MAY 2015 | VOLUME 100 NUMBER 5 | AMERICAN COLLEGE OF SURGEONS Bulletin

Going green

in the OR Contents

FEATURES COVER STORY: Strategies for sustainability: Going green in the OR 10 Tony Peregrin

PreOp program: Can we achieve a “trickle-up” effect? 18 Rachael A. Venn, Stefanie P. Lazow, and Gregory F. Dakin, MD, FACS

Surgeons develop visionary plan to bring corneal transplants to developing countries 22 Stephen G. Waller, MD; Maria S. Altieri, MD; and Rahul M. Jindal, MD, PhD, MBA, FACS

American College of Surgeons Foundation Annual Report 2014 29

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A PUBLICATION OF THE AMERICAN COLLEGE OF SURGEONS PROFESSIONAL ASSOCIATION (ACSPA)

Influencing THE ACS Health Policy in Washington ADVOCATE and the States Each month, rely on the ACS advocacy e-newsletter:  To keep you informed  To learn the College’s position on pertinent issues  To see how your involvement can make a difference.

Downloadable from most digital communications devices Visit www.facs.org/publications/newsletters/acs-advocate

Advocacy Summit • AMA House of Delegates/Surgical Caucus • Cancer • Chapter Advocacy • Training • Coding • Electronic Health Records • e-Prescribing • Grassroots Efforts • Health Information Technology • Legislative Action Center • Legislative Advocacy • Liability • Lobby Day Grant Program • Medicaid • Medicare • Medicare Physician Payment • Pediatric Issues • Physician Quality Reporting • Political Action Committee (SurgeonsPAC) • Quality and Patient Safety • Relative Value Update Committee (RUC) • Socioeconomics • Surgery State Legislative Action Center (SSLAC) • Surgical Quality Alliance • Trauma and EMS • Workforce

ACS Advocate Half Page for Bulletin_2_6_15.indd 1 2/6/2015 11:47:38 AM MAY 2015 BULLETIN American College of Surgeons Contents continued

STATEMENTS From the Archives: ACS Archives Disciplinary actions taken 67 houses practice records of Franklin Report on ACSPA/ACS activities, Statement in support of H. Martin 59 February 2015 68 motorcycle helmet laws 51 Adam J. Carey, MA, and Fabrizio Michelassi, MD, FACS Statement on physician tiering Dolores Barber and narrow network programs 52 Correction 73 A look at The Joint Commission: 75 cancer care facilities receive Monitoring OR fires to improve COLUMNS ACS CoC Outstanding Achievement patient safety 61 Award 74 Looking forward 7 NTDB data points: What’s cookin’? ACS in the news 75 David B. Hoyt, MD, FACS Who’s lookin’? 62 ACS Surgical History Group From residency to retirement: Richard J. Fantus, MD, FACS, and accepting poster abstracts One surgeon’s principles 54 Edmundo A. Rivera, MD until May 29 78 Henry Buchwald, MD, PhD, FACS, FRCSEng(Hon) NEWS SCHOLARSHIPS ACS Clinical Research Program: ACS NSQIP hospitals significantly 2014 IGS reports on experience Limited resection as a cure for early improve outcomes over time 64 from the perspective of a lung cancer: Time to challenge the MHSSPACS Leadership Group woman surgeon 80 2 | gold standard? 57 holds inaugural meeting in Maria Eliza M. Raymundo, MD, Nasser Altorki, MD, FACS; Chicago, IL 65 DMCC, FPUA, FPCS Leslie J. Kohman, MD, FACS; Dr. Michelassi honored with Linda J. Veit, MPH; Y. Nancy National Physician of the Year MEETINGS CALENDAR You, MD, MHSc, FACS; and Award 66 Judy C. Boughey, MD, FACS Calendar of events 84

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V100 No 5 BULLETIN American College of Surgeons The American College of Surgeons is dedicated CLINICAL CONGRESS to improving the care of the surgical patient and to safeguarding standards of care in an 2015 optimal and ethical practice environment. OCTOBER 4–8

EDITOR-IN-CHIEF Letters to the Editor McCORMICK PLACE | CHICAGO, IL Diane Schneidman should be sent with the writer’s DIRECTOR, DIVISION OF name, address, INTEGRATED COMMUNICATIONS e-mail address, and Lynn Kahn daytime telephone SENIOR EDITOR number via e-mail to Tony Peregrin dschneidman@facs. org, or via mail to EDITORIAL & PRODUCTION ASSISTANT Diane S. Schneidman, Matthew Fox Editor-in-Chief, Bulletin, American CONTRIBUTING EDITOR College of Surgeons, Jeannie Glickson 633 N. Saint Clair St., SENIOR GRAPHIC DESIGNER/ Chicago, IL 60611. PRODUCTION MANAGER Letters may be edited Tina Woelke for length or clarity. Permission to publish EDITORIAL ADVISORS letters is assumed Charles D. Mabry, MD, FACS unless the author Leigh A. Neumayer, MD, FACS indicates otherwise. Marshall Z. Schwartz, MD, FACS Mark C. Weissler, MD, FACS

FRONT COVER DESIGN Tina Woelke

Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800- 621-4111; e-mail: [email protected]; website: www.facs.org. Washington, Achieving Your Personal Best: DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701; website: www.tmiva.net/20fstreetcc/home. Improvement Based on Evidence Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2015 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. Officers and Staff of the American College of Surgeons

Gerald M. Fried, MD, AMERICAN COLLEGE OF FACS, FRCSC Advisory Council SURGEONS FOUNDATION Officers Montreal, QC Martin H. Wojcik Executive Director Andrew L. Warshaw, MD, FACS James W. Gigantelli, MD, FACS to the Board Boston, MA Omaha, NE of Regents ALLIANCE/AMERICAN PRESIDENT COLLEGE OF SURGEONS Carlos A. Pellegrini, MD, FACS B. J. Hancock, MD, FACS, FRCSC (Past-Presidents) CLINICAL RESEARCH Seattle, WA Winnipeg, MB PROGRAM IMMEDIATE PAST-PRESIDENT Enrique Hernandez, MD, FACS Kathryn D. Anderson, MD, FACS Kelly Hunt, MD, FACS Chair Jay L. Grosfeld, MD, FACS Philadelphia, PA Eastvale, CA Indianapolis, IN Lenworth M. Jacobs, Jr., MD, FACS W. Gerald Austen, MD, FACS CONVENTION AND MEETINGS FIRST VICE-PRESIDENT Hartford, CT Boston, MA Felix Niespodziewanski Kenneth L. Mattox, MD, FACS L. Scott Levin, MD, FACS L. D. Britt, MD, MPH, Director Houston, TX Philadelphia, PA FACS, FCCM DIVISION OF EDUCATION SECOND VICE-PRESIDENT Norfolk, VA *Mark A. Malangoni, MD, FACS Ajit K. Sachdeva, MD, Edward E. Cornwell III, Philadelphia, PA John L. Cameron, MD, FACS FACS, FRCSC MD, FACS, FCCM Baltimore, MD Director *Raymond F. Morgan, MD, FACS Washington, DC EXECUTIVE SERVICES SECRETARY Charlottesville, VA Edward M. Copeland III, MD, FACS Gainesville, FL Jane J. Lee-Kwon, MPS William G. Cioffi, Jr., MD, FACS Leigh A. Neumayer, MD, FACS Director, Executive Services Providence, RI Tucson, AZ A. Brent Eastman, MD, FACS Rancho Santa Fe, CA Maxine Rogers TREASURER Marshall Z. Schwartz, MD, FACS Director, Leadership Operations David B. Hoyt, MD, FACS Philadelphia, PA Gerald B. Healy, MD, FACS Wellesley, MA FINANCE AND FACILITIES Chicago, IL Howard M. Snyder III, MD, FACS EXECUTIVE DIRECTOR Gay L. Vincent, CPA Philadelphia, PA R. Scott Jones, MD, FACS Director Charlottesville, VA Gay L. Vincent, CPA Beth H. Sutton, MD, FACS 4 | Chicago, IL HUMAN RESOURCES Wichita Falls, TX Edward R. Laws, MD, FACS AND OPERATIONS CHIEF FINANCIAL OFFICER Boston, MA *Andrew L. Warshaw, MD, FACS Michelle McGovern Boston, MA LaSalle D. Leffall, Jr., MD, FACS Director Washington, DC Officers-Elect Steven D. Wexner, MD, FACS INFORMATION TECHNOLOGY Weston, FL LaMar S. McGinnis, Jr., MD, FACS Howard Tanzman Atlanta, GA (take office October 2015) *Michael J. Zinner, MD, FACS Director Boston, MA David G. Murray, MD, FACS DIVISION OF INTEGRATED J. David Richardson, MD, FACS Syracuse, NY COMMUNICATIONS Louisville, KY Lynn Kahn PRESIDENT-ELECT *Executive Committee Patricia J. Numann, MD, FACS Syracuse, NY Director Ronald V. Maier, MD, FACS Carlos A. Pellegrini, MD, FACS JOURNAL OF THE AMERICAN Seattle, WA COLLEGE OF SURGEONS FIRST VICE-PRESIDENT-ELECT Board of Seattle, WA Timothy J. Eberlein, MD, FACS Walter J. Pories, MD, FACS Governors/ Richard R. Sabo, MD, FACS Editor-in-Chief Greenville, NC Bozeman, MT SECOND VICE- Executive DIVISION OF MEMBER SERVICES PRESIDENT-ELECT Seymour I. Schwartz, MD, FACS Patricia L. Turner, MD, FACS Committee Rochester, NY Director Fabrizio Michelassi, MD, FACS Frank C. Spencer, MD, FACS M. Margaret Knudson, MD, FACS Board of Regents New York, NY New York, NY Medical Director, Military Health CHAIR Systems Strategic Partnership *Mark C. Weissler, MD, FACS Karen Brasel, MD, FACS Girma Tefera, MD, FACS Chapel Hill, NC Portland, OR CHAIR VICE-CHAIR Executive Staff Director, Operation Giving Back *Valerie W. Rusch, MD, FACS James C. Denneny III, MD, FACS EXECUTIVE DIRECTOR PERFORMANCE IMPROVEMENT New York, NY Alexandria, VA David B. Hoyt, MD, FACS Will Chapleau, RN, EMT-P Director VICE-CHAIR SECRETARY DIVISION OF ADVOCACY John L. D. Atkinson, MD, FACS Kevin E. Behrns, MD, FACS AND HEALTH POLICY DIVISION OF RESEARCH AND Rochester, MN Gainesville, FL Frank G. Opelka, MD, FACS OPTIMAL PATIENT CARE Medical Director, Quality Clifford Y. Ko, MD, MS, FACS Margaret M. Dunn, MD, FACS Diana L. Farmer, MD, FACS and Health Policy Director Dayton, OH Sacramento, CA Patrick V. Bailey, MD, FACS Cancer: James K. Elsey, MD, FACS Steven C. Stain, MD, FACS Medical Director, Advocacy David P. Winchester, MD, FACS Atlanta, GA Albany, NY Christian Shalgian Medical Director Henri R. Ford, MD, FACS Joseph J. Tepas III, MD, FACS Director Los Angeles, CA Jacksonville, FL Trauma: Michael F. Rotondo, MD, FACS Julie A. Freischlag, MD, FACS Medical Director Sacramento, CA

V100 No 5 BULLETIN American College of Surgeons Author bios*

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

a b c

d e f | 5

g h i

DR. ALTIERI (a) is a postgraduate DR. BUCHWALD (e) is professor of DR. FANTUS (h) is vice-chairman, year-3 resident in surgery, Stony surgery and biomedical engineering and department of surgery; medical director, Brook University Hospital, NY. Owen H. & Sarah Davidson Wangensteen trauma services; and chief, section of Chair in Experimental Surgery emeritus, surgical critical care, Advocate Illinois DR. ALTORKI (b) is professor of University of Minnesota, Minneapolis. Masonic Medical Center. He is clinical cardiothoracic surgery and chief, division professor of surgery, University of Illinois of cardiothoracic surgery, Weill Cornell MR. CAREY (f) is Archivist, ACS College of Medicine, Chicago, and Past- Medical College, New York, NY. Division of Member Services. Chair, ad hoc Trauma Registry Advisory Committee, ACS Committee on Trauma. MS. BARBER (c) is Assistant Archivist, DR. DAKIN (g) is associate professor American College of Surgeons (ACS) of surgery; associate attending surgeon; DR. JINDAL (i) is professor of surgery Division of Member Services, Chicago, IL. director, surgery clerkship; and director, and global health, department of surgery, minimally invasive surgical training DR. BOUGHEY Uniformed Services University of the (d) is professor of surgery laboratory, department of surgery, Health Sciences, Bethesda, MD. and vice-chair of research, department of New York-Presbyterian Hospital/ surgery, Mayo Clinic College of Medicine, Weill Cornell Medical Center. continued on next page Rochester, MN. She is Chair, ACS Clinical Research Program Education Committee.

MAY 2015 BULLETIN American College of Surgeons Author bios continued

j k l

m n o p 6 |

q m r s

DR. KOHMAN (j) is professor of DR. RAYMUNDO (n) is assistant professor, DR. WALLER (r) is associate thoracic surgery and medical director, University of the Philippines College of professor of surgery and global health, Upstate Cancer Center, Syracuse, NY. Medicine; attending urologist, Philippine department of preventive medicine General Hospital, Manila; and adjunct and biometrics, Uniformed Services MS. LAZOW (k) is a medical student assistant professor of surgery, Uniformed University of Health Sciences. at Weill Cornell Medical College. Services University of the Health Sciences. DR. YOU (s) is assistant professor, section DR. MICHELASSI (l) is the Lewis DR. RIVERA (o) is a surgical critical of colorectal surgery, department of Atterbury Stimson Professor and chairman, care fellow, Advocate Illinois Masonic surgical oncology, and medical director, department of surgery, Weill Cornell Medical Medical Center, Chicago, and a member Familial High-risk Gastrointestinal College; and surgeon-in-chief, New York- of the American Burn Association. Cancer Clinic, University of Texas MD Presbyterian/Weill Cornell Medical Center. Anderson Cancer Center, Houston. He is Chair, ACS Board of Governors. MS. VEIT (p) is projects manager, Upstate Cancer Center. MR. PEREGRIN (m) is Senior Editor, Bulletin of the American College of MS. VENN (q) is a medical student Surgeons, ACS Division of Integrated at Weill Cornell Medical College. Communications, Chicago, IL.

V100 No 5 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

ew medical and surgical institutions have the General surgery at CCH originated with Christian legendary history associated with Cook County Fenger, MD, a pathologist and the first chair of sur- FHospital (now Stroger Hospital of Cook Coun- gery at Northwestern University. Dr. Fenger trained ty) in Chicago, IL. Many Fellows of the American ACS founders, including Dr. Murphy and William College of Surgeons (ACS), particularly trauma sur- and Charles Mayo. At one point, all six Chicago-area geons, can recall doing at least one rotation through medical schools—Rush, Northwestern, University of Cook County Hospital (CCH), and most Americans Illinois, Loyola, University of Chicago, and Chicago are somewhat familiar with the institution as the Medical School—had attending surgeons and surgical model for the hospital featured in the long-running residents teaching and training at CCH with no finan- television series ER and for a cameo appearance in cial compensation. CCH started as an intern hospital the movie The Fugitive. and gradually became a residents hospital in the late Many Past-Presidents and other leaders of the 1930s, receiving approval from the recently formed American College of Surgeons (ACS)—including Accreditation Council for Graduate Medical Educa- John B. Murphy, the Mayo brothers, Albert Ochsner, tion in 1939. Allen B. Kanavel, Olga Jonasson, Robert J. Lowe, As some of you may know, a common practice in Herand Abcarian, and L.D. Britt (all MD, FACS)— the early days of surgical education was to demonstrate trained, taught, or practiced at or have been in some an operation in an amphitheater setting. Chicago’s way affiliated with CCH. Details about the impact first surgical amphitheater was built at CCH. As an | 7 that the hospital has had on all surgical specialties attending surgeon, Dr. Murphy began conducting his and its strong ties with the ACS are chronicled in a well-known surgical clinics in the amphitheater on Fri- new book, A History of Surgery at Cook County Hospital, day mornings. Karl Meyer, MD, FACS, and Raymond edited by ACS Fellows Patrick D. Guinan, Kenneth J. McNealy, MD, FACS, went on to use the amphitheater Printen, James L. Stone, and James S. T. Yao—each of for similar purposes, drawing crowds of physicians to whom trained and practiced at CCH. Some snippets observe their wet clinics. of the institution’s fascinating history as documented CCH also was one of the first institutions to use in the book follow. night surgeons. This position was designed to hone the skills of the attending surgeon and to develop the sur- gical judgment of surgical residents. Robert T. Vaughn, Service and education MD, FACS, a general surgeon at St. Luke’s Hospital, The first iteration of CCH was set up in the Fort was the assistant warden for night emergencies at CCH Dearborn trading post in 1803 to provide care to for 33 years (1917–1950),­­­­­­­­­­­­ providing clinical instruction U.S. Army soldiers. The first surgeon at Fort Dear- and care and making extensive contributions to the born was William C. Smith, and the first recorded surgical literature on topics ranging from osteomy- surgical procedure was a bilateral leg amputation elitis of the sternum to retrograde amnesia following performed by Elijah Dewey Harmon, MD, in 1832. skull fracture. That same year, Cook County was incorporated by In addition to being a leading surgical training the State of Illinois, and the hospital undertook its ground, CCH was the launching pad of many medi- continuing commitment to serving the sick, injured, cal and surgical services that have benefitted patients and medically indigent citizens of the county. From around the world. For example, Bernard Fantus, MD, 1876 to 2002, the main building was located at 1825 founded the first blood bank at CCH in 1937. Also in W. Harrison. Over the years, it grew into what the 1930s, Dr. Kanavel and Sumner L. Koch, MD, once was the largest general hospital in the world, FACS, established a burn surgical service at CCH. with 4,500 beds, and one of the nation’s most highly Renamed in Dr. Koch’s honor in the 1960s, the burn regarded training centers. center would prove remarkably successful in improv-

MAY 2015 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Right: The Beaux Arts facade of the hospital. Below: An 1890 amputation (with bare hands) in Ward 9. At the time, there were no designated operating rooms.

8 |

ing the survival rates and quality of life for burn vic- graduate training program in general surgery and the tims. In addition, Drs. Kanavel and Koch played an surgical specialties. He succeeded in many ways. influential role in fostering the growth of a world- With respect to surgical training, Dr. Freeark class hand surgery service. made two important moves: he established a two- Leaders at the CCH and of the ACS also made month rotation with surgeons at the Lahey Clinic, invaluable contributions to the development of the Burlington, MA; and he recruited renowned surgeons surgical specialties, including cardiothoracic, pediatric, George Block and Don Ferguson of the University neurological, vascular, urological, orthopaedic, plastic, of Chicago and Otto Trippel and John J. Bergan of otolaryngological, oral and maxillofacial, ophthalmic, Northwestern (all MD, FACS) to join the volunteer and colon-rectal surgery. attending staff. On the clinical side, Dr. Freeark and Robert J. Baker, MD, FACS, oversaw the development of the A new age nation’s first official dedicated trauma center—the The 1960s was a period of enormous political, social, CCH trauma unit—in 1966. The CCH trauma unit and scientific change. It also was a time when health became the conceptual model for trauma systems care and medical education were becoming more planning, patient care, and training throughout the intensely scrutinized. All of these factors had a signifi- nation. The trauma unit also housed a computerized cant effect on inner-city teaching hospitals like CCH. trauma registry developed in conjunction with the Richard J. Freeark, MD, FACS, was appointed chair University of Illinois, Chicago. As the value of trauma of the department of surgery at CCH in 1963 and medi- registries continued to rise, John Fildes, MD, FACS, cal superintendent in 1968. Dr. Freeark laid the ground- and Richard J. Fantus, MD, FACS (Bernard Fantus’s work for revitalizing the resources of the hospital to grandson), collaborated to establish the ACS National promote quality care and to establish a superior post- Trauma Data Bank® in 1989.

V100 No 5 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Left: A 1950s surgical ward. Near right: Dr. Murphy, wearing a special head lamp, performing a tendon repair of the hand. Far right: A Friday night in the trauma unit.

The socioeconomic turmoil affecting the city in upgraded. Clinical improvements included better the late 1960s and early 1970s and decades of neglect patient follow-up, reinstitution of the cardiac surgery took their toll on the institution. Dr. Freeark resigned program, recruitment of a full-time director of breast as medical superintendent in 1970. Gerald Moss, MD, surgery service, replacement of an outdated cancer FACS, from the University of Illinois took over the registry with an electronic record-keeping system, department of surgery in 1972 and led a significant establishment of the Hektoen Institute for Medical revitalization of the surgery program. He rebuilt the Research focused on advancement in surgical tech- freestanding residency program in general surgery nology, advancements in laparoscopic surgery, and | 9 by recruiting outstanding graduates of the program improved survival rates among critical care patients. to lead the divisions of general and pediatric surgery. He also retained outstanding residents in general sur- gery and the surgical specialties to train residents and A must read serve as attendings. For example, in 1972 he appointed The book ends with historical vignettes, and the print Dr. Abcarian, who began his training as an intern at edition also contains photos collected from CCH CCH in 1966, to serve as program director of the colon- alumni and the ACS Archives. This column has bare- rectal surgery residency and section chief of colon and ly skimmed the surface of all the information cov- rectal surgery at CCH—positions he would hold for 23 ered in this book and hardly touched upon the contri- years of tremendous growth and advancement. butions of ACS Fellows associated with CCH. Dr. Moss was succeeded by Olga Jonasson, MD, The editors are to be commended for their efforts FACS, a skillful academic, general, and transplant sur- to compile a comprehensive, compelling, and lov- geon. As chair of surgery at CCH, Dr. Jonasson led the ing reflection on an institution to which the surgical integration of the general surgery residency program profession and patients around the world are deeply with the University of Illinois program. A controver- indebted. I would encourage anyone who is interested sial move at the time, it ultimately improved surgical in learning more about the history of our profession training at CCH. Dr. Jonasson resigned from CCH in and the ACS to read the book. ♦ 1986 to serve as the Zollinger Professor and Chair, department of surgery, Ohio State University, Colum- bus. She ended her career at the ACS headquarters as Director of Surgical Education and Research. Her successor at CCH was Hernan M. Reyes, MD, FACS, chair of the CCH division of pediatric surgery. Under his leadership, the surgery departments were restructured, new leadership was appointed, and, to If you have comments or suggestions about this or other issues, please attract more competent attending staff, salaries were send them to Dr. Hoyt at [email protected].

MAY 2015 BULLETIN American College of Surgeons GOING GREEN IN THE OR

Strategies for sustainability:

10 |

Going green in the OR

by Tony Peregrin

V100 No 5 BULLETIN American College of Surgeons GOING GREEN IN THE OR

“When we say we are here for your health—we mean it on every level. Green OR programs are a great way to show commitment to the overall well-being of a patient—not just giving them medicine, but providing an environment in which they will be safer, cleaner, and healthier.” —Dr. Paluch

oing green, particularly in the operating room (OR), is a meaningful goal for many environ- Gmentally conscious surgeons, but for budget- wary hospital administrators, the decision to adopt more sustainable practices is often about the other green—money. Current research suggests sustain- able OR initiatives do, in fact, reduce operating cost while eliminating waste and improving environ- mental sustainability. According to Greening Health Care: How Hospitals Can Heal the Planet, U.S. hospitals produce more than 2.3 million tons of waste each year, with an average of 26 pounds of waste per staffed bed in the course of a single day.1 When the environmental ramifica- tions of these numbers are considered along with the impact on health care expenditures, the validity of | 11 cost-cutting environmental stewardship programs becomes increasingly apparent. Whether it’s the red bag waste reduction initiative of the Carolinas Medi- cal Center (CMC), Charlotte, NC, which resulted in a $50,000 per year savings, or the streamlining of surgical kits at the University of Minnesota Medical Center, Fairview, which has yielded $104,000 in sav- ings annually—these programs have demonstrated that they protect both the environment and the insti- tutions’ bottom line.2,3 In this article, surgeon leaders discuss effective green OR strategies, offer guidelines for reporting program outcomes, and highlight practical solutions for promoting the kind of culture change necessary to achieve long-lasting results.

