-like receptor TLR-4 resident in neurosurgery, Uni- ships awarded by the Board of peripheral tissue injury. This versity of Toronto, Toronto, Regents. Direct contributions scholarship is sponsored by ON. Research project: Tran- to support the Scholarship En- Wyeth Pharmaceuticals. scriptional programming of dowment Fund are welcome. Jonathan E. Kohler, MD, the myelin basic protein gene Fellows wishing to make tax- resident in surgery, University following spinal cord injury in deductible gifts to fund these of Washington, Seattle. Re- the mouse. vital programs are encouraged search project (to be conducted Christine Marie Ham, to contact the Development at Brigham & Women’s Hospi- MD, resident in surgery, Stan- Office at 312/202-5376. tal, Boston, MA): Thiol oxida- ford University, Palo Alto, CA. T h e requirements f o r tion and chronic inflammation Research project: Regulatory research-oriented scholarships in colon mucosa. analysis of bone morphoge- offered by the College for 2008 Susan C. Pitt, MD, resident netic protein5 (Bmp5) expres- will be published in a forthcom- in surgery, Indiana University sion in fracture healing. This ing issue of the Bulletin. This School of Medicine, Indianapo- scholarship is sponsored by information will also appear lis. Research project (to be Ethicon, Inc. on the College’s scholarships conducted at University of The Scholarship Endowment Web page, at http://www.facs. Wisconsin-Madison): Signaling Fund of the American College org/memberservices/research. pathways in gastrointestinal of Surgeons was established html. neuroendocrine tumors. in 1965 to provide income to

Online educatiOn center fOr cancer PrOgrams Promoting Quality Cancer Care An educational resource providing Webcast presentations for cancer program staff, physicians, and administrators.

Webcasts — Convenient, Self-Directed Distance Learning 24/7/365 • Fee-based sessions are hosted online in their entirety. (Staff from CoC-Approved Cancer Programs receive a 25% discount.)

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To Learn More, Visit the Online Education Center for Cancer Programs. www.facs.org/cancer/webcast The CoC is a multidisciplinary program of Sponsored jointly by the American College of Surgeons. the Commission on Cancer and the American Joint Committee on Cancer 88

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2007 Health Policy Scholars announced

Eight surgeons were select- of the College’s Health Policy Dartmouth-Hitchcock Medical ed to attend the Leadership Advisory Committee and the Center, Lebanon, NH Program in Health Policy and equivalent body for the sur- ACS/American Association Management at Brandeis Uni- gical specialty society each of Neurological Surgeons versity, Boston, MA, in June. physician represented. Health Policy Scholar: Gail Each health policy scholar- The selected scholars were Rosseau, MD, FACS, Neuro- ship included participation as follows: logical & Orthopedic Institute in the weeklong intensive ACS Health Policy Scholar of Chicago, Chicago, IL course, followed by a year’s for General Surgery: Da- ACS/American Academy of service as a pro tem member vid A. Axelrod, MD, MBA, Otolaryngology–Head & Neck

Dr. Axelrod Dr. Rosseau Dr. Burkey

Dr. Merlino Dr. Chang Dr. Garely

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JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS/American Society of Plastic Surgeons Health Poli- cy Scholar: David W. Chang, MD, FACS, M.D. Anderson Cancer Center, Houston, TX ACS/American Urogyneco- logic Society Health Policy Scholar: Alan D. Garely, MD, FACS, Winthrop-University Hospital, Mineola, NY ACS/Society of Thoracic Surgeons Health Policy Schol- ar: Max B. Mitchell, MD, FACS, University of Colorado Health Sciences Center, Den- Dr. Mitchell Dr. Davies ver, CO ACS/Society for Vascular Surgery Health Policy Schol- Surgery Foundation Health ACS/American Society of Co- ar: Mark G. Davies, MD, Policy Scholar: Brian B. Bur- lon and Rectal Surgeons Health PhD, FACS, University of key, MD, FACS, Vanderbilt Policy Scholar: James I. Mer- Rochester Medical Center, University Medical Center, lino, MD, FACS, MetroHealth Rochester, NY Nashville, TN Medical Center, Cleveland, OH

The Clowes ACS/AAST/NIGMS Mentored Clinical Scientist Development Award available

The American College of Surgeons and the salary support over and above that offered by the American Association for the Surgery of Trauma K08/K23 mechanism. announce a program that will provide supplemen- The application deadline is October 12. To apply, tal salary funding of up to $75,000 per year to an submit the complete K08 or K23 application simul- individual who has received a Mentored Clinical taneously to NIGMS and to Kate Early, the ACS Scientist Development Award (K08/K23) from the Scholarships Administrator. Preexisting applica- National Institute for General Medical Science tions and awards are not eligible for consideration. (NIGMS). This award is directed at surgeon- If applicants receive a K08 or K23 from NIGMS, scientists working in the early stages of their their applications will undergo further review by research careers and supports a three-, four-, or special committee for prospective supplemental five-year period of supervised research experience funding. Funding begins July 1, 2008. that may integrate didactic studies with labora- Awardees must be members in good standing of tory or clinical research. the College and eligible for membership in AAST. This award program offers a means to facilitate For further details, visit http://www.nigms.nih. the career development of individuals pursuing gov/ or e-mail Ms. Early at [email protected]. careers in trauma surgery research by enhancing 90

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACOSOG news ACOSOG Z9001 completed by David Ota, MD, FACS, Durham, NC, and Heidi Nelson, MD, FACS, Rochester, MN

ACOSOG (American College Health announced the early agent that targets a specific of Surgeons Oncology Group) closure of Z9001 because of the cancer-promoting pathway in Z9001 is a phase III random- superiority of Gleevec over pla- GIST. In essence, the mutation ized trial comparing postop- cebo in reducing postoperative in the c-kit proto-oncogene erative adjuvant Gleevec TM GIST recurrence. A process becomes the “Achilles’ heel” of versus placebo for patients was initiated to unblind the GIST with Gleevec targeting with resected gastrointestinal trial to identify those patients the tyrosine kinase activity in stromal tumors (GIST). The who are currently receiving c-kit. This effect is significant first patient was enrolled in placebo and to cross them over because other kinase inhibitors 2002. At that time, Gleevec to Gleevec administration. are currently in development (imatinib) was a relatively new Z9001 was significant for and exploit this strategy of anticancer agent for GIST. Un- ACOSOG. This trial demon- targeting the Achilles’ heel til the development of Gleevec, strates that ACOSOG can of other cancers. Examples there were no known effective design, conduct, and complete include sunitinib for renal adjuvant therapies for resected a phase III therapeutic trial. cell carcinoma, vandetanib for GIST. This trial was accruing ACOSOG also learned that if a medullary thyroid cancer, and at a rate of 15 patients per trial asks a scientifically impor- lapatinib for breast cancer. month with a target accrual tant question that appeals to Z9001 also shows that Gleevec of 803 patients. Enrollment the oncology community, then as a tyrosine kinase inhibitor is was predicted to be completed regardless of the prevalence of cytostatic to GIST. Its low oc- July 2007. the disease, the trial is likely to currence of side effects may The ACOSOG Data Moni- be completed. permit chronic administra- toring Committee (DMC) had There were more than 230 tion. Z9001 becomes one of the been meeting every six months enrolling sites for Z9001. Half early trials to demonstrate the to monitor efficacy and side the enrollment came from benefits of a tyrosine kinase effects. The ACOSOG DMC ACOSOG sites, and the mul- inhibitor for adjuvant therapy. meeting met in early April tiple other cooperative groups Future ACOSOG trials are be- 2007 and recommended to contributed to the enrollment. ing developed to study duration the ACOSOG group co-chairs This demonstrates the effec- of therapy of Gleevec in an that the trial had statisti- tiveness of the NCI Cooperative adjuvant setting. cally demonstrated improved Group mechanism to complete Scientific presentations by recurrence-free survival with such a complex trial. Ron DeMatteo, MD, FACS Gleevec and recommended Z9001 demonstrates that (Z9001 study chair), were closure of the trial. administration of Gleevec after planned for the June meet- The ACOSOG Group co- resection of GIST can lower ing of the American Society chairs discussed the findings the recurrence rate. Although of Clinical Oncology and the with the National Cancer In- GIST is a rare tumor, Z9001 October 2007 Clinical Congress stitute (NCI) and accepted the serves as a model for the devel- of the American College of Sur- recommendation of the DMC opment of other tyrosine kinase geons in New Orleans, LA. We for early closure of Z9001. On inhibitors for other types of want to thank all the ACOSOG April 12, a press release issued cancers in an adjuvant setting. investigators who enrolled pa- by the National Institutes of Gleevec is a unique anticancer tients into Z9001. 91

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Without your participation tient in an ACOSOG trial” community to enroll patients in this trial, ACOSOG would (2004;89[2]:12-15). Dr. Keill into this important trial.* never have been able to achieve wrote eloquently about his this important milestone. We participation as a patient in *Dr. Keill resides in Carmel Valley, also want to thank Ralph Keill, Z9001 and urged the ACS CA, and is doing well (personal communication). MD, FACS, who published an membership to enroll patients article in the February 2004 into Z9001. His timely article Dr. Ota and Dr. Nelson are Bulletin, “A surgeon reports contributed significantly to ACOSOG Group Co-Chairs. on his experience as a pa- the enthusiasm in the surgical