Single-use devices and surgical kits Dr. Paluch with trash from a single case, all to “The first step toward [creating] a green OR is to be disposed of as biohazardous waste. observe what is going on around you and to find out how you are contributing to your environmen- tal footprint,” said Tom Paluch, MD, a general sur- geon with the Kaiser Foundation Medical Center, San Diego, CA, and co-presenter of The Environmentally Responsible Surgical Practice Panel Session at the 2014 Clinical Congress. “Reducing disposable instrumen-

MAY 2015 BULLETIN American College of Surgeons GOING GREEN IN THE OR

“It’s interesting because people tend to come out of the woodwork as soon as you start to talk about green OR initiatives openly.... Other hospital systems and organizations may have this kind of program already in place, with people in place whose jobs are focused on these issues, and you might not even be aware of it. Go and see if something like this already exists.” —Dr. Klaristenfeld

tation is the single biggest way a surgeon can have a money,” he said. All opened instruments, regard- positive impact on the environment. We eliminated less of whether they are used in a procedure, must single-use devices (SUDs) for laparoscopy, and we went be sterilized again and repackaged. from consuming $300,000 worth of equipment a year Streamlining surgical kits or packs has been a prior- to virtually nothing—and that’s just in one hospital ity for Rafael Andrade, MD, FACS, a general thoracic here in San Diego,” said Dr. Paluch. surgeon at the University of Minnesota Medical Cen- Each year, Kaiser Permanente reduces medical ter, since 2009. Dr. Andrade, along with Lynn Thelen, 12 | waste by recycling and safely reusing SUDs, according RN, launched a grassroots OR Green Team to explore to Dr. Paluch. Recycling SUDs—which is conducted the feasibility of reducing waste at their hospital. After in strict accordance with U.S. Food and Drug Admin- soliciting input from colleagues, they examined 38 dif- istration (FDA) regulations—reduces purchasing and ferent types of OR packs to determine which devices, overall waste disposal costs.4 such as plastic basins, catheters, and syringes, were In addition to recycling SUDs, Kaiser Perman- unused and then instructed their product vendor to ente has partnered with MedShare, a not-for-profit remove the items from the packs.3 For example, a pack organization dedicated to repurposing unused, unex- designed for inserting an intravenous port in chemo- pired medical equipment that previously ended up therapy patients was whittled down from 44 devices in landfills. MedShare is one organization that redis- to 27, and disposable gowns and linens were replaced tributes these supplies to clinics and hospitals in the with reusable items. Overall, this initiative resulted in developing world.4 Approximately 2 million pounds a reduction of one pound of trash and $50 in supply of recoverable medical supplies can be found each cost savings per procedure.3 year in large, metropolitan U.S. academic medical “Most surgeons don’t know what exactly is in centers. Collectively, these materials hold a potential the kit when they enter the OR. They simply want value of at least $15 million per year.5 to come in and start operating and not waste time Another way surgeons can contribute to the trying to get [supplies that are] not available,” said sustainability of their health care institutions is by Dr. Andrade. “We explained to the surgeons that working with colleagues to standardize operative items that are never used are going to be removed packs and trays, according to Daniel Klaristenfeld, [from the kits] and that items that are sometimes used MD, FACS, FASCRS, a colorectal surgeon, Kaiser can be on hold in the room, but not included in the Permanente, San Diego, and moderator of the 2014 kit so they don’t get wasted every single time.” Dr. Clinical Congress Panel Session. “For common pro- Andrade said in-person meetings with hospital and cedures like gallbladder surgery or hernia repair, surgeon leaders were key in dealing with resistance we walk into a case and instead of having every and quickly led to acceptance and support of the ini- available instrument open and on the table, they tiative. “All upfront work—getting buy-in from the are available but not opened, which saves time and surgeons—is done in person,” he said.

V100 No 5 BULLETIN American College of Surgeons GOING GREEN IN THE OR

“Ours has been a grassroots movement; it was not led by administration.... Peer- to-peer communication means there is a representative from each group on the green team—surgeons, nurses, surgical technicians, physician assistants, custodians, and so on. If I need to get a message out to the surgeons, I talk to them as the surgeon representative on the green OR team.” —Dr. Andrade

Red bag initiative At CMC, red bags in the OR and intensive care units (ICUs) are designated for biohaz- ardous waste. According to B. Todd Heni- ford, MD, FACS, chief, division of gastro- intestinal and minimally invasive surgery, CMC, it costs 10 times as much per pound to dispose of these materials than other | 13 waste, primarily due to the cost of trans- porting and incinerating red bag waste, not to mention the effect of the toxic release of dioxin on the environment as a result of this processing. “What we found was that staff was throwing essentially everything that Disposable items removed from a single direct laryngoscopy kit. touched a patient into a red bag, so it was This kit is used approximately 40 time per month. simply a matter of educating our team- mates about the difference between biohaz- ardous materials and general waste, which typically goes to a landfill. While a landfill is not a great option, it is certainly better than incineration,” explained Dr. Heniford, co-author of “The green operating room: Simple changes to reduce cost and our car- bon footprint,” published in a 2013 issue of The American Surgeon.2 “We also found that in the ICUs the biggest trash cans held red bags, so people threw everything in there,” Dr. Heniford Digital scale display of the total weight in grams (equivalent to 22 oz) of disposable items removed said. “We changed the trash cans—I say from a single direct laryngoscopy kit. ‘we,’ but it was the institution’s custodial staff who suggested changing the size of the trash cans. They made the red bag trash can the smallest one in the room, and they

MAY 2015 BULLETIN American College of Surgeons GOING GREEN IN THE OR

“When we began our program, we decided it had to be cost-neutral.... And very quickly we were able to demonstrate with a few small, grassroots initiatives that not only were we able to remain cost- neutral, but we actually saved money. Saving money and reducing our carbon footprint energized the committee and captured the administrators’ attention.” —Dr. Heniford

also purposely placed these cans in the corner of the mentally safe/reduced product packaging, and even room so that you had to walk a few feet to dispose of general cleansers and solvents formulated specifically an item there,” he added. Staff members now have to for a reduced impact on the environment.8 In a sense, make more of an effort to dispose of an item in a red EPP can be considered “preventive medicine” that pro- bag, which serves as a reminder to only place heavily motes a healthy environment through products that soiled materials in these receptacles. are green friendly.8 Dr. Heniford said his institution observed a 75 per- According to Vanessa Lochner, director of EPP for 14 | cent reduction in red bag waste, with an estimated sav- Kaiser Permanente, buying green occurs in three dis- ings of more than $50,000 a year. The red bag initia- tinct phases:9 tive is a product of the CMC’s Green Operating Room Committee (GORC), formed in 2008 with members • Pre-sourcing: This step involves the work prior to a from surgical, nursing, anesthesia, and OR staff, and sourcing event—researching what various vendors have environmental services.2 to offer. For example, it might entail sending a chemi- Educating staff members on proper disposal of cal disclosure questionnaire to suppliers or reviewing a biohazardous waste versus general waste, rather than product category for reduced packaging opportunities. underscoring policy mandates and regulations, is the best way to ensure team member buy-in, according • Sourcing: In this phase, also known as procurement, to Dr. Andrade. At the University of Minnesota Medi- hospital administrators and green OR teams define their cal Center, staff members are now required to take an requirements so that suppliers in the marketplace may online course on proper waste disposal as part of their bid on goods and services. annual education requirements.6 • Implementation: This step is the execution phase of a project or initiative that produces a positive environ- Environmentally preferred purchasing mental outcome—one that is trackable with metrics. Surgical kit reduction, waste elimination, water con- servation, and other green OR initiatives essentially Surgeon leaders can have an impact on a facility’s start, in some form or another, with purchasing. Envi- purchasing decisions, Dr. Paluch suggests, particu- ronmentally preferred purchasing (EPP), according larly at the sourcing phase when product require- to Dr. Paluch, can be defined as the “purchase of prod- ments are addressed with vendors. Surgeons and OR ucts and services whose environmental impact have green teams can also contribute to EPP initiatives by been considered and found to be less damaging to assisting in product assessments, tracking purchas- the environment and human health when compared ing decisions, and monitoring cost-benefit analysis [with] competing products and services.”7 These items of these products and services. Perhaps most impor- could include reusable surgical instruments, environ- tantly, surgeons who are champions of EPP can help

V100 No 5 BULLETIN American College of Surgeons GOING GREEN IN THE OR

Dr. Heniford’s green team members package recycled surgical supplies for medical mission trips to developing countries. develop stakeholder and colleague engagement in these purchasing decisions by promoting the positive effects on the environment. In 2014, Johnson & Johnson, the pharmaceutical and manufacturing company, partnered with Harris Poll to measure the importance of sustainability issues among global health care professionals, including sur- geons, OR nurses, and hospital executives in the U.S. | 15 and five other countries.10 More than half (54 percent) of respondents to the study report that their hospitals currently incorporate sustainability into purchasing decisions, and 80 percent anticipate that will be the case within two years. More than 300 health care pro- fessionals participated in the 2014 survey, either online (289) or by phone (40).10 According to the study, health care professionals also agree it makes good financial sense for hospitals to go green, both in the U.S. (79 percent) and globally (69 percent). In fact, 67 percent of domestic and 60 percent of international respondents report a grow- ing commitment to sustainability from top hospital management.10 “The biggest reason for hospitals to be involved in green initiatives is cost savings—but it is a nice benefit to be able to say to the public that you are environmen- tal [stewards],” said Dr. Paluch. “When we say we are here for your health—we mean it on every level. Green Dr. Heniford participating in a 2010 Operation Hernia OR programs are a great way to show commitment to medical mission trip in Mongolia. The surgeons used the the overall well-being of a patient—not just giving them recycled surgical supplies donated by the CMC OR. medicine, but providing an environment in which they will be safer, cleaner, and healthier.” “By being green, we sacrifice nothing,” added Dr. Heniford. “Being green demonstrates our responsi- bility to not only to our patients but to our communities.”

MAY 2015 BULLETIN American College of Surgeons GOING GREEN IN THE OR

Culture change water run prior to an operation. Once we convinced Surgeon leaders can accelerate the culture change need- staff to use an alcohol-based waterless scrub—which ed to encourage and sustain green practices at their is as safe or safer than water scrub—we have [had] institutions. To ensure the longevity and success of an estimated savings of 2.7 million liters of water per these programs, surgeon leaders should develop a col- year in the ORs alone, in just our hospital.” Tethered laborative support network throughout the organiza- to this water-saving initiative were additional green- tion and provide hospital executives and staff members friendly cost savings from a decrease in washing and with measurable results. processing towels and lower sewer-use fees.2 “The raison d’etre for a hospital is not to be an envi- “When we began our program, we decided it had to ronmentally savvy organization; it is to take care of be cost-neutral,” said Dr. Heniford. “And very quickly the patient,” said Dr. Paluch. “How do we best do that? we were able to demonstrate with a few small, grass- By providing quality care, but also by being environ- roots initiatives that not only were we able to remain mental stewards. To make these kinds of changes, it cost-neutral, but we actually saved money. Saving mon- is as simple as going to the administration; and, yes, ey and reducing our carbon footprint energized the 16 | it is as difficult as going to administration. It’s like committee and captured the administrators’ attention.” turning a battleship with a canoe paddle—it’s not an In addition to offering hospital administrators easy thing to do. However, these initiatives tend to tangible, measurable results, such as cost savings and catch on—one, because it’s smart, and two, because waste-reduction outcomes, Dr. Andrade and his col- they save money. That is what gets people interested leagues were able to help achieve a culture change because it’s measurable. If you can’t measure it, you throughout his organization through peer-to-peer com- can’t manage it.” munication. “Ours has been a grassroots movement; Providing hospital administrators with tangible it was not led by [the] administration,” revealed Dr. results was the justification behind the first green Andrade. “Peer-to-peer communication means there is initiative—water conservation—led by the GORC team a representative from each group on the green team— at CMC. According to Dr. Heniford, the scrub cycles surgeons, nurses, surgical technicians, physician assis- of 100 consecutive physicians, nurses, residents, and tants, custodians, and so on. If I need to get a message technicians were observed to determine how much out to the surgeons, I talk to them as the surgeon rep- time they spent scrubbing before an operation. In all resentative on the green OR team. If someone needs to but two cases, water ran nonstop while staff members communicate something to the nurses, then the nurse scrubbed, whether their hands were under the water on the team conveys that information. We’ve empha- or not. And frequently, the water was left running even sized this model from the very beginning because it’s when no one was at the sink. To minimize this prob- where you get more bang for your buck. It’s not a sur- lem, OR sinks were outfitted with flow meters, and the geon imposing a message or request on nurses, or a GORC estimated daily, weekly, and yearly use. surgical tech trying to sell something to the surgeons. “We demonstrated to OR staff that we could save Peer-to-peer communication is the best way to engage real [amounts of] water by making a conscious effort to staff members in green initiatives,” said Dr. Andrade. conserve it,” said Dr. Heniford. “At that point, only 20 “It’s interesting because people tend to come out percent of the surgeons, nurses, and scrub techs used of the woodwork as soon as you start to talk about waterless scrub prior to surgery, and when we sur- green OR initiatives openly,” said Dr. Klaristenfeld. veyed staff, the reason was purely based on tradition. “Other hospital systems and organizations may have There must be something soothing about hearing the this kind of program already in place, with people in

V100 No 5 BULLETIN American College of Surgeons GOING GREEN IN THE OR

place whose jobs are focused on these issues, and REFERENCES you might not even be aware of it. Go and see if 1. Kaiser Permanente. Excerpts from Greening Healthcare: How something like this already exists.” Hospitals Can Heal the Planet. August 12, 2014. Available at: Transparency regarding the sustainability efforts http://share.kaiserpermanente.org/article/excerpts-from- greening-health-care-how-hospitals-can-heal-the-planet/. of a green OR team is also key to maintaining staff Accessed February 18, 2015. engagement. Reporting green team outcomes and 2. Wormer BA, Augenstein VA, Carpenter CL, et al. The green comparing results from previous years or even operating room: Simple changes to reduce cost and our results from different departments within the same carbon footprint. Am Surg. 2013;79(7):666-671. facility can help generate renewed interest in a water 3. Chen I. In a world of throwaways, making a dent in medical waste. The New York Times. July 5, 2010. Available use reduction program or a red bag initiative. at: www.nytimes.com/2010/07/06/health/06waste. “As a surgeon, being green is not going to be at html?pagewanted=all. Accessed February 18, 2015. the forefront of my daily existence, so the only way 4. Kaiser Permanente. Reducing, re-using, and recycling to to keep it a priority is to keep putting it in front of eliminate waste. May 30, 2014. Available at: http://share. me and my peers,” Dr. Paluch noted. His institu- kaiserpermanente.org/wp-content/uploads/2014/06/ WasteReduction-factsheet_20141.pdf. Accessed February 18, | 17 tion has a regular reporting cycle that details the 2015. team’s accomplishments on a monthly or bimonthly 5. American College of Surgeons. An estimated two million basis. “When we remind surgeons that the same pounds of unused medical supplies may be recoverable in patient care can be administered with environmen- U.S. operating rooms each year [press release]. October tal savvy or stewardship, we’re going to sign on to 2014. Available at: www.facs.org/media/press-releases/2014/ wan1027. Accessed February 23, 2015. this—but we need reminders because this is not 6. Hankel A. Greening the OR. Surgical Products. July 5, 2011. our primary focus.” Available at: www.surgicalproductsmag.com/articles/2011/0 “One of the most important things we were able 7/%E2%80%98greening%E2%80%99-or. Accessed February to do is keep score,” added Dr. Heniford. “Keeping 18, 2015. score energizes people because they see that they 7. Paluch T. A Skeptic’s Epiphany: Environmentalism in Surgical Product Procurement. Presented at 2014 American can make a difference.” College of Surgeons Clinical Congress; October 28, 2014; San Francisco, CA. 8. Practice Greenhealth. Environmentally preferable Conclusion purchasing. Available at: https://practicegreenhealth.org/ Demonstrating a return on the investment of time topics/epp. Accessed February 18, 2015. 9. Lochner V, Hayter S, Johnson R. Developing and Managing and resources is essential when launching a sustain- a Sustainable Portfolio Mix of EPP Projects. Presented at ability program and is likely the most convincing CleanMed2014; June 2-4, 2014; Cleveland, OH. way to foster a culture change throughout an orga- 10. Advancing sustainability in health care [news release]. nization. Surgeons are natural leaders who foster Johnson & Johnson. October 1, 2014. Available at: www. collaboration both inside and outside the OR and csrwire.com/press_releases/37402-Globally-Hospitals-are- Driving-Toward-Greener-Purchasing-Decisions-Greater- are essential to the long-term success of a green OR than-50-Increase-Expected-in-Next-Two-Years. Accessed initiative. Leading by example, surgeons can play a February 18, 2015. significant role in developing an interdisciplinary green team, encouraging reprocessing of single-use surgical devices, establishing a sustainable waste management program, and advocating for green- friendly purchasing practices. ♦

MAY 2015 BULLETIN American College of Surgeons PREOP PROGRAM

PreOp program:

Can we achieve a by Rachael A. Venn, Stefanie P. Lazow, “trickle-up” effect? and Gregory F. Dakin, MD, FACS

Few moments really have the power to change an individual, but most people can point to at 18 | least one or two life-altering events. For the lead author, Rachael A. Venn, one of these experiences occurred when she was in her early 20s and was given the opportunity to scrub-in on an operation. Up to this point, becoming a surgeon had never crossed her mind. But there she stood, holding a retrac- tor as if it were the most important task she would ever perform. And in that moment, it was. Words cannot adequately describe the intrigue and awe Ms. Venn felt at not only seeing, but touching the uterus, ovaries, and fallopian tubes, each with a gleam and texture that elude the diagrammatic representation of a medical textbook. By the time the last suture was placed, Ms. Venn knew a few things: she loved the operating room (OR), she had to be that close to a patient again, and she would go to medical school. What she did not know was that, based on the current structure of medical education, if she wanted to re-enter the OR, she would either have to wait several years until her sur- gery clerkship, or she would have to create the opportunity for it to happen sooner.

V100 No 5 BULLETIN American College of Surgeons PREOP PROGRAM

In light of ongoing concerns about the prospect of surgeon shortages in the near future and growing reports of reduced resident competency, the preclinical years may be an opportune time to pique medical students’ interest in surgery and guide them toward surgical careers.

reOp—a preclinical surgical exposure program ing demographic of an aging population, but also on established through a joint effort at Weill Cor- a concomitant decrease in the number of practicing Pnell Medical College and New York-Presbyterian general surgeons.1 Hospital, New York, NY—was the opportunity that These changes emphasize a need to better under- Ms. Venn and co-author Stefanie P. Lazow created in stand what drives medical student interest in pursuing their first year of medical school. This program ex- surgical training. Studies of clerkship students indicate plores the potential impact of preclinical surgical ex- that mentorship and hands-on participation in the OR posure on medical students’ specialty interest and are two factors that influence students’ desires to pur- their surgical confidence and competency. This arti- sue surgical careers.2 Several medical school programs cle describes the PreOp model and how it successfully have attempted to provide both components to first- offers increased surgical exposure to first-year medical and second-year medical students. These institutions students, providing preliminary data from an ongoing have found that participants in these programs had longitudinal study of this program. increased enthusiasm about surgery in comparison with matched control students who lacked such expo- sure.3,4 However, little long-term follow-up research Generating enthusiasm has been conducted to assess whether this increased Exposure to surgery and surgical education has histori- preclinical exposure ultimately affects specialty pref- cally been neglected in the preclinical years of medical erences or match outcomes. | 19 school. In light of ongoing concerns about the prospect Further complicating an undersupply of surgeons of surgeon shortages in the near future and growing is the current climate of resident education. Based on reports of reduced resident competency, the preclini- examination scores and clinical performance, work- cal years may be an opportune time to pique medical hour restrictions have been associated with a decline students’ interest in surgery and guide them toward in patient outcomes and resident education.5 The same surgical careers. Intensive surgical exposure at this studies described previously also found that preclini- time may contribute to a “trickle-up” effect, providing cal students who experienced more intensive surgi- students with early training that will not only stimu- cal exposure had consistently higher self-reported late surgical interest, but also serve as a foundation for confidence ratings when asked about basic surgical increased competency at subsequent stages of their skills.3,4 Using confidence as a proxy for competence, careers. which has yet to be directly measured, these results Most U.S. medical schools follow a two-plus-two suggest that targeting interested students for training pattern, in which the first two years of the curricu- earlier in their medical education may enhance their lum are classroom-based, and the last two are clini- preparedness as third-year clerks, then as residents, cal. While there has been a recent push to incorporate and ultimately as young attending surgeons—a sort more skills-based learning and patient interaction into of trickle-up effect. the preclinical years, early, structured surgical expo- sure is still lacking. This dearth of early hands-on experience is espe- Introducing PreOp cially problematic given projected physician short- With these possibilities in mind, the authors set out ages. The U.S. Department of Health and Human to design a program that offers medical students men- Services recently published a report indicating that tored and active participation in the OR, starting from by the year 2020, the field of general surgery will their first month of medical school to the time of their experience a shortage of more than 20,000 surgeons, residency match. The purpose of this study is not only meaning demand for their services will far exceed the to show that there is a place for intensive surgical supply. This projection is based not only on the chang- exposure in the preclinical years, but also to share a

MAY 2015 BULLETIN American College of Surgeons PREOP PROGRAM

The authors, from left: Ms. Lazow, Ms. Venn, and Dr. Dakin.

successful model that can be readily implemented in interest in surgery, either by signing up to participate medical schools throughout the country. Examining in Weill Cornell’s already established but less intensive the factors that influence student satisfaction, career surgical interest group or by applying to PreOp with- interest, and confidence and competency in preclini- out being accepted. cal exposure programs may help guide the early stages Both PreOp and control students completed baseline of training for the next generation of surgeons. and end-of-year surveys to gauge the extent to which surgical exposure influenced their specialty preferences. Over the next three years, these two cohorts will be fol- Study design lowed longitudinally and resurveyed to assess whether The PreOp pilot program ran from September 2013 to participation in PreOp affects the following: specialty June 2014 as a collaborative effort between Weill Cor- preference and ultimate match outcome, self-report- nell Medical College and New York-Presbyterian Hos- ed preparation before and after the third-year surgical pital. Participants included 10 attending surgeons, who clerkship, and competency during the third-year sur- served as mentors, and 10 first-year medical students. gical clerkship as measured by the professor’s evalua- 20 | (One of the 10 selected students decided to terminate tions and grades. Thus, PreOp is a prospective cohort his participation in PreOp and was not replaced.) study that will span all four years of medical school. The mentors were recruited across a number of spe- cialties—including cardiothoracic, general, neurologic, and plastic surgery, as well as otorhinolaryngology, and Preliminary results urology—and were selected based on their interest in Data collection and statistical analysis included only the medical education and their willingness to engage pre- nine PreOp students who completed all 10 months of clinical students in the OR. rotations. Results from the pilot year indicate that the Students from the class of 2017 were invited to apply PreOp program successfully provided students with and were accepted the summer before matriculating. increased hands-on surgical exposure. All PreOp stu- Admittance to the program was based upon a qualita- dents scrubbed in for at least one operation during tive review of a student’s personal statement and his or the year, and the PreOp students had the opportunity her curriculum vitae by Gregory F. Dakin, MD, FACS, to scrub in on more than half of the total rotations the surgical faculty sponsor and a co-author of this arti- (52.6 percent). These numbers are in stark contrast to cle, and Charles L. Bardes, MD, associate dean of admis- the control group, in which only one student had the sions at Weill Cornell Medical College. Each month, opportunity to scrub in throughout the year, despite students rotated with one of the mentors, spending one the fact that the control students observed more than to five days in the OR and/or clinic. A parallel skills 43 procedures. Moreover, all PreOp students were able component, which consisted of four skills workshops to suture intraoperatively during at least one rotation, and two lectures, was designed to increase both student while none of the students in the control group had a confidence and competence with basic surgical skills. similar opportunity. As part of a study approved by the institutional Preliminary statistical analysis was performed to review board at Weill Cornell Medical College, PreOp assess factors that increased student satisfaction with program students completed a monthly survey detail- each individual rotation. This assessment showed that ing their involvement with and impression of that increased hands-on participation in the OR through month’s rotation. Nine matched control first-year medi- scrubbing in was related to increased student satisfac- cal students were recruited based on a demonstrated tion and higher rotation evaluations (p<0.001), sup-

V100 No 5 BULLETIN American College of Surgeons PREOP PROGRAM

porting previously reported findings of the importance of hands-on REFERENCES participation in developing student surgical interest.3 1. Harris S. Physician shortage spreads After establishing a substantial difference in surgical exposure across specialty lines. Association of between the PreOp and control students and determining which fac- American Medical Colleges. Available at: www.aamc.org/newsroom/ tors influenced student satisfaction on a per rotation basis, students reporter/oct10/152090/physician_ were asked whether 10-month participation in the PreOp program shortage_spreads_across_specialty_ affected career interest overall. All PreOp and control students initially lines.html. Accessed July 3, 2014. expressed an interest in exploring surgery at the start of the year. The 2. Berman L, Rosenthal MS, Curry L, students also were asked to anticipate how likely they would be to apply Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: to match into a surgical field as fourth-year students. PreOp students Role models, mentoring, and reported increased surgical interest at the end of the year as compared engagement in the operating room. J with the beginning, with seven (77.8 percent) reporting being very likely Am Coll Surg. 2008;207(6):793-800. to apply to match into surgery at the end, compared with four (44.4 per- 3. Drolet BC, Sangisetty S, Mulvaney cent) at the start of the program. In contrast, only two (22.2 percent) of PM, Ryder BA, Cioffi WG. A mentorship-based preclinical elective | 21 the control students reported being very likely to apply to match into increases exposure, confidence, surgery at the end of the year—a number that remained unchanged and interest in surgery. Am J Surg. from the start of the year. 2014;207(2):179-186. 4. Sammann A, Tendick F, Ward D, Zaid H, O’Sullivan P, Ascher N. A surgical skills elective to expose preclinical Ready for implementation medical students to surgery. J Surg Res. PreOp was designed to provide students with attending mentorship 2007;142(2):287-294. and hands-on participation in the OR starting from their first month 5. Ahmed N, Devitt KS, Keshet I, et of medical school. Its successful implementation supports the idea that al. A systematic review of the effects such programs can be readily formed and can offer markedly increased of resident duty hour restrictions in surgery: Impact on resident wellness, surgical exposure in comparison with conventional shadowing. training, and patient outcomes. Ann Preliminary data indicate that similar programs should promote Surg. 2014;259(6):1041-1053. hands-on participation to maximize student satisfaction. The authors’ goal is to determine whether surgical exposure through preclinical pro- grams like PreOp can enhance both surgical interest and competency. This study is unique in its longitudinal nature, and the authors intend to continue following PreOp students to assess surgical competency and confidence throughout their four years of medical school. They anticipate that follow-up studies will show that preclinical students represent an ideal target population for career recruitment and earlier training, potentially providing a solution to the dual problem of physi- cian shortages and inadequate resident preparation. ♦

Disclosure The PreOp program is funded by an education grant from W.L. Gore & Associates, Inc.

MAY 2015 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

Surgeons develop visionary plan to bring corneal transplants to developing countries

by Stephen G. Waller, MD; 22 | Maria S. Altieri, MD; and Rahul M. Jindal, MD, PhD, MBA, FACS

HIGHLIGHTS • Explains the unique characteristics associated with corneal transplants, including eye banking in the U.S. and Central and South America • Describes the need for corneal transplants in developing nations • Offers a PPP model for bringing corneal transplants to underserved countries Dr. Waller (top left) looks on as Dr. Jain (a local eye surgeon, at microscope) and a local nurse assistant (left) • Provides details on how the authors transplant a cornea. Drs. Jindal and Patel observe. implemented the PPP model in Guyana

V100 No 5 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

any developing nations now have health care countries has become a priority. Despite some efforts by providers that offer specialty care. For exam- various governmental and nongovernmental organiza- Mple, kidney transplantation was practically tions, the supply of corneas falls short of the demand.4 nonexistent in low- and middle-income countries and Keratoprosthesis, use of an artificial cornea, may be an end-stage renal disease was considered a death sen- alternative to corneal transplant in a small percentage tence until recent years.1-3 Since 2008, a renal trans- of the cases.5 plant program launched in Guyana by Rahul M. Corneal opacities are cited as the third most com- Jindal, MD, PhD, MBA, FACS (coauthor of this arti- mon cause of blindness and represent 7 percent to cle), and colleagues has carried out 26 living kidney 25 percent of all causes of blindness worldwide.6-8 Cor- transplants, numerous peritoneal dialysis catheter neal blindness is more common in developing countries placements, and vascular access procedures for hemo- and is underreported, thus making it difficult to esti- dialysis.1 Dr. Jindal’s team has delivered lectures and mate its true prevalence.7 The epidemiology of corneal held press conferences to raise local physician and pa- blindness varies by region and age and is dependent on tient awareness of the transplant program. They also the ocular diseases that are endemic to the geographic have initiated a public health project to train selected location. Corneal blindness is a leading cause of perma- individuals living in each village (average education nent visual impairment, as scarring and vascularization of 12th grade and above) in basic clinical skills, such of the cornea cannot be reversed.9 as recording blood pressure and blood sugar mea- Most causes of corneal blindness in developing coun- | 23 surements, and noting lifestyle modifications, in- tries are either treatable or preventable.10 According to cluding dietary practices, and hygiene levels, which a 2005 study, the diseases that most frequently lead to will allow the student team to act as primary health corneal blindness include trachoma, onchocerciasis, care workers.1 leprosy, ophthalmia neonatorum, and xerophthalmia.8 More recently, the team established a successful, In a study of 12,899 participants in India, the most com- sustainable corneal transplant program in Guyana. mon causes leading to corneal blindness included pte- To launch this program, Dr. Jindal and his colleagues rygium (34.5 percent), ocular trauma (22.3 percent), used a private-public partnership (PPP) model, work- and infectious keratitis (14.9 percent).11 Infectious, trau- ing with government agencies to attain sponsorship matic, and autoimmune corneal diseases were the three to help offset costs, build surgical capacity, establish leading causes of corneal blindness in China.12 A study an infrastructure for an eye bank, identify appropri- from Tanzania reported corneal infections, vitamin A ate patients, and provide reliable follow-up. This arti- deficiency, and measles as the top three causes of bilat- cle describes some of the key features of a successful eral corneal blindness.13 corneal transplantation system, such as the establish- In South America, common causes leading to blind- ment of accredited eye banks; the factors that influence ness include pterygium, ocular trauma, and trachoma, the success of a corneal transplant program; how the among others. Ocular trauma constituted 30 percent authors successfully implemented the PPP model; and to 40 percent of all ophthalmological emergencies. Tra- the lessons learned in developing this program. choma is another condition that leads to corneal blind- ness. Some reports from Latin America cite relatively small numbers of infections, which may indicate the Need in developing countries problem is being underdiagnosed.14 In Mexico, a report Although the prevalence of blindness is greatest in from 2007 showed up to 42 percent of children in cer- developing countries, the availability of corneal trans- tain locations are affected by the condition.15 In Brazil, plant surgery and donor tissue is lowest in such places. prevalence varied from 2.2 percent in major cities to 50 As this disparity has become increasingly apparent to percent in remote areas, although more recent reports health officials, establishing eye banks in low-income suggest decreasing prevalence.16-18

MAY 2015 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

The transplant team with a pre- corneal transplant patient. From left: Dr. Jain; the first corneal transplant recipient in Guyana; Drs. Jindal, Waller, and Patel; and Mr. Subraj.

Eye bank requirements and procedures ESSENTIAL RESOURCES FOR The key to any successful transplant program is rigorous CORNEAL TRANSPLANTS organ banking. Eye banks in the U.S. must be certified by the • Documentation of cleanliness Eye Bank Association of America (EBAA), which was estab- lished in 1961 to serve as the national accrediting organiza- • Access to sterile surgical instrument

packs, gloves, gown, mask tion for eye banks in the U.S., and the U.S. Food and Drug Administration. Eye banks in Central and South America, as • Sufficient outlets and back-up power well as the Caribbean, should be certified by the Pan Ameri- • Solutions: Sterile saline for irrigation can Association of Eye Banks, also known as Associação Pan- • Recording refrigerator: 24/7/365, 2–8o C Americana de Bancos de Olhos (APABO). To attain certification, eye banks must have a medical • Sink, counter space, laminar flow hood, director—an ophthalmologist with expertise in cornea trans- access to slit lamp biomicroscope plantation—and an administrative director on staff. The 24 | • Endothelial cell counter medical director is responsible for ensuring the application • Tissue: Labeled and segregated into four of medical standards to all aspects of the system, educating distinct and separate groups: in process, health care personnel, releasing and distributing corneal quarantine, research, ready for release tissue, and overseeing the waiting list. The administrative director, on the other hand, is responsible for public aware- • Optisol GS or McCarey-Kaufman medium ness and quality control and interacts with accreditation (the two types of storage media for agencies, including the APABO, the ministry of health in the the harvested cornea that include host nation, and the national association of ophthalmology. gentamicin and streptomycin) Eye bank staff also must include at least one technician • Penlight, slit lamp, specular who is certified by APABO. The technician’s responsibilities microscope, optical coherence include obtaining the consent of the family for corneal dona- tomography to evaluate the eye tion, conducting a medical history review, examining the • Trephines, trephine handle, donor, evaluating the eye and determining appropriateness donor corneal punch of tissue for transplantation, retrieving tissue by following eye bank standard operating procedures (SOPs), and obtain- ing serologic testing of the donor. The essential materials needed for a bank to operate appropriately are described in the sidebar on this page. To operate an independent eye bank, SOPs, including medical standards to protect the tissue recipient and the tech- nician, must be established and followed. Processes related to uniform evaluation procedures, recipient and donor data collection, quality assurance procedures, outcome analysis, and accountability should also be established. The technician must follow SOPs regarding consent of the family for corneal donation; obtaining medical history in a uniform manner; and ensuring that there are no specific contraindications for

V100 No 5 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

TABLE 1. Country Cost* COSTS OF CORNEAL U.S. $16,500 TRANSPLANT Guyana Subsidized by our sponsor IN DEVELOPING AND DEVELOPED Netherlands $7,942–$14,807 COUNTRIES Canada $3,171 Singapore $3,710 *Costs are estimates South Africa $1,300 based on conversions India $ 2,100–$2,300 from native currencies to U.S. dollars, and Spain $5,650 may have changed since the data was Turkey $8,640 initially published.

donation, such as positive human immunodeficiency Estimated average cost per patient of corneal trans- virus status, hepatitis status, or an injectable drug abus- plantation in the U.S. is approximately $16,500.23 In er profile. The technician should also rule out active other countries, the cost of corneal transplant ranges infection of the eye. Other SOPs cover the acquisition from $1,300 to $14,807. Table 1, this page, compares of tissue and serologic testing. The medical director costs of corneal transplant in different countries.23-37 oversees all these tasks performed by the technician and ensures an equitable system for the transplant waiting list, with priority given to younger patients and indi- Availability of corneas in the U.S. viduals with bilateral blindness. The number of cornea donations in the U.S. is increas- ing. A 2013 report from 76 domestic and 10 interna- | 25 tional eye banks cited 72,736 total corneal grafts—a Factors for success 5.9 percent increase from the previous year. Accord- Corneal transplantation is one of the most successfully ing to the EBAA, 48,229 corneal transplants were per- performed tissue transplant procedures. The unique formed during 2013 in the U.S., and 29,646 corneas were properties of corneal transplants have been previous- obtained from donor registries in 2013.32 The success ly described in the medical literature.19 Specifically, of eye banks in the U.S. is largely attributed to public research suggests that corneal transplantation success awareness regarding organ donation. rates have been associated with the immune privilege Due to the EBAA’s efficient framework described status of the avascular cornea. Disparity between recipi- previously and to high rates of eye donation, the U.S. ent and donor at the major histocompatibility complex has sufficient quantities to both meet domestic demands (HLA) is the predominant reason for allograft rejection and provide tissue to international recipients.33 A simi- and the need for immunosuppressive therapy in other lar program in the developing world is the National Eye transplanted tissues. For corneal transplantation, how- Bank of Sri Lanka, which has emerged as an exemplar ever, a large, multicenter study showed that neither of corneal donation and international export of cor- HLA-A, -B, nor HLA-DR antigen matching reduced neas in Asia and serves as a role model for developing corneal graft failure and ABO blood group matching countries.34 was also insufficient to reduce the risk of graft failure.20 The EBAA authorizes each eye bank to be respon- Recipients of corneal transplant typically require sible for distribution of tissue using a list of profession- shorter hospital stays (in some cases, just two hours), als and institutions approved to receive ocular tissue. If incur lower hospital charges, and often need only topi- complications occur, such as rejection of the cornea, the cal immunosuppressive therapy.21 In addition, com- transplant surgeon must notify all eye banks involved pared with other transplants in which donor age may in the recovery, processing, storage, final distribution, play a role, multi-center trials have shown that donor tissue evaluation, and donor eligibility determination. age was unimportant in corneal transplant patients It is expected that the transplant surgeon will notify the younger than age 75, as long as the endothelial cell eye bank of surgical complications and one-year follow- count was satisfactory.22 up even if the corneal transplant is done in another

MAY 2015 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

TABLE 2. RECIPIENT INFORMATION

Age Previous Postoperative (years) visual corrected Recipient and sex* Diagnosis Procedure acuity visual acuity Complications 22 Keratoconus with 6/9 1 Penetrating keratoplasty 6/24 N/A F apical scar (pinhole) 20 Keratoconus with 2 Penetrating keratoplasty 1/60 6/9 N/A M apical scar 48 Pseudophakic bullous 3 Penetrating keratoplasty HM‡ 6/9 N/A M keratopathy 36 Leucomatous corneal 4 Penetrating keratoplasty HM‡ 6/6 N/A M opacity

Penetrating keratoplasty Mild sub-epithelial 72 Post bee sting corneal 5 with cataract extraction with HM‡ 6/36 haze with high M decompensation intraocular lens implant† astigmatism

36 Keratoconus with 6 Penetrating keratoplasty 4/60 6/9 N/A M apical scar *F-Female, M-Male; †Penetrating keratoplasty with cataract extraction with intraocular lens implant; ‡Hand motions close to face.

REFERENCES country. However, disposal of corneas in excess of demand 1. Babakhani A, Guy SR, Falta EM, Elster EA, Jindal depends on the individual eye bank and on the relationship TR, Jindal RM. Surgeons bring RRT to patients in established between them and the U.S. or foreign corneal Guyana. Bull Am Coll Surg. 2013;98(6):17-27. transplant surgeons. 2. Jindal RM, Falta EM, Baines LS, Elster EA. Health policy for renal replacement therapy in developing 26 | countries. J Healthcare, Sciences, and the Humanities. 2011;1(1):41-54. PPP model at work 3. Barsoum RS. Chronic kidney disease in the Humanitarian missions are essential to meet the need developing world. N Engl J Med. 2006;354(10):997-999. for sight restoration in developing countries, and several 4. Rao GN, Gopinathan U. Eye banking: An introduction. Comm Eye Hlth. 2009;22(71):46-47. organizations in the U.S. support the growth of eye banks 5. Oliveira L, Cade F, Dohlman C. Keratoprosthesis around the developing world. There are variations on our in the fight against corneal blindness in developing model of PPP that include training of local surgeons and countries. Arq Bras Oftalmol. 2011;74(1):5-6. funding from private sources in the U.S. or internationally. 6. Dandona R, Dandona L. Corneal blindness in a southern In 2013, for example, the Lions Eye Bank of Delaware Val- Indian population: Need for health promotion strategies. Br J Ophthalmol. 2003;87(2):133-141. ley, Philadelphia, PA, provided corneas to transplant sur- 7. Pascolini D, Mariotti SP. Global estimates of visual geons for a mission in Kenya.35 The San Diego Eye Bank, impairment: 2010. Br J Ophthalmol. 2012;96(5):614-618. CA, is involved in the International Cornea Project, which 8. Garg P, Krishna PV, Stratis AK, Gopinathan U. is responsible for missions to provide corneas for transplan- The value of corneal transplantation in reducing tation around the world.36 Another example is the Cornea blindness. Eye (Lond). 2005;19(10):1106-1114. 9. World Health Organization. State of the World’s Sight. Research Foundation, which sponsored a surgeon to teach Vision 2020: The Right to Sight 1999–2005. Available advanced surgical techniques to Nepali surgeons.37 at: http://apps.who.int/iris/handle/10665/43300. At the beginning of 2014, we realized that there was Accessed January 3, 2015. an acute need in Guyana for subspecialty surgical ser- 10. World Health Organization. Action plan for the vices, in addition to kidney transplantation. We took an prevention of avoidable blindness and visual impairment 2009–2013. Available at: www.who.int/ incremental approach by reviewing the need for corneal blindness/ACTION_PLAN_WHA62-1-English.pdf. transplantation. This analysis was subjective, as Guyana Accessed March 9, 2015. has no centralized registry for eye diseases. On the first 11. Sheng XL, Li HP, Liu QX. Prevalence and associated visit, Dr. Waller discussed eye banking and transplantation factors of corneal blindness in Ningxia in northwest with Guyanese ophthalmologists and screened 20 patients, China. Int J Ophthalmol. 2014;7(3):557-562. eight of whom were suitable candidates for corneal trans- continued on next page plants; the transplants were subsequently performed for six patients. Dr. Waller joined the team on its 19th visit and

V100 No 5 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

Dr. Stephen Guy (left) and Dr. Jindal discuss ultrasound Dr. Waller (right) findings on a kidney and a local transplant patient. physician examine The local Guyanese a patient before radiologist (right) is surgery. Dr. Panchal.

performed the corneal transplants during the 20th visit. Oth- REFERENCES (CONTINUED) er members of the team continued their work with kidney 12. Gupta N, Vashist P, Tandon R, Gupta SK, Dwivedi transplantation and related procedures during these visits. S, Mani K. Prevalence of corneal diseases in the The six successful corneal transplants were performed rural Indian population: The Corneal Opacity Rural Epidemiological (CORE) Study. Br J Ophthalmol. within a week by the Guyanese surgeon under the super- 2015;99(2):147-152. vision of Dr. Waller. Donor age ranged from 26 to 75 years 13. Rapoza PA, West SK, Katala SJ, Munoz B, Taylor HR. old (mean 63 years). Endothelial cell count ranged between Etiology of corneal opacification in central Tanzania. 2,101 and 3,195 cells/mm2 (mean 2,509 cells/mm2). Recipi- Int Ophthalmol. 1993;17(1):47-51. ent age ranged from 20 to 72 years (mean 39 years). Most 14. Furtado JM, Lansingth VC, Carter MJ. Causes of blindness and visual impairment in Latin America. (83.3 percent) of the recipient population were male. The Surv Ophthalmol. 2012;57(2):149-177. diagnosis leading to corneal blindness included keratoco- 15. Goldschmidt P, Vanzzini ZV, Diaz Vargas LB. nus with apical scar (three patients), pseudophakic bullous Chlamydia trachomatis in the conjunctive of | 27 keratopathy (one patient), leucomatous corneal opacity (one children living in three rural areas in Mexico. Rev patient), and trauma (one patient). The operation performed Panam Salud Publica. 2007;22(1):29-34. 16. Koizumi IK, Medina NH, D’Amaral RK. Prevalence on all patients was penetrating keratoplasty. All patients had of trachoma in preschool and schoolchildren in the improvement in their vision postoperatively (see Table 2, city of Sao Paulo. Rev Saude Publica. 2005;39(6):937- page 26). No complications were noted, except in the case 942. of the patient with traumatic eye injury, who experienced 17. Paula JS, Medina NH, Cruz AA. Trachoma mild epithelial haze at six months’ follow-up. among the Yanomami Indians. Braz J Med Biol Res. 2002;35(10):1153-1157. Our work was made possible because of an intricate part- 18. Lucena AR, Velasko E, Cruz AA, Akaishi P. nership between the private and public sectors. In a devel- Epidemiology of trachoma in the village of oping country like Guyana, few patients could afford the Araripe plateau—Ceara State. Arq Bras Oftalmol. cost of corneal transplantation. The Guyanese government 2010;73(3):271-275. plays a significant role in facilitating physician licenses and 19. Niederkorn JY, Larkin DF. Immune privilege of corneal allografts. Ocult Immunol Inflamm. liability coverage, and importing generic medications, free 2010;18(3):162-171. of charge to the patients, while local medical staff identifies 20. The Collaborative Corneal Transplantation patients and provides pre- and postoperative care under the Studies Research Group. The Collaborative supervision of Dr. Waller in case of corneal transplants and Corneal Transplantation Studies. Arch Ophthalmol. Dr. Jindal in case of kidney transplants. Our team continues 1992;110(10):1392-1403. 21. Millman Research Report 2014. Available at: www. to advise Guyanese physicians via e-mails/Skype and tele- milliman.com/uploadedFiles/insight/Research/ phone calls on postoperative care. health-rr/1938HDP_20141230.pdf. Accessed February 11, 2015. 22. Writing Committee for the Cornea Donor Study Ensuring sustainability Research Group, Mannis MJ, Holland EJ. The effect of donor age on penetrating keratoplasty Conventionally, limited tissue availability and a lack of for endothelial disease: Graft survival after 10 trained personnel have made corneal transplants in devel- years in the Corneal Donor Study. Ophthalmology. oping countries unaffordable and inaccessible. A sustainable 2013;120(12):2419-2427. corneal transplant capacity in a developing country requires continued on next page

MAY 2015 BULLETIN American College of Surgeons CORNEAL TRANSPLANTS IN DEVELOPING COUNTRIES

REFERENCES (CONTINUED) skilled local surgeons, and our team engaged in teach- 23. The Lewin Group, Inc. The cost-benefit analysis of ing and supervising local surgeons. We also are working corneal transplant. Available at: www.restoresight.org/ with the government of Guyana to establish an eye bank wp-content/uploads/2014/03/Lewin-Study-Sept-2013. based on U.S. standards. pdf. Accessed January 4, 2015. 24. Campbell K. Six successful cornea transplants completed In addition, a waiting list is being generated so that at Balwant Singh Hospital 2014. iNews Guyana. Available corneas can be optimally allocated for transplantation. at: www.inewsguyana.com/six-successful-cornea- Two corneas that our team brought to Guyana from the transplants-completed-at-balwant-singh-hospital/. U.S. went unused as one patient who was screened in the Accessed February 8, 2015. initial visit declined surgery, and the other procedure was 25. Balwant Singh Hospital successfully performs six corneal transplant operations. Guyana Times. August 2, 2014. canceled because of the patient’s uncontrolled diabetes. Available at: www.guyanatimesgy.com/2014/08/02/ Care will be taken to avoid these situations in the future balwant-singh-hospital-successfully-performs-six-cornea- by creating a larger waiting list of suitable patients and transplant-operations/. Accessed March 19, 2015. by ensuring that local eye surgeons examine transplant 26. van den Biggelaar FJ, Cheng YY, Nuijts RM, et al. candidates at regular intervals to verify suitability for Economic evaluation of endothelial keratoplasty techniques and penetrating keratoplasty in the transplantation. At press time, the U.S. team’s next visit Netherlands. Am J Ophthalmol. 2012;154(2):272-281. was scheduled to take place in April 2015. 27. Roussy JP, Aubin MJ, Brunette I, Lachaine J. Cost of Patients, the government of Guyana, and the media 28 | corneal transplantation for the Quebec health care appreciate that U.S. surgeons have undertaken a com- system. Can J Ophthalmol. 2009;44(1):36-41. plex surgical procedure using corneas donated by U.S. 28. Tan TE, Peh GS, George BL. A cost-minimization patients as illustrated by positive reports in the Guyanese analysis of tissue-engineered constructs for corneal 24,25 endothelial transplantation. PloS One. 2014;9(6):1-9. press. Ultimately, we strive to ensure that corneal 29. Meyer D. The new challenge of corneal transplantation in transplants in Guyana involve appropriate and equitable South Africa. S Afr Med J. 2007;97(7):512. patient selection, well-trained and informed surgeons, 30. We Care India. Low Cost Lasik Eye Surgery. Available at: and meticulous follow-up care. ♦ www.wecareindia.com/eye-surgery/price-guide.html. Accessed on January 23rd, 2015. 31. Treatment Abroad. Compare the cost of cornea transplant abroad. Available at: www.treatmentabroad. Acknowledgements com/costs/eye-surgery/cornea-transplant. Accessed The authors would like to acknowledge the contributions March 19, 2015. made by the following individuals to both this article and the 32. Eye Bank Association of America. 2013 Eye Banking Statistical Report. Available at: www.restoresight.org/ corneal transplant program: George Subraj, philanthropist wp-content/uploads/2014/04/2013_Statistical_Report- and president, Zara Realty, Queens, NY, who funded the pro- FINAL.pdf. Accessed January 5, 2015. gram; the Government of Guyana for providing the use of fa- 33. Eye Bank Association of America. Available at: www. cilities and medications; the staff of Balwant Singh’s Hospital, restoresight.org/. Accessed January 12, 2015. Georgetown, Guyana, where the transplants were performed; 34. National Eye Bank of Sri Lanka. Available at: www. nationaleyebank.lk/AboutUs.php. Accessed February 10, and Neeraj Jain, MD, eye surgeon at Balwant Singh’s Hospital, 2015. for compiling the waiting list, follow-up data, and performing 35. Lions Eye Bank of Delaware Valley. Helping those who the corneal transplants under the supervision of Dr. Waller. need it most. forSight. Available at: www.lebdv.org/ images/stories/newsletters_annual-reports/2014 lebdv forsight.pdf. Accessed March 9, 2015. 36. San Diego Eye Bank. Available at: www.sdeb.org/. Disclaimer Accessed February 10, 2015. The views expressed in this article are those of the authors and 37. The Visionary. Available at: www.cornea.org/images/ do not reflect the official policy of the U.S. Department of the uploads/documents/Visionary_-_Summer_2013.pdf. Army, the U.S. Department of Defense, or the U.S. govern- Accessed February 6, 2015. ment. No financial conflict of interest exists.

V100 No 5 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

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AMERICAN COLLEGE OF SURGEONS FOUNDATION

AN ENDURING LEGACY

ANNUAL REPORT 2014

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

The American College of Surgeons (ACS) Foundation promotes voluntary philanthropy from Fellows and friends of the ACS. The generosity of donors allows the ACS Foundation to provide funding for ACS initiatives and its goals of improving surgical patient care and ensuring the professional standing of surgeons wherever they practice.

30 |

Doors of the J.B. Murphy Memorial Auditorium Building; its purchase was one of the first ACS projects supported by contributions from Fellows

V100 No 5 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

FROM THE PRESIDENT

hroughout the history of the American College of Surgeons (ACS), philanthropy has played an important role in shaping its narrative. From the start, Fellows have responded to the call for contributions, establishing many of the ACS benefits that we so greatly Tvalue. Each time you give, you are fulfilling this legacy of generosity started more than 100 years ago. Many of you—300 Fellows and organizations—supported the 1913 Legacy Campaign with extraordinary commitments, honoring those who came before us while providing for current needs and future generations.

The enriching portfolio of benefits that is offered by the ACS is only possible with the continued philanthropic support of the Fellowship. Dues revenue and industry contributions alone are insufficient to ensure the longevity and proliferation of many non-revenue programs. | 31

Your contributions to the Sustaining Fund directly support the future of surgery by underwriting Fellowship benefits, including scholarships, Operation Giving Back, patient education, lifelong learning, trauma education, research, the Surgeon Specific Registry, and other initiatives that do not generate revenue. Each gift makes an impact and helps ACS Fellows provide the finest care to surgical patients.

Thank you for answering the call to be part of this great ACS legacy and giving from love of your profession, your patients, and your American College of Surgeons.

Best,

David B. Hoyt, MD, FACS Executive Director, American College of Surgeons President, American College of Surgeons Foundation

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

AN ENDURING LEGACY—MADE POSSIBLE BY YOU

“I do believe that our legacy is important and that we have an opportunity every day to elevate our profession. This may seem somewhat idealistic to some, but for me, I see Foundation giving as my chance to fulfill the Pledge of Fellowship where it states that we as Fellows of the ACS will ‘cooperate in advancing the art and science of surgery.’ I want to support other young surgeons and surgeons in training, as we will always be strongest as a collective group continuing to expand opportunities.”

Dr. Jones —Mark A. Jones, MD, FACS

“I believe that the ACS Foundation is important to supporting and improving surgery. It’s a continued investment in the profession I remain passionate about.” —Sherry M. Wren, MD, FACS

32 | Dr. Wren

“As a subspecialty surgeon, I find the ACS educational benefits are superlative. Clinical Congress meeting courses always have something of interest for all surgeons. The Bulletin and JACS cover a wealth of surgical material and keep all of us abreast of the politics of health care, which affects all surgeons.

“We all give to philanthropic causes; the Foundation of the ACS is an extremely worthy cause and a way to support the future of

Dr. Atkinson surgery. After all, the ACS represents all of us.” —John L.D. Atkinson, MD, FACS

“We all are given many gifts, including our ability to operate and change our patients’ lives. We need to give back on many levels.” —Ruth L. Bush, MD, FACS

Dr. Bush V100 No 5 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

“It is my belief that the people who came before us provide the roadmap. It’s up to us to follow the roadmap and hopefully leave our footprints on it so that others can get to the place they want to go. That’s what giving to the College does. It leaves a footprint for others to follow.” —Idatonye I. Afonya, MD, FACS

Dr. Afonya and Mrs. Linda Afonya

“Supporting the ACS Foundation is just one way that I am able to give back to an organization that has given me so much. It’s my way of paying it forward as I continue to become increasingly involved in the ACS and look to support all of the young surgeons in training today. I believe it is critical to involve Resident Members | 33 and Associate Fellows today, as they will ultimately become the leaders of this unparalleled House of Surgery tomorrow.” —Brian J. Santin, MD, Associate Fellow

Dr. Santin and Dr. Crystal Santin

“The College is a top philanthropic priority of mine, as I have benefited enormously from my membership in the ACS. I have enjoyed innumerable educational opportunities and have especially enjoyed the fellowship with other College members. The ACS embodies all that I hold dear about the field of surgery—the noble intention to continuously improve the surgical care of patients, the educational mission, and the fellowship of surgeons.” —Kenneth W. Sharp, MD, FACS

Dr. Sharp and Mrs. Jane Sharp

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

LETTER FROM THE CHAIR

hat a remarkable year 2014 has been for philanthropy at the American College of Surgeons Foundation. As Chair, I am continually inspired when I witness a donor matching his or her philanthropic passion with a College program. Your generosity means so much to the Wsuccess of the College, and it is a great privilege to see the meaningful impact that philanthropy has on both the donor and the recipient. A tradition of the College since its inception in 1913, this spirit of giving has been particularly prevalent during the recent Centennial celebration through the 1913 Legacy Campaign. You and other donors responded so generously to the campaign, and it is with gratitude that we list each of you within the full report (available online at www.facs.org/about-acs/acs-foundation/about/ annual-report). The Foundation’s single beneficiary is the College, and its Sustaining Fund underwrites lifelong 34 | learning, quality initiatives, volunteerism, and other Fellowship benefits that cannot generate revenue.

You are an integral part of these important initiatives.

Equally important was the renewed energy that has invigorated the Foundation with the placement of new volunteers and Chapter Philanthropic Champions who were recruited to promote the campaign. I am delighted and grateful to have these enthusiastic ambassadors join the Foundation.

In total, more than $3.3 million in past and current philanthropic dollars were expended during the 2014 fiscal year. I hope you are proud to know that your gift is an investment in the surgical profession and in the care of patients.

Sincerely,

Amilu Stewart, MD, FACS Chair, American College of Surgeons Foundation

V100 No 5 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

2014 AT A GLANCE: GIVING REPORT

Fiscal year ending June 30, 2014 TOTAL DONATIONS AND COMMITMENTS: $2,227,454

TOTAL EXPECTANCIES (PLANNED GIFTS): $210,000

TOTAL EXPENDITURES FROM CURRENT DONATIONS AND INVESTED FUNDS: $3,303,067

| 35

Scholarships: $1,579,528

Archives, Patient Education, Operation Giving Back, Trauma Education and Research, and Other Nonrevenue Programs: $1,535,802

Lectureships and Other Awards: $187,737

Made Possible by You!

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

Developing innovative education resources Improving quality of care Fostering tomorrow’s surgical leaders Promoting the image of the profession Bringing surgeons together Outreach through surgical volunteerism

The ACS Foundation Board of Directors is pleased to announce that more than $3 million in donations and commitments has been contributed to these ACS mission-critical activities by generous participants in the 1913 Legacy Campaign. Beginning in the Centennial celebration year of the College, the purpose of this campaign was to honor the historic milestone and secure transformative

36 | gifts for current needs and emerging opportunities.

Campaign gifts have been directly invested in the three pillars of the College’s mission: The Surgeon, The Profession, and The Societal Good.

Thank you to all the Fellows and friends who answered the call to invest in the future of the College and the surgical profession.

ACS Operation Giving Back delegation members Adrienne Fueg, MD, FACS (front left), and Joelle Pierre, MD (front right), with women in Sohna, India

V100 No 5 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

1913 Legacy Campaign Donors (as of December 2014)

LEADERSHIP GIFT DONORS Ching Ho, MD, PhD, FACS Dr.† and Mrs. Frank T. Padberg, Sr. Dr. and Mrs. George W. Holcomb III Danny and Paula Robinette Tyler and Mary Hughes Dr. Pon Satitpunwaycha Rayford Scott Jones and Christine Stacy William Sternfeld, MD, FACS Drs. Samuel E. and Annette V. Landrum Drs. Lisa and Scott Langenburg Organizations Keith D. Lillemoe, MD, FACS Applied Medical Technology, Inc. (AMT) Dr. and Mrs. Richard A. Lynn Coloplast Corp. Drs. Lloyd D. and Eleanor MacLean Smith & Nephew Ron and Lauren Maier Dr. and Mrs. Kenneth L. Mattox CHAMPION GIFT DONORS Dr. Mary J. Milroy Patricia R. and W. Gerald Austen, MD, FACS Dr. and Mrs. Ralph R. Ocampo Dr. and Mrs. H. Randolph Bailey Dr. I. Benjamin Paz Dr. and Mrs. Raghuvir B. Gelot Carlos and Kelly Pellegrini Dr. and Mrs. Paul H. Jordan, Jr. Martine B. and William P. Reed Dr. Mary H. McGrath Dr. and Mrs. J. David Richardson Drs. Samuel P. and Leaena N. Reyes Bryan and Linda Richmond Dr. and Mrs. Andrew L. Warshaw Joseph Victor Sakran, MD, MPH Terry Sarantou, MD, FACS Organizations Dr. and Mrs. William F. Sasser Amgen Inc. Drs. Pamela P. Scott and Razaullah A. Khwaja Dr. and Mrs. Edward L. Seljeskog DISTINGUISHED GIFT DONORS Dr. Kenneth W. Sharp and Mrs. Jane E. Sharp John L.D. Atkinson, MD, FACS Dr. Fawzi Soliman Dr. and Mrs. Choong H. Baick David A. Spain, MD, FACS Dr. William A. Bernie Drs. Steven C. Stain and Hyacinth R. C. Mason James G. and Cynthia G. Chandler Michael J. Sutherland, MD, FACS Dr. Mehmet Ali Haberal S. Rob Todd, MD, FACS | 37 Dr. and Mrs. Julius H. Jacobson II Dr. Patricia L. Turner Dr. Frank G. Opelka Dr. and Mrs. Leonard J. Weireter, Jr. Dr. and Mrs. Richard B. Reiling Dr. Sherry M. Wren Drs. Thomas R.† and Nona C. Russell Dr. Michael J. Zinner Dr. Amilu Stewart Organizations Organizations ACS Section on Oral and Maxillofacial Surgery Olympus Corporation of the Americas Jeannette and H. Peter Kriendler Charitable Trust USU Surgical Associates/Henry Jackson Foundation Pacific Coast Surgical Association for the Advancement of Military Medicine Region VII Committee on Trauma Trauma and Critical Care Foundation MAJOR GIFT DONORS Dr. Suresh and Mrs. Deborah Agarwal SPECIAL GIFTS DONORS Drs. M. T. and A. J. Amirana Dr. William W. Allen Dr. Nicole Baril Dr. Manjit Singh Bains Dr. Barbara L. Bass Dr. Megan K. Baker Dr. and Mrs. R. Daniel Beauchamp Dr. L. D. Britt/Eastern Virginia Medical School Kevin E. and Patti J. L. Behrns Dr. Ruth L. Bush and Mr. William A. Fife IV Dr. Peter and Peggy E. Bistolarides Joseph B. Cofer, MD, FACS William Cioffi, MD, FACS, Edward E. Cornwell III, MD, FACS and Theresa Graves, MD, FACS Dr. and Mrs. Christopher J. Daly Dr. Alexander W. Clowes Dr. and Mrs. Timothy J. Eberlein Arthur Cooper, MD, FACS Dr. and Mrs. Eric W. Fonkalsrud Chris Cribari, MD, FACS Drs. Roger S. Foster, Jr., and Baiba J. Grube E. Christopher Ellison, MD, FACS, Dr. and Mrs. Jay L. Grosfeld and Mary Pat Borgess, MD Dr. Sharon M. Henry Dr. and Mrs. Donald E. Fry Jonathan and Jo Carol Hiatt Kirby R. Gross, COL MC U.S. Army Dr. and Mrs. Jamal J. Hoballah Dr. B. J. Hancock Dr. and Mrs. Abdul Haye Khan Mary T. Hawn, MD, FACS, and Eben L. Rosenthal, Dr. and Mrs. LaSalle D. Leffall, Jr. MD, FACS Dr. Susan M. L. Lim

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

Dr. and Mrs. Charles E. Lucas Dr. David R. Farley Charles and Ruth Mabry Dr. Diana L. Farmer Dr. Jane E. Mendez Dr. Francis D. Ferdinand Dr. and Mrs. J. Wayne Meredith Dr. James W. Fleshman, Jr. Dr. David S. Mulder Gary S. Flom, MD, FACS, FAAP Patricia J. Numann, MD, FACS Dr. Henri R. Ford Dr. Christopher K. Payne Dr. and Mrs. Kenneth A. Forde Dr. and Mrs. Ole A. Peloso Dr. Julie A. Freischlag Dr. and Mrs. Clifford M. Phibbs, Jr. Dr. John Q. Gallagher Dr. and Mrs. John T. Preskitt Dr. Joseph T. Gallagher Antonio and Vivian Robles Nancy L. Gantt, MD, FACS, and Dr. David A. and Kathleen Sweetman Rothenberger Raymond J. Boniface, MD, FACS Shelton Viney, MD, FACS Dr. and Mrs. Stuart A. George Laura E. Witherspoon, MD, FACS, Dr. Gregory M. Georgiadis and Harold D. Head, MD, FACS Dr. Ghali E. Ghali Dr. Karanbir S. Gill Organizations Dr. Amy J. Goldberg Dana Foundation Dr. Michael A. Golden Eastern Virginia Medical School Dr. Thomas H. Gouge Southern California ACS Chapter Dr. and Mrs. David E. Grambort Dr. and Mrs. Frederick Leslie Greene CAMPAIGN GIFT DONORS Dr. Ronald I. Gross Dr. David B. Adams †Dr. Margaret Hanlon Dr. Jose I. Almeida Dr. Sara L. Hartsaw Peter and Berit Andreone Charitable Fund of the Sioux Dr. Syed Hashmi Falls Area Community Foundation Dr. Enrique Hernandez Dr. Nancy L. Ascher Dr. David B. and Beth Hoyt Dr. and Mrs. John A. Aucar Dr. Roy E. Hutchison Harriet W. and Arthur H. Aufses, Jr., MD, FACS Dr. and Mrs. J. Bruce Jackson Robert R. and Janet Bahnson Dr. Lenworth M. Jacobs, Jr. Dr. and Mrs. Charles M. Balch Dr. Judith M. Johnson 38 | Dr. Kelly L. Banks Dr. Mark A. Jones Dr. Gerald J. Bechamps Danielle A. Katz, MD, FACS Dr. and Mrs. Robert E. Berry Dr. Harold L. Kent Kirby and Lynn Bland Dr. and Mrs. Norman M. Kenyon Dr. Ewing T. Boles, Jr. Jack and Elaine Kilkenny Daniel J. Bonville, MD, FACS Dr. Donald H. Klotz, Jr. Dr. Robert Borrego Dr. Shanu N. Kothari Dr. Marilyn J. Borst Dr. Mark Kuhnke Dr. Mary-Margaret Brandt Dr. Albert Kwan Dr. Karen J. Brasel Dr. Lorrie A. Langdale Dr. R. Phillip Burns Drs. Max and Sue Langham Dr. and Mrs. Reginald A. Burton Dr. James W. Large Dr. Patricia M. Byers Dr. and Mrs. Edward R. Laws Miguel A. Cainzos Dr. Eli N. Lerner Mr. Richard Campbell Dr. L. Scott Levin Dr. Philip R. Caropreso Erik J. Lichtenberger, MD, FACS Dr. Debi P. Chaudhuri and Mrs. Mithu Chaudhuri Dr. Thomas C. Litton Dr. Amalia L. Cochran Dr. Luis E. Llerena Dr. and Mrs. Joseph A. Corrado Dr. Charles W. Logan and Joyce W. Logan Dr. Myriam J. Curet Dr. and Mrs. Lawrence Lottenberg Drs. Alice and Edward Dachowski Dr. Marcel C. C. Machado Barbara L. Dean Dr. and Mrs. Mark A. Malangoni Dr. James C. Denneny III Dr. Matthew B. Martin Dr. Daniel L. Dent John H. Matsuura, MD, FACS Dr. Hector A. DePaz Dr. and Mrs. Arthur S. McFee Craig S. Derkay, MD, FACS LaMar and Julia McGinnis Therese M. Duane, MD, FACS, FCCM Jaime H. Membreno, MD, FACS Ernest Dunn, MD, FACS Anthony and Marian Meyer Dr. Margaret M. Dunn Dr. Fabrizio Michelassi Drs. A. Brent and Sarita Eastman Joseph P. Minei, MD, FACS Dr. James K. Elsey Dr. and Mrs. Raymond F. Morgan Dr. Douglas W. Fain Kenric M. Murayama, MD, FACS

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Dr. and Mrs. David L. Nahrwold Everett D and Geneva V Sugarbaker Foundation Deepak G. Nair, MD, FACS Foundation of the American Society Don and Natalie Nakayama of Transplant Surgeons Dr. Lena M. Napolitano Francis Beidler Foundation Drs. Leigh A. Neumayer and David A. Bull Illinois ACS Chapter Dr. Juan J. Nogueras Japan ACS Chapter Dr. Michael S. Nussbaum Jim Henry, Inc. Drs. Donna M. Pietrocola and Steven Pinheiro Massachusetts ACS Chapter Alan B. Pillersdorf, MD, FACS Oral and Maxillofacial Surgery Associates Dr. Thomas E. Reeve III South Carolina ACS Chapter George F. Reinhardt, MD, FACS Southwestern Surgical Congress Dr. and Mrs. Layton F. Rikkers The Surgical Section of the National Dr. Geoffrey L. Risley Medical Association Dr. James F. Ross Western Thoracic Surgical Association Dr. Sharona B. Ross Dr. Chad A. Rubin SPECIAL THANKS TO Dr. Marc S. Rubin THE 1913 LEGACY CAMPAIGN Dr. Valerie W. Rusch NATIONAL VOLUNTEER COUNCIL Dr. Hilary A. Sanfey Drs. Brian and Crystal Santin Suresh Agarwal, MD, FACS Dr. Michael D. Sarap John L.D. Atkinson, MD, FACS Mark Savarise, MD, FACS Charles M. Balch, MD, FACS Dr. Marshall Z. Schwartz Ruth L. Bush, MD, FACS Dr. and Mrs. M. Michael Shabot James G. Chandler, MD, FACS Dr. and Mrs. Wihbi A. Shu’Ayb William G. Cioffi, Jr., MD, FACS Drs. Laurel and Scott Soot Christopher J. Daly, MD, FACS Jennifer Starkey Ms. Barbara L. Dean Dr. Michael R. Starks Daniel L. Dent, MD, FACS Dr. Steven M. Steinberg E. Christopher Ellison, MD, FACS Dr. Keith R. Stephenson James K. Elsey, MD, FACS Dr. Ronald M. Stewart James W. Fleshman, Jr., MD, FACS Dr. and Mrs. Robert P. Sticca Donald E. Fry, MD, FACS | 39 Beth H. Sutton, MD, FACS Enrique Hernandez, MD, FACS Dr. Danny M. Takanishi, Jr. David B. Hoyt, MD, FACS Spence M. Taylor, MD, FACS Tyler G. Hughes, Sr., MD, FACS Dr. Joseph J. Tepas III Mark Kuhnke, MD, FACS Dr. and Mrs. Gregory A. Timberlake Charles A. Lucas, MD, FACS Dr. and Mrs. Gary L. Timmerman Richard A. Lynn, MD, FACS Dr. Renam Catharina Tinoco LaMar S. McGinnis, Jr., MD, FACS Gail T. Tominaga, MD, FACS Mary H. McGrath, MD, MPH, FACS Dr. and Mrs. Courtney M. Townsend, Jr. Fabrizio Michelassi, MD, FACS Dr. Jon A. van Heerden Patricia J. Numann, MD, FACS Dr. and Mrs. Mark C. Weissler Richard B. Reiling, MD, FACS Dr. Ronald D. Wenger Layton F. Rikkers, MD, FACS Dr. Cheryl A. Wesen Danny R. Robinette, MD, FACS Steven D. Wexner, MD, PhD(Hon), FACS, Hilary Sanfey, MB, BCh, FACS FRCS, FRCSEd William F. Sasser, MD, FACS Dr. and Mrs. William E. Wheeler Kenneth W. Sharp, MD, FACS Dr. and Mrs. Lorin D. Whittaker, Jr. David A. Spain, MD, FACS Dr. Mallory Williams Steven C. Stain, MD, FACS Dr. John F. Wolz Steven M. Steinberg, MD, FACS Dr. Randy J. Woods Amilu Stewart, MD, FACS Dr. Jack Zeltzer Ronald M. Stewart, MD, FACS Sheila and Jay Zwischenberger Jon A. van Heerden, MB, ChB, FACS, FRCS †Deceased Andrew L. Warshaw, MD, FACS

Organizations American Association for Thoracic Surgery American Society of Breast Surgeons Arizona ACS Chapter Association of Women Surgeons Central Surgical Association

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

YOUR SUPPORT IN ACTION: SCHOLARSHIPS, AWARDS, AND FELLOWSHIPS

The scholarship and fellowship awards, a philanthropic tradition of the American College of Surgeons, play an important role in shaping future surgical leaders and researchers. In the 2014 fiscal year, nearly $1.6 million was provided to surgeons through a variety of awards, all supported through the generous contributions of friends and Fellows. Resident Research Scholarships Faculty Research Fellowships Clinical Scholar in Residence Fellowships International Guest Scholarships Special Traveling Fellowships Leadership Training Scholarships

“Obtaining the American College of Surgeons Resident Research Award has been a valuable experience from start to finish. . . . With the important lessons I have learned during these two years, relating both directly to the laboratory as well as to my future career, I believe that I have taken an important step ahead in starting a career in academic surgery.” —John R. Klune, MD

“It was indeed an honor to be awarded the Claude H. 40 | Organ, Jr., MD, FACS, Memorial Traveling Fellowship this year. Over the years, my interests in academic surgery have widened to have a focus on leadership and on global health. This award allowed me to marry both interests in a capstone experience that I will always remember.” —Anees B. Chagpar, MD, FACS

Dr. Chagpar (right)

“The ACS Clinical Congress was a superior educational and interactive event for me. I am extremely grateful to the Scholarship Committee for awarding me this high honor and am indebted to the late Dr. Oweida and his widow, Mrs. Oweida, for providing this great experience for rural surgeons such as myself. In fact, I have already implemented some of what I learned at the ACS meeting in my own practice. This experience has given me a renewed enthusiasm and higher level of expertise for caring for my patients as I continue to practice rural surgery in Pendleton, OR.” —John M. McBee, MD, FACS Dr. McBee (right) accepting his fellowship award from ACS Immediate Past-President Carlos A. Pellegrini, MD, FACS

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Pon Satitpunwaycha, MD, FACS, Community Surgeon Travel Awards At the 2014 ACS Clinical Congress, four surgeons from various countries, including Iraq and Nigeria, benefited from the generosity of Dr. Pon Satitpunwaycha. His reason for this extraordinary philanthropy is clear: “I am grateful for the opportunity this country has given me. At this point in my life, I feel obliged to give back. I hope this fund leads to a better understanding and friendship between countries.” Dr. Pon’s gift also funded two additional traveling fellowships and support of the annual scholarships luncheon at the ACS Clinical Congress.

“It was a wonderful event in my life to be selected as one of the surgeons in the world to receive one of the 2014 Dr. Pon Community Surgeon Travel Awards. It is an honor to get this privilege from the largest organization for surgeons in the world, and it is a distinguished point in my professional life. It is my duty to give more commitment for patient care, education, and research.” —Dr. Haidar M. Muhssein, Iraq, Pediatric Surgery

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International Guest Scholarship recipients, including Pon Satitpunwaycha, MD, FACS, Community Surgeon Travel Award recipients

The Jeannette and H. Peter Kriendler Charitable Trust The Jeannette and H. Peter Kriendler Charitable Trust has supported the College since 2004 with grants dedicated to training young surgeons through the Resident and Associate Society of the American College of Surgeons (RAS-ACS) Leadership Scholarship Award. Three scholarships are awarded to Resident Members and Associate Fellows, covering tuition, travel, and subsistence to attend one of the following ACS leadership courses: • Outcomes Research Course • Leadership and Advocacy Summit • Residents as Teachers and Leaders

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

Murray F. Brennan, MD, FACS, International Guest Scholarship The College’s International Relations Committee (IRC), in partnership with the ACS Foundation, led the effort of the scholarship initiative in honor of Murray F. Brennan, MD, FACS. An esteemed Fellow of the ACS since 1977, Dr. Brennan has been an advocate for international engagement as a member of the IRC. The Murray F. Brennan, MD, FACS, International Guest Scholarship recognizes its namesake for his enduring collegiality and the value of investing in quality patient care wherever surgeons practice.

“Altogether the 2014 Murray Brennan International Guest Scholarship was a great experience for me that brought up sustainable new perspectives of various aspects of surgery. I thank the American College of Surgeons for selecting me for this once-in-a-lifetime experience.” – Roland S. Croner, MD, FACS, of Erlangen, Germany, the 2014 Brennan Scholar

Thomas R. Russell, MD, FACS, Faculty Research Fellowship After serving the American College of Surgeons as Executive Director from January 2000 to January 2010, Thomas R. Russell, MD, FACS, dedicated the next three years to the philanthropic endeavors of the College as the Chair of the ACS Foundation. Dr. Russell had long been a passionate supporter of continuing and enhancing a culture of philanthropy at the ACS and was a natural fit as Chair. With his heartfelt advocacy, he inspired many Fellows to join him in making a meaningful contribution to the ACS Foundation.

The ACS Foundation Board of Directors established the Thomas 42 | R. Russell, MD, FACS, Faculty Research Fellowship to honor Dr. Russell’s advocacy for increased scholarly opportunities at the College. More than $250,000 was given by generous Fellows and friends as a tribute to Dr. Russell’s service to ACS and the surgical profession. The recipients will be outstanding young surgeons who desire to pursue professional development and/or promising research initiatives.

Dr. Russell’s legacy will continue on through the many young surgeons who carry out important work through the support of his namesake scholarship. His imprint will permanently remain on the College and ACS Foundation.

A full memoriam and Thomas R. Russell, MD, FACS, Faculty Dr. Russell and Dr. Nona Russell Research Fellowship donor listing are available on the ACS Foundation’s website (www.facs.org/acsfoundation), as is the announcement of the first Russell Scholar.

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SUPPORT FOR SURGEONS

Advanced Trauma Life Support® In 2014, donations to the Trauma Education Fund supported the development of the Advanced Trauma Life Support® (ATLS®) programs in the Republic of Georgia and Mongolia. The Republic of Georgia held its inaugural ATLS course, training 15 physicians in the Student Course and 10 physicians in the Instructor Course. Also, training materials were translated in preparation for the first ATLS training course in Mongolia, which will take place in the fall of 2015. Groundwork for Ghana, Bangladesh, and El Salvador has also begun.

Republic of Georgia

Rural Surgery Initiative The Nora Institute Advanced Skills Course for Rural Surgeons brings together rural surgeons through- out the U.S. and provides them with expert mentoring in a variety of disciplines. The course uses a blended learning format that consists of an e-learning component for knowledge acquisition followed by a hands-on mentored skills session. Amy Halverson, MD, FACS, and a team of rural surgeons and adult | 43 learning experts have developed 11 distinct learning modules.

The 2014 Nora Institute Advanced Skills Course for Rural Surgeons took place on October 25 in San Francisco, CA, in conjunction with the ACS Clinical Congress. This course welcomed 38 participants, the highest enrollment in a Nora Institute skills course to date.

AJCC Cancer Staging Manual The American Joint Committee on Cancer (AJCC) formulates and publishes systems of classification of cancer, including staging and end-results reporting, that will be acceptable to, and used by, the medical profession for selecting the most effective treatment, determining the prognosis, and continuing the evaluation of cancer control measures. The AJCC is composed of 20 member organizations, and its activities are administered by the American College of Surgeons.

Considered by many to be the gold standard reference for cancer staging, the AJCC Cancer Staging Manual is the resource used by physicians and health care professionals throughout the world to facilitate the uniform description and reporting of neoplastic diseases. The 8th edition of the AJCC manual will define the stratification criteria for the design and interpretation of cancer clinical trials involving adjuvant and neo-adjuvant therapies for all forms of cancer. It will incorporate advances made in cancer research, staging, diagnosis, and treatment since the seventh edition was published in 2009 and will be in effect for all cancer cases recorded on or after January 1, 2017. The manual will be self-published in both print and electronic formats.

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

HONORING LEADERSHIP

The Jameson L. Chassin, MD, FACS, Award for Professionalism in General Surgery Established to honor the life and career of Jameson L. Chassin, MD, FACS, this award is annually presented to young surgeons who are currently in a general surgery residency. The 2014 recipient is Katie White Russell, MD, chief resident in general surgery at the University of Utah.

Dr. Russell (center, holding award)

44 | The Joan L. and Julius H. Jacobson II Promising Investigator Award For a decade, the Joan L. and Julius H. Jacobson II Promising Investigator Award has recognized outstanding surgeons engaging in research, advancing the art and science of surgery, and demonstrating early promise of significant contribution to the practice of surgery and the safety of surgical patients. The award is supported through a generous endowed fund established by Dr. and Mrs. Jacobson and administered by the ACS Surgical Research Committee.

Olga M. Jonasson, MD, FACS, Lectureship Using the proceeds from an endowment established to honor the life and leadership of Dr. Jonasson, the 2014 Olga M. Jonasson Lecture was presented by Barbara L. Bass, MD, FACS.

The ACS Women in Surgery Committee, the friends and colleagues of Olga Jonasson, and women in surgery throughout the country established this lecture in 2007 to honor the memory of Olga M. Jonasson, MD, FACS, who was a leader in academic surgery, exemplified by her becoming the first woman chair of academic surgery in U.S. history. She was a devoted teacher and mentor to countless numbers of surgeons, both men and women.

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THE SUSTAINING FUND

Gifts made to the ACS Sustaining Fund directly support the future of the surgical profession by funding education and research. The purpose of these unrestricted funds is to ensure stability and advancement of the College’s mission and provide a source of internal capital for College priorities. The Sustaining Fund supports program activities that do not have the ability to produce revenue. Examples of mission-critical activities supported through the Sustaining Fund include the Archives, Patient Education, Scholarships and Fellowships, and Operation Giving Back.

Operation Giving Back Operation Giving Back (OGB) continues to pursue its mission to recognize, connect, support, enable, and celebrate surgeons committed to humanitarian outreach. The 2014 Clinical Congress International Surgery track and the Surgical Humanitarian Outreach track included a skills course for the international volunteer surgeon as well as panel sessions.

Girma Tefera, MD, FACS, joined the staff of the ACS Division of Member Services as the new Medical Director of the OGB program. The recipient of the Pfizer/ACS Surgical Volunteerism Award in 2011, Dr. Tefera is professor of surgery, department of surgery, University of Wisconsin, Madison. In addition, he is vice-chair, division of vascular surgery, and chief of vascular surgery, Middleton Veteran Affairs Hospital, in Madison. In his new role with the OGB program, Dr. Tefera will develop and lead ACS Clinical Congress | 45 programs in global surgery, coordinate the College’s response to disasters worldwide, develop new programs and opportunities for surgeon volunteers, communicate the work of OGB, and increase College participation and recognition among other similar global organizations. He also will oversee a redesign of the OGB website to match members’ needs with volunteer opportunities. Dr. Tefera Dr. Tefera stated that he looks forward to partnering with individual ACS members, ACS committees, nongovernment organizations, and government agencies. “In the developing world, trauma and noncommunicable diseases, particularly cancer, have reached epidemic proportions. Trauma will be the third leading cause of death in most sub-Saharan countries. I believe the Committee on Trauma and the Commission on Cancer can play a major role in helping to build systems and train the health care workforce that is desperately needed,” he said. For more information about the OGB program, visit www.operationgivingback.facs.org.

Patient Education A new initiative to improve outcomes for patients requiring complex wound management was recently announced by the Surgical Patient Education Program of the ACS Division of Education. The ACS will release a new structured teaching and verification program that uses engaging media and self-assessment checklists to educate surgical patients and their families about delivering self-care for wound conditions. An estimated 60 percent of wounds managed in the home occur in patients following their discharge after surgical treatment, and the ACS program will address a critical gap in the availability of standardized patient education resources.

MAY 2015 BULLETIN American College of Surgeons ACS FOUNDATION ANNUAL REPORT

HONORING GENEROSITY

Distinguished Philanthropist Award The American College of Surgeons Foundation proudly acknowledges the philanthropy of individuals who have distinguished themselves through their extraordinary investment in the mission of the American College of Surgeons. We are pleased to honor them with the Distinguished Philanthropist Award.

Recipients Patricia R. and W. Gerald Austen, MD, FACS (2014) Dr. Elias S. Hanna (2013) Dr. Murray F. Brennan (2012) Drs. Thomas R.† and Nona C. Russell (2011) Dr. and Mrs. Norman M. Kenyon (2010) Dr. and Mrs. Richard B. Reiling (2009) †Dr. Paul F. Nora (2008) †Dr. and Mrs. Maurice J. Jurkiewicz (2006) Dr. Robert W. Hobson II† and Mrs. Joan P. Hobson (2005) †Drs. C. Rollins and Margaret H. Hanlon (2004) †Dr. William W. Kridelbaugh (2003) Dr. and Mrs. Robert E. Berry (2002) Patricia R. and W. Gerald Austen, MD, FACS, 2014 Distinguished Philanthropists Dr. Pon Satitpunwaycha (2001)

46 | Dr. and Mrs. Paul H. Jordan, Jr. (1999) Dr. and Mrs. LaSalle D. Leffall, Jr. (1998) “Whether you wish to designate a specific program Dr. and Mrs.† Eric Lincke (1997) or give to the Sustaining Fund, your gift will be an Dr. and Mrs. Neil C. Clements (1996) investment in surgical innovation and the surgical Dr.† and Mrs. Scott W. Woods (1995) leaders of tomorrow. The American College of The Abdol Islami Family and Foundation (1994) Surgeons plays a distinctive leadership role in Dr. Julius H. Jacobson II (1993) promoting quality for our surgical patients and †Dr. Oliver H. Beahrs (1992) The Clowes Family and The Clowes Fund (1991) providing lifelong education experiences for our †Dr. John Conley (1990) contemporaries and our successors. So much was †Dr. Armand Hammer (1989) accomplished in the College’s first century, and we are encouraged to know that its mission and values †Deceased will endure into the next 100 years. We are so proud to be a part of the ACS legacy and its future success.” —Patricia R. and W. Gerald Austen, MD, FACS

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THE MAYNE HERITAGE SOCIETY

Membership in the Mayne Heritage Society, named in honor of the College’s first planned gift donor, Earl Mayne, MD, FACS, recognizes Fellows who have provided a bequest or other “planned” gift of any size to the College MHS through their estate plan. For those Fellows who believe that the future of MAYNE HERITAGE surgery and the continued vitality of the American College of Surgeons are SOCIETY intertwined, an estate gift is an ideal form of investment.

†Dr. William W. Allen †Dr. Mary L. McKenzie Kathryn and French Anderson The Estate of Harold H. Metz, MD, FACS Dr. William A. Bernie †Dr. Alvin W. Mooney James G. and Cynthia G. Chandler Dr. William R. Muir Dr. and Mrs. Neil C. Clements Dr. and Mrs. Henry A. Norum Dr. Amalia L. Cochran Dr. Patricia J. Numann Dr. Benjamin L. Crue, Jr. Dr. Frank G. Opelka Dr. and Mrs. Martin L. Dalton, Jr. Dr.† and Mrs. Frank T. Padberg, Sr. Gary S. Flom, MD, FACS, FAAP †Dr. Frederick W. Plugge IV Dr. and Mrs. Henry Gans Dr. and Mrs. Stuart M. Poticha Dr. and Mrs. David E. Grambort Dr. and Mrs. Richard B. Reiling †Dr. Wilfred Guerra Danny and Paula Robinette Dr. and Mrs. Peter S. Hedberg Antonio and Vivian Robles Dr.† and Mrs. Robert W. Hobson II Dr. and Mrs. Martin C. Robson | 47 Dr. Robert T. J. Holl-Allen Drs. Thomas R.† and Nona C. Russell Mary and John Iacuzzo, MD, FACS Dr. and Mrs. Russell L. R. Ryan Dr. and Mrs. Paul H. Jordan, Jr. Dr. and Mrs. William F. Sasser †Dr. and Mrs. M. J. Jurkiewicz Dr. and Mrs. Paul R. Schloerb The Estate of Samuel Kantor, MD, FACS Drs. Pamela P. Scott and Razaullah A. Khwaja The Estate of Harry E. Keig, MD, FACS Dr. and Mrs. Andrew G. Sharf Dr. and Mrs. Norman M. Kenyon William Sternfeld, MD, FACS †Dr. William W. Kridelbaugh Dr. Amilu Stewart Yeu-Tsu Margaret Lee, MD, FACS Dr. Hugh H. Trout III Dr. and Mrs. LaSalle D. Leffall, Jr. †Dr. and Mrs. Irving W. Varley Dr.† and Mrs. Joseph H. Lesser †Dr. Arie D. Verhagen Dr. and Mrs.† Eric T. Lincke Dr.† and Mrs. Alexander J. Walt Dr. and Mrs. Richard A. Lynn Dr. and Mrs. W. Merle Warman Dr. Marcel C. C. Machado Dr. and Mrs. Andrew L. Warshaw Dr. and Mrs. James V. Maloney, Jr. The Estate of Claude E. Welch, MD, FACS †Dr. Hector and Mrs. Ruth Marin Dr. and Mrs. David P. Winchester Richard W. and Pennie B. Martin †Dr. A. Stark Wolkoff The Estate of Dr. Earl H. Mayne, MD, FACS Dr.† and Mrs. Scott W. Woods LaMar and Julia McGinnis †Deceased

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Support Your American College of Surgeons

WAYS TO GIVE Becoming a philanthropic partner of the American College of Surgeons is one of the best ways to make a lasting mark on the profession. You can donate to the Sustaining Fund, which provides funding for current needs within nonrevenue programs, or you can designate your gift to a specific College program, such as Scholarships, Trauma, Cancer, or Operation Giving Back.

Annual Gifts You can donate online at www.facs.org/about-acs/acs-foundation or through the mail by check or money order, payable to the following:

American College of Surgeons Foundation 633 N. Saint Clair St. Chicago, IL 60611-3211

The Fellows Leadership Society Join a philanthropic community of generous supporters who invest in optimal care for patients and the surgical profession. The major gift society of the ACS Foundation, the Fellows Leadership Society offers increased donor recognition, an invitation to an annual luncheon, and use of the hospitality center during 48 | the ACS Clinical Congress. The entry level is $1,000 per year; a commitment of $10,000 or more will provide additional benefits and can be contributed in multi-year installments.

Appreciated Securities Gifts of appreciated stock can offer significant tax savings. Contact your broker, and provide the required instructions authorizing the transfer of stock to the American College of Surgeons. Call the ACS Foundation at 312-202-5338 for transfer instructions.

Planned Gifts Did you know there are many ways to give to the ACS Foundation besides writing a check? With a little planning, you can include a gift to us within your overall estate or financial plans. These types of gifts are known as “planned gifts,” and they often provide you with two main benefits:

• Your gift is generally deferred until after your lifetime, so your current income is not affected. • With many planned gifts, you have the right to change your mind at any time throughout your lifetime, if necessary.

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The ACS Foundation staff would be honored to discuss a possible deferred gift with you. There are a number of giving vehicles you may consider, including a charitable gift annuity, a retirement plan, and insurance.

The easiest way, though, is to name the ACS as a beneficiary by including the official legal bequest language for the American College of Surgeons Foundation:

“I give and bequeath to the ACS Foundation, Chicago, Illinois, the (sum of $_____or _____ percent of the rest, residue, and remainder of my estate). This gift shall be used to further the educational mission of ACS in such a manner as the Board of Regents of the College may direct.”

Please contact us: American College of Surgeons Foundation 633 N. Saint Clair St. Chicago, IL 60611-3211 312-202-5338 [email protected] www.facs.org/about-acs/acs-foundation

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The American College of Surgeons Foundation is recognized as a tax-exempt, not-for-profit organization. Contributions to the American College of Surgeons Foundation are tax-deductible to the extent allowed by law.

MAY 2015 BULLETIN American College of Surgeons Dr. and Mrs. Julius H. Jacobson II—Dr. and Mrs.† Eric T. Lincke—Dr.† and Mrs. Robert W. Hobson II—Patri- cia R. and W. Gerald Austen, MD, FACS—Dr. and Mrs. Neil C. Clements—Dr. and Mrs. Raghuvir B. Gelot— Dr. and Mrs. David E. Grambort—Dr. EliasACS FOUNDATION S. Hanna—†Dr. ANNUAL Thomas REPORT G. Howrigan—Suzanne Nora Johnson & David G. Johnson Foundation—Dr. and Mrs. Paul H. Jordan, Jr.—Dr. and Mrs. LaSalle D. Leffall, Jr.—Dr. and Mrs. Kenneth L. Mattox—Mrs. Elizabeth L. Organ—Dr.† and Mrs. Frank T. Padberg, Sr.—Dr. Christopher K. Payne—Dr. and Mrs. Richard B. Reiling—Danny and Paula Robinette—Antonio andVivian Robles—Drs. Thomas R.† and Nona C. Russell—William Sternfeld, MD, FACS—Dr. Amilu Stewart—Dr. and Mrs. Andrew L. Warshaw—Prof. and Mrs. John Wong—James G. and Cynthia G. Chandler—Jeannette & H. Peter Kriendler Charitable Trust—Yeu-Tsu Margaret Lee, MD, FACS—Dr. Mary H. McGrath—Dr. and Mrs. Henry A. No- rum—Drs. Samuel P. and Leaena N. Reyes—Dr. and Mrs. Choong H. Baick—Dr. and Mrs. H. Randolph Bai- ley—Dr. and Mrs. Norman M. Kenyon—Dr. and Mrs. Charles E. Lucas—Jim and Linda Robinson Foundation, Inc.—Dr. and Mrs. Martin C. Robson—Dr. and Mrs. David P. Winchester—Drs. Naji N. and Nada A. Abum- rad—Drs. M. T. and A. J. Amirana—Kathryn and French Anderson—Dr. William A. Bernie—Dr. and Mrs. Robert E. Berry—Dr. and Mrs. Merrill N. Bradley—Drs. L. D. and Charlene Britt—Dr. Henry C. Cleveland— Chris Cribari, MD, FACS—Dr. Benjamin L. Crue, Jr.—Dr. and Mrs. Martin L. Dalton, Jr.—Drs. David and Kelli Dunn—Drs. Roger S. Foster, Jr., and Baiba J. Grube—Dr. and Mrs. Henry Gans—Dr. and Mrs. Vincent A. Gaudiani—Dr. and Mrs. Lee Gillette—Kirby R. Gross, COL MC U.S. Army—Dr. Mehmet Ali Haberal—Dr. and Mrs. Peter S. Hedberg—Ching Ho, MD, PhD, FACS—Mary and John Iacuzzo, MD, FACS—Dr. and Mrs. J. Bruce Jackson—Rayford Scott Jones and Christine Stacy—Dr. Donald H. Klotz, Jr.—Dr. Anna M. Ledger- wood—Keith D. Lillemoe, MD, FACS—Dr. and Mrs. Robert J. Lucas—Dr. and Mrs. Richard A. Lynn—Drs. Lloyd D. and Eleanor MacLean—Dr. and Mrs. James V. Maloney, Jr.—Dr. John Atkinson—Richard W. and Pennie B. Martin—Dr. J. Burton Mayes—LaMar and Julia McGinnis—Dr. and Mrs. David L. Nahrwold—Dr. and Mrs. Ralph R. Ocampo—Dr. Frank G. Opelka—Carlos and Kelly Pellegrini—Dr. and Mrs. Ole A. Pelo- so—Dr. and Mrs. Stuart M. Poticha—Dr. and Mrs. Basil A. Pruitt, Jr.—Martine B. and William P. Reed—New YorkDr. and Mrs. J. David Richardson—Dr. and Mrs. Russell L. R. Ryan—Dr. and Mrs. William F. Sass- er—Dr.50 | and Mrs. Edward L. Seljeskog—Dr. Kenneth W. Sharp and Mrs. Jane E. Sharp—Dr. and Mrs. Wihbi A. Shu’Ayb—Drs. Steven C. Stain and Hyacinth THANK YOU R. C. Mason—Dr. Hugh H. Trout III—Dr. and Mrs. Joseph J. Verska—Dr.† and Mrs. Alexander J. Walt—Dr. Abdul W. M. Abdul-Wahab—Dr. and Mrs. Idatonye and Linda Afonya—Dr. Suresh and Mrs. Deb- orah Agarwal—Dr. Andrew H. Ahn—Dr. Maria Allo—Dr. and Mrs. James A. Allums—Dr. James A. Ander- son—Dr.† and Mrs. Michel W. Andre-Kildare—Dr. Anthony Atala—Dr. and Mrs. John A. Aucar—Harriet W. and Arthur H. Aufses, Jr., MD, FACS—Dr. and Mrs. Vatche H. Ayvazian—Robert R. and Janet Bahnson—Dr. Manjit Singh Bains—Dr. and Mrs. Panagiotis E. Balas—Dr. and Mrs. Charles M. Balch—Dr. and Mrs. Charles R. Bales—Drs. Ralph M. and Shirley A. Bard—Dr. Nicole Baril—Dr. Fawzi Soliman—Dr. Barbara L. Bass—Dr. and Mrs. R. Daniel Beauchamp—Kevin E. and Patti J. L. Behrns—Dr. and Mrs. H. V. Belcher—Dr. and Mrs. Harvey W. Bender, Jr.—Dr. and Mrs. Ronald B. Berggren—Dr. and Mrs. Enrique S. Bermudez—Dr. and Mrs. Louis C. Bernhardt—Dr. Peter and Peggy E. Bistolarides—Kirby and Lynn Bland—Ernest F. J. Block, MD, MBA, FACS—Dr. Ewing T. Boles, Jr.—Dr. and Mrs. Edgar O. Borrero—Rev. Talmadge A. Bowden, Jr., MD, FACS—Drs. David W. and Cathy J. Brenner—Dr. and Mrs. James G. Brooks, Jr.—Drs. Dale and Sharon Buch- binder—Dr. and Mrs. Michael J. Bukstein—Dr. Stephen D. Burstein—Dr. and Mrs. Reginald A. Burton—Dr. Phillip L. Cacioppo—Dr. and Mrs. John L. Cameron—Mr. Richard Campbell—Dr. Francisco Cardenas—Dr. Frank A. Cebul—Dr. and Mrs. William E. Chambers—Dr. James K. Champion—†Dr. Francis Chanatry—Dr. and Mrs. Paul J. Chappano—Dr. Pamela S. Chassin—The Chassin Family—Dr. and Mrs. Kenya Chiba—Dr. and Mrs. Winston Chu—William Cioffi, MD, FACS, and Theresa Graves, MD, FACS—Dr. and Mrs. William C. Cirocco—Dr. Thomas V. Clancy—Dr. Ching Ho—Dr. and Mrs. Abilio A. Coello—Joseph B. Cofer, MD, FACS—Dr. and Mrs. Isidore Cohn, Jr.—Dr. and Mrs. Paul E. Collicott—Dr. Denton A. Cooley—Dr. and Mrs. Edward M. Copeland III—Dr. and Mrs. Joseph A. Corrado—Drs. Bard and Pamela Cosman—Dr.†and Mrs. Jerome M. Cotler—Dr.† and Mrs. George E. Cruft—Dr. and Mrs. Anatolio B. Cruz, Jr.—Dr. and Mrs. Kenneth Cruze—MarylandDr.V100 No 5 BULLETIN American Myriam College of J. Surgeons Curet—Dr. and Mrs. F. Joseph Dagher—Dr. and Mrs. Michael C. Dalsing— Dr. and Mrs. Christopher J. Daly—ohn M. Daly, MD, FACS, and Family—Dr. and Mrs. Herbert Dardik— Dr. and Mrs. Ralph G. De Palma—Dr. Clay O. Demattei—Dr. Michael J. Demeure—Dr. and Mrs. Daniel T. Dempsey—Dr.† and Mrs. James A. DeWeese—New York Dr. Mohd Yusuf Dhar—California STATEMENT

Statement in support of motorcycle helmet laws

The following statement was originally developed by the Subcommittee on Injury Prevention and Control of the American College of Surgeons (ACS) Committee on Trauma and published in the February 2001 issue of the Bulletin. The ACS Board of Regents approved this updated statement at its February 2015 meeting.

otal care of the trauma patient includes endorse- BIBLIOGRAPHY Tment of measures designed to prevent or reduce in- Bellal J, Anderson KT, Rhee P, et al. Universal helmet laws juries. Regarding the use of motorcycle helmets, the reduce traumatic brain injuries in young motorcyclists. ACS recognizes the following: Available at: www.facs.org/media/press-releases/2014/ anderson1028. Accessed March 16, 2015. Coben JH, Steiner CA, Miller TR. Characteristics of • Helmets reduce the risk of death and head injury in motor- motorcycle-related hospitalizations: Comparing states cycle riders who crash. with different helmet laws. Accident Analysis Prev. 2007;39(1):190-196. • It is estimated that between 1982 and 2001, more than Croce MA, Zarzaur BL, Magnotti LJ, Fabian TC. Impact of motorcycle helmets and state laws on society’s 12,000 motorcyclists lost their lives as a result of not using burden—a national study. Ann Surg. 2009;250(3):390-439. a helmet. Cummings P, Rivara FP, Olson CM, Smith KM. Changes in traffic crash mortality rates attributed to use of alcohol, | 51 • Unhelmeted motorcyclists are 40 percent more likely or lack of a seat belt, air bag, motorcycle helmet or bicycle than a helmeted rider to sustain a fatal head injury and helmet, United States, 1982–2001. Inj Prev. 2006;12(3):148-154. Hooten KG, Murad GJA. Helmeted vs nonhelmeted: A 15 percent more likely to suffer a non-fatal injury. retrospective review of outcomes from 2-wheeled vehicle accidents at a Level 1 trauma center. Clin Neurosurg. • Helmeted motorcycle riders have up to an 85 percent 2012;59:126-130. reduced incidence of serious, severe, and critical brain Hundley JC, Kilgo PD, Miller PR, et al. Non-helmeted injuries compared with unhelmeted riders. motorcyclists: A burden to society? A study using the National Trauma Data Bank. J Trauma. 2004;57(5):944-949. Kraus JF, Peek C, McArthur DL, Williams A. The effect • Motorcyclists with a brain injury incur average inpa- of the 1992 California motorcycle helmet usage law tient health care costs that are more than twice the costs on motorcycle crash fatalities and injuries. JAMA. incurred by hospitalized motorcyclists without a brain 1992;272:1506-1511. injury. Liu BC, Ivers R, Norton R, et al. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2004;(2):CD004333. • A large portion of the economic burden of motorcycle Max W, Stark B, Root S. Putting a lid on injury costs: The crashes is borne by the public. economic impact of the California motorcycle helmet law. J Trauma. 1998;45(3):550-556. • When universal helmet use laws are enacted, helmet use National Highway Traffic Safety Administration. Traffic safety facts. Motorcycle Helmet Use Laws. DOT HS 810 increases to nearly 100 percent, and fatalities and serious 887W. January 2008. Available at: www.transportation. injuries decrease. nebraska.gov/nohs/pdf/TSFMCHelmetUseLaws2008. pdf. Accessed March 16, 2015. • When universal helmet use laws are repealed, helmet United States General Accounting Office: Highway Safety: use decreases and fatality and serious brain injury rates Motorcycle Hemet Laws Save Lives and Reduce Costs to Society. (GAO/RCED-91-170). Washington DC: U.S. increase. General Accounting Office, July 1991. Watson GA, Zador PL, Wilks A. The repeal of helmet use Therefore, the ACS supports efforts to enact and sus- laws and increased motorcycle mortality in the United tain universal helmet laws for motorcycle riders. ♦ States (1975–1978). Am J Pub Health. 1980;70(6):579-585.

MAY 2015 BULLETIN American College of Surgeons STATEMENT

Statement on physician tiering and narrow network programs

The following statement was developed by the American College of Surgeons (ACS) Health Policy and Advocacy Group and was approved by the ACS Board of Regents at its February 2015 meeting.

s health care plans create incentives to improve able care may be limited when such payor-based Aquality and reduce costs, many entities have programs are imposed on plan benefits without started using physician-tiering protocols direct- regard to quality. ing patients to choose certain physicians; or they The ACS supports the following physician tier- are offering a narrow network, reducing the num- ing and narrow network programs: 52 | ber of available providers. Both of these protocols rank physicians based on cost, and some networks • Programs that use transparent methods and are rank providers based on quality, as well. These rooted in logic that patients, physicians, and other protocols are often improperly implemented, rely stakeholders in the delivery system can comprehend. on faulty data, use inappropriate cost measures, lack transparency, and lead to the misclassifica- • Programs that use quality measures that meet tion of physicians. The College regards the provi- nationally accepted standards for quality based on sion of high-quality surgical care as a top priority importance, scientific acceptability, feasibility, and and strongly urges that federal or state govern- usefulness. Composite measures that combine qual- ment agencies, hospitals, health care organiza- ity and cost should be held to the same high stan- tions, insurance companies, or other interested dards and should include regular audits for reliabil- parties develop policies to ensure that every con- ity and validity. sideration be given to patients so they receive the highest quality surgical care. • Programs that have metrics that incorporate care Given the current state of performance measure- from all appropriate providers and are in accordance ment in health care, the ACS believes that tiering with nationally recognized standards. Health care or narrowing accessibility of out-of-network phy- delivery is an outcome of the actions of many indi- sicians should be based on quality of care rather viduals and the systems that support them. than cost of care. Although the ACS agrees with efforts that appropriately lead to the efficient deliv- • Programs that incorporate accepted risk adjustments ery of care, we believe that such protocols should be for outcomes and socioeconomic status to ensure based solely on quality until reliable and valid meth- ongoing access for patients who are at higher risk ods evaluating both cost and quality are available, for complications and poor outcomes. ensuring the smallest potential risk of misguiding patients who are seeking surgical care. Cost alone • Programs that involve physicians and physician orga- should never be considered an adequate metric, and nizations in the development and implementation patients should understand that access to reason- of any protocol.

V100 No 5 BULLETIN American College of Surgeons STATEMENT

Although the ACS agrees with efforts that appropriately lead to the efficient delivery of care, we believe that such protocols should be based solely on quality until reliable and valid methods evaluating both cost and quality are available, ensuring the smallest potential risk of misguiding patients who are seeking surgical care.

• Programs that never tier physicians or remove physi- metrics used must be explicitly stated. This trans- cians from health plan networks based on cost alone. parency is necessary so that patients can understand Payors should rely on nationally validated and reli- that access to care may be limited when such pro- able quality metrics, and while cost data should be grams impose restrictions without regard to qual- transparently available to patients to allow them ity. Entities should partner with physician stake- to apply cost information independently in the holders if they are interested in developing reliable | 53 decision-making process, these data should not be resource-use measures that do not run the risk of used to make network decisions. denying patients access to quality care. ♦

• Programs that set appropriate benchmarks that incentivize all physicians to achieve optimal clini- cal outcomes and high-value care.

• Programs that impose minimal burdens on physi- cians so as to avoid impeding the provision of care or patient access to care.

• Programs that provide an opportunity for patients, physicians, or other stakeholders in the delivery sys- tem to appeal any classification of the physician in the program.

The ACS is not aware of any physician tiering or narrow network programs that meet these cri- teria. This gap is likely due, in part, to the lack of transparency associated with these program. The ACS recommends that payors discontinue such pro- grams and direct their efforts toward quality mea- sures currently available to encourage providers to participate in learning health systems and quality improvement efforts. However, if measures of both quality and cost are used for these programs, the

MAY 2015 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

One surgeon’s principles

by Henry Buchwald, MD, PhD, FACS, FRCSEng(Hon)

am in my 80s, and I know now have many outstanding myself most fortunate to be Postoperative complications women surgeons who quite Iable to make that statement. can be solved intraoperatively naturally exhibit the hand I have been a surgeon for nearly Carefully plan your contemplated of the woman. In Europe, 50 years. I am grateful for those procedure beforehand. Do every speed is sometimes valued years of doing what I believe I dissection, every anastomosis, for its own sake. Continental was meant to do while enjoying and every operative step in surgeons often boast about almost every moment of that your imagination before you how quickly they can do a time. I am an academic who holds enter the operating room. procedure, as if they lived in a dual appointment in surgery Intraoperative care and thought, the 19th century. However, in and biomedical engineering. In careful technique, refusal to the age of advanced anesthesia that role, I have attempted to be compromise for convenience, and respiratory control, speed a mentor to residents in terms redoing a repair if in doubt, is a poor second to gentleness. of surgical care, technique, and constant reflection often Tissues are delicate; handle 54 | and the attributes of practice will prevent the agonies of them carefully. Bleeding can that govern our discipline. complications for your patient. almost always be avoided. Over the years, based on my Further, no matter how often Adhesions can be teased apart. experience, I have formulated I have done a particular The proper wrist posture when certain principles regarding procedure, before the patient sewing with a curved needle the provision of care that have is closed or the instruments will avoid suture cut marks. guided my career. I offer these 10 removed, I replay the entire The finer the anastomotic principles in the hope that they operation in my mind. If I suture material, the less likely may be of interest to others. am not satisfied with my a leak or stenosis will occur. mental video, I go back and try to remedy my concerns. It’s always your fault A learning curve can take time Except for liability litigation, this but should not take lives precept is a good way to approach Gentleness, not speed, is the It revolts me to hear surgeons the acceptance of responsibility cardinal surgical virtue boast of lowering their for the well-being and the life Paraphrasing a surgical maxim mortality rates during their that a patient entrusts to you. from the 15th century, Harvey learning curve. When a Anticipate exigencies and attempt Cushing, MD, FACS, allegedly surgeon emerges from training, to prevent untoward events. told aspiring surgeons: “The the surgeon should expect Acknowledge bad decisions, surgeon should have the no mortality or significant even if they appeared to be the eye of the eagle, the heart morbidity because of a lack of most rational choices when they of the lion, and the hand of skill. A learning curve should were made. When assessing a the woman.” Unfortunately, never be measured in patient bad outcome, recognize that some surgeons have gotten mortality, but should rather be there are no acts of God. I tell these precepts confused and determined by time involved residents that if a patient falls exhibit the “hand” of the lion in performing a procedure and out of bed, it’s their fault. or the eagle. Fortunately, we improvement in technical skills.

V100 No 5 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

Intraoperative care and thought, careful technique, refusal to compromise for convenience, redoing a repair if in doubt, and constant reflection often will prevent the agonies of complications for your patient.

were considered dummies, the and relished by its originator Venerate life cast-offs of medical training. before it is subjected to critical The employment of care Many years later, I was invited examination. After indulging conferences in intensive care units, to consider a job offer as chief the initial thought, however, it wherein every person who has of surgery at a prestigious is time to explore the literature had contact with the patient— northeastern university. I was and re-examine the concept as well as an exogenous ethicist, told that the internists would for originality and feasibility. in some cases—recommend life work-up my patients and decide If others have not previously or death to a patient’s family has for or against a procedure; that and definitively conducted the become ubiquitous. Reinhold the anesthesiologists would experiment, or there are no strong Niebuhr, a 20th century American take care of them during and data indicating that the concept theologian, abhorred decision immediately after an operation; cannot be made a reality, then it making by a committee and put and that the internists, with is time to plan the investigation his trust in the individual. For a the help of their specialists in and, if the search for funding is surgical patient, that individual cardiology, would then again take successful, to initiate the study. | 55 should be the surgeon. If the patient over their care. I asked, “What Thus, my research advice is this: does not have untreatable cancer, is left for me to do?” My escort think first, then read, then think dementia, or a terminal diagnosis, was surprised by my question again, but perhaps don’t read the surgeon should, in my opinion, and responded, “You operate, voluminously at first, for that be the advocate for life, even if of course.” In other words, the may inhibit a good thought. limited, and not for death. Further, surgeon was still viewed by some with respect to ageism in making as a technician. I have always surgical decisions, I have known a denied that conception of our Be of service to the community surgeon who in case discussions role. I believe the surgeon is Sooner or later, we should emerge commonly expressed the opinion an internist who can use his/ from the shelter of our working that attempting an operation her hands to follow through and personal time and engage or providing all-out care should on what the mind dictates. in community activities, such as be tempered and possibly not In other words, competence joining service organizations or offered when the patient was in manual dexterity does not initiating a novel contribution more than 65 years old. I have preclude cognitive ability. to society. In my case, I always believed (even before I chose, together with Arthur J. reached that age) that people Roberts, MD, FACS, a former older than age 65 deserve to live Think creatively cardiovascular surgeon and and should have any surgical Laboratory or clinical research professional football quarterback, procedure deemed necessary. leads to invention, and invention and with the endorsement of the is the product of imagination. National Football League (NFL) The imaginative process can Players Association, to start the Be proud of your craft be stunted by over-reading or Living Heart Foundation-Heart, I attended medical school on the over-analyzing at the beginning Obesity, Prevention & Education East Coast, where, as a rule in of the process. An idea should (LHF-HOPE) program. This those long-gone days, surgeons be dissected, contemplated, activity screens former NFL

MAY 2015 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

I believe the surgeon is an internist who can use his/her hands to follow through on what the mind dictates. In other words, competence in manual dexterity does not preclude cognitive ability.

players throughout the country namely, metabolic surgery. We events of caring for patients, for obesity, diabetes, heart are focusing on technology— thinking about a new problem disease, hypertension, and other laparoscopic, robotic, single and thinking anew about an ailments, and refers them for orifice, natural orifice old one, the unpredictability further diagnostics and therapy transluminal endoscopic surgery. and ever-changing novelty of to a regional center of excellence. But, no matter how beguiling events, and the physical pleasure In phase two of the LHF-HOPE technologic change is, we need of working with your hands. program, lectures are scheduled to embrace the paradigm shift The word “surgery” is derived featuring former players who have to metabolic surgery, which from the Greek words “cheiros,” reclaimed their good health. They the late Richard L. Varco, MD, a hand, and “ergon,” work. In speak on the hazards of obesity FACS, and I defined in 1978 as essence, we are defined as hand and other health care problems “the operative manipulation of laborers. Thus, as surgeons we to professional organizations a normal organ or organ system live a continuous adventure, are and industry groups. They also to achieve a biological result physically active, and literally 56 | participate in public forums for a potential health gain.”* able to shape events not only and presentations to the media. There are myriad examples of with our minds, but with our Since the public doesn’t typically metabolic surgery, starting with hands. It is only fitting that my pay a great deal of attention to surgery for peptic ulcer disease, 10 principles conclude with suggestions by members of the where surgeons operated on the fact that a surgeon will medical profession and by most normal stomachs and vagal nerves spend the majority of his or lay advisory groups, it is our hope without touching yet healed the her life in the practice of this that they might listen to some pathologic lesion—the duodenal chosen vocation. Therefore, of the country’s most admired ulcer. Presently, metabolic surgery take joy in the process. ♦ athletes—football players. is best represented by bariatric surgery, where surgeons operate on the gastrointestinal tract to Note Know where we are in our achieve a neurohormonal shift in This column is based on professional time continuum metabolism in order to engender the graduation address that Surgery has moved from weight loss and ameliorate obesity Dr. Buchwald delivered when he incisional (such as draining comorbidities. The ultimate goal was accorded Honorary Fellowship abscesses) to centuries of of metabolic surgery research is in the Royal College of Surgeons excisional procedures (primarily knowledge of the mechanisms of England in March 2014. for cancer), to reparative and etiology of the diseases we cardiac, transplantation, and treat (for example, diabetes). implantation operations. We maintain this heritage, but we must also move forward into Joy is in the process the next phase of our discipline, Successful outcomes are satisfying and awards are *Buchwald H, Varco RL (eds). Metabolic Surgery. New York, NY, USA: Grune and gratifying, but the joy of surgery Stratton; 1978. is in the process—the daily

V100 No 5 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Limited resection as a cure for early lung cancer: Time to challenge the gold standard?

by Nasser Altorki, MD, FACS; Leslie J. Kohman, MD, FACS; Linda J. Veit, MPH; Y. Nancy You, MD, MHSc, FACS; and Judy C. Boughey, MD, FACS

ung cancer remains the was favored because of fewer lobectomy in well-selected leading cause of cancer- loco-regional recurrences.1 patients.5-7 The timing is right Lrelated death in the U.S. With to challenge the gold standard increased use of diagnostic and of lobectomy for early-stage screening computed tomography Ongoing advances NSCLC in a multicenter trial. (CT) scans, many lung cancers It has been 20 years since the are discovered when they are results of the LCSG trial were small (≤ 2 cm). Do these small published in the Annals of Thoracic CALGB 140503 cancers require a standard Surgery.1 Over the course of these CALGB 140503 is a Phase III lobectomy, or can a more two decades, significant advances randomized trial of lobectomy limited resection, such as wedge have occurred in screening, versus sublobar resection for resection or segmentectomy staging, and treatment of early- small (≤ 2 cm) peripheral NSCLC. along with identical lymph stage lung cancer. CT scanning, Since 2007, 533 patients have | 57 node dissection, provide a which can detect much smaller been randomized, making similar oncologic outcome? nodules, is now universally used this the largest multicenter An active North American for both diagnosis and screening. trial evaluating this question. Phase III trial, Cancer and New generation CT and Target accrual is 692, more Leukemia Group B (CALGB) positron emission tomography than twice the LCSG accrual. 140503, is expected to help scans provide more accurate Eligible patients include determine whether small noninvasive assessment and those who are older than 18 cancers require a standard staging, including the ability years of age with a peripheral lobectomy. The clinical trial to distinguish between solid, lung nodule measuring ≤ 2 cm is designed to reveal whether part-solid, and slow-growing on a CT scan and suspected or a limited resection (wedge non-solid lesions, which have proven lung cancer. The nodule resection or segmentectomy) a more indolent course. must be peripherally located provides equivalent survival to Japanese oncologists were (defined as in the outer one- a lobectomy for treatment of the first to identify a group of third of the lung) and the patient early-stage non-small cell lung patients who could achieve physiologically suited for either cancer (NSCLC). The current high survival rates with limited lobectomy or limited resection. “gold standard” of lobectomy for resection.2-4 Many surgeons Patients must not have had a NSCLC was established by the now have experience with previous malignancy within 1995 Lung Cancer Study Group segmentectomy, both open and three years (with the exception (LCSG) trial that randomized video-assisted, making sublobar of non-melanoma skin cancer, patients with peripheral stage 1 resection feasible and applicable superficial bladder cancer, or (up to 3 cm) NSCLC to lobectomy for more of these patients. In cervical carcinoma in situ). versus limited resection in 267 addition, single institution Excluded from this trial are patients. Survival results were studies have shown that limited patients who have previously not statistically different between lung resection provides similar undergone chemotherapy and/ the two groups, but lobectomy local control and survival to or radiotherapy, as well as

MAY 2015 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

CALGB 140503

patients with locally advanced or metastatic disease. REFERENCES Patients are registered before surgery. During surgery, 1. Ginsberg RJ, Rubinstein LV. Randomized trial of the cancer diagnosis is confirmed, if not previously lobectomy versus limited resection for T1 N0 non- 58 | determined by preoperative biopsy, and the required small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;60(3):615-622. regional nodes are determined to be negative by frozen 2. Koike T, Yamato Y, Yoshiya K, Shimoyama T, Suzuki section (levels 4, 7, and 10 on the right; levels 5 or 6, 7, R. Intentional limited pulmonary resection for and 10 on the left) (see figure, this page). The patient peripheral T1 N0 M0 small-sized lung cancer. J Thorac is then intraoperatively randomized to either limited Cardiovasc Surg. 2003;125(4):924-928. resection or lobectomy. Patients are followed for five 3. Okada M, Nishio W, Sakamoto T, et al. Effect of tumor size on prognosis in patients with non-small cell lung years to determine disease-free and overall survival rate. cancer: The role of segmentectomy as a type of lesser The results of CALGB 140503 are vital for evaluating resection. J Thorac Cardiovasc Surg. 2005;129(1):87-93. the surgical management of patients with early stage 4. Okada M, Yoshikawa K, Hatta T, Tsubota N. Is lung cancer (T1aN0), a population that is under- segmentectomy with lymph node assessment an represented in clinical trials. The implementation of alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? Ann Thorac Surg. 2001;71(3):950-960. CT screening for lung cancer, now approved by the 5. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge Centers for Medicare & Medicaid Services, will result resection versus lobectomy for stage I (T1 N0 M0) in the diagnosis of even more small peripheral lung non-small-cell lung cancer. J Thorac Cardiovasc Surg. cancers for which surgical treatment will be indicated.8 1997;113(4):691-698. Many of these patients have poor lung function 6. Read RC, Yoder G, Schaeffer RC. Survival after conservative resection for T1 N0 M0 non-small cell related to prior smoking behavior. Preservation lung cancer. Ann Thorac Surg. 1990;49(3):391-398. of lung function by limited resection, if equal to 7. Keenan RJ, Landreneau RJ, Maley RH Jr, et al. lobectomy in cancer control, will result in a better Segmental resection spares pulmonary function in quality of life for these individuals and maximize patients with stage I lung cancer. Ann Thorac Surg. options for treatment of future second primaries. 2004;78(1):228-233. 8. Centers for Medicare & Medicaid Services. Decision Surgeons are urged to contribute to these research Memo for Screening for Lung Cancer with Low Dose efforts by recommending this trial for their eligible Computed Tomography (LDCT) (CAG-00439N). patients to help determine the optimal extent of February 5, 2015. Available at: www.cms.gov/ surgical resection for oncologic control of early-stage medicare-coverage-database/details/nca-decision- lung cancer, and decide whether it’s time to change the memo.aspx?NCAId=274. Accessed March 1, 2015. gold standard of lobectomy for early-stage NSCLC. ♦

V100 No 5 BULLETIN American College of Surgeons FROM THE ARCHIVES

ACS Archives houses practice records of Franklin H. Martin

by Adam J. Carey, MA, and Dolores Barber

mong the prized holdings in the American College of ASurgeons (ACS) Archives are the papers of ACS founder Franklin H. Martin, MD, FACS, and his wife, Isabelle H. Martin. Within that collection are the four record books of Dr. Martin’s gynecology practice. One labeled “Laparotomy” was used from 1891 to 1900, and the other three record | 59 books highlight Dr. Martin’s practice from 1896 to 1917.

Dr. Martin’s Renowned gynecologist practice records books. Above: A cover with red rot. Dr. Martin received his medical Right: A laparotomy record. degree in 1880 from the Chicago Medical College (now Northwestern University’s Feinberg School of Medicine, Chicago, IL), and from 1886 to 1888, he was a professor of gynecology at a postgraduate medical school called the Chicago Policlinic. Dr. Martin read his first authored paper, “Treatment of fibroid tumors of the uterus by electrolysis, with a description of Apostoli’s Method,” at a meeting of the American Medical Association in 1886. The following year, he began his long tenure as a gynecologist at the Women’s Hospital of Chicago. During that time, he authored A Treatise on Gynecology.

MAY 2015 BULLETIN American College of Surgeons FROM THE ARCHIVES

60 |

Detail of Dr. Martin’s laparotomy record.

Patients traveled long of the John B. Murphy Memorial should consist exclusively of distances, even by today’s Auditorium, Chicago, and were wool…. No cotton, silk, or standards, to see Dr. Martin. In subject to sporadic heating and linen fabric should be permitted addition to Chicago, there are air conditioning. In 2002, the in contact with the skin.” many patient addresses from books were transferred to the A full listing of the 96 boxes Indiana, Michigan, Missouri, and Archives located in the College’s of Dr. Martin’s papers can be Iowa recorded in the practice headquarters in Chicago, but found in the Archives section of records. Interestingly, the names their leather bindings had the College’s website at www. of married patients were entered already deteriorated with age facs.org/about-acs/archives. We using the husband’s name (“red rot”) and are in need of welcome your suggestions for (for example, Mrs. John Jones, conservation treatment. The any other artifacts from the ACS rather than Mrs. Jane Jones). pages, however, are in very Archives that you would like to good condition. Laid within see featured in this column. ♦ the pages are hand-drawn Records survive illustrations, various notes on improper storage loose sheets, and completed For many decades, these practice test result forms. One sheet records books were kept next to of instructions to a patient the boiler room in the basement advises, “All undergarments…

V100 No 5 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Monitoring OR fires to improve patient safety

hen you see smoke in spark or smoke in the OR. An the operating room institution that is perpetually Reporting surgical fires W(OR), do you consider it aware of opportunities for error To help the FDA learn as much a surgical fire? Under The Joint and investigates these situations as possible about a surgical fire Commission’s updated definition, is exhibiting the characteristics of incident, the following information “fire, flame, or unanticipated a high-reliability organization— should be included in the reports: smoke, heat, or flashes occurring one in which the goal is zero during an episode of patient care” incidents of patient harm. • Make and model of devices is considered a sentinel event, The Joint Commission and the thought to be ignition sources even if the source is extinguished American College of Surgeons (such as electrosurgical units, and the patient is unharmed.* both participate in the U.S. Food lasers, and fiberoptic cables) The revised sentinel event and Drug Administration’s (FDA) definition became effective partnership, Preventing Surgical • Make and model of devices or January 1 and was developed in Fires. According to the FDA, drugs that were fuel sources an effort to encourage OR staff an estimated 550 to 650 surgical (such as drapes or antiseptic to investigate and take action fires occur in the U.S. annually, skin preparation agents) whenever a fire occurs. Even and despite the fact that the root though fires are not subject to causes of surgical fires are well • Whether supplemental oxygen was mandatory reporting to The Joint understood, OR fires still occur. used and at what concentration | 61 Commission, under the sentinel The goals of the Preventing event policy a comprehensive Surgical Fires initiative are to: • Delivery system used to supply systematic analysis (such as a supplemental oxygen (such root-cause analysis) must be • Increase awareness of factors as an endotracheal tube) conducted in all instances of that contribute to surgical fires fire. The analysis is required • Any additional identifying to determine how an event • Disseminate surgical information, including happened and what can be done fire prevention tools catalog and serial number to prevent it from occurring again. The purpose of this • Promote adoption of risk- • A complete description of the activity is to establish a series of reduction practices event, including patient outcome preventative steps that should be followed to avoid a recurrence. Health care professionals • The health care provider’s The process is meant to be who are involved in a surgical description of the event and non-punitive and is intended fire are encouraged to report the thoughts on how the device to help health care institutions event to The Joint Commission contributed to the event improve patient safety. and to MedWatch, the FDA Analysis of close calls or Safety Information and Adverse • Device design or labeling that may events where the patient is Event Reporting Program have contributed to the event unharmed is important because (accessible at www.accessdata.fda. the potential for patient injury gov/scripts/medwatch). Surgeons • Whether the device has been exists every time there is a employed by institutions that are evaluated, including the evaluation subject to the FDA’s user facility results, if available *The Joint Commission. Sentinel Event reporting requirements should Policy, January 2015. Available at: www. jointcommission.org/assets/1/6/CAMH_24_ follow the reporting procedures For more information, go to SE_all_CURRENT.pdf. Accessed March 25, 2015. established by their facilities. www.fda.gov/preventingsurgicalfires. ♦

MAY 2015 BULLETIN American College of Surgeons NTDB DATA POINTS

What’s cookin’? Who’s lookin’?

by Richard J. Fantus, MD, FACS, and Edmundo A. Rivera, MD

ccording to the American in an adult, while taking only for 2013, admissions medical Burn Association (ABA) half that time to create an injury records were searched using ANational Burn Repository of similar depth in a child. The the International Classification 2010 Report, scald burns accounted relationship, however, is not of Diseases, Ninth Revision, for 54 percent of all burns in linear. Water at a temperature Clinical Modification (ICD-9- children younger than five years of 58°C will take approximately CM) diagnoses codes. Specifically old. More than 90 percent of five seconds to cause a full searched were records for hot water scalds are due to hot thickness injury in an adult, but children age 12 or younger with cooking or drinking liquids.1 only one second in a child.3 place of injury codes (E-code) Fortunately, most pediatric scald Furthermore, liquid volumes E849.0 (home) and an external burns are not fatal and are minor that may appear small, whether cause of injury code E924.0 (burns enough that the victim can avoid they are in a cup or saucepan, can from hot liquids and vapors, admission to the hospital. actually affect a large portion of a including steam). A total of For young children especially, child’s body. The “rule of nines” is 3,183 records were found; 3,033 62 | the kitchen may be regarded as a quick and easy way to estimate records contained a discharge the most dangerous room in the total body surface area (TBSA) status, including 2,912 patients entire household. Adults often involvement in an adult, but the discharged to home, 78 to acute fail to recognize a child’s ability rule does not uniformly apply care/rehab, and 43 sent to skilled to access hazardous objects in to children. Because children nursing facilities; none died. the kitchen and the subsequent have proportionally larger heads, These patients were 52.8 percent likelihood of injury. Ultimately, Lund-Browder charts estimate male, on average 5.4 years of age, negligence on the part of the the extent of burns that allow for had an average hospital length caregiver is the key issue.2 the varying proportion of body of stay of 3.8 days, an average surface in different ages. While intensive care unit length of stay a burn involving the entire head of 5.1 days, an average injury Pediatric scald injuries in an adult may be only 9 percent severity score of 3.0, and were The severity of a scald injury of the TBSA, it would be 19 on the ventilator for an average depends on the temperature percent in a one-year-old toddler. of 9.4 days. Almost 60 percent of of the liquid and the duration This proportional increase in all injuries occurred in children of exposure. Younger children TBSA is exacerbated by the fact five years of age or younger. have thinner skin, resulting in that toddlers tend to reach up to (See Figures 1 and 2, page 63.) deeper injuries compared with pull hot liquid containers down, adults who are exposed to the which make their heads and faces same temperature and contact more prone to significant injury. Prevention time. Coffee, tea, hot chocolate, Children are creative and and other hot beverages can be resourceful; therefore, identifying served to adults at temperatures Causes and effects all the potential hazards that of 160–180°F/71–82°C.1 Water To examine the occurrence of may lead to serious injury is at a temperature of 50°C will pediatric scald injuries in the paramount. A study at a major take approximately 10 minutes National Trauma Data Bank® burn center involving scalded to cause a full thickness injury (NTDB®) research dataset children younger than age five

V100 No 5 BULLETIN American College of Surgeons NTDB DATA POINTS

FIGURE 1. AGE OF SCALD INJURY VICTIMS

FIGURE 2. HOSPITAL DISCHARGE STATUS

| 63

found that microwave-related Bulletin. The NTDB Annual REFERENCES injury was an unaddressed Report 2014 is available on the 1. American Burn Association. mechanism not found in major ACS website at www.facs.org/ Community Fire and Burn prevention resources.4 This quality-programs/trauma/ntdb. Prevention Program. American Burn Association, Scald Injury Prevention, type of finding opens an avenue In addition, information is Educator’s Guide. Available at: for awareness, education, and available on the website about www.ameriburn.org/Preven/ possible engineering safeguards. how to obtain NTDB data for ScaldInjuryEducator’sGuide.pdf. It may also underscore that the more detailed study. If you are Accessed January 10, 2015. mechanisms for scalds and other interested in submitting your 2. Hunt JL, Arnaldo BD, Purdue GF. Prevention of Burn Injuries. In cooking-related pediatric injuries trauma center’s data, contact Herndon DN (Ed). Total Burn Care, need further investigation to Melanie L. Neal, Manager, 4th Edition. Philadelphia, PA: W.B. develop targeted and effective NTDB, at [email protected]. Elsevier; 2012:52. preventive strategies. A kitchen 3. Moritz AR, Henriques FC. Studies with tantalizing smells may of thermal injury: II. The relative importance of time and surface lead to curiosity regarding Acknowledgment temperature in the causation of what’s cookin’; when it comes Statistical support for this article cutaneous burns. Am J Pathol. to preventing injury, though, it has been provided by Chrystal 1947;23(5):695-720. is who’s lookin’ that counts. Caden-Price, Data Analyst, and 4. Lowell G, Quinlan K, Gottlieb L. Throughout the year, we Alice Rollins, NTDB Coordinator. Preventing unintentional scald burns: Moving beyond tap water. will be highlighting these data Pediatrics. 2008;122(4):799-804. through brief reports in the

MAY 2015 BULLETIN American College of Surgeons NEWS

ACS NSQIP hospitals significantly improve outcomes over time

Most hospitals participating The study is based on ACS “These results show that in the American College of NSQIP data collected between hospitals committed to measuring Surgeons National Surgical 2006 and 2013. Complications and acting on their clinical data, Quality Improvement Program included in morbidity were implementing steps to improve, (ACS NSQIP®) improve surgical superficial, deep, or organ and establishing a culture for outcomes over time, and space SSI; failure to wean; continuous quality improvement improvement continues with each pneumonia; renal complications; can achieve significant reductions 64 | year that hospitals participate urinary tract infection; cardiac in patient harm,” said Clifford in the program, according complications; and vein Y. Ko, MD, MS, MSHS, FACS, to a study recently published thrombosis/pulmonary embolism. Director, ACS NSQIP and online in Annals of Surgery.* Annual reductions allow ACS Division of Research The study by the American hospitals committed to and Optimal Patient Care. College of Surgeons (ACS) participation in the program to “Studies have consistently research team found that among see significant improvements shown that reliance on clinical hospitals currently participating accumulate over time, data is necessary for hospitals in the program for at least according to the study authors. to get an accurate picture of three years, 69 percent reduced For example, by year five of their outcomes and to identify their mortality rate, 79 percent participation, an average-size areas for improvement. reduced their complications hospital is likely to prevent Because of inaccuracies, it rate, and 71 percent reduced at least seven deaths, 150 is often inappropriate to their surgical site infection (SSI) complications, and 66 SSIs per use administrative data to rate. It was estimated that, on 10,000 surgical procedures. A make quality improvement average, these hospitals reduced large hospital with 800 to 1,000 assessments,” Dr. Ko added. “We their death rate by 0.8 percent beds could prevent twice as many now have enough evidence to per year, their complications instances of patient harm, study know that the best approach to rate by 3.1 percent per year, and authors noted. The estimates quality improvement requires their SSI rate by 2.6 percent per likely underestimate the actual clinical outcomes data. Then, year, based on comparisons with benefits of the program as some once hospitals have an accurate rates from the previous year. complications were excluded measure of their quality, they from the study because they must act on that data to improve.” *Cohen ME, Liu Y, Ko CY, Hall BL. Improved could not be counted consistently At press time, the study surgical outcomes for ACS NSQIP hospitals over time and because multiple was scheduled to be published over time: Evaluation of hospital cohorts with up to 8 years of participation. Ann complications in the same later this year in the print Surg. 2015; Feb. 26 (e-pub ahead of print). patient were omitted. edition of Annals of Surgery. ♦

V100 No 5 BULLETIN American College of Surgeons NEWS

At the MHSSPACS meeting (from left): Drs. Tefera, Winchester, Turner, Elster, and Cordts; Colonel Martin; Dr. Knudson; Colonel Gross; Admiral Bono; Mr. Kirk; Dr. Hoyt; Ms. Bura and Ms. Blair.

MHSSPACS Leadership Group holds inaugural meeting in Chicago, IL

The Leadership Group of the newly MHSSPACS LEADERSHIP GROUP formed Military Health System Sameera Ali, Administrative Director, Continuous Quality Improvement, Strategic Partnership American College ACS Division of Research and Optimal Patient Care of Surgeons (MHSSPACS) held its Jeffrey Bailey, MD, FACS, Director, Institute for Surgical inaugural meeting March 31 at the Research, U.S. Air Force, San Antonio, TX College’s headquarters in Chicago, Patrick Bailey, MD, FACS, Medical Director, ACS Division of Advocacy and Health Policy IL. ACS Executive Director David B. Patrice Gabler Blair, MPH, Associate Director, ACS Division of Education | 65 Hoyt, MD, FACS, and Captain Eric Admiral Raquel Bono, MD, FACS, ACS Governor, U.S. Navy Elster, MD, FACS, chair, department of Connie Bura, Associate Director, ACS Division of Member Services surgery, Uniformed Services University of the Health Services, and U.S. Navy Jean Clemency, Administrative Director, ACS Trauma Programs staff transplant surgeon, Walter Reed Paul Cordts, MD, FACS, Department of Defense, Health Affairs National Military Medical Center, Captain Eric Elster, MD, FACS, Chair, Department of Surgery, Uniformed Bethesda, MD, co-chaired the meeting. Services University of the Health Services, and U.S. Navy staff transplant M. Margaret Knudson, MD, FACS, surgeon, Walter Reed National Military Medical Center, Bethesda, MD the new Medical Director for the Col. Kirby Gross, MD, FACS, U.S. Army, Director, Military Joint Trauma System MHSSPACS, organized the meeting, David B. Hoyt, MD, FACS, ACS Excecutive Director which was attended by leaders from Donald Jenkins, MD, FACS, Executive Committee, ACS Committee on Trauma the U.S. Army, Navy, and Air Force, as Garrett Kirk, MPH, Program Administrator, MHSSPACS well as representatives of key divisions M. Margaret Knudson, MD, FACS, Medical Director, MHSSPACS of the ACS that are involved in this new partnership. The group considered Colonel Matthew Martin, MD, FACS, Trauma Medical Director and Chief, Surgical Critical Care, Madigan Army Medical Center, Joint Base Lewis-McChord, WA four major topics that will be jointly addressed by the partnership, including Colonel Todd Rasmussen, MD, FACS, Director, U.S. Combat Casualty Research Program, U.S. Air Force quality of care in the military health system, education and training in Michael Rotondo, MD, FACS, Director, ACS Trauma Programs combat care for military surgeons, Ajit Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education trauma and combat casualty research, C. William Schwab, MD, FACS, Captain (Retired), U.S. Navy and the military’s Joint Trauma System. Lieutenant Colonel Thomas Stamp, MD, FACS, ACS Governor, In addition, the group discussed U.S. Air Force Academy, CO plans for a new military surgical Girma Tefera, MD, FACS, Medical Director, ACS Operation Giving Back society, called the Excelsior Society, Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services which will meet for the first time at the ACS Clinical Congress in 2015. ♦ David P. Winchester, MD, FACS, Medical Director, ACS Cancer Programs

MAY 2015 BULLETIN American College of Surgeons NEWS @MATTHEWCARASELLA.COM Dr. Michelassi honored with National Physician of the Year Award

Dr. Michelassi (right) receives the award from John J. Connolly, EdD, president and chief executive officer, Castle Connolly Medical Ltd.

Fabrizio Michelassi, MD, FACS, for patients with rectal cancer and the World Journal of Surgery. He Chair of the American College ulcerative colitis. His experience has been the recipient of many of Surgeons (ACS) Board of and expertise in treating Crohn’s awards, including the Andrew Governors, was awarded the disease led him to develop a W. Mellon Foundation Award, Castle Connolly 2015 National novel bowel-sparing procedure, the American Cancer Society Physician of the Year Award for now known as the Michelassi Cancer Development Award, and 66 | Clinical Excellence on March strictureplasty, which obviates the Distinguished Leadership 23 in New York, NY, at the 10th chronic intestinal obstruction Award from the Crohn’s and annual National Physician of in extensive Crohn’s disease Colitis Foundation of America. the Year Awards, sponsored by without sacrificing the intestine. John B. Mulliken, MD, FACS, Castle Connolly Medical Ltd. Dr. “I am truly humbled to receive professor of surgery, Harvard Michelassi is the Lewis Atterbury this award,” Dr. Michelassi Medical School and co-director, Stimson Professor and Chairman, said. “It is amazing to me that Vascular Anomalies Center and department of surgery, Weill someone could receive an director, Cranofacial Centre, Cornell Medical College, and award like this just for doing Boston Children’s Hospital, surgeon-in-chief at New York- something that has been such received a Lifetime Achievement Presbyterian/Weill Cornell a pleasure to do: taking care Award at the 2015 Castle Connolly Medical Center, New York. of patients in a compassionate, National Physician of the Year Dr. Michelassi is a renowned expert, professional way.” Awards. In addition, Henry Brem, gastrointestinal surgeon and an Dr. Michelassi is a clinician, MD, FACS, Harvey Cushing expert in the surgical treatment researcher, and teacher who has Professor of Neurosurgery, of gastrointestinal and pancreatic served as a visiting professor ophthalmology, oncology cancers, as well as inflammatory at nearly 50 national and and biomedical engineering, bowel disease. A prolific author international institutions. He has and director, department of of more than 270 papers, book delivered more than 40 named neurosurgery, Johns Hopkins chapters, and abstracts, Dr. lectures and keynote addresses. University School of Medicine, Michelassi has made significant He is associate editor of the Baltimore, MD, was recognized contributions to surgical treatment Annals of Surgical Oncology and for Clinical Excellence. of pancreatic and colorectal serves on the editorial board Find more information cancers, ulcerative colitis, and of five prestigious medical regarding the Castle Crohn’s disease. He has pioneered journals: Journal of Gastrointestinal Connolly awards and a list the development of techniques Surgery, Surgery, British Journal of all 2015 honorees at www. that improve the quality of life of Surgery, Annals of Surgery, and castlecconnollyawards.com. ♦

V100 No 5 BULLETIN American College of Surgeons NEWS

Disciplinary actions taken

The Board of Regents of the American College of DEFINITION OF TERMS Surgeons (ACS) took the following disciplinary Following are the disciplinary actions actions at its February 6–7 meeting in Chicago, IL: that may be imposed for violations of the principles of the College: • A senior Fellow, a general surgeon from Kula, HI, • Admonition: A written notification, was censured. This action was taken following warning, or serious rebuke. disciplinary action by the State of Washington • Censure: A written judgment, condemning Department of Health, Medical Quality Assurance the Fellow or Member’s actions as Commission. The surgeon was ordered to permanently wrong. This is a firm reprimand. surrender his license to practice medicine in the state • Probation: A punitive action for a stated period following a finding of unprofessional conduct. of time, during which the Member: (a) loses the rights to hold office and to participate as a leader • Robert A. Weiss, MD, an ophthalmic surgeon from in College programs; (b) retains other privileges Chicago, IL, was expelled from the College. This action and obligations of membership; (c) will be was taken following disciplinary action by the Illinois reconsidered by the Central Judiciary Committee | 67 periodically and at the end of the stated term. Department of Financial and Professional Regulation, which suspended his license to practice medicine for • Suspension: A severe punitive action for a unprofessional and immoral conduct following his arrest period of time, during which the Fellow or Member, according to the membership status: on four felony charges of unauthorized videotaping. (a) loses the rights to attend and vote at College meetings, to hold office, and to participate • Christopher J. Kovanda, MD, FACS, a plastic as a leader, speaker, or panelist in College surgeon from Maple Grove, MN, had his full programs; (b) is subject to the removal of the Fellowship privileges restored following a period Member’s name from the public listing and of probation. Dr. Kovanda fulfilled the condition mailing list of the College; (c) surrenders his or for reinstatement that the ACS Board of Regents her Fellowship certificate to the College, and no longer explicitly or implicitly claims to be a imposed on his Fellowship in June 2012. ♦ Fellow of the American College of Surgeons; (d) pays the visitor’s registration fee when attending College programs; (e) is not subject to the payment of annual dues. When the suspension is lifted, the Fellow or Member is returned to full privileges and obligations of Fellowship. • Expulsion: The certificate of Fellowship and all other indicia of Fellowship or membership previously issued by the College must be forthwith returned to the College. The surgeon thereafter shall not explicitly or implicitly claim to be a Fellow or Member of the American College of Surgeons and may not participate as a leader, speaker, or panelist in College programs.

MAY 2015 BULLETIN American College of Surgeons NEWS

Report on ACSPA/ACS activities, February 2015

by Fabrizio Michelassi, MD, FACS

The Board of Directors of the • Peer-to-peer solicitation through National Institutes of Health, American College of Surgeons the ACSPA-SurgeonsPAC’s and cancer quality measurement. Professional Association Captain Program and the Planning is under way for (ACSPA) and the Board of Resident Leadership Council the second annual legislative Regents (B/R) of the American briefing. The topic will be College of Surgeons (ACS) met • Leadership engagement Accreditation Makes a Difference. February 6–7 at the College’s headquarters in Chicago, IL. • Leadership giving 2015 Leadership & The following is a summary of Advocacy Summit their discussions and actions. At the time of the Board meeting, ACS the 2015 Leadership & Advocacy Summit was scheduled to take ACSPA Division of Advocacy place April 18–21 at the JW In 2014, the ACSPA political and Health Policy Marriott, Washington, DC. 68 | action committee (ACSPA- The past year saw an increase in General Stanley McChrystal was SurgeonsPAC) raised more the frequency of communications scheduled to deliver the keynote than $589,997 (including both to members on advocacy and address on tools for successful personal and corporate funds) policy-related topics. Besides leadership. Other speakers on the from 1,974 ACS members and the monthly e-newsletter, agenda were planning to discuss staff. Of this amount, more The ACS Advocate, and regular the current political environment than $529,422 is personal submissions to NewsScope and in Washington, DC, and across (hard) dollars and $60,575 the Bulletin, Patrick V. Bailey, the country, as well as the status is corporate (soft) dollars. MD, FACS, Medical Director of of important health care issues. In the 2014 election cycle, Advocacy, is writing a regular The ACSPA-SurgeonsPAC the ACSPA-SurgeonsPAC column for ACS Surgery News. was preparing to sponsor a contributed $1,053,500 to 151 The Health Policy and luncheon talk by Washington Post candidates, leadership PACs, Advocacy Group (HPAG) met political reporter Chris Cillizza. and party committees. Of at the ACS Washington office, The ACSPA-SurgeonsPAC this amount, 60 percent was January 11–12, to discuss and set also was scheduled to hold distributed to Republicans the division’s 2015 agenda and a fundraising event and and 40 percent to Democrats; activities. In addition, the annual raffle. Once again, Resident 92 percent of SurgeonsPAC Commission on Cancer Advocacy Scholarship grants were made dollars were spent on Committee planning meeting available to help encourage candidates/incumbents took place October 25, 2014. The the participation of a new who won their seats. focus of the 2015 agenda will generation of surgeon advocates. The primary areas of focus be on funding for survivorship for the ACSPA in 2015 include care plan creation and delivery, AMA House of Delegates increasing the following: reimbursement for helping The ACS delegation participated patients navigate cancer care, in the Interim Meeting of the • The number of clinical research, access to American Medical Association SurgeonsPAC members oncology drugs, funding for the (AMA) House of Delegates,

V100 No 5 BULLETIN American College of Surgeons NEWS

November 7–11, 2014, in Dallas, Mississippi, Pennsylvania, introduced, a strong response TX. ACS representatives at and South Carolina. will be generated against repeal. the meeting included John Armstrong, MD, FACS • Medical liability reform: A • Affordable Care Act (Delegation Chair); Jacob state Supreme Court case in implementation: Narrow/tiered Moalem, MD, FACS (Young California has the potential to networks have gained prominence Physicians Section delegate); overturn the state’s Medical with regard to state regulatory ACS Regent Leigh Neumayer, Injury Compensation and activity. The AMA released MD, FACS; Naveen Sangji, Reform Act and will be closely four model bills relating to MD, member, ACS Resident monitored. In addition, provider these issues, and the National and Associate Society (RAS- shield legislation, which would Association of Insurance ACS); and Patricia L. Turner, ban the use of public/private Commissioners is updating its MD, FACS, Director, ACS payor guidelines as evidence model legislation. In addition, Division of Member Services. in a liability lawsuit, may Medicaid expansion efforts are Many resolutions and reports gain some traction in 2015. expected in Indiana, Texas, | 69 were discussed and adopted at Utah, Virginia, and Wyoming. the meeting. One of the most • Bariatric surgery coverage: significant issues discussed was Numerous state exchanges do • Scope of practice: Emboldened a Council on Medical Service not require coverage for bariatric by victories in 2014, optometrists report focused on Medicaid surgery, and advocates continue are expected to aggressively primary care payment increases. to work with state insurance seek the permission to The ACS and other surgical commissioners to include bariatric perform surgery, and advanced specialty societies were able to surgery in the essential benefits practice nurses will push for amend the report language to package. Efforts are also under independent practice. The emphasize that any payment way to address instances of benefit possibility of implementing increases for one group should discrimination in those states a definition of surgery in have a neutral or positive affect where bariatric surgery is part of Connecticut and Massachusetts on payment for other specialties. the essential benefits package. will continue in 2015.

ACS State Advocacy Strategy • Trauma: The Committee on Position statement The State Affairs team Trauma (COT) is working on The B/R approved the ACS provided the HPAG with its advocacy agenda for 2015, Statement on Physician a state legislative action with preliminary interest Tiering and Narrow Network agenda for 2015. Issues focused on injury prevention Programs (see page 52). suggested for primary focus and trauma systems funding. In include the following: addition, there may be attempts in Texas to repeal the Driver Division of Education • Uniform Emergency Volunteer Responsibility Program, which The Division of Education Health Practitioners Act: States adds an extra fee for automobile recently received re-accreditation targeted for grassroots advocacy violations to support the state’s and a commendation for include Florida, Georgia, trauma system. Should a bill be innovation and compliance from

MAY 2015 BULLETIN American College of Surgeons NEWS

the Accreditation Council for integration of ethics throughout from contracting the Ebola virus Continuing Medical Education. the organization. Several and to guide them through the In addition, the ACS is now on individuals with specific expertise process of recognizing symptoms a six-year cycle for accreditation and experience in ethics are slated in patients. This information of continuing medical to join the committee this year. was disseminated through education programs, instead the ACS website and the ACS of the usual four-year cycle. Communities. Featured content Division of Integrated includes a Surgical Protocol for Committee on Ethics Communications Ebola developed by Past-ACS The Committee on Ethics Governor Sherry M. Wren, MD, continues to move forward with Online properties FACS, and Adam L. Kushner, projects identified at a strategic In December 2014, monthly MD, MPH, FACS. Pragmatic planning meeting, which analytics for the College’s information for surgeons also convened in April 2014. Alberto public website, facs.org, was presented during a 2014 R. Ferreres, MD, PhD, MPH, revealed the following: Clinical Congress Panel Session. 70 | FACS, has been selected to serve as editor of a book that will define • 545,787 monthly page views Surgeons-at-work photos the framework for the field of In November, all members surgical ethics as it has evolved • 207,502 sessions were invited to submit candid during the last 10 years. The photos of themselves at work book will be used to define the • 142,524 users who viewed for inclusion on the ACS important domains and essential 2.63 pages per session website. Photos began appearing components of surgical ethics. online in February 2015. At the time of the B/R Most website visitors meeting, discussions were used desktop devices (78.19 Clinical Congress newsletter continuing with regard to the percent), followed by mobile A daily electronic newsletter, development of activities for devices (14.99 percent), and Clinical Congress Daily Highlights, surgeons committed to advanced then tablets (6.82 percent). was sent to all members of the study in surgical ethics. Efforts As of January 2015, the College ACS during Clinical Congress. discussed at the time included had 92 active online Communities The newsletter contained 34 establishment of a collaborative covering a variety of member complex articles and three videos program with the MacLean interest areas. The site has already on key scientific sessions. Full- Center at the University of received more than 388,000 page length articles were posted on the Chicago, IL, that would establish views since the first community ACS Clinical Congress website. a summer-long fellowship in launched in late July 2014. In the inaugural year of surgical ethics or a more extended distribution, results included: certificate-based program. Soon Ebola resources after the Board meeting, that Last October, the College • Daily distribution to fellowship was approved. assembled a variety of resources nearly 51,000 people In addition, Committee on and news stories to keep members Ethics membership is being informed of recommended • Click-through rates to the full expanded to allow better strategies to protect themselves articles housed on the Clinical

V100 No 5 BULLETIN American College of Surgeons NEWS

Congress site were 11 percent Chapters The Essentials option has the higher than industry averages The College approved the highest enrollment of all the formation of a Jordan Chapter, Adult participation options, At the 2015 Clinical Congress, the College’s 40th international with 262 sites; however, the the Program Committee will chapter. Abdalla Y. Bashir, Procedure Targeted option, with appoint a single Medical Editor MB, BCh, FRCSEd, FACS, 225 hospitals, is experiencing for the newsletter who will serves as the ACS Governor the greatest growth. The coordinate the entire review for the Jordan Chapter. With Pediatric option represents process on all days of the the formation of the Jordan slightly more than 10 percent conference, assign reviewers for Chapter, the total number of of overall participation. each day, and provide unified chapters is 107—67 domestic Enrollment in ACS NSQIP oversight for the reviews. (including two Canadian grew by 16 percent in the 12 chapters) and 40 international. months leading up to the B/R meeting. Of the 610 enrolled Division of Member Services Membership hospitals, 48 are international The B/R accepted a change sites, and continued international | 71 Marketing campaign in status from Active (dues- growth is expected with The ACS has launched the paying) to Retired for 180 significant interest from Canada, Realize the Potential of Your Fellows, and from Senior (non- Australia, New Zealand, Saudi Profession campaign focused on dues paying) to Retired for Arabia, South Korea, and Oman. recruiting more young surgeons 19 Fellows for a total of 199 Additional reporting to become Fellows by leveraging Fellows. The B/R also accepted improvements have been made to peer-to-peer connections the resignation of 10 Fellows. help participants more efficiently and social media. Campaign The effort to promote ACS access and analyze data. New buttons were distributed at membership will continue Case Details and Custom Fields the 2014 Clinical Congress, in 2015 with networking Reports were scheduled for and a recruitment video was events in select communities release in the first quarter of shown on the Clinical Congress around the country and 2015. These reports will provide shuttle buses, encouraging non- activities at the Leadership participants with the ability Fellows to realize the potential & Advocacy Summit. to run reports for case data, of their profession through data captured in custom fields, involvement in the College. or case and custom fields data An engaging video based Division of Research and efficiently combined into one on the theme “100 Years, 100 Optimal Patient Care report for site-specific research. Reasons to Join” was widely A full suite of reports also was distributed through ACS ACS NSQIP developed for all ACS NSQIP communication and social A total of 610 hospitals Collaboratives to facilitate media channels, and the goal is participate in the College’s the collection and analysis of for it to be continually shared National Surgical Quality data across multiple sites in a among young surgeons with Improvement Program Collaborative, or Collaborative their colleagues and peers to (ACS NSQIP®), 547 of which performance benchmarked drive interest in the ACS. participate in adult NSQIP. against all of ACS NSQIP.

MAY 2015 BULLETIN American College of Surgeons NEWS

Information is available across Registry (SSR) as a tool for Flum, MD, FACS, took place 34 models, which were selected individual surgeon data capture. December 4–6, 2014, at ACS based on the recommendations Approximately 6,000 surgeons headquarters. The three- of the ACS NSQIP Clinical participate in the SSR and have day course is designed for Team given current focal submitted at least 20 cases clinical and health services areas of quality improvement and nearly 6 million records. researchers with varying across ACS NSQIP sites. Surgeons continue to use the degrees of experience in the The 2015 ACS NSQIP National registry as a case log system. field. The course included Conference is scheduled for July The overarching aim of the 13 faculty members who 25–28 in Chicago, IL. A major SSR is to fulfill the regulatory led didactic lectures as well theme on the 10th anniversary requirements being used to as breakout sessions. of the conference will be to assess individual surgeons. The ACS Clinical Scholars recognize and celebrate ACS Three of the regulatory items in Residence program is a two- NSQIP hospitals and their being addressed include: year, on-site fellowship in applied dedication to improving the surgical outcomes research, 72 | care of the surgical patient. • The Centers for Medicare & health services research, and Medicaid Services Physician health care policy. This program MBSAQIP Quality Reporting System offers surgery residents a unique At present, 773 surgery opportunity to work with the centers are participating in • Maintenance of Certification College. The clinical scholars the Metabolic and Bariatric (MOC) Part 4 by the American become embedded with the Surgery Accreditation and Board of Surgery (ABS) College’s ongoing quality Quality Improvement Program and the American Board of improvement initiatives, (MBSAQIP). Of these centers, Colon and Rectal Surgery such as the ACS NSQIP, the 608 are fully accredited, 66 are National Cancer Data Base, the data collection-only centers • Submission of cases to the Trauma Quality Improvement that have not yet applied for ABS during the MOC exam Program (TQIP), guideline accreditation, and 99 are initial development, and accreditation applicants for accreditation. By Educational programs programs. The application expanding the accreditation The Clinical Trials Methods processes for 2016–2018 options to include varying levels Course will again be chaired by appointments closed April 3. and surgical volume expectations Kamal M. F. Itani, MD, FACS, Two new ACS Clinical (comprehensive, band, low and will take place this fall at Scholars in Residence will acuity, and comprehensive with the ACS headquarters. This five- be starting their fellowship adolescent qualifications), the day, intensive course is based on at the ACS in July 2015: ACS is opening participation in four successfully conducted and in the MBSAQIP to a broader published clinical trials that are • Kristen Ban, MD, a surgery range of bariatric centers. used to teach the methodology resident at Loyola University of design and implementation Medical Center, Maywood, IL Surgeon Specific Registry of a controlled clinical trial. The ACS has continued to The Outcomes Research • Jason Liu, MD, a resident at the develop the Surgeon Specific Course, chaired by David R. University of Chicago Hospital

V100 No 5 BULLETIN American College of Surgeons NEWS

TQIP A total of 278 hospitals American College of Journal of the American participate in TQIP. There are Surgeons Foundation College of Surgeons 257 Adult TQIP participants: The ACS Foundation has The Journal of the American College received a proposal from of Surgeons (JACS) now has two • 147 Level I, 121 state-designated, Rahul K. Shah, MD, FACS, biostatisticians who thoroughly and 92 ACS-verified and David J. Brown, MD, who review papers submitted trained as fellows under the for possible publication. • 114 Level II, 90 state-designated, direction of ACS Past-President More than 3,500 Fellows and 77 ACS-verified Gerald B. Healy, MD, FACS, earned Maintenance of FRCSEng(Hon), FRCSI(Hon), to Certification credit through • Four hospitals are both ACS establish a traveling fellowship the JACS continuing medical Level II and State Level I in Dr. Healy’s name. A steering education (CME) program in 2014, committee, led by Drs. Shah with 79,806 CME credits granted. • 41 centers in the process and Brown, will be established JACS has more than 600 of joining adult TQIP to lead the outreach effort followers on Twitter | 73 toward a goal of $200,000. ACS (@JAmCollSurg), and plans are There are 45 hospitals President Andrew L. Warshaw, in place to expand the journal’s enrolled in Pediatric TQIP: MD, FACS, FRCSEd(Hon), social media presence. Lillian has agreed to join the steering S. Kao, MD, FACS, JACS Social • 24 combined adult and committee. The ACS Foundation Media Editor, is working with pediatric centers and 21 will provide operational the RAS-ACS to involve and standalone pediatric facilities oversight and management of reach out to younger members the effort to seek donations from and to increase readership • 31 hospitals are in the process trainees, colleagues, family, among this crucial cohort. of joining Pediatric TQIP and friends of Dr. Healy. The JACS articles are being steering committee and the picked up by national media, Position statement Foundation will identify and as a result of the journal’s The B/R approved the engage potential “founding collaboration with the ACS update Statement in Support donors.” A public announcement Public Information team. ♦ of Motorcycle Helmet was made in April to seek gifts Laws (see page 51). from a broader audience.

Correction The Residency to Retirement column, “The ACS motto: What does it really mean?” on page 32 of the March 2015 Bulletin, provides the incorrect case for the Latin word omnibus. The word is used in the dative case. ♦

MAY 2015 BULLETIN American College of Surgeons NEWS

75 cancer care facilities receive ACS CoC Outstanding Achievement Award The Commission on Cancer (CoC) of the • Motivate other cancer programs to work American College of Surgeons (ACS) has toward improving their level of care granted its 2014 Outstanding Achievement Award to 75 accredited cancer programs • Facilitate dialogue between award recipients and throughout the U.S. Award criteria were health care professionals to share best practices based on qualitative and quantitative surveys conducted last year. • Encourage honorees to serve as quality- Go to the ACS website to view a care resources to other cancer programs complete list of the award-winning cancer programs at www.facs.org/quality-programs/ The 75 award-winning cancer programs cancer/accredited/about/outstanding/2014. represent approximately 15 percent of programs The award increases awareness of the surveyed by the CoC in 2014. “These 75 cancer quality of cancer care and the choices available programs currently represent the best of the best for cancer patients and their loved ones. In when it comes to cancer care,” said Daniel P. addition, the awards do the following: McKellar, MD, FACS, Chair of the CoC. “Each of these facilities is not just meeting nationally • Recognize cancer programs that achieve excellence recognized standards for the delivery of quality in providing quality care to cancer patients cancer care; they are exceeding them.” ♦

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V100 No 5 BULLETIN American College of Surgeons NEWS

ACS in the

Editor’s note: Media around the children eating whole peanuts world, including social media, Canadian-born surgeon or even smaller pieces as frequently report on American Susan Mackinnon pioneered they are a choking hazard.” College of Surgeons (ACS) activities. nerve transfer surgery Following are brief excerpts from Ottawa Citizen, March 13, 2015 news stories published from “Nerve transfer surgery Study: Participating October 2014 through March 2015 reconnects a working nerve to in ACS NSQIP provides that mention key ACS programs a healthy muscle by rerouting surgical outcome and initiatives, including research it down another nerve’s improvements over time findings that appear in the pathway to the hand. Two Surgical Products, March 2, 2015 Journal of the American College years ago, [Susan] Mackinnon “The majority of hospitals | 75 of Surgeons. To access the news [MD, FACS] received the participating in the American items in their entirety, visit the prestigious Jacobson Innovation College of Surgeons National online ACS Newsroom at www. Award of the American Surgical Quality Improvement facs.org/media/acs-in-the-news. College of Surgeons for her [Program] (ACS NSQIP[®]) pioneering work…. During improve surgical outcomes her trailblazing career, [Dr.] over time, and improvement Mackinnon has developed continues with each year a series of new treatments that hospitals participate in for patients with serious the program, according to a peripheral nerve injuries.” new study published online today in Annals of Surgery.”

Whole peanuts dangerous for kids under 5 Too few breast cancer Health eNews Daily, March 11, 2015 patients getting radiation “A new study finds that after mastectomy: Study children who are exposed to US News & World Report, food containing peanuts early February 17, 2015 in life may avoid being allergic “If women with locally to the popular food. This advanced breast cancer sounds like good news, but the plan to have a mastectomy American College of Surgeons but are not offered follow- (ACS), as well as the American up radiation therapy, they Academy of Pediatrics section should ask their doctor why, for Otolaryngology, advise [Dr. Quyen Chu, professor against babies and young of surgery at Louisiana State

MAY 2015 BULLETIN American College of Surgeons NEWS

University Health Sciences department of surgery at said Pellegrini, who wasn’t Center] recommended. Weill Cornell Medical Center involved in the study.” “The study was published in New York and chair of the online recently in the Journal of [B]oard of [G]overnors of the the American College of Surgeons.” American College of Surgeons, Infections most common said surgeons are obligated to cause of readmissions educate their patients on what after surgery How to make surgery safer the evidence says are the pros New York Times, February 3, 2015 Wall Street Journal, and cons of robotic surgery. “The researchers analyzed February 16, 2015 “‘Unless we inform the 2012 data from 346 hospitals “Little wonder that hospitals patient population on this, involved in an American are searching for new ways to there will be a drive from College of Surgeons quality get their safety numbers up. the consumer that trumps improvement program. One such effort involves helping everything else, because at that Results were published hospitals pinpoint their own point hospitals and physicians Tuesday in the Journal of the 76 | problems. Many hospitals are are caught in a difficult American Medical Association. participating in the National dilemma,’ [Dr.] Michelassi The study notes that hospital Surgical Quality Improvement said. ‘Hospitals and physicians readmissions are a focus of [Program], or NSQIP, overseen are caught in the dilemma nationwide efforts to control by the American College of to either continue to deliver hospital costs and improve Surgeons and adapted from an optimal care or to respond quality of patient care.” effort at Veterans Administration to market requests.’” hospitals that helped decrease postoperative death rates by Studies find tracking surgical 47% from 1991 to 2006. ‘All too Trauma surgery may not complications doesn’t often, patients are being harmed be riskier at night improve outcomes by preventable complications,’ Reuters, February 6, 2015 Wall Street Journal, February 3, 2015 says Clifford Ko [MD, FACS], “The findings also might “Clifford Ko [MD, FACS], a colorectal surgeon at UCLA not be relevant for more [D]irector of the American and director of NSQIP. Many complex surgeries, said Dr. College of Surgeons’ [D]ivision hospitals don’t collect reliable Carlos Pellegrini [MD, FACS, of [R]esearch and [O]ptimal data on their own adverse FRCSI(Hon)], chair of the [P]atient [C]are, said the data events, and ‘you can’t improve surgery department at the the two studies relied on, based a hospital’s surgical quality University of Washington in on billing codes, aren’t accurate if you can’t measure it.’” Seattle and a [P]ast- gauges of patient outcomes. He [P]resident of the American also said that most hospitals use College of Surgeons. the registry data individually, Is da Vinci robotic surgery “‘The exploratory to target specific areas of a revolution or a ripoff? laparotomy in general is a care for improvement, not for Healthline, February 12, 2015 relatively straightforward broad comparisons. ‘Hospitals “Dr. Fabrizio Michelassi procedure for which mortality need data, and it has to be [MD, FACS], the chair of the or morbidity are very low,’ good data,’ Dr. Ko said.”

V100 No 5 BULLETIN American College of Surgeons NEWS

and Health Policy], at the breast cancers, the 2011 rate Trauma kits help police control Washington office of the of 38.1% may be too high, the severe bleeding, saving lives American College of Surgeons, authors warn. The National Washington Post, January 26, 2015 said he also found the penalty Accreditation Program for Breast “In 2012, the FBI and the disappointing. ‘It’s extremely Centers from the American American College of Surgeons discouraging when a large College of Surgeons recommends gathered medical and law number of physicians are not that no more than 50% of enforcement leaders from able to comply with the program patients with early-stage breast around the country to review when all of them would wish cancer have mastectomies, such incidents and come up with to perform exceedingly well,’ while the recommended cap ways to improve victim survival he said in a phone interview. in Europe is only 30%. rates. They took inspiration ‘That leaves us deeply concerned “‘Current U.S. rates from the emergency medical about the program’s education probably would not meet training and supplies soldiers and implementation—is it too the European benchmark,’ receive for combat situations.” much, too fast, too soon? Is it the researchers wrote. that practices aren’t ready, and “The study was based on cases | 77 now we’re penalizing them?’” reported to the National Cancer Saving blood, dollars and lives Data Base, a joint project of the Wall Street Journal, January 15, 2015 American Cancer Society and the “Following the right Work hour limits for American College of Surgeons guidelines on blood transfusion doctors in training don’t Commission on Cancer. About could reverse these disturbing improve patient safety 70% of newly diagnosed cancers trends. Analyzing data on Los Angeles Times, December 9, 2014 are reported to the database.” transfusions from the National “The other study, led by Surgical Quality Improvement researchers from the American Program, we estimate that College of Surgeons and End to global payments a reducing blood usage by 30%— Northwestern University, focused “nightmare,” surgeons say a fairly conservative target for on 535,499 patients who had HealthLeaders Media, eliminating waste—could result surgeries in 131 hospitals. These November 12, 2014 in a repurposing of 12 million researchers came to pretty much “A new Medicare rule that nursing hours, annual reductions the same conclusion: ‘Reform unbundles global surgeons’ fees of 200,000 wound complications was not associated with a change for thousands of procedures and eight million fewer patient in the likelihood of death or not only bucks a national trend days in the hospital; as many as serious morbidity,’ they wrote.” toward episode-based pay, it will 50,000 lives could be saved.” confuse millions of beneficiaries who will receive a dozen or Doctors stumped as more more bills instead of one, each Doc groups pan meaningful breast cancer patients requiring a 20% co-payment. use penalties remove healthy breasts “That’s the concern of the MedPage Today, December 19, 2014 Los Angeles Times, November 19, 2014 American College of Surgeons, “Frank Opelka, MD [FACS, “Although there is no ideal whose [Medical Director of Medical Director for Quality mastectomy rate for early-stage Quality and Health Policy]

MAY 2015 BULLETIN American College of Surgeons NEWS

Frank Opelka, MD, [FACS,] says manage the condition and empty the policy, announced last month, their bag at home. Another video More women having will be ‘an administrative burden guide helps patients prepare for reconstruction surgery after for surgeons…a nightmare to recovery from a lung procedure, breast cancer treatment track,’ and ultimately, ‘penny- including pneumonia prevention.” US News & World Report, wise and pound-foolish.’” October 3, 2014 “Breast reconstruction can Why you can’t rely on be done with saline or silicone What to expect when cancer center ads implants, or the patient’s own you have surgery Consumer Reports, October 10, 2014 abdominal tissue. Among high- Wall Street Journal, October 12, 2014 “The more than 1,500 centers risk patients, breast reconstruction “Some organizations have accredited by the Commission with implants rose 14 percent programs to instruct patients on Cancer, a program of the and the use of a patient’s own in skills they will need after American College of Surgeons, abdominal tissue rose 10 surgery. The American College are required to meet standards percent over 15 years. That’s 78 | of Surgeons offers a video-based for quality, follow treatment according to the study from the tutorial to help ostomy patients— guidelines, and track performance October issue of the Journal of the those who will have a surgically to improve care. You can American College of Surgeons.” ♦ created opening in the abdomen find accredited centers on the to allow waste to leave the body— commission’s website.”

ACS Surgical History Group accepting poster abstracts until May 29

The American College of Surgeons Surgical The authors of all posters chosen for display History Group (ACS SHG) has issued a call will receive continuing medical education for abstracts for the inaugural ACS SHG credit and will be notified by July 15. View the Poster Presentation at Clinical Congress 2015, ACS website at www.facs.org/about-acs/archives October 4−8 at McCormick Place, Chicago, for set-up and presentation guidelines as well IL. The College encourages submissions from as answers to frequently asked questions. ACS Fellows, Retired and Senior Members, Submit abstracts and additional questions International Fellows, Resident and Associate to Adam Carey, MA, ACS Archivist and Society Members, and Medical Student Members SHG Coordinator, at [email protected]. with an ACS sponsor. The deadline for abstract Abstracts must be limited to 250 words. submissions is 5:00 pm CDT, Friday, May 29. Late submissions will not be accepted. ♦ The posters should examine the historical impact on the development of today’s surgeon.

V100 No 5 BULLETIN American College of Surgeons Proudly display that you’re a Fellow of the American College of Surgeons

As a Fellow, you are dedicated to improving the care of surgical patients. You have pledged to place the welfare and rights of your patients above all else, to respect each patient’s autonomy and individuality, and to advance your knowledge and skills throughout your career.

Share these commitments with your patients by displaying the Fellowship Pledge poster in your waiting room, exam room, or office.

Visit http://bit.ly/1EkGKSh to purchase or download a poster today. SCHOLARSHIPS

2014 IGS reports on experience from the perspective of a woman surgeon

Dr. Raymundo (left) at the Scholars and Travelers Luncheon with Dr. Liquete. by Maria Eliza M. Raymundo, MD, DMCC, FPUA, FPCS

The following is a summary of pertained to the format of skills and knowledge of its my experience as the American informed consent forms (ICFs). recipients, but also their abilities College of Surgeons (ACS) The UCSF ICF included not as researchers and academicians. International Guest Scholar (IGS) only the customary consent for in 2014. Specific topics discussed the procedure, but also a section include my rotations at U.S. detailing and/or defining Rotation at Stanford 80 | medical centers and at the ACS each patient’s willingness to At Stanford University Medical Clinical Congress. This report have his or her removed tissue Center (SUMC), CA, I had the also provides some insights into used for research. Although privilege of observing my mentor, the challenges women surgeons this type of document may Benjamin I. Chung, MD, FACS, continue to face in balancing already be widely used in assistant professor of surgery their work and personal lives. U.S. hospitals, it was my first and chief, robotic surgery. exposure to this type of ICF. Working with Dr. Chung, I Coming from my own directly observed the superb Rotation at UCSF country’s national referral surgical skills of a colleague who Medical Center center and teaching hospital, was young, yet was adept at I began my adventure as an I thought adapting such a managing even the most complex ACS IGS at the University of format would greatly advance cases through robotic surgery. California, San Francisco (UCSF) research for academic purposes I also collaborated with Medical Center under the and save time and resources James D. Brooks, MD, FACS, mentorship of Maxwell V. Meng, in securing ethics clearance professor and vice-chair, MD, FACS, professor and chief for retrospective studies. At department of urology, on a of uro-oncology. I was able to the same time, each patient research project. This experience observe multiple uro-oncologic can discuss directly with his was invaluable in completing procedures at the hospital in or her physician what most a research paper on prostate Mount Zion and the Moffitt Long research activities entail, cancer screening while I was at Hospital, allowing me good thus placing the power of the SUMC. Dr. Brooks’ alternate exposure to rare and common informed decision directly view on the controversial subject cases managed both with in the patients’ hands. provided a broader perspective traditional open surgery and This experience demonstrated on the matter, leading to a laparoscopic and robotic surgery. that the International Guest more well-rounded and robust Unexpectedly, the key lesson Scholarship has the potential manuscript. We are proud that I took away from this rotation not only to enrich the clinical our review paper, “Prostate

V100 No 5 BULLETIN American College of Surgeons SCHOLARSHIPS

Although a limited number of sessions were specific to urology, I learned a great deal at the Clinical Congress, and several sessions will be important in my research work on prostate and other urologic cancers. I also attended other sessions that would aid me in my role as an educator to residents and medical students at my university.

cancer and the Filipino: An Philippine College of Surgeons, and share our thoughts with updated review of publications,” approached me. They offered committee members. This has been accepted for publication their congratulations and aspect of the meeting allowed in the Journal of Urology and encouraged me to share my me to compare and contrast Research. At press time, a final experiences with other young my work and practice in the publication had not yet been set. surgeons when I returned home Philippines with theirs. This rotation reinforced to encourage more Filipinos to All scholars at the 2014 my growth both as a clinician apply for this scholarship in the Clinical Congress had a chance to and as a researcher through future. It was likewise inspiring showcase their chosen research my interactions with leaders to meet Rose Marie Liquete, MD, work, providing a rich learning in the field of uro-oncology. It a Philippine College of Surgeons environment for all of us. It was | 81 also has provided me and my regent, during the International a more formal and organized home university with a valuable Scholars and Travelers dinner, as setting, in which we learned from network for future collaboration. she was the first Filipino woman contemporaries how surgeons surgeon to serve as an ACS IGS. in their respective countries Although a limited number of practice and hone their craft. 2014 Clinical Congress sessions were specific to urology, From more developed countries, The 2014 Clinical Congress of the I learned a great deal at the I learned details on research ACS took place October 26–30 in Clinical Congress, and several involving new technology and San Francisco, CA. My experience sessions will be important in its practical applications in at the Clinical Congress began my research work on prostate developing countries, such as with the Opening Ceremony, and other urologic cancers. I the Philippines. Presentations by where each of the scholars was also attended other sessions that surgeons from other developing introduced to the attendees. I would aid me in my role as an nations helped me see how was pleased that officers from the educator to residents and medical other young surgeons deal with Philippine College of Surgeons students at my university. challenges and problems that were on stage, as well. It added Perhaps the best experience are similar to those situations meaning to see these leaders of the entire Clinical Congress that I encounter, and how from my country beaming with was having the opportunity to they have been able to achieve pride that one of their junior meet the other scholars, as well lasting progress in resource- colleagues had been chosen as the Officers and Staff Liaison of poor academic scenarios. as a scholar for this year. the ACS International Relations Indeed, after the Congress, After the ceremony, Jesus Committee. The reception and I felt I had grown immensely V. Valencia, MD, MHPEd, luncheon provided us with a as a surgeon, educator, and and Arturo E. Mendoza, Jr., more relaxed environment researcher, confidently able to MD, FACS, president and vice- where we could discuss our take on the role of a leader when president, respectively, of the experience with fellow scholars I returned to my home country.

MAY 2015 BULLETIN American College of Surgeons SCHOLARSHIPS

Dr. Raymundo (second from left) with other urologic surgeon scholars, left to right: Benjamin Turney, DPhil, MSc, MA, FRCS, Oxford, U.K.; Rajeev Kumar, MB, BS, MS, MCh, New Delhi, India; and Luke Harper, MD, Réunion, France.

Congress were instrumental in more women in surgery, the Challenges my enrichment as a surgeon and possibility of women advancing I was originally granted the clinician, as a researcher and into leadership positions likewise scholarship for use in 2013, but academician, and as a teacher and increases. I would like to use complications in my pregnancy mentor to my junior colleagues. this experience as an impetus to precluded me from traveling to My personal difficulties as be more visible, beginning with the U.S. that year. Fortunately, a new mother also made me sharing my experience as an 82 | the ACS graciously allowed realize the unique challenges ACS IGS through this report. me to postpone my rotations that still exist for women in most Because of the role that and attendance at the Clinical surgical fields, especially in the mentorship plays in the success Congress until the following year. corridors of academic institutions. of a woman surgeon, I would The challenges of starting a I was fortunate to have met encourage the IRC to provide family greatly affected my 2014 Dr. Liquete at the Clinical more women role models as experience, as well. Decisions had Congress luncheon, allowing us mentors to future scholars. I to be made regarding whether to establish an informal mentor- also would encourage scholars to bring my baby with me or mentee relationship between a to seek out women leaders in leave him with my family in the leading surgeon from my own their host institutions to enrich Philippines, as my husband lives country who has successfully their experience and provide and works abroad. Once I decided raised children while fostering a fertile learning environment to bring my son with me, finding a thriving career, and a junior for their professional growth as adequate child care became physician just beginning her surgeons and academicians, as an obstacle. It created time family and surgical career. well as their personal growth limitations, hindering my ability Strong mentorship from a female not only as wives and mothers to participate in early morning colleague and family support but as women in general. ♦ or evening conferences and were enumerated by multiple lectures at my host institutions, published studies as key in as I had to work around the hours breaking through the glass ceiling that day care was available. for many women in surgery. Many successful female surgeons have also relayed how heightened Lessons learned visibility through public speaking My five months of rotations at and conference presentations two top-notch U.S. hospitals and are important to recruit more my attendance at the 2014 Clinical women into our ranks. With

V100 No 5 BULLETIN American College of Surgeons ® SELECTED READINGS in GENERAL SURGERY

Spend Your Time Learning, Not Searching Selected Readings in General Surgery (SRGS®) is the premier literature review for general surgeons.

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* The American College of Surgeons (ACS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing Subscribe today! medical education for physicians. The ACS designates this enduring material for a maximum of 80 AMA PRA Category 1 Credits™ annually. Physicians www.facs.org/publications/srgs should claim only the credit commensurate with the extent of their or call 800-631-0033 participation in the activity.

AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION Blended Surgical Education and Training for Life

2014 SRGS Bulletin Ad_NOV2014.indd 1 10/7/2014 9:22:38 AM MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit www.facs.org/events or http://web2.facs.org/ChapterMeetings.cfm

Missouri Chapter Illinois Chapter MAY May 29–31 June 18–20 Lake Ozark, MO Peoria, IL Vermont Chapter Contact: John Kirby, Contact: Luann White, May 21 [email protected], [email protected], Burlington, VT www.moacs.org www.ilchapteracs.org Contact: Jeanne M. Kunkle, [email protected]

Florida Chapter JUNE JULY May 22–23 Gainesville, FL Austria-Hungary Chapter North Carolina Contact: Jennifer Starkey, June 3–5 & South Carolina Chapter [email protected], Linz, Austria July 17–19 www.floridaacs.org Contact: Albert Tuchmann, Pinehurst, NC [email protected] Contact: Jennifer Starkey, Jamaica Chapter [email protected], May 23–24 Brooklyn-Long Island Chapter www.ncfacs.org and www.scfacs.org 84 | Kingston, Jamaica June 9 Contact: David Hunter, Garden City, NY Tennessee Chapter [email protected] Contact: Teresa Barzyz, July 31–August 2 [email protected], Knoxville, TN Southwest Missouri Chapter www.bliacs.org Contact: Wanda McKnight, May 29 [email protected], Joplin, MO Lebanon Chapter www.tnacs.org Contact: Cathy Leiboult, June 11–13 [email protected] Beirut, Lebanon Contact: Muhammad Younis, Mexico Federal [email protected], FUTURE CLINICAL District Chapter www.facs-lebanon.org May 29–30 CONGRESSES Sonora, Mexico Northeast Mexico Chapter Contact: Rosa Aurora Ruiseco, June 11–13 2015 colegioamericanodecirujanos@ Nuevo León, Mexico October 4–8 yahoo.com.mx Contact: Raul Lozano-Quiroga, Chicago, IL [email protected] Maine Chapter & 2016 New Hampshire Chapter Washington Chapter October 16–20 May 29–31 & Oregon Chapter Washington, DC Bar Harbor, ME June 11–14 Contact: Jennifer Starkey, Cle Elum, WA 2017 [email protected], Contact: Harvey Gail, October 22–26 www.mainefacs.org and www.nhfacs.org [email protected], San Diego, CA www.wachapteracs.org and www.oregonchapteracs.org

V100 No 5 BULLETIN American College of Surgeons