Operation Giving Back Volunteer opportunities available

The Operation Giving Back orthopaedic and maxillofacial base for available opportunities (OGB) database is continually surgeons who can serve for at by indicating your practice sta- expanding with new volunteer least two weeks in West Africa. tus as “retired,” more informa- opportunities, including open- Those interested in volunteering tion can be found on the OGB ings at the following agency: with Mercy Ships should reflect Web site in the “Resources for Mercy Ships is a global charity a spirit of community and a Retirees” section under the that has operated hospital ships high level of commitment to one heading “Resource Center” on in developing nations since 1978. another and living according to the main toolbar. There is also Mercy Ships’ programs promote biblical principles. relevant licensing and liability health and well-being by serving OGB provides surgical volun- information on a state-by-state the urgent surgical needs of the teers with a wealth of resources, basis in the “Legislative and poor and empowering develop- including pertinent information Liability Issues” section. ing communities in Africa, Asia, for retired surgeons who are To learn more about these Central America, and the Carib- interested in remaining active and other volunteer opportu- bean. On board the hospital ship through volunteer activities. nities and resources, please M/V Africa Mercy, Mercy Ships In addition to the ability to visit the OGB Web site at www. is seeking ophthalmologists and search the volunteerism data- operationgivingback.org.

• View surgical news • Interact with surgical communities • Update CME credits • Enter case log information • Track resident hours and more—all at: e-facs.org 92

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS CALL FOR SUBMISSIONS 2008 Clinical Congress of the American College of Surgeons

Oral presentations h h Surgical Forum Program Coordinator: Kathryn L. Matousek, The American College 312/202-5336, [email protected] of Surgeons (12 $1,000 Excellence in Research Awards weregivenin2007) Division of Education h Papers Session Program Coordinator: Beth Cherry, welcomes submissions 312/202-5325, [email protected]

to the following programs Poster presentation to be considered h Scientific Exhibits Program Coordinator: Kay Anthony, for presentation at 312/202-5385, [email protected]

h Video presentation h Video-Based Education the 94th annual Program Coordinator: GayLynn Dykman, 312/202-5262, [email protected] Clinical Congress, Submission information October 12–16, 2008, h Abstracts are to be submitted online only

San Francisco, CA h Submission period begins November 1, 2007

h h Deadline: 5:00 pm (CST), March 1, 2008 h Late submissions are not permitted

h Abstract specifications and requirements for each individual program will be posted on the ACS Web site at www.facs.org. Review the information carefully prior to submission.

h Duplicate submissions (submitting the same abstract to more than one program) are not allowed.

Call for Submissions 2008-Bullet1 1 6/14/2007 10:00:53 AM A look at The Joint Commission Low health literacy puts patients at risk

Far too often, ordinary citi- be a verification of identifica- using “teach back”—a method zens are placed at risk for tion at all. Patients who don’t whereby the patient communi- unsafe care because important hear well or who don’t under- cates back to the caregiver what health care information is com- stand English may nod amiably was said—and placing calls to municated using medical jar- in agreement without under- patients the evening before gon and unclear language that standing, much less agreeing surgery, the cancellation rate exceed their literacy skills. In with, what has been said. dropped tenfold.* The Joint Commission’s new- The solution to this verifica- The typical informed consent est public policy white paper, tion problem is to never state form is incomprehensible for “What Did the Doctor Say?”: the patient’s name and ask the readers at any level. Research- Improving Health Literacy patient to confirm it. Instead, ers have found that among to Protect Patient Safety, the having a patient state his or patients who sign an informed existing communications gap her name is safer practice and consent form,  percent do between patients and caregiv- appropriate as long as staff con- not know the exact nature of ers is framed as a series of siders the patient’s reliability to the operation to be performed, challenges involving literacy, do so. During the preoperative and most—60 percent to 70 language, and culture, and sug- time-out, if possible, the verifi- percent—did not read or under- gests multiple steps that need cation and marking should take stand the information contained to be taken to narrow or even place with the patient awake, in- in the form.† close this gap. volved, and aware. The patient’s To promote change in the way “Effective communication is name, procedure, and the site to informed consent is obtained, a cornerstone of patient safety,” be operated on should be stated the National Quality Forum says Dennis S. O’Leary, MD, aloud, exactly as these items has developed a guide to help president of The Joint Commis- appear on the informed consent organizations comply with its sion. “If patients lack basic un- form and all team members Safe Practice 10, which calls derstanding of their conditions should actively acknowledge for organizations to ensure that and the what’s and why’s of the agreement. patients or legal surrogates un- treatments prescribed, thera- If the patient does not under- derstand proposed treatments peutic goals can never be real- stand the implications of his or and their complications. ized, and patients may instead her diagnosis and prevention or These issues related to in- be placed in harm’s way.” treatment plans, an untoward formed consent are among those Situations where surgeons event may occur. The same is addressed by the 35 specific may encounter challenges relat- true if the treating physician recommendations contained in ed to low health literacy include does not understand the patient The Joint Commission’s white the preoperative verification or the cultural context within *Institute of Medicine. Roundtable on process, informed consent, and which the patient received criti- Health Literacy Meeting 3, Washington, preoperative and postoperative cal information. DC; September 14, 2006. orders to patients. In the University of Virginia † N a t i o n a l Q u a l i t y Fo r u m . For patients with low health Health System, 8 percent of Implementing a National Voluntary Consensus Standard for Informed literacy or language barriers, a operating room cancellations Consent: A User’s Guide to Healthcare nod of recognition during the were traced to poor patient com- Professionals. NQF: Washington, DC. identification process may not prehension of instructions. By 2005. 94

VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS paper. Included among the consent process and related ical liability insurance dis- other specific recommendations forms counts for physicians who apply for improvement in the white • The use of established patient-centered communica- paper are the following: patient-communication meth- tion techniques • The sensitization, edu- ods, such as teach back “What Did the Doctor Say?”: cation, and training of clini- • Health care organizations’ Improving Health Literacy to cians and health care organiza- assessment of the literacy levels Protect Patient Safety is avail- tion leaders and staff regard- and language needs of the com- able at www.jointcommission. ing health literacy issues and munities they serve org . The report is part of a con- patient-centered communica- • The integration of patient tinuing series of white papers tions communication as priority into on key public policy issues that • The enhanced training and emerging physician pay-for- have an impact on patient safety use of interpreters for patients performance programs and health care quality. • The redesign of informed • The provision of med-

NTDB® data points The rockets’ red glare by Richard J. Fantus, MD, FACS, and Joshua Fantus, Chicago, IL

This month marks the 231st birthday of the U.S. The first Fourth of July celebration in 1777 involved bell-ringing, fir- ing of guns, lighting of candles, and firecrackers. Each year on or around the Fourth of July, this celebration is repeated around the country with fire- works. Legend has it that the dis- covery of fireworks dates back more than 2,000 years to when a Chinese cook inadvertently mixed together three kitchen ingredients common at that time (saltpeter, sulfur, and charcoal). When lit, the result was colorful flames. When en- closed in a bamboo shoot and explosions synchronized with occur when individuals take ignited, a tremendous explosion music simulcasts. These exhi- matters into their own hands. resulted. bitions are magnificent but re- According to the Centers for Each year the fireworks dis- quire handling by pyrotechnic Disease Control and Preven- plays become more elaborate, professionals and involve many tion’s Web site (http://www. and it is common to see paired safety procedures. Problems cdc.gov/ncipc), their data show 95

JULY 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS that in 2004 there were 9,600 homes; there were six deaths. sure others are out of range people treated in emergency These data are depicted in the before lighting, only light on a departments; two-thirds of figure on page 95. Victims were smooth flat surface away from these injuries occurred in the 90 percent male and on aver- flammable materials, never try month surrounding the 4th of age 24 years of age; there was to relight fireworks, and keep July. Among these patients, an average length of hospital a bucket of water nearby. If 40 percent were 14 years or stay of 4.1 days and an average you choose to light your own younger, 76 percent were male, injury severity score of 5.48; of fireworks and get a close look and eight died. The top three those tested, almost one-third at the rockets’ red glare, make causes of injury were firecrack- were positive for alcohol. sure the bombs bursting are in ers, sparklers, and rockets. The lighting of fireworks the air. To examine the occurrence of is serious business; after all, Throughout the year, this these injuries in the National they are black powder deriva- column will provide brief Trauma Data Bank® Dataset tives. Laws on fireworks vary monthly reports. The full 6.0, we used the International from state to state, and though NTDB Annual Report Version Classification of Diseases, Ninth individuals untrained in large 6.0 is available on the ACS Revision, Clinical Modification pyrotechnics should not handle Web site as a PDF file and a cause of injury code E 923.0 for large fireworks, the U.S. Con- PowerPoint presentation at accident caused by explosive sumer Products Safety Com- http://www.ntdb.org. material—fireworks. There mission (http://www.cpsc.gov) If you are interested in sub- were 710 records found with has recommended some simple mitting your trauma center’s discharge status recorded. Of safety measures: Never allow data, contact Melanie L. Neal, these, 609 were discharged children to play with or ignite Manager, NTDB, at mneal@ to home, 85 to acute care/ fireworks, read and follow all facs.org. rehabilitation, and 10 to nursing warnings and instructions, be

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VOLUME 92, NUMBER 7, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS