NOVEMBER 2006 Volume 91, Number 11

FEATURES Stephen J. Regnier Editor A growing crisis in patient access to emergency care: A different interpretation and alternative solutions 12 Donald D. Trunkey, MD, FACS Linn Meyer Director of Health care competition in Georgia: Communications Still restricted for general surgeons 23 Jon H. Sutton Karen Stein Associate Editor Error reduction through team leadership: The surgeon as a leader 26 Diane S. Schneidman Gerald B. Healy, MD, FACS; Jack Barker, PhD; and Capt. Gregory Madonna Contributing Editor Equipment for ambulances 30 Tina Woelke ACS Committee on Trauma; American College of Emergency Graphic Design Specialist Physicians; and the National Association of EMS Physicians Alden H. Harken, Program for Accreditation of Education Institutes becomes a reality 34 MD, FACS Carlos A. Pellegrini, MD, FACS; Ajit K. Sachdeva, MD, FACS, FRCSC; Charles D. Mabry, and Kathleen A. Johnson, EdM MD, FACS Jack W. McAninch, MD, Murphy Memorial Building restored 36 FACS Stephen J. Regnier Editorial Advisors

Tina Woelke Front cover design DEPARTMENTS

From my perspective 4 Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director Future meetings

Dateline: Washington 6 Clinical Congress Division of Advocacy and Health Policy 2007 New Orleans, LA, What surgeons should know about... 8 October 7-11 Developments in pay for performance 2008 San Francisco, CA, Julie Lewis October 12-16 2009 Chicago, IL, October 11-15

Spring Meeting 2007 Las Vegas, NV, April 21-24 2008 To be announced 2009 To be announced On the cover: General surgeons in Georgia are facing a struggle regarding the restrictions placed on them by Certificate of Need laws (see page 23). Photo courtesy of Punchstock. NEWS Bulletin of the American College of Surgeons (ISSN Edward M. Copeland III 0002-8045) is published installed as 87th ACS President monthly by the American Col- 39 lege of Surgeons, 633 N. Saint Patricia J. Numann receives Clair St., Chicago, IL 60611. It 2006 Distinguished Service Award 40 is distributed without charge to Fellows, to Associate Fellows, College names six Honorary Fellows in 2006 42 to participants in the Candi- date Group of the American Citation for Sen. Sirpa L. Asko-Seljavaara, MD 42 College of Surgeons, and to medical libraries. Periodicals Mary H. McGrath, MD, MPH, FACS postage paid at Chicago, IL, and additional mailing offices. Citation for Prof. Jorge Cervantes 44 POSTMASTER: Send address Carlos A. Pellegrini, MD, FACS changes to Bulletin of the American College of Surgeons, Citation for Prof. Clair Nihoul Fékété 45 633 N. Saint Clair St., Chicago, Andrew L. Warshaw, MD, FACS IL 60611-3211. Canadian Pub- lications Mail Agreement No. Citation for Prof. Armando Marquez-Reveron 46 40035010. Canada returns to: Eduardo A. Souchon, MD, FACS Station A, PO Box 54, Windsor, ON N9A 6J5. Citation for Prof Maurice E. Müller 48 The American College of Bruce D. Browner, MD, FACS Surgeons’ headquarters is located at 633 N. Saint Clair Citation for Prof. Niall O’Higgins 49 St., Chicago, IL 60611-3211; John E. Connolly, MD, FACS tel. 312/202-5000; toll-free: 800/621-4111; fax: 312/202- Surgery Down Under: Report of the 2006 Australia 5001; e-mail:postmaster@ and New Zealand Travelling Fellow 52 facs.org; Web site: www.facs. org. Washington, DC, office Robert R. Cima, MD, FACS, FASCRS is located at 1640 Wisconsin Ave., NW, Washington, DC Report of the 2006 ACS Traveling Fellowship to Germany 59 20007; tel. 202/337-2701, fax Michael G. Franz, MD, FACS 202/337-4271. Unless specifically stated 2008 ACS ANZ Chapter Travelling Fellowship available 62 otherwise, the opinions ex- pressed and statements made A look at the Joint Commission: in this publication reflect the Wrong site surgery and the Universal Protocol 63 authors’ personal observations and do not imply endorse- Operation Giving Back: Volunteer opportunities available 65 ment by nor official policy of the American College of Sur- Senior civilian surgeons sought geons. for combat trauma care program 65

©2006 by the American NTDB® data points: Horse sense 67 College of Surgeons, all rights Richard J. Fantus, MD, FACS, and John Fildes, MD, FACS reserved. Contents may not be reproduced, stored in a Trauma meetings calendar 68 retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

All-Products-Ad(revised07-06).in1 1 8/4/2006 10:56:16 AM From my perspective

s the nation seeks to build a safer, more effective, consumer-based health care

system, it will no longer be enough for

A surgeons and other physicians simply to say that they provide quality care. They will need to support such claims with data. To ensure that surgeons have the necessary ’’ and appropriate information available to them, medical and surgical organizations are being asked to engage in a new spectrum of activities. More specifically, we are moving into an era where sur- gical practice is expected to be more transparent. Our resources will be well What surgeons do, how we do it, and how well we perform is information that payors and patients spent because we must expect us to provide so that they can make value- based health care decisions. Hence, the College make certain that we now finds that it must lead and participate in ef- forts to accumulate, evaluate, and apply outcomes can continue to develop and quality data relevant to surgical practice. All of the College’s efforts in taking a leadership programs that generate role to create a more data-driven, quality-based health care system will require increased use of accurate outcomes data both our financial and our human resources. How- ever, our resources will be well spent because we and quality measures. must make certain that we can continue to develop programs that generate accurate outcomes data and quality measures. ’’ New expectations for the ACS The Centers for Medicare & Medicaid Services (CMS) and other government agencies are looking In addition, we are working with a number of to the College and to other medical and surgical consortia that are vetting quality measures, in- organizations to develop accurate and meaning- cluding the American Medical Association’s Physi- ful quality measures. These groups intend to use cian Consortium for Performance Improvement, this information to reward physicians and other the AQA (formerly the Ambulatory Health Quality providers who apply evidence-based medicine to Alliance), the National Quality Forum, and the improve patient care. As a result, the College is Hospital Quality Alliance. Because these coalitions participating in a number of activities to gener- are looking at quality measures across the spec- ate outcomes data and to establish quality mea- trum of health care services, we recently formed sures as well as guidelines for surgical care. the Surgical Quality Alliance (SQA). This group To these ends, we have been bringing the ACS is composed of more than 20 surgical specialty National Surgical Quality Improvement Program societies, all working together to generate metrics (ACS NSQIP) into the private sector. At this point, of quality care specific to this profession. the ACS NSQIP, the only validated, risk-adjusted We also need to make the most of our National tool for assessing surgical outcomes, is now being Cancer Data Base and National Trauma Data applied in more than 100 hospitals. An emerging Bank®. These repositories hold the types of in- challenge for the College will be to develop defined formation that will be useful in developing qual- modules of ACS NSQIP, so that medical centers ity indicators and measures, which can then be can focus their outcome measures on specific types provided to the various agencies and panels that of surgical care. are studying quality improvement. 

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Furthermore, we need to adopt a more academic will do so in an uncompromisingly ethical and orientation, having more surgeon researchers transparent manner. working within our divisions to evaluate the infor- In addition, we anticipate that the recently mation we are amassing and to report our findings. formed American College of Surgeons Foundation To encourage young surgeon participation in these will prove to be an effective vehicle for acquiring activities, we have launched a clinical scholars new funding while nurturing the growing spirit program. Presently, two surgical residents are of philanthropy among Fellows. The brainchild of working full-time at the College within the Divi- the late Oliver H. Beahrs, MD, FACS, the Founda- sion of Research and Quality Improvement as tion provides numerous opportunities for Fellows part this effort. to give back to our wonderful profession. Because Another area that is critical to our viability in its operating costs are supported by the College, a transformed health care system is our clinical every dollar contributed through the Founda- trials programs. We will need to evaluate not only tion is applied directly to fund the program or treatments for cancer patients, but for individuals project for which it is accepted. To learn more experiencing other conditions that involve opera- about the individual giving opportunities avail- tive care as well. In order for these clinical trials able through the Foundation, go to www.facs.org/ to succeed, we will need the support and active acsfoundation/. involvement of surgeons, calling upon them to The College is currently in the unique position enroll patients in these promising efforts to im- of being able to play a leadership role in helping prove patient care. surgeons navigate the new health care delivery system. Please feel free to contact me to confiden- Resources needed tially discuss how you can leave a legacy that will Needless to say, it takes resources to conduct enable the College to maintain and strengthen its all these significant projects. Just as importantly, leadership role in the years ahead. we want to keep our dues at their current level. Hence, we are actively exploring alternative sourc- es of revenue beyond our traditional dues and fee structure to offset these inextricable costs. Currently only approximately 30 percent of the College’s operations are supported by dues. Other sources of funding include the educational grants and meeting sponsorships that corporations pro- Thomas R. Russell, MD, FACS vide, the clinical trials funding we receive from the National Institutes of Health, and our endowment fund earnings. One way to develop the new financial resources we foresee being necessary to fund our widening sphere of activity would be to seek further corpo- rate and foundation support. However, in this era of increased public scrutiny, we must avoid even the perception of conflicts of interest. Hence, we will be very carefully exploring all ap- propriate funding sources, including those compa- nies and other organizations that will benefit from the work we are doing. Because the quality-based, data-driven work we are doing will be of value to employers, insurance carriers, and government agencies seeking to reduce their health care costs, If you have comments or suggestions about this or we might consider seeking investments from these other issues, please send them to Dr. Russell at fmp@ entities. As we pursue new revenue sources, we facs.org. 

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dateline Washington prepared by the Division of Advocacy and Health Policy

After more than two years as Administrator of the Centers for Medi- CMS administrator care & Medicaid Services (CMS), on September 5, Mark B. McClellan, resigns MD, PhD, announced his plans to vacate that post in early October. Before heading CMS, Dr. McClellan served as Commissioner of the U.S. Food and Drug Administration and, before that, as a member of the White House Council of Economic Advisers and as a senior health policy aide to the President. At press time, possible successors, at least on an interim basis, in- cluded the following: Leslie V. Norwalk, Deputy Administrator of CMS; Herb Kuhn, Director of the agency’s Center for Medicare Management; and Julie Goon, Special Assistant to President Bush and former Direc- tor of Medicare outreach at the U.S. Department of Health and Human Services (HHS). The CMS Administrator oversees Medicare, Medicaid, and the federally subsidized State Children’s Health Insurance Pro- gram, which together serve approximately 90 million Americans and account for more than $535 billion a year in federal spending. For more information about CMS, go to http://www.cms.hhs.gov/.

On August 22, President Bush signed an executive order intended Executive order to increase the “transparency” of the nation’s health care system. promotes The order applies to all federal health care programs administered or sponsored by HHS as well as the Department of Defense, Depart- transparency ment of Veterans Affairs, and Office of Personnel Management. The order calls on these entities to carry out the following efforts: • Share with beneficiaries information about payments to health care providers • Provide information to beneficiaries about the quality of services provided by physicians, hospitals, and other health care providers; the standards for measuring quality are to be developed in collabora- tion with multistakeholder groups and alliances • Encourage adoption of health information technology (IT) standards to facilitate the rapid exchange of health information • Support facilities and providers identified as providing high- quality and efficient care The Administration anticipates that this information will enable consumers to make informed choices when selecting physicians and hospitals and that they will seek care from proven providers and avoid unnecessary costs. Private and non-federal health programs are being encouraged to collaborate with the federal government on these efforts. The executive order takes effect January 1, 2007. For more informa- tion, go to http://www.hhs.gov/news/press/2006pres/20060822.html.

To help ensure timely implementation of the executive order for CMS acts to increasing transparency in health care, HHS Secretary Mike Leavitt implement order convened a summit of business and health care leaders on August 24 to discuss related issues. Among the concepts discussed at the meeting were plans to construct a network of pilot programs for increasing transpar- ency through the use of health IT and price and quality measures. 

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In another effort to implement the order, HHS plans to charter six “collaboratives” across the country, which will be charged with finding the best ways to gather price and quality information and report it to consumers. Quality and price information collaboratives will continue to be established until that information is available throughout the nation. Efforts to establish those entities and carry out many other tasks essential to making the health care system more transparent will be coordinated by a steering committee that was set up before the summit took place. In addition, HHS has launched a Web site on its transparency- related activities, which can be accessed at http://www.hhs.gov/ transparency/.

In related news, CMS announced August 21 that Medicare payment ASC transparency information for 61 procedures performed in ambulatory surgery cen- information posted ters (ASCs) is available on its Web site. The announcement marks the second set of geographically based information about cost and/or quality that CMS has made available; data on Medicare payment for 41 procedures performed in inpatient hospital settings were posted in June. The ASC cost information covers charge and Medicare payment data for facility costs associated with a limited number of services, broken down at the county, state, and national levels. The Administration plans to post additional information on quality and cost pertaining to hospital outpatient and physician services this fall. The new ASC information is accessible at http://www.cms.hhs. gov/HealthCareConInit/03_ASC.asp#TopOfPage.

On August 8, CMS released a report and regulatory plan regarding Specialty hospital physician ownership of specialty hospitals, as required in the Deficit report issued Reduction Act enacted earlier this year. CMS found that by “focusing on certain types of cases, specialty hospitals have the potential to increase the quality of care and to provide care (including surgical procedures) in a more efficient manner.” Release of the report effectively ended the moratorium that CMS had imposed on extending Medicare coverage to new specialty hospi- tals. However, the plan includes new enforcement measures requir- ing the facilities to disclose to CMS their financial arrangements with physician investors and to inform patients, before providing care, that staff physicians have ownership interests in the hospital. In addition, current anti-kickback laws prohibit specialty hospitals from providing a physician investor with a return that is dispropor- tionately larger than his or her investment. With respect to emergency care, CMS clarified that the Emergency Medical Treatment and Active Labor Act requires specialty facili- ties, regardless of whether they have an emergency room, to accept patient transfers if they have the capacity to appropriately care for the patient. For a copy of the report, go to http://www.cms.hhs. gov/apps/media/press/release.asp?Counter=1941. 

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about…

Developments in pay for performance by Julie Lewis, Associate for Quality Programs, and Shawn Friesen, Government Affairs Associate, Division of Advocacy and Health Policy

ver the course of the past two years, six aims to improve health care, including safe, federal policymakers—legislative and effective, patient-centered, timely, efficient, and Oregulatory—have devoted considerable equitable care. effort to developing a Medicare physician reim- Other studies and reports followed, supporting bursement system that links payment with the the IOM’s claim that a significant opportunity for quality and efficiency of patient care, also known health care improvement exists. In 2004, Rand as value-based purchasing or pay for performance Health conducted a study of 13,000 adults in 12 (P4P). As a first step in this transition, immedi- metropolitan areas and reviewed 6,700 medical ate attention has been directed at finding ways records. The study, which included 439 indicators of measuring processes of care that lead to better for 30 acute and chronic conditions, revealed that patient outcomes. adults receive only 55 percent of recommended At both the legislative and regulatory levels, care.2 The Rand report is but one example of the Fellows of the American College of Surgeons and growing body of evidence to support the IOM’s staff of the ACS Division of Advocacy and Health conclusions. Policy are educating federal policymakers about These reports, in conjunction with the skyrock- the organization’s ongoing efforts in surgical eting costs of health care, brought all stakeholders quality improvement (QI). We have discussed the to the table to explore ways to improve quality potential promise of utilizing quality efforts in a and lower costs. It is generally understood that P4P framework as well as the potential challenges the current payment model often rewards phy- associated with many P4P models. sicians’ ability to control volume rather than The question surrounding P4P is no longer a quality. The assumption behind value-based question of if, but a question of when. The govern- purchasing is that providing high-quality health ment, private health insurance companies, and care is less financially draining on the system. other private organizations are actively developing For surgery, it is assumed that high-quality care P4P models. The following questions and answers reduces surgical complications, length of stay, are designed to help Fellows understand the his- and readmission rates, all of which lead to cost tory, current environment, and possible impact savings. For patients, the rewards include receiv- of a P4P system. ing evidence-based care, avoiding unnecessary complications, and returning to daily activities What is the history/concept behind value- and work sooner. based purchasing? What role does the Centers for Medicare Over the past several years, the Institute of & Medicaid Services (CMS) play in this ef- Medicine (IOM) released reports, known as the fort? Pathways to Quality Care series, promoting a patient-centered, evidence-based approach to In October 2005, CMS announced the launch health care. The series extends the work of the of the Physician Voluntary Reporting Program first report released in 2001, Crossing the Quality (PVRP) to collect performance data on physicians. Chasm, which reached the conclusion, “Quality The PVRP collects clinical data through submis- problems are everywhere, affecting many patients. sion of G-codes by the physicians on claim forms. Between the health care we have and the care we G-codes are administrative codes that include a could have lies not just a gap, but a chasm.”1 In “G” followed by four digits and represent actions response to that conclusion, the IOM developed the physician has (or has not) taken. The PVRP 

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS has undergone many changes within the last year, workgroup of the American Medical Association’s including a reduction in the number of included (AMA) Physician Consortium for Performance performance measures. Today, 16 measures are Improvement (PCPI). He also explained that available for physicians to report to CMS. Five because of the unique nature of surgery, a P4P of the measures pertain to surgery: two that are system designed for hospitals or primary care specific to coronary artery bypass grafts and the physicians may be inapplicable to surgery. rest related to antibiotic prophylaxis, deep vein The day before the hearing, Rep. Michael Bur- thrombosis prophylaxis, and use of autogenous gess, MD (R-TX), introduced the Medicare Physi- AV fistula in end-stage renal disease patients. cian Payment Reform and Quality Improvement Unfortunately, the program has been fraught Act of 2006 (H.R. 5866). H.R. 5866 is the third with problems, including specifications of mea- bill introduced in the past two years that would sures that limit participation by many specialties set parameters for quality reporting. H.R. 5866 and measures that evaluate a facility or system would establish a voluntary quality reporting of care rather than the actions of the individual program using measures that are evidence-based physician. The College, through the Surgical and risk-adjusted and developed by physician or- Quality Alliance (SQA), sent two letters to CMS ganizations and specialty societies. The structure regarding the PVRP, asking for problems with of the quality program would be similar to the the program to be addressed and for additional physician-led approach to P4P envisioned in the measures to be included, allowing for greater Medicare Value-Based Purchasing for Physicians’ surgical participation. CMS has acknowledged Services Act of 2005 (H.R. 3617), which was the flaws in the program but has been slow to introduced in July 2005 by Rep. Nancy Johnson correct them. (R-CT), Chair of the Ways and Means Health It is important that Fellows are familiar with Subcommittee. this program. Depending on congressional ac- In June 2005, Sen. Charles Grassley (R-IA) and tion this year, a pay-for-reporting or P4P system Sen. Max Baucus (D-MT), the respective Chair could resemble or include the PVRP. Although the and Ranking Minority Member of the Senate Fi- College has successfully developed performance nance Committee, introduced the Medicare Value measures that more accurately represent evi- Purchasing Act of 2005 (S. 1356). That bill would dence-based guidelines and the surgeon’s respon- have set more general parameters and provided sibilities, the foundation of the program is likely greater discretion to the Secretary of Health and to remain, including the collection of clinical data Human Services and, ultimately, CMS in measure through additional administrative codes. development. Although the bills differ, both envi- sion some form of vetting process that includes What are the latest developments in con- physician organizations and specialty societies, gressional efforts to move toward a P4P such as the College and the AMA PCPI. system? What are the implications for Medicare 5On July 2 and 27, the House Energy and Com- physician payment? merce Subcommittee on Health held a two-day hearing, “Medicare Physician Payment: How to On August 8, CMS announced that the formula Build a Payment System that Provides Qual- used to calculate annual updates to the Medicare ity, Efficient Care for Medicare Beneficiaries.”3 physician fee schedule conversion factor, known Frank G. Opelka, MD, FACS, testified on behalf as the sustainable growth rate (SGR), will pro- of the College and outlined the organization’s QI duce a cut of 5.1 percent in Medicare payments efforts as well as the challenges surgery faces in for physician services in 2007. Combined with developing reliable measures.4 Dr. Opelka also additional regulatory changes, this reduction updated subcommittee members on the College’s would actually result in cuts of 10 percent or efforts to develop quality measures for potential more for some surgical procedures. In May, the use in a P4P program, noting our formation of Medicare trustees released their projections that the SQA and involvement in the perioperative Medicare physician payments will be reduced 

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 4.7 percent to 5.1 percent annually through In addition, the College has also been actively 2015. These decreases result from the design engaged in promoting Medicare payment reform of the SGR, which requires that whenever a that could facilitate the move toward P4P in a year’s spending on physician services exceeds manner that recognizes the unique nature of the designated spending target, the money surgery and other physician services. Dr. Opelka must be recouped in future years. Because of outlined this proposal, developed by the College the cumulative nature of the SGR, the cost of and the American Osteopathic Association, in repealing the SGR is estimated at $218 billion his testimony on July 27. The proposal would over 10 years. eliminate the universal volume target of the Because of the belief that improved patient SGR and replace it with the service category outcomes will ultimately reduce costs, any ef- growth rate, with separate volume targets based fort to reform the Medicare physician payment on the type of service. Not only would this system will almost certainly include some form proposal recognize that some services, such of P4P. All three bills discussed earlier would as major procedures, are not experiencing the attach an incentive or reward to participation same volume growth as other services, but it in a quality measurement program. Both H.R. also would provide a framework for initiating 3617 and S. 1356 would base Medicare reim- a basic P4P system with measures are that are bursement levels on participation in a quality applicable to the specific type of service and have reporting program and ultimately on patient proven to be effective. For example, in the case outcomes; and although H.R. 5866 would not of major procedures, measures that could apply directly link Medicare payments to quality re- to most situations and may improve patient out- porting, it would allow participating physicians comes include preoperative smoking cessation, to “balance bill” high-income Medicare patients. marking the surgical site, a surgical timeout, In addition, along with their quality reporting and appropriate postoperative follow-up. programs, both H.R. 3617 and H.R. 5866 would At press time, Congress had not yet taken ac- repeal the SGR. tion on Medicare payment and quality reporting. The link between Medicare payment rates College leaders and staff had been in regular and P4P was particularly evident in last year’s contact with members of Congress about the discussions regarding the Deficit Reduction need to stop the cut, the need to provide an in- Act (DRA), which retroactively rescinded the crease in Medicare payments, and possible P4P 4.4 percent payment cut that went into effect models and other payment reforms. January 1. In December 2005, during DRA negotiations with House and Senate leaders at What could a P4P structure look like in the House Ways and Means and Senate Finance the coming years? Committees, the AMA, in exchange for the guar- antee of stopping the scheduled 4.4 percent cut In discussions about the model for Medicare in Medicare payments in 2006, agreed to develop physician payment reforms, the Hospital Qual- 140 measures covering 34 clinical subjects by the ity Initiative (HQI) led by CMS has received end of 2006. The AMA also agreed to ensure that the most consideration. In 2003, as a part of physicians would report on three to five quality the Medicare Modernization Act (MMA), hos- measures in 2007. pital organizations—in exchange for full infla- The development of the 140 performance tionary payment increases in 2005, 2006, and measures is on schedule for the end of 2006, 2007—agreed to report on 10 basic measures. and the College has been actively engaged in Those hospitals not reporting the data would conversations with policymakers about sur- not receive the full payment update and instead gery’s progress in measure development and would have their inflationary payment increase the related need to avert the 5.1 percent cut. reduced by 0.4 percent in those years. Whether physicians will ultimately be required Like the HQI, physician P4P would initially to report on three to five measures come Janu- provide increased payments to physicians who ary 1 remains uncertain. follow basic protocols; ultimately, though, 10

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS policymakers want to base payment levels on cooperation with the AMA’s PCPI. The periop- outcomes. To a great extent, both Representa- erative care workgroup, co-chaired by R. Scott tive Johnson and Senators Grassley and Bau- Jones, MD, FACS, Director of the ACS Division cus envision modified versions of the HQI for of Research and Optimal Care, developed a physician P4P in their bills. Through different measure set that was scheduled for final PCPI approaches, both would set payment levels approval in October. The following measures for physicians who report on basic quality aimed at reduction of surgical infections and measures and ultimately move toward basing venous thromboembolism are included in the payment on physicians’ patient outcomes. Phy- set: sicians who do not report the quality measures • The surgeon ordered prophylactic anti- or meet the quality threshold in future years biotics to be delivered within one hour before would be paid at lower levels. Because outcome incision measurement, if wrongly structured, could un- • The anesthesiologist administered pro- dermine care provided to higher-risk patients, phylactic antibiotics within one hour before the College has stressed the importance of in- incision cluding appropriate risk adjustments. Related • The surgeon ordered appropriate cepha- provisions have been included in each of the losporin for antibiotic prophylaxis bills mentioned earlier. • The surgeon ordered prophylactic anti- Critical to a meaningful P4P system that biotics to be discontinued within 24 hours of produces better patient outcomes is the compi- surgery end-time (non-cardiac patients) lation of clinical data that cannot be captured • The surgeon ordered prophylactic anti- in claims. To this end, the College has encour- biotics to be discontinued within 48 hours of aged policymakers to not create incentives that surgery end-time (cardiac patients) would discourage surgeons from participating • The surgeon ordered appropriate venous in data-collection instruments, such as the thromboembolism prophylaxis ACS National Surgical Quality Improvement Following approval by the PCPI, the measure Program (NSQIP). One option under discussion set will be submitted to various organizations is allowing physicians to participate in clinical for additional vetting and endorsement. databases in lieu of reporting on basic quality measures. What else is the College doing regarding P4P? What performance measures might sur- geons have to report on? Over the past year, the College has dramati- cally increased its own efforts and its focus At press time, Congress had yet to define on efforts by private and government payors the structure of a pay-for-reporting or P4P to implement performance measurement and system for 2007. Measures could be very gen- value-based purchasing programs. The College eral “structural” measures, including the use continues to manage the SQA, chaired by Dr. of information technology, participation in Opelka, which includes 20 surgery-related clinical databases, or practice in an accredited specialty societies that organize efforts around facility. However, Congress could implement a quality improvement initiatives. To align the program similar to the PVRP discussed previ- activities and increase collaboration among ously, in which performance measures are sub- surgical specialties, the SQA coordinates let- mitted through the claims processing system. ters to private and government entities on This system would likely include process (not behalf of the surgical community. The SQA outcome) measures for surgery. also has provided opportunities for specialties In an effort to ensure that appropriate surgi- to speak with federal and private health care cal measures are used, the College serves as leaders to educate them about current surgical the lead organization for the development of efforts to improve quality and lower costs and perioperative care performance measures in continued on page 61 11

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 12

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he Division of Advocacy and Health (GDP). In addition, pharmaceutical costs are Policy of the American College of Sur- out of control. There has been a 1,250 percent geons has recently come out with a very increase in these costs in the last 25 years. That timely white paper entitled, “A Growing is eight times more than defense and nine times TCrisis in Patient Access to Emergency Surgical more than Veterans Affairs (VA) services and Care,”1 which addresses a true crisis in patient benefits.2 Furthermore, there are problems with care. The paper recommends some short-term malpractice insurance costs. The U.S. is the only solutions and ends with long-term solutions for Western society that has a contingency fee and dealing with the crisis. However, it is my con- where punitive damages go to the plaintiff or the tention that short-term and long-term solutions attorneys; in most instances, punitive damages tweaking the current system will not work. In were designed to fix the process or system that my opinion, because of its many problems, our is at fault. The current U.S. health care system health care system is dysfunctional and this, in could be described as the best mediocre health turn, leads to dysfunctional care. care in the world. Access to U.S. health care is a lottery, and what used to be a not-for-profit Measures of an effective system system has become a for-profit system.

In February 2000, former President Bill Clin- Origins of the crisis: Managed care ton said, “We do have the best health care system in the world,” a sentiment echoed by President To better understand the crisis in health care, George W. Bush in June 2003: “We live in a great we only have to go back a few years. When I country that has got the best health care system was growing up, there were several hospitals in in the world, and we need to keep it that way.”2 eastern Washington but no health maintenance Unfortunately, the evidence does not support organizations (HMOs). the statements of these two Presidents. One The first HMO was started just before World barometer of measuring effectiveness of a health War II. Edgar J. Kaiser founded the system care system is the average life span and the per to take care of shipyard workers, and it was capita cost. In the U.S., we have an average life a relatively effective system. It is noteworthy span of 77.8 years at a cost per capita per year that, as I personally observed, organized medi- of $4,887. Compare these figures with those in cine, including administrators and physicians, Spain, where the life span is 79.6 years at a cost shunned Kaiser and perceived it as a socialized of $1,100; Canada, where the average life span is form of medicine. The next advance in managed 80.2 years at a cost of $2,792; and Japan, where care is attributed to Alain Enthoven, a whiz kid they live an average of four years longer than we who served under Robert McNamara during do in the U.S. and at a cost of $2,003 per year.2 the early parts of the Viet Nam War.2 It was Another measure of health care system ef- Enthoven who came up with the “body count” fectiveness is the infant mortality rate. In the methodology for measuring the progress of the U.S., the infant mortality rate is 6.9 deaths per war and whether the U.S. was successful. To 1,000 live births. In Denmark, it is 5.3; France, quote a three-star general, this concept was “the 4.6; Sweden, 3.4; and Japan, 3.2. In fact, in height of arrogance.”2 After Viet Nam, Enthoven the World Health Organization (WHO) Global went to Stanford University, where he developed Ranking of Healthcare, the U.S. is number 29, his Consumer Choice Health Plan alternative between Costa Rica and Slovenia, which are both to combat the high cost of health care (10.5% developing countries.2 of our GDP) at that time. This, in turn, led to Access is a major problem in the current sys- the development of two fairly large HMOs, U.S. tem, with 44 million having no insurance and Healthcare and Humana. These were both very another 105 million underinsured. The costs of unpopular with physicians because fees were coverage are 50 percent greater in the U.S. than negotiated or salaries were provided. in any other Western society—$1.7 trillion— In contrast, the chief executive officers of these which is 16 percent of our gross domestic product firms did extremely well, and at least one made 13

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS it into the Forbes list of 400 richest Americans. From the patient’s perspective, it’s difficult to The concept of managed care also received an understand these various fees and how they are additional stimulus after Bill Clinton was elected determined. President in 1990. He charged Hillary Clinton An illustrative example is from Presbyterian/ with developing a strategy for a nationalized St. Luke’s Medical Center, a HCA hospital in health care system. The Jackson Hole Confer- Denver, CO.2 A woman gives birth to a baby girl ence was held in 1992, but its failure to include who has defective bronchial tubes. This requires the very providers of health care in this plan the baby to stay in the hospital for several weeks, was not met with enthusiasm. The conference after which time, the patient is discharged, and did lead, however, to increases in HMOs, both the father receives a bill for $213,802. This government and for-profit systems. charge is six times the father’s salary. He writes For-profit systems soon outstripped govern- back that he cannot pay this bill, and the hos- ment plans. Most of the government plans have pital responds by adjusting the bill downward been failures, including those in Tennessee by $85,520. This leaves a settlement amount of and Oregon. According to an article in the Wall $128,281, on which the hospital demands pay- Street Journal in December 2004, TennCare, a ment in 30 days. If the baby’s father cannot pay government-managed care system, cost the State the adjusted amount, he is offered a credit card. of Tennessee one-third of its entire budget.3 It The entire amount is charged to the credit card, did cover 1.3 million of the state’s 5.8 million and he has 40 years to pay at 17 percent inter- people, but the article characterized it as beset est. The total amount paid would be $777,153, by 10 years of mismanagement and lawsuits. The with annual payments of $21,833, which is two Oregon plan—championed by John Kitzhauber, thirds of the father’s annual salary. MD, an emergency physician who at the time was HCA’s record is very blemished. In 2003, the in the state senate—was very comprehensive, company made $21.8 billion in revenue. HCA but the legislature removed the portion that defrauded Medicare, Medicaid, and Tricare out would require small businesses to contribute to of $63 million and overcharged the uninsured in employee health insurance under the modified 2002 by $2.1 billion. The company has paid $840 Medicaid system. It was also very innovative million in criminal fines, civil restitution, and in that there was public input, particularly on penalties of $250 million were paid to Medicare to prioritizing the various diagnostic treatment settle overbilling. Altogether, HCA has paid more pairs; however, the legislature was not required than $1.72 billion for fraudulent practices.2 to cover all diagnoses and/or treatments. The The second largest HMO is Tenet, since buying inception of HMOs was intended to control National Medical Enterprises. Tenet physicians costs; however, corrupt management has become and administrators have allegedly overbilled pa- common. tients, insurers, and Medicare. The company has Private HMOs took off, and the largest of also charged for services and treatment never these is the Hospital Corporation of American provided; signed false insurance claims; paid (HCA), which now consists of approximately $40 million to doctors in kickbacks; and paid 200 hospitals.2 Under this for-profit paradigm, $379 million in criminal fines, civil damages, there are several tiers of fees for various dis- and penalties.2 ease processes. For example, at the Oklahoma Managed care is not limited to hospitals. There Medical Center, a craniotomy for an uninsured are very large physician practice groups that patient is $85,400. This is essentially a “retail” have also set up organizations to provide out- price. The same procedure, when billed to Blue patient care. One of the largest is MedPartners, a Cross Blue Shield, is $14,600, and the same southern California practice group that allegedly procedure under Medicare is $13,900. In Or- made $6 billion per year and in 1995 went public. lando, FL, the Seventh Day Adventist Hospital PhyCor, the second largest practice management charges an uninsured patient $35,200 for an group, proposed a merger with MedPartners.2 appendectomy, whereas under commercial in- When the books were examined, there was a surance, it’s $7,000, and for Medicare, $6,200. mythical profit, and, in fact, the company had 14

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS lost more than $1.2 billion. MedPartners went ’’ into bankruptcy, and the company was bought at a significant discount by KPC Medical Manage- ment. For the next few months, KPC offered in- surance to multiple people, and it, in turn, went bankrupt; however, the owner, Kali P. Chaudhuri, The current U.S. health MD, did not suffer personal financial losses. care system could be Call centers described as the best There are other scams that can adversely affect mediocre health care in our current health care system. One such scam is the so-called call center.2 Ostensibly, the purpose the world. Access of such call centers is to triage calls and to direct the patient to the appropriate clinics or possibly to U.S. health care is a even the emergency room. Unfortunately, these call centers are also used to delay any visits in lottery, and what used the expectation that the patient may not need it at a later date. It is particularly unfortunate to be a not-for-profit that the individuals who are doing triage may system has become have limited training and may not appreciate the emergent nature of some of these calls. a for-profit system. To better understand how call centers work, consider the example of a 74-year-old woman in San Leandro, CA. She’s been a patient at a given ’’ HMO0 for 5 years. She awakens one morning with pain in her abdomen but primarily in her back. She calls her physician’s office at 8:15 am, and this call is forwarded to a call center. The person at the call center says that her physician cannot see her today because he is not in. The ing our nighttime hours. These X rays are digi- patient’s daughter comes over, and they make tized, sent to these various centers, and a report a second call, again trying to get access to the is returned, usually within approximately 30 HMO. Subsequently, a third and fourth call are minutes. The following morning when the U.S. also made, both with an appeal to somehow be radiologists come back to the hospital, though seen by a physician. After the fifth call, shortly a therapeutic decision has been made, they do after noon, an appointment is scheduled for her “over reads” of these X rays and charge for these. to see her physician at 4:30 pm. He sees her and In many instances, the surgeon or specialist makes an immediate diagnosis of an abdominal surgeon has already read his or her own X rays aortic aneurysm and sends her to the hospital, at night or relied on the report from the “Night whereupon the aorta ruptures. She is rushed Hawk” radiologist. This is unethical. for emergency surgery and receives 20 units of blood. Postoperatively, she never regains con- Bureaucracy sciousness and dies. There are offshore call centers that handle With the development and expansion of physicians’ appointments and even diagnostic ca- HMOs, the medical bureaucracy—includ- pabilities, such as X rays. Many of these centers ing Current Procedural Terminology (CPT) go under the rubric of “Night Hawk” and may be codes—has also soared.2 There are more than located in the U.S. or abroad. These diagnostic 7,800 of these codes that allow physicians and radiology call centers primarily read X rays dur- hospitals to bill patients through their insurance 15

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS companies. These CPT codes are developed by ship primarily sells Lupron, a medicine for pros- the American Medical Association (AMA), which tate cancer that essentially does an endocrine has a 16-member editorial panel, including 11 orchiectomy. The other drug marketed by this physicians, that applies five-digit numbers to firm is Prevacid, a drug for acid reflux. Starting various diagnoses and procedures. These codes in the mid-1990s, TAP provided free samples of are used throughout the U.S., and royalties are Lupron to urologists. It was heavily marketed, charged for these codes. This brings in approxi- and 14,316 urologists prescribed Lupron in mately $70 million to the AMA.2 1997. It is noteworthy that 482 of these urolo- There are geographic differences in what these gists received 25 percent of the entire Medicare procedures are worth, and there is manipula- payments ($126 million) for Lupron. Overall, tion of the codes by applying modifiers dealing TAP made $2.5 billion. In many instances, with complexity and time spent. This leads to a the free samples were sold by the physicians “reimbursement jungle.” There is an American to the patients and they also billed Medicare. Academy of Professional Coders, which consists TAP provided a 2 percent management fee to of more than 35,000 members.2 Their job is to high-volume urology practices and a $25,000 maximize billing or, if they work for the govern- unrestricted educational grant. For urologists ment, to make sure that the codes are legitimate. who were particularly frequent prescribers of In Seattle, there are more than 755 health insur- Lupron, lavish entertainment and trips were ance products. This plethora of health insurance provided by TAP. products is due to various coders from different But TAP is not the only pharmaceutical firm organizations trying to maximize the billing. It is involved in fraud cases. Under similar circum- no wonder that the patients cannot understand stances, Pfizer was fined $49 million for its drug, the concept of retail prices, insurance prices, and Lipitor. Glaxo-Smith-Kline was fined $88 million Medicare prices. Similarly, there are length-of- for fraud in marketing Paxil, an antidepressant. stay guidelines developed by Milliman, which are Bayer paid $275 million in fines for its drug Ad- used in utilization review and reimbursement of olat, a drug for high blood pressure. Astra Zeneca hospitals by insurance companies. Some of these was fined $355 million for misuse of Zoladex, a guidelines are arbitrary and essentially relieve drug similar to Lupron.2 the physician or health care extender (NP, PA) of using judgment. Workforce shortages The cost of the medical bureaucracy is stagger- ing. In the U.S., it’s $1,059 per capita per year. In There are numerous other problems adversely contrast, in Canada, it’s $307. In the U.S. health affecting health care delivery. In 2002, Cooper care system, administrative workers account for published an article on physician supply.5 He 27.3 percent of total health care costs. In Canada, predicted that there would be a shortage of this figure is 3.1 percent. If the U.S. had a single physicians that would not be relieved by physi- payor system, this would save $375 billion a year cian extenders, including nurse practitioners in health care costs, according to a 2003 article and physicians’ assistants. A follow-up paper in in the New England Journal of Medicine.4 The 2004 stated that by 2020, the deficit will be as authors of this study estimated that there are great as 200,000 physicians, primarily special- 1 million workers (specifically, middlemen) who ists, particularly in the surgical fields but also are doing unneeded work. gastroenterology and cardiology.6 This shortage will have a profound negative effect in several Pharmaceuticals areas—including rural surgery and care for the elderly—and, as noted in the ACS’ white paper Physicians and pharmaceutical companies also mentioned previously in this article, is already contribute to unneeded charges. A particularly a major problem in trauma and emergency noteworthy example is what happened with TAP, surgery. a partnership of Abbott Laboratories in the U.S. The shortage of trauma surgeons is now ex- and Takeda Laboratories in Japan. This partner- acerbated and will be worse in 2010 when the 16

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 1 Baby Boomers begin to reach age 65. The average age of a general surgeon in the U.S. is 52 years. There has been a recent decline in applicants to general surgery programs, and this is further influenced by gender. (See Figures 1 and 2, this page). Graduating medi- cal students are at least 50 percent female, but very few apply to general surgery (7%, or a little more than 500 ap- plicants).7 Based on my own observations over the past 20 years, part of this disinterest in general surgery seems to be the hours required, part of it is lifestyle, and part of it is a desire to combine a profes- sional career with a traditional role as a parent, and it also re- flects that the general surgery Source: National Residency Matching Plan. Available at: http://www.nrmp. programs have not provided a org/matchoutcomes.pdf. Published in Archives of Surgery.7 structure whereby physicians can do both. In addition, general surgery Figure 2 continues to become more fragmented and specialized, but the general surgery spe- cialists have one commonal- ity: they don’t want to take trauma call. In a 1990 study, Esposito polled all surgeons in Washington state about treat- ing trauma patients (response rate of 50%).8 The top four fac- tors influencing the decision not to treat trauma patients were time commitment, com- pensation, dissimilar reim- bursement, and a perceived increased medical/legal risk. In the ACS’ white paper, similar findings were found.1 The report indicates that sur- geons are taking call five to 10 Source: National Residency Matching Plan. Available at: http://www.nrmp. times a month; they may do org/matchoutcomes.pdf. Published in Archives of Surgery.7 this at two or more hospitals, and the hospital bylaws, which 17

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS typically require surgeons to participate in on- jury severity score >15 is 3.5 times higher than call panels, may allow older surgeons to opt out. the rate for their younger counterparts. They There was a perception by surgeons that they spend more time in the intensive care unit and were being sued by patients who were first seen do not have a good return to independent living in the emergency department. status or quality of life after trauma episodes. A problem that is not mentioned in the white The lack of general surgeons also negatively paper is that specialty surgeons and general affects the Department of Defense (DOD) and surgeons are increasingly asking for exorbi- its need for surgeons. Approximately 20 percent tant on-call pay. This monetary request ranges of DOD surgeons are active-duty surgeons; 80 anywhere from $1,000 a night to more than percent must come from the reserve. Unfortu- $7,000 in some of the subspecialties, such as nately, young surgeons do not tend to join the neurosurgery. reserves. Studies conducted by the U.S. General A related problem is the recruitment of Accounting Office after Desert Storm showed medical students into general surgery and some that surgeons were not being trained properly surgical specialties, particularly neurosurgery for trauma, particularly the active duty sur- (see Table 1, this page). The data from the Na- geons; however, the DOD has recently improved tional Residency Matching Program show the this over the last four years.9-11 number of positions offered by general surgery Another negative impact on trauma care and neurosurgery are flat or slightly decreased, is that many trauma centers are closing or whereas the number of positions in orthopae- downgrading their level of care. Since 2003, dics is slightly increased. Also note that general “dumping” has become an increasing problem surgery and, to a lesser extent, neurosurgery in for level I and II trauma centers. This phenom- the U.S. have depended on international medical enon is characterized by community hospitals graduates to fill their available positions. calling the trauma centers and speaking to an A major problem by 2010 will be the 30 percent emergency physician or surgeon because they increase in the elderly population. It used to have a trauma case that they cannot provide be that the peak in death rate from injury was care for—either because of lack of personnel or in the age range of 16 to 24 years. We are now the patient’s case is too complex. Once many seeing a bimodal distribution with an increased of these patients reach the trauma center, they death rate in the elderly. They are more active, are observed and then discharged the following and unfortunately, the mortality rate for an in- morning.

Table 1: Positions offered in various specialties and percentage filled Specialty 2002 2003 2004 Offered % filled, U.S. % total Offered % filled, U.S. % total Offered % filled, U.S. % total General surgery 1,039 75.3 94.4 1,049 82.7 99 1,044 84.8 99.8 Neurosurgery 39 74.4 82.1 39 94.9 97.4 43 86.0 88.4 Orthopaedics 569 93.0 99.3 575 92.7 98.8 589 93.0 99.8

Specialty 2005 2006 Offered % filled, U.S. % total Offered % filled, U.S. % total General surgery 1,051 80.4 99.3 1,047 83.3 99.9 Neurosurgery 19 84.7 89.5 18 83.3 88.9 Orthopaedics 610 91.0 99.2 615 89.6 97.4 18

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Another major problem in trauma care is What can be done? that rehabilitation beds are not available after a severe injury. The General Accounting Of- The solutions necessary for this dysfunctional fice did a study showing that only one in eight health care system will require a major para- patients with traumatic brain injury receive digm shift. I do not believe that tweaking the appropriate rehabilitation following their current system or maintaining the status quo acute care.12 Rehabilitation is particularly a will be acceptable. The current system is an ad- problem in patients who have no insurance. mixture of employer/employee (patient), union- I treated a male patient approximately eight negotiated health care. There is government- months ago who was 36 years of age, mar- provided health care, including the military, ried, and had four sons. He started his own VA, and public health. There is government- construction company but, unfortunately, he contracted health care, which is made up of did not have enough money to buy health in- Medicare, Medicaid, and Tricare. And there are surance, which would have cost $6,000 a year a number of patients who are not insured or for a family of six. He fell while constructing underinsured. This system is aggravated by a a building and became paralyzed. As a result free-enterprise pharmacy industry and a medical of the accident, his acute care was provided by litigation system that does not fix what’s wrong my hospital free of charge, but we could not with health care and that primarily benefits find a rehabilitation facility that would take trial lawyers. him. We taught his wife the bare necessities There is no question that the current system of care for a paraplegic, but obviously he is at is already undergoing some changes and/or high risk for complications, and with his wife tweaking based on the global economy. In doing most of the care at home, she will be un- Thomas L. Friedman’s book The World is Flat, able to work and provide for the family. With he points out that the U.S. is already outsourcing so many stories like this, it is not surprising pharmaceuticals, and we even outsource some that the WHO ranks U.S. health care in the surgical procedures.13 We have been importing range of developing countries. health care professionals for many years—

Table 2: Comparison of costs of procedures in the U.S., India, Thailand, and Singapore

U.S. insurers’ cost U.S. retail India Thailand Singapore

Angioplasty $25,704–37,128 $57,262–82,111 $11,000 $13,000 $13,000

Gastric bypass 27,717–40,035 7,988–69,316 11,000 15,000 15,000

Heart bypass 54,741–79,071 122,424–176,835 10,000 12,000 20,000

Heart balve 71,401–103,136 159,326–230,138 9,500 10,500 13,000

Hip replacement 18,241–26,407 43,780–63,238 9,000 12,000 12,000

Knee replacement 17,627–25,467 40,640–58,702 8,500 10,000 13,000

Hysterectomy 9,591–13,854 20,416–29,489 2,900 4,500 -----

Spinal fusion 25,302–36,547 62,778–90,699 5,500 7,000 9,000 19

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS primarily nurses, but more recently physicians This is potentially the biggest pool of talented and surgeons. In order to fill general surgery individuals who could solve the shortage of gen- slots, 18 percent to 23 percent are being filled eral surgeons. In order to attract them into the by foreign medical graduates. I’ve already men- specialty, we will have to solve lifestyle issues tioned in this article that the U.S. outsources di- such as protected time, both during training agnostic radiology—the country also outsources and during their practice. Emergency medicine medical bureaucracy, and medical call centers has increasingly become an attractive career serving the U.S. are common in India. It is ironic choice for women because they can do shift work. that one of the top three reasons for U.S. manu- The concept of the emergency general surgeon facturers to outsource to Asia and Mexico is the who would do trauma and emergency surgery high cost of U.S. health care.13 is most likely going to be accomplished by full- Outsourcing surgical procedures is already time surgeons who do shift work in acute care a reality, and patients are traveling to India, hospitals. Based on a 40-hour workweek, full- Thailand, and Singapore for major surgical time surgeons work approximately 160 hours procedures.14 As shown in Table 2 on page 19, a month. To assign 12 or 13 shifts of 12 hours the cost to hospitals for each operation, based each would come close to this, which means on U.S. insurers’ cost and U.S. retail cost, are that within a two-week period, a surgeon could compared with the same costs in India, Thailand, fulfill his or her workload and have the next two and Singapore. It should be noted that the costs weeks off. (There are obviously many variations in these countries as shown in the table include of this model.) This is precisely what occurs in airfare.14 emergency medicine. Hospitals could participate There are many disadvantages to a “world is by providing 24-hour child care for physicians flat” model. This includes the brain drain from and nurses. There are probably few perks that these developing countries. There is also a major would be more attractive from the standpoint problem in assessing knowledge and professional of maintaining a professional career and a tra- competence. For example, India has 205 medical ditional role as a parent. schools, of which 20 are private.15 Medical de- grees from these private schools can sometimes Health care as a public good be bought. A recent study in the British Medi- cal Journal showed that the state-run medical I have noted elsewhere that most economists schools in India have problems with infrastruc- argue that medicine should be considered a ture, such as inadequate faculty and facilities, in public good similar to military, firefighters, and almost 50 percent of these state-run schools.16 police.17 This public good could be provided by Another problem exists in regards to import- government-directed care as opposed to con- ing surgeons from these countries. The only test tracted care. The access problem would certainly they must pass is the U.S. Licensing Medical be solved. The disadvantages of a public good Examination. This exam does not include knowl- model is it does not address who pays, costs may edge or psychomotor tests related directly to be excessive, and there would be a loss of incen- surgery. Knowledge tests could be developed that tives. Detractors of the public good model also would be similar to the ones that the American point to the European experience as an example Board of Surgery administers, and with virtual of “bad” care, largely due to the wait time for simulators, psychomotor skills could be tested. elective surgery cases. This is particularly true These virtual simulators, however, are quite in England and Scandinavian countries. Detrac- costly. Probably the biggest disadvantage of the tors also complain about the lack of specialty “world is flat” model is that it is a short-term surgeons in just a few centers. In most public solution. It does not ensure a steady output of good systems, there is still a double standard, as physicians and/or specialists in the U.S. some individuals will always pay more through A vexing issue is the one of gender. At the insurance or through their own means to have present time, female medical students mostly “better” care, usually characterized by upscale have not been attracted to the field of surgery. private hospitals and clinics. 20

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Solutions commission’s first charge would be to determine who pays how much now. This would include In the recent book Critical Condition, Bar- government, such as VA, Tri-Care, Medicare, lett and Steele suggested 13 solutions for the and Medicaid. It would also include commercial dysfunctional U.S. health care system.2 They insurance that employers pay for and Workers’ argue strongly for universal health care, which Compensation. The commission should then de- I would strongly support. They also argue for a termine if the amount paid by the various payors single payor system. This approach may or may is fair. If not, it should assign a percentage or per not be the best method. Countries such as Ger- capita amount to the various groups. many have a multiple payor system that seems I would propose that the remainder of the costs to work quite well and may provide competition would be paid by a value-added tax on essentially by insurers. all goods. That means that all potential users of The authors also argue for a commission, the health care system would be responsible for which they arbitrarily name the U.S. Council on a share of medical costs. Healthcare, to oversee this change. They suggest I personally would favor a multiple payor sys- that this be modeled after the Federal Reserve tem. The health care commission would also have System and be a quasigovernment council. My to address such issues as responsibility of provid- impression is that the Federal Reserve is a very ing care, as in the example of retirees: Is contin- ponderous bureaucracy and not one to emulate. ued medical care and/or insurance after retiring Every patient in this new system would have a the responsibility of the firm they worked for or defined level of basic care; there would be flexible the government, or is it a shared responsibility? copays and catastrophic care. All of these items I Another issue that may have to be addressed if would certainly support. The patient would have managed care organizations continue in the U.S. freedom of choice, both for physicians and hos- is the creation of a watchdog organization with pitals, and this is also easily supportable. There teeth that could deal with corrupt practices. would be a disease prevention component to the Corrupt management should not be tolerated. If solutions to the crisis, and this is sorely needed. the U.S. had universal health care, it is projected Japan’s very strong disease prevention emphasis that one-fourth of the current budget would be most likely contributes to the increased longevity eliminated just simply by eliminating the bu- of its citizens. Barlett and Steele also argue that reaucracy of the current system.4 there should be a curtailment of out-of-control I would favor arbitration or medical courts to drug costs. There should be patient education solve the malpractice issue. One of the more vex- and oversight of insurers. The final two solutions ing issues is how to solve pharmaceutical costs. would be to reverse overdiagnosis/overtreatment There are lots of problems with the current sys- and to arbitrate malpractice cases. tem. Congress has contributed to these problems, A simpler set of solutions has been proposed such as by forbidding Medicare to be able to nego- by the Progressive Policy Institute.18 This group tiate with pharmaceutical companies in order to argues for universal health care equal to what get discounted drugs on a mass purchase basis. the members of Congress have, which would also Another practice that has to be discouraged is require a shared responsibility for the cost of the relationship of pharmaceutical companies coverage. Physicians and hospitals would be paid to physicians. “Detail” men and women should according to their performance, and information not be able to give free drugs and/or free trips to technology would be deployed for better care physicians or pay for educational expenses. and lower cost. Health courts would be created for reliable justice in malpractice cases, and a Summary national care center would be created to speed medical breakthroughs. In summary, the current U.S. health care sys- Another vexing solution will be payment of tem is broken. It is a high-cost, mediocre system. the system. I believe a national commission on Access is a major problem. Pharmaceutical costs health care should be appointed by Congress. The are out of control. Malpractice insurance costs 21

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS are egregious, and there is no question that solu- rar, Straus and Giroux; 2005. tions will be difficult. In my opinion, leadership 14. Kher U. Outsourcing your heart. Time. May 21, 2006. Available at: http://www.time.com/time/ will not come from the Executive Branch of our magazine/article/0,9171,1196429-1,00.html. Ac- government, and Congress is so partisan at the cessed October 5, 2006. present time that the elected officials are simply 15. Directory of Medical Schools in India. Available impotent in dealing with health care and other at: www.iime.org/database/asia/india.htm. Ac- cessed September 1, 2006. problems. Until recently, organized medicine has 16. Kumar S. Report highlights shortcomings not provided any solutions either. I believe the in private medical schools in India. BMJ. American College of Surgeons has been taking 2004;328:70. a leadership role. However, long-term solutions 17. Trunkey D. What price commitment? Bull Am will require more than tweaking the current Coll Surg. 2003;88:4-16. 18. Kendall D. Fixing America’s healthcare sys- dysfunctional system.  tem. Available at: www.ppionline.org/ppi_ ka.ctm?knlAreaID=111. Accessed September 1, References 2006. 1. Division of Advocacy and Health Policy. A grow- ing crisis in patient access to emergency surgical care. Bull Am Coll Surg. 2006;91:9-18. 2. Barlett DL, Steele JB. Critical Condition. New York: Doubleday/Random House; 2004. 3. HillaryCare in Tennessee: The disaster that might have been for the entire country (editorial). Wall Street Journal. December 6, 2004. Available at: www.opinionjournal.com/forms/printThis. html?id=110005987. Accessed September 22, 2006. 4. Woolhandler S, Campbell T, Himmelstein DU. Cost of health care administration in the United States and Canada. N Engl J Med. 2003;349:768- 775. 5. Cooper RA, Getzen TE, McKee HJ, Land P. Eco- nomic and demographic trends signal an impend- ing physician shortage. Health Aff. 2002;21:140- 154. 6. Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med. 2004;141:705- 714. 7. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: The potential impact on general surgery. Arch Surg. 2002;137:259-267. 8. Esposito TJ, Maier RV, Rivara FP, Carrico LJ. Why surgeons prefer not to care for trauma patients. Dr. Trunkey is profes- Arch Surg. 1991;126:292-297. sor of surgery, Oregon 9. Operation Desert Storm: Full Army medical capa- Health & Science Uni- bility not achieved. Washington, DC: U.S. General versity School of Medi- Accounting Office; 1992. GAO/NSIAD-92-175. cine, Portland, OR. 10. Operation Desert Storm: Improvements required in the Navy’s wartime medical care program. Washington, DC: U.S. General Accounting Office; 1993. GAO/NSIAD-93-189. 11. Operation Desert Storm: Problems with Air Force medical readiness. Washington, DC: U.S. General Accounting Office; 1993. GAO/NSIAD-94-58. 12. Traumatic brain injury: Programs supporting long-term services in selected states. Washington, DC: General Accounting Office; 1998. GAO/ HEHS-98-55. 13. Friedman TL. The World Is Flat. New York: Far- 22

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS urgical care in this country has made the CON process, it also controls which tremendous strides over the past cou- surgical specialties may apply for exemp- ple of decades. New technology and tions to the CON process for ASCs. In fact, improvements in surgical technique under the state’s CON program, single Shave revolutionized the provision of this care, specialty ASCs are exempt from the CON including a shift in site of service for some requirements and do not have to obtain procedures from hospitals to ambulatory a CON to build and operate their facility. surgery centers (ASCs). Millions of patients Rather, they must apply to the Department benefit from this change, receiving high- of Community Health (DCH) for a letter of quality, cost-effective, and safe surgical care non-reviewability (per regulations issued in for a variety of surgical procedures. 1998). Because general surgery is defined In some states, certificate of need (CON) as a “multispecialty” rather than a “single laws can be highly restrictive when it comes specialty,” general surgeons are ineligible to the construction of ASCs, making it more for the exemption. difficult for patients to receive care in these In other words, the state of Georgia, settings. One state in particular, Georgia, contrary to every other state in the nation, not only tightly controls the development of considers general surgeons to be nonspe- health care facilities and services through cialists.

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NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Why Georgia’s CON rule is a problem vide Georgia surgeons the opportunity to send Because of the current definition of general a letter to Gov. Sonny Perdue (R), urging him to surgery in the state’s CON regulations, general work with the DCH to address this issue. surgery groups have been prevented from open- ing ASCs in Georgia. One in particular, Albany The origin of CON regulations Surgical PC, began the process in a different During the 1970s, the federal government en- way: Instead of applying for a letter of non-re- acted legislation requiring states to adopt CON viewability they knew the proprietors wouldn’t programs. The intent of CON legislation was to get, they filed a lawsuit to overturn the defini- restrain skyrocketing health care costs, prevent tion of general surgery as a multispecialty. As the unnecessary duplication of health resources, the lawsuit worked its way through the Georgia and achieve equal access to quality health care at courts, the American College of Surgeons and a reasonable cost. By the early 1980s, most states the Medical Association of Georgia filed amicus were in compliance, although by 1986, Congress briefs in support of Albany Surgical. After years had repealed this requirement in light of the of legal wrangling, the state’s Court of Appeals ascendency of free markets and competition and ruled that general surgery did not qualify for decreasing reliance on government regulation. the single specialty exemption, and the Georgia The U.S. Federal Trade Commission and Supreme Court affirmed that the regulation the Department of Justice issued a report— defining general surgery as a multispecialty Improving Health Care: A Dose of Competi- was authorized by the CON statute. However, tion—in 2004, recommending that states with the courts did rule DCH had the authority to CON programs should reconsider whether these determine what a specialty was and how it was programs best serve their citizens’ health care defined. needs. This report notes that, “On balance, CON programs are not successful in containing Additional attempts to change the rules health care costs, and that they pose serious anti- After the case was finished in 2003, other competitive risks that usually outweigh their efforts were undertaken to gain recognition purported economic benefits. Market incumbents for general surgery as a single specialty in the can too easily use CON procedures to forestall CON rules. In 2004, the DCH considered revi- competitors from entering an incumbent’s mar- sions to its guidelines governing CON for ASCs, ket.... Indeed, there is considerable evidence that with organized medicine urging the group to CON programs can actually increase prices by add general surgery to the definition of a single fostering anti-competitive barriers to entry.”* specialty. The DCH insisted it did not have the authority to do this despite the specific rulings Further advocacy—Change the definition of the appellate courts to the contrary. Subse- In 2005 and 2006, other efforts were under- quent to this, the Board of Community Health taken to revise the definition of general surgery. was asked to consider a similar action, but an The Georgia General Assembly, while refusing to opinion issued February 1, 2005, from the attor- pass legislation to do so, did adopt a bill establish- ney general’s office reiterated the position that ing the State Commission on the Efficacy of the the department does not have the authority to Certificate of Need Program in the Department revise what is in the CON statute. of Community Health; its mission is to conduct Georgia Attorney General Thurbert E. Baker a broad study of the CON program and report was asked to reconsider the previous opinion back with recommendations by July 1, 2007. and issue an opinion putting his office in line As such, the commission began meeting on a with the courts by stating that the DCH has full monthly basis. authority to promulgate rules defining what At one such meeting, in October 2005, Thomas is or is not a single specialty within the CON Gadacz, MD, FACS, ACS Governor for Georgia, process. In addition, the Surgery State Legisla- *U.S. Department of Justice. Improving health care: A healthy tive Action Center, a Web-based advocacy tool dose of competition. 2004. Available at: http://www.usdj.gov/atr/ sponsored by the College, was activated to pro- public/health_care/204694.htm. Accessed May 18, 2006. 24

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS testified on behalf of the Georgia Chapter that From this point forward general surgery is a single specialty. Not only The ACS, Georgia Chapter, the GSGS, and did he thoroughly describe the education and MAG will continue to advocate on behalf of gen- training that general surgeons receive, but he eral surgeons. The GSGS has hired an executive presented letters from the American Board of director/lobbyist to assist with these efforts. Medical Specialties, American Medical Associa- Advocacy will certainly focus on the definition tion, American College of Surgeons, American of general surgery but could expand to complete Board of Surgery, American Society of General repeal of the state’s CON program (depending Surgeons, Georgia Chapter, and Georgia Sur- on the CON Commission report recommenda- gical Society that general surgery is a single tions). specialty. An independent political action committee Not unexpectedly, the commission voted to (PAC) was formed earlier this year with the continue to discuss the issue and to address it in stated goal of repealing CON in Georgia. The the final report for the legislature in 2007. CON PAC believes that CON regulations are In February 2006, the Georgia Health Strate- unconstitutional, stifle free markets, and dis- gies Council invited representatives from the criminate against physicians. Georgia Chapter, Georgia Society of General In the interim, it is important for Georgia Surgeons, and Medical Association of Georgia to general surgeons and their allies to attend address the issue of general surgery as a single meetings of the CON Commission, Board of specialty. Once again, Dr. Gadacz presented in- Community Health, and Health Strategies controvertible evidence that general surgery is Council to maintain visibility and involvement a single specialty, only to have politics and profit in the process. Hospital representatives are al- win out over patient care when the council voted ways in attendance at these meetings, as they 12-9 to table revising the definition until the clearly understand the importance of advanc- commission presents its report. ing their agenda within the state’s regulatory Also in February, surgeons met with Rhonda Me- structure. (The meeting dates are available at dows, MD, the new Commissioner of the Georgia the DCH Web site at http://dch.georgia.gov/02/ Department of Community Health. At this meet- dch/home/0,2467,31446711,00.html). Georgia ing were W. Lynn Weaver, MD, FACS, President of hospitals do not want to compete with ASCs the Georgia Chapter; Lamar McGinnis, Jr., MD, and will do whatever it takes to keep general FACS, ACS Representative; Chris Smith, MD, surgeons (and any other specialists) from being FACS, president of the Georgia Society of General able to open these facilities. A recent example of Surgeons (GSGS); and Dr. Gadacz. During this such efforts is that hospitals have been buying collegial conversation, Dr. Medows recognized up surgical practices, achieving greater control general surgery as a single specialty. over the health care marketplace in their geo- graphic areas, and ensuring that freestanding No meetings in Georgia ASCs won’t be built. The College received a request from the Medi- Finally, Georgia surgeons should be staunch cal Association of Georgia (MAG) that the ACS grassroots advocates and regularly contact inform Governor Perdue and the state Chamber their state legislators to discuss these issues. of Commerce that the College would no longer Ultimately, it will be up to the Georgia General conduct meetings in Georgia until the general Assembly to act on the recommendations coming surgery situation is resolved. The ACS Executive from the CON Commission, and established rap- Committee agreed to this request in December port with legislators will be essential for surgery 2005, and the governor and Chamber of Com- to achieve desired results: recognition of general merce were notified of this decision in early Janu- surgery as a specialty. E ary 2006. The economic impact of this decision is sizeable, since the College’s annual Clinical Congress generates an economic benefit of $30 million to $60 million. 25

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Authors’ note: This is the third in a series of articles we have prepared for publication in the Bulletin, focusing on how the crew resource management (CRM) training techniques used in avia- tion may be applied in surgery. In the first article of the series (Bull Am Coll Surg. 2006;91[2]:10-15), we presented the basic concepts of CRM training and its possible application in the operating room. In the second article (Bull Am Coll Surg. 2006;91[6]:24-26), we focused on the seven principles for leading high-performance teams. In this article, we discuss the learned behaviors of effective leaders. 26

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS iven the intensity of surgical train- the team assembled. In addition, he neglected ing, many individuals assume that to educate the team and develop a plan of ac- once a resident has mastered the tion to deal with any eventuality. In spite of technical skills and scientific knowl- his military training, the author had failed edge involved in surgery, his or her education his first test of leadership. Needless to say, is complete. However, research in other in- the valuable lesson this experience provided Gdustries shows that technical excellence alone remains with him to this day. does not always guarantee a positive outcome. As this example demonstrates, being a Because the systems in which surgeons work good leader and getting the most from a team are becoming increasingly complex, and be- are not directly linked to clinical expertise. cause of the heightened emphasis on patient Leadership requires formal training centered safety and performance measures, surgeons on advancing the associated behaviors. Be- must position themselves not only as trained cause leadership is a learned skill, it requires technicians, but also as leaders of high- constant practice and reinforcement until it performance teams. Furthermore, effective becomes second nature. Furthermore, the cul- leadership is rooted in formal training tar- ture within which one operates must reinforce geted at developing the behaviors necessary these behaviors. to bring out the best in each member of the operative team. Command Soon after starting his practice, one of the Before discussing leadership, a closely re- authors of this article (GBH) encountered lated but significantly different concept must a patient in extreme airway distress with a be addressed: command. Command involves a massive obstructing carcinoma of the larynx. governing figure granting another individual Feeling immense confidence in his surgical the power to exercise authority in a formal ability after five years of training and two and, oftentimes, impersonal way. Command years in the military, the author took the pa- is prevalently addressed in military, aviation, tient to the operating room for an emergency and some business circles, but it is infrequent- tracheotomy. Believing that no unmanageable ly discussed in the health care setting. problems would arise, the surgeon chose not Because representatives of many different to discuss a plan of care with either the nurses specialties often collaborate on a case, it is or anesthesiologist assigned to the case. But common for people of equal rank to compete suddenly, as the patient was being prepared, for final authority. However, if a team or an he arrested. The young anesthesiologist as- organization can formalize who is in command signed to the case had never experienced this for any given procedure, more effective team- situation and literally froze. He was helpless to work is possible. In the operating room or a establish an airway by intubation. The nurses catheter laboratory, it is much more evident present were giving lunch relief to the regular who will be in command. Nonetheless, that nurses assigned to the room and were inexpe- individual must still serve as a good leader. rienced in this type of situation and, thus, of In discussing leadership in aviation, it is no help. Thus, this surgeon had placed himself important to remember that a commander who on a surgical island of his own creation, sur- seeks to capture the team’s collective wisdom rounded by a group of individuals who were of is not suffering from “paralysis by analysis” or no assistance to the most important person in encouraging “groupthink.” Rather, he or she is the room: the patient. After shouting numer- employing a highly effective model for achiev- ous commands to a dysfunctional team, the ing the best outcomes. Nothing we discuss surgeon was able to perform a cricothrotomy regarding gathering input or even changing an and establish an airway while getting cardiac opinion based on that input reduces the real or function to resume. perceived authority of the person in charge. This inexperienced surgeon failed to exercise Again, no direct parallel exists in health any leadership and to evaluate the skills of care, but the federal regulations and com- 27

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS pany manuals that apply to aviation all state Think about the different teams on which you unequivocally that the pilot is in command and have served. How did the teams with a positive is responsible for the safety of the passengers, climate differ from those with a poor climate? crew, cargo, and aircraft. The captain is account- Which ones functioned better? able for every aspect of a flight. Although maxi- A study by Robert Ginnett, PhD, shows that mum collaboration is encouraged, for a team to the long-term outcome of a team’s performance operate effectively, there must be one—and only can be determined within its first 90 seconds one—final decision maker. together.* A team with a leader who gathers the team together to discuss the procedure before- Leadership hand always performs better than a team that Leadership is defined by the commander’s skipped the preoperative briefing. Briefings allow willingness to let team members exercise their the team to review the case and set expectations. rights and responsibilities to ensure a safe and They also include discussion of contingency plans positive outcome. In other words, although there in the event of complications. Dr. Ginnett’s study can be only one commander, anyone on the team also showed that teams that conducted briefings can exhibit leadership. Also note that leadership performed better when faced with a surprising is both a right and a responsibility. Team mem- situation, even if the contingency plan discussed bers may have a right to speak up, but they also was not the one actually used. have a responsibility to do so—in terms of health Timeouts are already used in the operating care, this means a responsibility to the patient, room, but this process should be taken one step to fellow team members, even team members’ further by expanding these timeouts into more own professional conscience. comprehensive briefings. Briefings don’t have Some people may claim that ascribing these to be exhaustive. An exchange of first names, a duties to all members of the team is just “hot brief synopsis of the case, and anticipated out- tub” medicine, but exactly the opposite is true. comes in both normal conditions and abnormal How difficult do you think it would be for a ju- conditions are all that are necessary. People nior team member to suggest a difficult strategy respect strength and humanity. It is a very to a department chair, for example, and risk a powerful combination, and briefings provide public dressing down? Or even for a peer to ap- an opportunity for the person in command to proach a colleague? Team training is designed exhibit these traits. In a study at Concord Hos- not to create a perfect world but to improve pital, Concord, NH, Ginnett found that briefings synergy in an imperfect world. were either time neutral or even saved time as a So, leadership means two things: (1) individual result of better understanding of expectations. team members have a right and responsibility Briefings are an extraordinarily effective means to voice their opinions and concerns; and (2) of building loyal, highly functioning teams, and the team leader must create a synergistic envi- they establish the attending surgeon as the ronment. It cannot be emphasized enough that leader. encouraging and promoting teamwork does not Leadership is also defined by professionalism. weaken the respect that surgeons receive. Indeed, Interestingly, the very first definition of a “pro- the experience of the authors suggests that sur- fession” in the dictionary centers on the taking geons who encourage teamwork in the operating of vows in a religious community. Like religious room engender higher levels of respect. leaders, professionals in other fields typically have the highest regard for their calling and will Leadership characteristics strive to meet the highest standards. Although Teams that have effective leadership are dis- it is important that we have these expectations tinguished by the following characteristics: a of ourselves, leaders also seek to draw excellence positive team climate, briefings and timeouts, from their team members. and professionalism. *Ginnett RC. First Encounters of the Close Kind: The A good leader fosters a positive climate that al- Formation Process of Airline Flight Crews [dissertation]. New lows for a free and synergistic exchange of ideas. Haven, CT: Yale University [date not available]. 28

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS A leadership exercise to improved performance, reduced effort and During the authors’ leadership workshop, mental strain, and better outcomes. E physicians are asked to break into smaller groups and discuss the various leadership styles they observed over the years. They are asked to share stories with each other and with the whole class. Dr. Healy is otolaryn- Typical behaviors that workshop participants gologist-in-chief, Children’s Hospital, associate with poor leaders are a lack of com- Boston, MA. He is the munication skills, a tendency to guard rather Chair of the Board of than share information, an “it’s all about me” Regents. attitude, uncontrolled temper, and arrogance as a cover for low self-confidence. Conversely, the students generally describe strong leaders as excellent communicators who are willing to put the team first (sometimes at great sacrifice to themselves), highly competent, unflappable, and self-confident. This emphasis on self-confidence—among surgeons, in particular—almost inevitably leads to a discussion of the pitfalls of big egos. However, it could be asserted that surgeons, Dr. Barker is manag- like pilots, must have tremendous egos and ing principal and vice- president of research supreme self-confidence. Surgeons and pilots and development, Mach couldn’t do what they do without believing One Leadership, and in their ability to handle any problem—they Airbus first officer for couldn’t survive. Nonetheless, a good leader United Airlines, Miami, knows how to keep that ego in check to achieve FL. high performance.

Surgeon leaders Unquestionably, the current surgical train- ing process produces professionals of the highest technical caliber and cognitive abil- ity. However, these attributes alone do not guarantee positive outcomes. To achieve ex- cellence and ensure patient safety, surgeons Capt. Madonna is need a complete understanding of their role managing principal and chief executive as leaders and must undergo formal training officer, Mach One in team dynamics. A major challenge before Leadership, and a the profession is that surgeons know how to 737 captain for a major fully take on a leadership role in the clinical U.S. airline, Ft. Lauder- setting and improve the synergy of operative dale, FL. teams. Modern medicine makes extraordinary de- mands on surgeons’ time, so some readers may believe that leadership training is too time-consuming and not worth the effort. However, the experience of the authors has shown that obtaining this skill set can lead 29

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NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS t was a historic day for the American College of Surgeons on June 28, because Ithe ACS Program for Accreditation of Education Institutes made its first set of accreditation decisions. Seven institutions were accredited as level I ACS-accredited education institutes (see box, next page). The decisions were made by the Accreditation Review Committee (see box, next page) based on the review of the completed applications and surveyors’ reports. Accrediting educa- tion institutes was a significant milestone for the College. The program was officially unveiled at the 2005 ACS Clinical Congress in San Francisco, CA. The aim of the program is to offer new and innovative educational programs to sur- geons, surgical residents, medical students, members of the surgical team, and surgical patients. The program should enhance pa- tient care and patient safety through educa- tion. The goals of the program are consistent with the College’s mission. During the fiscal year 2006-2007, the ACS Division of Education expects to receive 20 to 25 applications from either level I or level II institutes. ACS staff has been contacted by several institutions about the requirements necessary to become accredited or for appli- cations. Many of the institutions requesting 34

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ACS-accredited education institutes, ACS Program for Accreditation as of June 2006 of Education Institutes Accreditation Review Committees Centre of Excellence for Surgical Education and Innovation Review Committee I University of British Columbia, Vancouver, BC Chair: Carlos A. Pellegrini, MD, FACS, Seattle, WA Peter B. Angood, MD, FACS, Oakbrook Terrace, IL Minimally Invasive Surgery Education Center Robert W. Bailey, MD, FACS, Miami, FL University of California–Irvine, School of Medicine, Mark W. Bowyer, MD, FACS, Col., USAF, MC, Burke, VA Orange, CA Daniel B. Jones, MD, FACS, Boston, MA Helen M. MacRae, MD, FACS, FRCSC, Toronto, ON Simulation and Skills Center A. Karim Qayumi, MD, PhD, FRCSC, Vancouver, BC Beth Israel Deaconess Medical Center, Lelan F. Sillin III, MD, MSEd, FACS, Rochester, NY Boston, MA C. Daniel Smith, MD, FACS, Atlanta, GA

Basic Advanced Trauma Computer-Assisted Virtual Review Committee II Experience Medical Simulation Program The University of New Mexico Health Science Center, Chair: Carlos A. Pellegrini, MD, FACS, Seattle, WA Albuquerque, NM Richard J. Finley, MD, FACS, FRCSC, Vancouver, BC Gerald M. Fried, MD, FACS, FRCSC, Montreal, QC Institute for Clinical Simulation and Patient Safety John G. Hunter, MD, FACS, Portland, OR Temple University School of Medicine, Lenworth M. Jacobs, MD, MPH, FACS, Hartford, CT Philadelphia, PA Adrian E. Park, MD, FACS, FRCSC, Baltimore, MD Robert V. Rege, MD, FACS, Dallas, TX Southwestern Center for Minimally Invasive Surgery Richard M. Satava, MD, FACS, Seattle, WA University of Texas Southwestern Medical Center, Dallas, TX Staff: Ajit K. Sachdeva, MD, FACS, FRCSC, Chicago, IL Institute for Surgical and Interventional Simulation Kathleen A. Johnson, EdM, Chicago, IL University of Washington, Seattle, WA

accreditation information are in the process of or how to apply for accreditation, please contact building their own facilities, which will house Kathleen Johnson at [email protected] or surgical skills centers. In anticipation of the work 312/202-5276. E required to process these new applications during the next year, ACS staff is aiming to recruit and train an additional 25 surveyors. Dr. Pellegrini is Henry Based on the goals of the program and the N. Harkins Professor and chair, department interest among institutions, we believe the of surgery, University ACS Program for Accreditation of Education of Washington, Seattle, Institutes will shift the paradigm for how surgi- and a member of the cal education is delivered and will enhance the Board of Regents. educational opportunities available. The insti- tutes will offer educational programs to support acquisition and maintenance of competence and maintenance of certification. The institutes will also engage in collaborative education research and development. For future information about the ACS Pro- gram for Accreditation of Education Institutes 35

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Murphy Memorial Building restored

by Stephen J. Regnier, Editor PHOTO BY ROSALINDWEDDINGS.COM BY PHOTO

36

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ttendees at last month’s Clinical Congress street level is embraced by curved stairways which in Chicago, IL, had the opportunity to return to a central porch between round pillars see the newly restored historic John B. reaching up to the portico.”1 The front of the AMurphy Memorial Building at 50 East building is dominated by high bronze doors that Erie St. This year, a number of tours of the Mur- were contracted for production through the Tif- phy Memorial were conducted during the week of fany Studios at a cost of $19,650.2 A green colored the Clinical Congress, and participants witnessed patina was added to the doors in 1987. Plans are firsthand the remarkable detail the preservation under way to restore the bronze finish and to coat architect used to bring the auditorium back to its the doors to inhibit future corrosion. original splendor. The doors are broken into sculptured panels, six of them portraying important names in medicine: (1) History Aesculapius, the Greek god of medicine who is also The Murphy Memorial Building was built in depicted on the College’s seal alongside a Western honor of Dr. Murphy (1857–1916), a founding medicine man; (2) Louis Pasteur, PhD, a French member of the College. Shortly following his chemist and microbiologist, whose discovery that death, his friends sought to honor him by forming microorganisms cause disease led to the origina- the John B. Murphy Memorial Association. A ma- tion of a preservation process that bears his name; jor goal of the association was to erect a building (3) Ephraim McDowell, MD, an American surgeon that would be the first part of a center devoted to who performed the first successful ovariotomy in education in surgery, which was also to include an 1809; (4) Joseph Lister, MD, an English surgeon auditorium and library. The Murphy Auditorium and baron, whose work ushered in the modern era was built on the property of the American College of antiseptic surgery; (5) Sir William Osler, MD, an of Surgeons, with the agreement that the College English physician perhaps best remembered as a would maintain the building as a memorial to Dr. great clinician and skillful writer; and (6) William Murphy. Crawford Gorgas, MD, a military sanitarian who Ground was broken on the Murphy Auditorium prevented the spread of yellow fever during the in 1923, and dedication ceremonies took place construction of the Panama Canal.2 June 10–11, 1926. The building was accepted by The interior of the auditorium features a large, Rudolph Matas, MD, FACS, President of the Col- domed central space. The space above the dome, lege. The cost was $600,000, subscribed by more accessible by a small elevator, housed the library than 2,000 individuals and organizations. The and reading rooms until 1963. Thereafter, it was Murphy Memorial Building was hailed by many a repository for books and used infrequently. as one of the most impressive monumental build- In the center of the north wall of the auditorium ings of the time.1 is a tall, multicolored stained-glass window with back-lighting (see photo, opposite). This magnifi- Design cent window was designed and manufactured by The architects of this gorgeous building were the Willet Company of Philadelphia, PA, and was Marshall and Fox. The architectural design of the presented by C. H. Mathiessen, a friend of Dr. auditorium was in the French Renaissance style Murphy.1 and is reminiscent of the Chapelle de Notre-Dame Adorning the walls of the auditorium are por- de Consolation, which memorializes the victims traits of Dr. Murphy; ACS Founder Franklin of a fire that destroyed the Bazar de la Charite in H. Martin, MD, FACS; and many ACS Past- May 1897. The similarity in architectural design Presidents. Most of the subjects are shown in is evident on both the exterior and interior of the presidential robes. auditorium. The entrance to the Murphy Auditorium re- Renovation mains visually striking. “A central door at the The Murphy Auditorium was first renovated in 1987, because of the growing need for space Opposite: The stained glass window in the Murphy Me- by various departments of the College. In 2003, morial Auditorium. several years after the College moved all its offices 37

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS PHOTO BY ROSALINDWEDDINGS.COM BY PHOTO

The Murphy Auditorium set up for the recent Jacobson Award banquet.

to the new headquarters building at 633 N. Saint as one of Chicago’s premier event venues. The Clair St., restoration work began on the interior auditorium can accommodate up to 210 guests for auditorium. banquets, 300 guests for receptions, 166 guests The restoration architectural firm of Antunov- for classroom functions, and approximately 520 ich Associates, under the direction of architect guests as a theater. William A. McMillan, conducted the restoration. Further information regarding the Murphy Seating was removed from the main floor area Auditorium may be obtained online at www. and a floating wood floor was installed. Moveable murphyauditorium.com, or by contacting Kelly platforms were custom-made to extend the stage Neilson, Event Coordinator, at 312/202-5298 or area an additional six feet to accommodate larger e-mail [email protected], or Susan Rishworth, stage events. A new audio/audiovisual system was Archivist, at 312/202-5270 or e-mail srishworth@ installed, and the heating and air conditioning facs.org. E systems were completely overhauled. The work was completed in June 2006 and the References Murphy Auditorium has been returned to its origi- nal glory. Virtually every detail has been restored 1. American College of Surgeons. College Properties. 3 12th ed. Chicago, IL: ACS; 1996. or replicated to its original design. 2. Garneski S. The Murphy doors present: Six impor- tant contributors to medical science. Erie News. Event venue 1986;186:1-2. The College maintains ownership of the Murphy 3. Murphy Auditorium. Available at: http://www. Auditorium and in June opened it to the public murphyauditorium.com. Accessed September 10, 38 2006.

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Edward M. Copeland III installed as 87th ACS President

Edward M. Copeland III, University of Texas, Houston, MD, FACS, a surgical oncolo- from 1971 to 1972. He became gist from Gainesville, FL, was a diplomate of the American installed as the 87th President Board of Surgery in 1971. of the American College of Dr. Copeland’s career as a Surgeons during Convoca- surgical educator began at the tion ceremonies that preceded University of Texas Medical the College’s 2006 Clinical School at Houston, and at M.D. Congress in Chicago, IL. Dr. Anderson Hospital, where he Copeland is the Edward R. progressed from assistant pro- Woodward Distinguished Pro- fessor of surgery to professor fessor, department of surgery, of surgery (1972–1982). He University of Florida College also served as project director of Medicine, Gainesville. for the National Large Bowel Dr. Copeland, a native of Cancer Project of the National McDonough, GA, received his Cancer Institute from 1981 bachelor’s degree from Duke through 1982. University, and is a 1963 Alpha Dr. Copeland’s time at the Omega Alpha graduate of Cor- University of Texas ended in nell University Medical School, 1982, when he moved to the Dr. Copeland New York, NY. He completed University of Florida College of his general surgery residency Medicine in Gainesville, serving in the department of surgery at as chairman of the department the Hospital of the University of surgery (1982–2003). He was utive Committee (1995–1996); of Pennsylvania, Philadelphia then elected distinguished pro- Secretary of the Executive (1964–1969). From 1966 to fessor—a position he has held Committee (1994–1995); and 1967, he was a research fellow since 2004. In addition, from as a member of the Commit- in the Harrison Department of 1994 to 1999, Dr. Copeland was tee on Socioeconomic Affairs Surgical Research Hospital of the first director of the Univer- (1995–1996), the Committee the University of Pennsylva- sity of Florida Shands Cancer to Study the Fiscal Affairs of nia, and from 1968 to 1969, he Center and served as the in- the College (1994–1995), and served as a clinical fellow for terim dean of the University the Committee on Physician’s the American Cancer Society at of Florida College of Medicine Health (1992–1994). the Hospital of the University (1996–1997). Dr. Copeland has been an of Pennsylvania, Philadelphia. A Fellow of the American active member of the Col- Following his residency, Dr. College of Surgeons since 1974, lege’s Board of Regents since Copeland served as a major Dr. Copeland has been an active 1997. In addition to serving as in the U.S. Army (1969–1971) participant in and leader of Chair (2003–2005), he served and received a Bronze Star for numerous College activities, in- as Chair of the Executive Com- his service in Viet Nam. He cluding serving as Chair of both mittee (2003–2005), Chair then completed an advanced the Board of Governors and of the Finance Committee senior fellowship in cancer the Board of Regents. He has (2003–2005), Chair of the Mem- surgery at the M.D. Anderson served on the College’s Board of ber Services Liaison Commit- Hospital and Tumor Institute, Governors as Chair of the Exec- tee (2001–2003), Vice-Chair 39

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of the Executive Committee land has been actively involved edge, having served as a mem- (2002–2003), and Vice-Chair as a member of the College’s ber of 17 editorial boards, of the Board (2002–2003). He Commission on Cancer. including the Journal of the has also served on the Board of In addition to his service to American College of Surgeons, Regents Executive Committee the College, Dr. Copeland has Journal of Surgical Research, (1999–2001 and 2003–2006), held many leadership posi- Annals of Surgery, Surgery, Honors Committee (1997– tions in organized surgery. Cancer, Annals of Surgical 1999 and 2003–2006), Member He has served as chairman Oncology, Cancer Research, Services Liaison Committee (1990–1991) and vice-chairman and Surgical Oncology. Fur- (1997–2003), and Finance (1989–1990) of the American thermore, he has published Committee (1994–1995 and Board of Surgery and president 435 journal articles and book 2003–2006). of the Association for Academic chapters and 84 abstracts and Dr. Copeland has also served Surgery, Halsted Society, Soci- editorials. He has been the in leadership roles on numer- ety of Surgical Chairs, Society editor or co-editor of 18 books, ous other College committees of Surgical Oncology, South- including The Breast: Compre- including Chair (2002–2003) ern Surgical Association, and hensive Management of Benign and Vice-Chair (2001) of the the Southeastern Surgical and Malignant Diseases, which Program Committee; Execu- Congress. He is a member of is now in its third edition. tive Chair (1990–1993) and many other surgical organiza- Dr. Copeland has devoted a Executive Vice-Chair (1988– tions, including the American major part of his career to sur- 1990) of the Medical Motion Surgical Association, Eastern gical research in surgical nutri- Pictures Committee; and as Surgical Society, Society of tion, metabolism, and tumor Chair of the Committee on Clinical Surgery, International biology. He has collaborated on Young Surgeons (1982–1983). Society of Surgery, and Society multiple studies funded by the He has also served as a member for Surgery of the Alimentary National Institutes of Health. of the Executive Compensa- Tract. Dr. Copeland is also the Dr. Copeland currently re- tion Committee (2003–2006), recipient of the Distinguished sides in Gainesville with his Nominating Committee of the Alumnus Award from the M.D. wife, Martha. They have two Fellows (1991–1992), Commit- Anderson Hospital and Tumor children—Ted (IV), who prac- tee on Video-Based Education Institute. tices law in Tampa, FL, and (1987–1997), and Committee Dr. Copeland has shown a Cathy, who works for Coca- on Young Surgeons (1978– strong commitment to the dis- Cola in Atlanta, GA. 1983). In addition, Dr. Cope- semination of surgical knowl-

Patricia J. Numann receives 2006 Distinguished Service Award

The Board of Regents of the College’s highest honor for her for her concerns regarding the American College of Surgeons lifelong interest in education; social setting of quality surgi- presented Patricia J. Numann, in appreciation of her influence cal practice; for her dedication MD, FACS, of Syracuse, NY, and support in shaping the ca- to the maintenance of respon- with the 2006 Distinguished reers of women in surgery; in sible, professional conduct Service Award last month acknowledgement of her skill through surgical and medical during the Clinical Congress as a surgeon; for contributions societies; and in admiration in Chicago, IL. The Board to the surgical literature in of her many accomplishments, honored Dr. Numann with the matters of surgical interest; commitment, devotion, and 40

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS unselfish service to further the ment (2002); member, Ad Hoc higher causes of the surgical Committee on the Environment profession. of Residency Education (2002); Dr. Numann is currently the American Board of Surgery the Lloyd S. Rogers Profes- (ABS) Representative to the sor of Surgery at State Uni- Advisory Council for General versity of New York (SUNY) Surgery (1999–2002); member, Upstate Medical University in Board of Regents Communica- Syracuse. She graduated from tions and Organization Liai- SUNY Health Science Center son Committees (1999–2000); (HSC) in Syracuse in 1965 member (1993–1999) and Can- and completed her residency cer Liaison Physician for the in general surgery at SUNY Committee on Cancer (1985) HSC University Hospital from and member of its Education 1966 to 1970. After completing Committee (1993–1999); Co- her postgraduate training, Dr. Chair (1982–1999) and member Numann began her service at (1976–1981), Surgical Educa- the Veteran’s Administration tion and Self-Assessment Pro- Hospital and SUNY Upstate grams 3 through 10; member, Dr. Numann University Hospital in 1970; Graduate Medical Education she continues to work as staff Committee (1992–1998); mem- surgeon there today. ber, Committee on Surgical Dr. Numann’s academic ca- Education in Medical Schools for Surgical Education; Asso- reer has been centered at SUNY (1987–1996); Chair, Nomi- ciation of Veterans Adminis- HSC, serving as assistant pro- nating Committee of Fellows tration Surgeons, Central New fessor of surgery (1970–1975), (1995); member, Task Force York Surgical Society, and Soci- associate professor of sur- for Physician Reimbursement ety of University Surgeons. gery (1975–1989), professor Review Committee (1989); Moreover, Dr. Numann has of surgery (1989–present), member, Continuing Educa- been a key contributor to the Distinguished Teaching Pro- tion Committee (1978–1988); surgical profession through a fessor (1994–present), and Dis- and member, Public Service wide body of published works tinguished Service Professor Announcement Task Force that she has authored or co- (2000–present), as well as as- (1983). authored. sociate dean of SUNY HSC Col- In addition to Dr. Numann’s In recognition of Dr. Nu- lege of Medicine (1978–1984), involvement with the College, mann’s continued and dedi- associate dean of clinical af- she has also been a leader cated service to and on behalf fairs (1989–1994), and medical of numerous organizations of the College and the surgical director of University Hospital within the surgical commu- community, the Board of Re- (1997–present). nity, including Chair of the gents is pleased to present Dr. Since Dr. Numann became a ABS (2001–2002) and founder Numann with the College’s Fellow of the American College of the Association of Women highest honor, the 2006 Distin- of Surgeons in 1974, she has Surgeons (1981), as well as an guished Service Award. made outstanding contribu- active member of the American tions to and on behalf of the and International Association College. She was Second Vice- of Endocrine Surgery, Inter- President of the College from national Society of Surgery, 1999 to 2000. She has also American Society of Breast served as a member of the Edu- Surgeons, American Surgical cation Task Force on Practice- Association, Association for Based Learning and Improve- Academic Surgery, Association 41

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College names six Honorary Fellows in 2006

Honorary Fellowship in the Malades, Paris, France. MPH, FACS, San Francisco, American College of Surgeons • Armando Marquez- CA; Carlos A. Pellegrini, MD, was awarded to six prominent Reveron, MD. Dr. Marquez FACS, Seattle, WA; Andrew L. surgeons from Switzerland, was professor of surgery, Cen- Warshaw, MD, FACS, Boston, Venezuela, Mexico, France, tral University of Caracas, and MA; Eduardo A. Souchon, MD, Finland, and Ireland during staff surgeon, Centro Médico FACS, Houston, TX; Bruce D. Convocation ceremonies at last de Caracas and Centro Médico Browner, MD, FACS, Farming- month’s Clinical Congress in Docente La Trinidad, Caracas, ton, CT; and John E. Connolly, Chicago, IL, that preceded the Venezuela. MD, FACS, Orange, CA. official opening of the College’s • Maurice E. Müller, MD. This year, 1,186 surgeons annual Clinical Congress. At Professor Müller is a founder of from around the world were the awards presentation—one the Maurice E. Müller Founda- admitted into Fellowship dur- of the highlights of the Con- tion for Continuing Education, ing the College’s Convocation gress—the following recipients Research, and Documentation ceremonies. were honored: in Orthopaedic Surgery, Berne, Sir Rickman Godlee, Pres- • Sirpa Asko-Seljavaara, Switzerland. ident of the Royal College MD. Dr. Asko-Seljavaara is a • Niall O’Higgins, MB, of Surgeons (England), was senator in the Parliament of BCh, BAO(Hon). Professor awarded the first Honorary Fel- Finland. O’Higgins is chair of surgery lowship in the College during • Jorge Cervantes, MD, and a senior professor of sur- the College’s first Convocation FACS. Dr. Cervantes is head of gery, University College, Dub- in 1913. Since then, 401 inter- the surgical program at Ameri- lin, Ireland, and consultant nationally prominent surgeons, can British Cowdray Hospital, surgeon, St. Vincent’s Univer- including the six chosen this Mexico City, Mexico. sity Hospital, Dublin. year, have been named Honor- • Claire Nihoul Fékété, The Honorary Fellowships ary Fellows of the American MD. Dr. Fékété is chief of were presented on behalf of the College of Surgeons. the department of pediatric College by the following indi- surgery, Hôpital des Enfants viduals: Mary H. McGrath, MD,

Citation for Sen. Sirpa L. Asko-Seljavaara, MD by Mary H. McGrath, MD, MPH, FACS, San Francisco, CA

Madam President, it is an of the Parliament of Finland. sinki and is the vice-president honor to present to you Sirpa She is the vice-president of the of the Health Committee of L. Asko-Seljavaara of Helsinki, Parliament Members of Uusi- Helsinki City. Finland, for Honorary Fellow- maa (South Finland) and is a Her interests in the parlia- ship in the American College of member of the Administration ment are health care, physicians Surgeons. Committee and the Committee and other health care person- Senator Asko-Seljavaara is a of Health and Social Affairs. nel, senior citizens, university plastic surgeon who has been Senator Asko-Seljavaara also politics, maritime interests, and serving since 2003 as a member sits on the City Council of Hel- environmental issues. 42

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Sirpa graduated from high scientific papers in national school in Lahti, a little city and international journals. Her 100 km north of Helsinki. Her research over two decades has hobbies as a teenager were girl focused on the development of scouting and horseback riding. new microneurovascular flaps, She met her husband, Seppo Sel- the pathophysiology and blood javaara, during a teenage theater flow dynamics in free flaps, and production in which they both the hemodynamics and wound had acting roles. Sirpa and Seppo healing of burns. have been married 38 years and Sirpa has been a guest lecturer have two adult sons and three at multiple international plastic grandchildren (Lumi who is five; surgical and burn society meet- Luka, age two; and Rasmus, who ings. She gave the 1984 Everett is also two). Sirpa’s and Seppo’s Evans Memorial Lecture for the hobbies are sailing and spending American Burn Association and time in their summer house in became an honorary member the Finnish Archipelago. of the organization. She was Dr. Asko-Seljavaara completed overseas visiting professor for Senator Asko-Seljavaara training in surgery and plastic the American Society of Plastic surgery at the University of Surgeons Educational Founda- Helsinki and joined the faculty tion in 1991. In 1997, she gave there in the department of plas- the named address, the Maliniac tic surgery. She became chief Memorial Lecture, at the annual ies and on the editorial board of the department of plastic meeting of the American Society of nine international medical surgery at Helsinki University of Plastic Surgeons in San Fran- journals. Hospital in 1990, was named cisco, CA. She was awarded the Sirpa’s great joy is teaching, professor by the president of Pohjola Award by the Finnish and she has supervised eight Finland in 1994, and was an- Medical Foundation in 2001 and graduate students for their nounced as the professor of became an honorary member doctoral examinations in the plastic surgery at Helsinki Uni- of the European Association of faculty of medicine at Helsinki versity in 2002. Plastic Surgeons in 2006. University. The thesis of her Sirpa is one the world pio- She was president of the recent 2006 doctoral candidate neers in reconstructive micro- Finnish Surgical Society from is titled ”Functional Outcomes surgery. She did her first free 2000 to 2002. Prior to that, after Free Flap Reconstruc- microvascular flap in the late she served as president of the tions in Oral and Pharyngeal 1970s. Since then, she has re- Finnish Association of Plastic Cancer.” planted and transplanted thou- Surgeons from 1983 to 1985 and Sirpa is an extraordinary sands of free flaps to cover leg as president of the European woman—a plastic surgeon, a injuries, head and neck tumors, Association of Plastic Surgeons senator, a researcher, a teacher. and breast reconstructions. from 1996 to 1997. She sat on She has an incisive mind and She developed and taught mi- the executive committee of the is courageous and indepen- crovascular and flap dissection International Confederation dent in a most charming way. techniques throughout Scandi- of Plastic and Reconstructive I am proud to recognize her navia and Europe and took her Surgery from 1995 to 2003, and as a colleague, role model, and expertise to Russia, Taiwan, and on the executive committee of friend. Madam President, it Saudi Arabia. the European Burn Association is my privilege to present this She has made major contribu- from 1992 to 1995. In all, she is distinguished plastic surgeon, tions as one of the international a member, honorary member, Sen. Sirpa Asko-Seljavaara, leaders of microsurgical innova- or corresponding member of 18 for Honorary Fellowship in the tion, publishing more than 300 international medical societ- American College of Surgeons. 43

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Citation for Prof. Jorge Cervantes by Carlos A. Pellegrini, MD, FACS, Seattle, WA

Madam President, it is my also occurred at this early age. pleasure to introduce Dr. Jorge While bicycling one day, he met Cervantes, a Fellow of the Amer- a young lady by the name of ican College of Surgeons and a Lucero. It was love at first sight most distinguished surgeon and they would be married five from Mexico City. years later. The Spanish word Dr. Cervantes was born April lucero refers to light, specifically 27, 1938, in the small town of the light associated with the ris- Guasave in the state of Sinaloa, ing morning sun. It is the light Mexico, where his family had that guides the farmers as they lived for several generations. start their morning chores. It is He bore the name of the most the light that brings the songs famous writer in the Spanish of the birds that brighten the language and exhibits even to- day. Lucero has been the light day many of the emotional traits that has provided Jorge with of that writer’s main character, his guidance and his cheer. To- Don Quixote de la Mancha. His gether they have three daugh- first five years of education were ters and two sons, all of whom Professor Cervantes in a small “centro escolar” in are in the audience today. Guasave. At a very early age, Toward the end of medical his parents sent him away to school, Jorge applied to the Or- pursue his high school educa- ganization of American States tion elsewhere since there were for a special scholarship that ond to none and introducing to no such facilities in Guasave. would allow him to come to Mexico the field of minimally Alone, and for the first time Washington, DC, first for a ro- invasive surgery. In a very re- in a semi-foreign place, young tating internship and then for cent ceremony, he was given the Jorge developed some of the a full residency at Georgetown ABC’s gold medal for achieve- attributes of leadership that University. At the completion ment and service in recognition would characterize his future of his training, he joined the of his long-standing service to life when he was elected to the faculty as an instructor and the institution. presidency of his school’s stu- remained there until the day His leadership and his Ameri- dent association. he successfully completed his can surgical education mani- Upon completion of high American Board of Surgery fested themselves during these school, he moved to Mexico certification. At that time, and years in many ways. Dr. Cer- City, where he entered the Au- following the commitment to vantes was instrumental in tonomous University of Mexico his family and to himself, he the development and growth in 1955 and obtained his bach- returned to Mexico City to join of the Mexico Federal District elor’s degree in 1957. By then, the American British Cowdray Chapter of the American Col- he had developed an interest (ABC) Hospital and its school of lege of Surgeons and was one in medicine and was admitted medicine as a clinical professor. of the founding members of the to the medical school at the He has remained in the same Mexican Society of Surgery in University of Mexico when he institution for more than 30 1977, a society that would make was only 19 years of age. An im- years, rising through the ranks him its president in 1983. He portant event that would have to become the chief of surgery, has been instrumental in the a profound influence in his life organizing a service that is sec- organization of several Latin 44

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS American meetings in Mexico approximately 100 chapters, and leader of surgery in Latin Amer- and has played a major role in 200 papers on all aspects of medi- ica and the Spanish-speaking the Latin American Federation cine, and he participates actively world, a teacher of the art and of Surgery and, most recently, on many editorial boards in the science of surgery, and a great in the International Society of U.S., Mexico, and Colombia. friend, Dr. Jorge Cervantes, to Surgery. He has been a constant Madam President, it is with be admitted to Honorary Fellow- promoter of excellence in sur- great honor that I now present to ship in the American College of gery and has written two books, you a great surgeon, a powerful Surgeons.

Citation for Prof. Clair Nihoul Fékété by Andrew L. Warshaw, MD, FACS, Boston, MA

Madam President, I am hon- important medical and scientific ored to present to you Prof. societies of France, Professor Claire Nihoul Fékété of Paris, Fékété has been active in deliv- France, for Honorary Fellow- ering surgical care to the under- ship in the American College of served abroad. For many years, Surgeons. she has been a council member Professor Fékété was born in of the Chain of Hope, which pro- Belgium and did her medical vides pediatric surgical services training in Paris. She trained in underdeveloped countries in pediatric surgery with Pro- in Africa and Southeast Asia. fessor Pellerin at the Hôpital Since 1988, she has gone on des Enfants Malades in Paris missions to perform operations and with Peter Rickman at the for congenital malformations Alder Hey Children=s Hospital and to teach in West Africa. in Liverpool. During that time, She is the founder of “Hand in she visited the unit of W. Hardy Hand,” a benevolent association Hendren at Massachusetts Gen- for hospitalized children. She eral Hospital (MGH) and began is an honorary member of the Professor Fékété an enduring friendship and surgical section of the Ameri- professional association with can Academy of Pediatrics, the Prof. Patricia Donahoe, like American Pediatric Association, her a world leader in pediatric and the British Association of surgery, whose work focuses on Pediatric Surgeons from which were also the first to discover gender development and repair she received the Forshall Medal the molecular pathogenesis of of intersex anomalies. She has in 2003. In 2004, my institu- neonatal hyperinsulinism and been a professor of pediatric tion, MGH, had the privilege of to work out effective methods of surgery since 1975 at the Medi- hosting her as the fifth annual determining the focal form from cal School of the Paris 5th Uni- MGH/Johns Hopkins lecturer the diffuse form, thereby saving versity. In 1998, she was named and visiting professor. many babies from 95 percent Professor Exceptional Class. In Professor Fékété=s research pancreatectomy. She is regarded 1990, she became chief of the and clinical accomplishments as one of the world authorities department of pediatric sur- have been broad and deep. on intersex abnormalities, to gery at the Hôpital des Enfants Her group was the first to which she has contributed enor- Malades. define a gene mutation in mously through her innovative In addition to her roles in the Hirschsprung=s disease. They surgery and her understanding 45

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of the molecular pathogenesis of and has served as an expert at France. She was recently ap- these disorders. Most recently, the Court of Appeal of Paris for pointed to serve as the repre- her group has also discovered Fetal Medicine and Pediatric sentative from France to the additional genetic defects con- Surgery. She is working with European Union to deal with tributing to the Rokitansky Syn- colleagues around Europe to health issues. drome, which causes absence of establish an extensive European For diversion, Professor Féké- the Mullerian structures. She is database for rare malformations té loves music and sailing and the author of approximately 200 for which they are seeking to has successfully raised two publications. define therapeutic classification sons. One of Professor Fékété’s and treatment protocols. For Madam President, it is my great skills is regional orga- her many contributions, she privilege to present this world- nization. She has contributed has been awarded a Chevalier renowned surgeon, Prof. Claire greatly to the organization of de l’Ordre National du Mérite Nihoul Fékété, for Honorary the referral of infants diag- in 1980 and the Chevalier de Fellowship in the American Col- nosed prenatally with congeni- l’Ordre de la Légion d’Honneur lege of Surgeons. tal anomalies in the Paris region in 1999 by the president of

Citation for Prof. Armando Marquez-Reveron by Eduardo A. Souchon, MD, FACS, Houston, TX

Madam President, Fellows do for those patients. They are and Guests. It is with great going to die anyway, so we keep pride and honor that I present them far away from the others to you Prof. Armando Marquez- who we can cure.” Reveron for Honorary Fellow- This reply did not concur ship in the American College of with Armando’s ideas of be- Surgeons. Armando Marquez-R ing a physician. He decided to was born in Caracas, Venezu- become a junior resident in the ela, in 1921. He received his recently opened Oncologic Hos- medical (MD) degree in 1945 pital of Venezuela, The “Luis from the Central University Razetti Institute.” It was at of Caracas. At that time, he that center where he learned started his academic career the basic principles of surgical as an instructor to medical oncology from one of his men- students, teaching the art of tors, Dr. Bernardo Guzman- physical examination in the Blanco, who induced him to go school of medicine. to “the ‘Memorial’ Hospital,” His interest in the field of later Memorial Sloan-Ketter- Professor Marquez-Reveron oncology started when he was ing (MSKCC). At MSKCC, he a medical student and he no- rotated under the tutelage of ticed that cancer patients were the legendary surgeons such placed in the most distant and as Hayes Martin, George Pack, lonely rooms of the hospital Alexander Brunshwig, Frank the star fellow performing the wards. When he asked the Adair, Edward (Ted) Miller, “commando” operations of nurses the reason why that was and so on. There he earned the head and neck, as well as done, the answer he received the nickname of “Armando radical pelvic exenterations. He was: “There is nothing we can Commando,” when he became also learned the team approach 46

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to the treatment of the cancer in Venezuela on cancer-related burg festival, an event that he patient with radiation and che- problems, and president of the attended for almost 40 years motherapy applied as adjuncts Venezuelan Oncology Society. until he physically could not for the treatment of patients He earned numerous national travel anymore. with neoplastic diseases. and international decorations Armando was a maestro in After his chief residency, he and mentions related to cancer surgery and the art of patient stayed at MSKCC for three patient care and well being. He care and a storyteller. He was more years. When departing became a member of numer- legendary for remembering for his native Venezuela, one of ous surgical societies, but he data from the history of sur- his mentors, Dr. George Pack, was particularly dedicated to gery and of his native Caracas, wrote him this note: the American College of Sur- as well as jokes that he told geons and always encouraged to make patients and people My dear Armando: One of young surgeons to join the ACS. around him happy. He was a the rich rewards which comes He always said the College is true maestro as a human being, to the practitioner and teacher “the only society dedicated to as a son, as a father, and as a of surgery, is the reflected the well being of patients by husband, and he was a good credit which accrues to him improving the quality of the friend to all. through the accomplishments surgeons and keeping them At the age of 84, he became a of his pupils. What I am at- honest.” cancer patient and as such he tempting to say, my dear Ar- He dedicated extra time in became an example to all when mando, is how proud I am of educating students at the medi- he stated, “I need to finish this you, and how I rejoice in your cal school where he became full chemotherapy quickly so I can inevitable great destiny in our professor and the mentor of go back to work and care for my chosen and mutual profession. many generations of surgical patients.” Unfortunately, he Sincerely, George Pack (May residents. Armando became a cannot be here to receive one 13, 1958). legendary surgeon as he op- of the highest honors the Col- erated tirelessly, performing lege can give to one of its most Armando went back to Ca- radical head and neck surgery devoted members. Armando racas and started a campaign as well as radical gastrointes- died on June 9. to educate surgeons and resi- tinal and gynecologic surgery He was so proud when he was dents in radical surgical tech- with exemplary, clean surgical notified about the nomination niques and comprehensive care technique and excellent post- as honorary member. In the for cancer patients as well as operative care. He set examples name of his family, his wife and teaching rudiments of physical of continuity of care when he teammate in surgery, and in therapy and rehabilitation. dedicated many hours in his the name of all the Venezuelan Later, Armando was an in- clinic, personally following surgeons, we thank the College vited guest as an instructor at all the patients. He published for this special posthumous MSKCC for the postgraduate many surgical papers, articles, nomination. courses for the treatment of and book chapters in the His- Madam President, it is a head and neck malignancies panic literature. privilege, a pleasure, and an organized by Dr. John Conley at Armando Marquez-Reveron honor to present to you my Columbia University. Armando became a true surgical maestro mentor, teacher, and friend, was appointed chief of the to residents during his career Maestro Armando Commando surgical gynecologic service of as professor in the medical Marquez-Reveron, for an Hon- the Luis Razetti Hospital. His school. He was not only a mae- orary Fellowship in the Ameri- leadership in the fight against stro in medical-related issues can College of Surgeons. cancer continued as he became but also in other topics such as president of the Latin Ameri- opera, art, antiques, wine, and can Cancer Federation, consul- dressing codes. He became an tant to the Minister of Health enthusiast of the yearly Salz- 47

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Citation for Prof. Maurice E. Müller by Bruce D. Browner, MD, FACS, Farmington, CT

Madam President, I am hon- the Die Arbeitgemeinschaft ored to present to you Prof. für Osteosynthesefragen (AO), Maurice E. Müller from Bern, which is roughly translated into Switzerland, for Honorary Fel- the Association for the Study of lowship in the American College Internal Fixation. of Surgeons. Professor Müller In the succeeding 48 years, has had a distinguished career the AO has evolved from its and has contributed greatly in humble beginning to become many areas of orthopaedic sur- an influential international gery, but he is best known as network of surgeons, scientists, the architect of modern fracture educators, manufacturers, and surgery. businessmen that dominates Prior to his revolutionary ef- the field of fracture surgery. forts, fractures had been treated Maurice Müller has been the for decades with plaster and formative genius at the center traction. An excessive emphasis of this amazing story. Recog- on rest, thought necessary for nized early in his career for his boney union, led to frequent technical mastery of hip recon- joint stiffness and muscle at- struction and fracture surgery, Professor Müller rophy. The turning point in his he also had great organizational career came in February 1950 talent. He understood that his when he visited Robert Danis revolutionary surgical methods in Brussels, Belgium. Danis could only become universal had achieved absolutely stable if they were promulgated by a many others the importance osteosynthesis through plates committed group of surgeons of recording clinical results, with compression devices. His who would continuously expand he established an organized methods allowed the patient im- in numbers to form a school of documentation process to cap- mediate mobilization of the in- fracture management. He ap- ture information on fracture jured extremities and prevented plied his leadership and man- procedures performed at AO the stiffness and disability that agement skills to shape the clinics throughout Switzerland were usually seen with tradi- AO to be the organization that and many other countries. He tional methods. These concepts made his vision of modern frac- championed the development formed the basis of the sys- ture management a reality. of a technical commission that tem of fracture treatment that By 1960, he had already de- brought surgeons, engineers, Maurice Müller subsequently signed a full armamentarium manufacturers, and market- developed. of instruments and implants, ing experts together to develop He formed an association with which served as the basis for all instruments and implants uti- a small group of other Swiss future developments. In an ar- lizing the information gleaned surgeons who were impressed rangement, which is still unique from the documentation pro- with his surgical results and to this day, he negotiated to have cess. saw the potential for his ideas. the manufacturers return a por- Professor Müller insisted on In November 1958, they real- tion of the profit on the implants the development of a basic sci- ized their dream of organizing to the AO to underwrite educa- ence institute to examine the an association for internal tion and research. biologic and mechanical basis fixation with the formation of Understanding years before of fracture fixation and heal- 48

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ing. The AO Institute in Davos ter spica casts. We treated other things did change rapidly in the became one of the world’s fore- fractures with long plaster casts years following my graduation. most research centers, and its that immobilized the joint above Most of the methods I learned investigators have elucidated and below the fracture, and we as a resident are now historical important aspects of fracture kept everyone at rest. notes. healing following internal fixa- As a chief resident in 1977, Gifted with extraordinary tion. I learned of a Swiss group of surgical talent, intellectual Education has been another surgeons called “AO” that was capacity, determination, vision, major interest for Professor just beginning to introduce new organizational skill, and cha- Müller. He ensured that frac- surgical methods for fracture risma, Maurice Müller caused ture methods be taught to sur- treatment to the U.S. Having a revolutionary change in frac- geons through highly organized developed an interest in trau- ture management. Thousands courses that included bioskills ma, I traveled to Davos to at- of patients all over the world laboratories. The annual AO tend their annual course. At the can trace their survival or courses in Davos have been center of a largely European recovery from skeletal injury acclaimed as models for such faculty was Professor Müller, and return to function to the educational endeavors. who radiated an unusual dy- tireless work of this remarkable The period in which I trained namism and had a larger than man. Prof. Maurice Müller has was the cusp of the old English life presence. It was obvious definitely played a pivotal role system of fracture management. that their beautifully organized in the history of surgery, and it It was routine to keep femur Swiss-made equipment and is with great pride that I pres- fracture patients hospitalized sophisticated education meth- ent him for Honorary Fellow- for six weeks in traction followed ods would captivate American ship in the American College by months in cumbersome plas- orthopaedic surgeons. In fact, of Surgeons.

Citation for Prof. Niall O’Higgins by John E. Connolly, MD, FACS, Irvine, CA

Madam President, it was Our Niall is the professor my pleasure exactly 25 years of surgery in the University ago in 1981, before this Con- College, Dublin, the outgoing vocation, to present Professor president of the Royal College Eoin O’Malley, a distinguished of Surgeons in Ireland, and cardiac surgeon of Dublin, Ire- a prodigious author of 255 land, for honorary Fellowship articles in peer-reviewed sur- in our College. Now tonight it gical journals. He is also past- is my distinct pleasure to pres- president of the World Fed- ent his first cousin, Prof. Niall eration of Surgical Oncology O’Higgins, also of Dublin, for Societies; an honorary member the same honor. Could it be that of both the French Academy of both Eoin and our Niall are Surgery and the Royal College descendants of the 5th century of Surgeons of Glasgow; and Irish warlord known as Niall a world-renowned authority of the Nine Hostages, who it on breast cancer, particularly is thought can be genetically on prognostic and predictive traced to at least one of every factors. Professor O’Higgins 12 Irishmen worldwide? Education and medicine run 49

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS in the O’Higgins family. Both teaching. Of the 200 students cycling—say, for example, a of Niall’s parents were physi- going through surgery each short jaunt of 376 miles from cians, as is his wife, Rosaleen, year at his medical school, Bordeaux to Paris, even in a and one of his children. he personally undertakes the heat wave of 106 degrees! Also, Not only is Niall an active, surgical training of half of the he is fond of his MG sports car accomplished surgeon, but class. It is no exaggeration that and camping in France with both the current dean of his the students characterize him his wife and their four children medical school and the presi- as a god for his devotion to each August. dent of his university selected their teaching. Any students Thus, it is my special honor him when they were housemen who need special help get it to present this remarkable, for further training or, as we personally on Saturdays from erudite, warm, and modest would say, interns. this professor, who graduated surgeon for Honorary Fellow- I suspect also that we have first place in his medical school ship in our College. never had an Honorary Fel- class. low more devoted to student His number-one hobby is

• View surgical news

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• Update CME credits

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VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION

The American College of Surgeons Division of Education presents the Personal Financial Planning and Management Course for Residents and Young Surgeons, which uses an interactive/lecture format to arm surgeons with basic financial management skills. The course is designed to educate and equip young surgeons with the knowledge to manage their personal financial future, including debt management, preparation for significant life events (such as retirement or college education of their children) and proper planning for financial stresses related to their surgical practice.

Objectives At the end of the course, the participants will be able to describe: • The essentials of personal financial management as they relate to young surgeons in practice and residents and their families. • The impact of interest rates and time upon loans, compound interest, and the implications for debt Fellows of the American College of Surgeons: $120 management. Non-Fellow: $215 • The building blocks necessary for the surgeons to invest RAS member: $75 successfully. Surgical Resident, not a RAS member*: $95

• The importance of time in reducing the risk of investing. *Non-RAS residents must supply a letter confirming status as a resident from a program • The basics of mutual funds, stocks, bonds, and other director or administrator, and are limited to one CD-ROM. (Additional $16 for shipping and handling of international orders.) investment vehicles. • How to evaluate and choose a financial advisor. Orders may be placed through ACS Customer Service at 312/202-5474 or via the College’s Web site at: www.acs-resource.org Intended audience: For more information contact Linda Stewart • Surgical residents and surgeons recently in practice. at [email protected], or tel. 312/202-5354 Surgery Down Under: Report of the 2006 Australia and New Zealand Travelling Fellow by Robert R. Cima, MD, FACS, FASCRS, Rochester, MN

“Take frequent vacations from active work, to attend clinics and walk hospital wards. See things for yourself; reading alone is not enough.”

—Dr. William J. Mayo, graduation address, Rush Medical College, June 15, 1910

It was those words of Dr. Wil- liam J. Mayo that inspired me to apply for the American Col- lege of Surgeons Australia and New Zealand (ANZ) Travelling Fellowship. The ANZ Travel- ling Fellowship was a chance for me to walk the wards and interact with surgeons who had a different style of training in Dr. Cima catching his lunch in the beautiful waters off Newcastle, New a totally different health care South Wales. environment. This would be an opportunity to see what was different; but as I found out, it was more of an experience disrepair and there were enor- city sits in the center of the that demonstrated how similar mous mounds of coal along the gorgeous countryside, which we are. river’s edge. However, a closer is home to some of Australia’s look revealed a city undergoing finest vineyards. Newcastle a renaissance. The city’s wa- My host, Dr. Gerard Coren, After approximately 23 hours terfront is being revived with FRACS, a general surgeon in of flying time, I arrived at my new restaurants, shops, con- a community hospital about first stop in Australia, New- dominiums, and green spaces. 60 minutes further north of castle, New South Wales. I had Newcastle has become a popu- Newcastle, met me the next been invited to speak at the lar place for Australians to re- morning to bring me to the Hunter Valley Surgical Soci- locate. Just approximately two large regional medical center, ety annual meeting. As I rode hours north of Sydney, there is The John Hunter Hospital. I into town from the airport, a lower cost of living and less was introduced to one of the evidence of Newcastle’s indus- crowded environment without colorectal surgeons. It was here trial past was clearly evident. forsaking beautiful views of that the question that I had in Large industrial sites lay in the ocean and a river. Also, the the back of my mind about this 52

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS whole trip—“How much would we have in common?”—was an- swered. To some extent, we had almost everything in common. We talked about the common problems I assume surgeons everywhere share: not enough time in the operating room, too long of turnover time, too much paperwork, not enough help, less resident coverage, and too much government bu- reaucracy. The Hunter, as it is called, is the regional referral center for trauma, highly complex sur- gery, or critically ill patients. It was here that I began to notice a theme that repeated itself throughout my travels A view of the magnificent Sydney Harbor Bridge. in Australia and New Zealand. Resource allocation and region- alization of care is affecting all the hospitals in ways that may opportunity to meet with the institution’s multidisciplinary not have been intended. In Dr. junior and senior registrars to approach to advanced colorec- Coren’s smaller community review cases. I presented a few tal cancer, and the second was hospital, there has been a shift complex inflammatory bowel a discussion of how to assess in resources that has left it disease cases. Most memorable surgical quality. There was a understaffed in many critical was a comment from one of presentation by a medical on- areas. This change by necessity the junior registrars when cologist about the new chemo- requires more patients—even asked what he would do for a therapeutic regimens for colon patients who could be treated very complex case of multiple and rectal cancer. Although the in his hospital for such diseases enterocutaneous fistulas. His talk was informative, the most as acute appendicitis—to be response was that although important and telling point transferred to the Hunter for he didn’t know what to do, was in the discussion that fol- treatment, which, in turn, he certainly would “love to be lowed. It was here that I was taxes the personnel and re- at the operation”—surgeons introduced to another theme sources of the regional center are surgeons no matter where that I would see again during for care that could and should they practice, and I felt right my visit: the important role be provided closer to the pa- at home. evidence-based medicine has tients’ homes. This was a very on the allocation of resources important learning point, as I Hunter Valley Surgical Society in Australia and New Zealand. continue to hear about the on- The Hunter Valley Surgical Nothing highlighted this more going discussions and debates Society meeting had a number than discussing the role of the about regionalization of care of very stimulating presenta- new biologic therapies in the in the U.S. tions and discussions about treatment of advanced colorec- The Hunter is a large teach- the care of patients with intes- tal cancer and the astronomi- ing hospital that provides tinal malignancies. I gave two cally high cost relative to the nearly all the tertiary care talks at the conference. The benefits in survival. This point in the region. I had the great first presentation was on my led to an animated roundtable 53

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS discussion on how to deliver quality care with limited re- sources and some of the very unique challenges that the Aus- tralian government faces. It was fascinating for me to learn how the Australians are trying to deliver prenatal and obstetric care to a region the size of a couple of New England states but with a population of only 250,000 people. Although I am used to hearing about access problems in the U.S., this was a very unique situation that, although difficult, the Austra- lian government and the Royal Australasian College of Surgeons (RACS) are trying to solve with ingenuity and by taking ad- vantage of new communication technology. I will be very inter- ested to see how they solve this Northshore Regional Hospital, one of the main public hospitals in Auckland, problem because I think there New Zealand. will be a great deal to learn that could be used in the U.S. Although it may sound as if I spent most of my time tour- ing hospitals and talking, Dr. Coren and his colleagues cer- tainly showed me a wonderful time with a festive dinner at which I sampled a number of the outstanding regional wines. The next day was spent tour- ing the region after a morning on the ocean where we caught our lunch. Dr. Coren was kind enough to bring me to his beau- tiful home in the countryside where we grilled our morning catch and I could visit with his family. I could not have asked for a better start to my travel- ing fellowship.

Sydney/RACS congress A small sample of the beautiful western New Zealand coastline on the After three great days in New- Tasmanian sea. castle, I headed to Sydney for the annual RACS scientific con- 54

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS gress. The congress was held at the Sydney Convention Center on Darling Harbor. It was four days of lectures, seminars, and presentations. Having a limited number of obligations, I was free to attend many different lectures. The diversity of topics was outstanding. They ranged from the newest information on colon cancer genetics, to the history of military surgery in Australasia, to discussion of how to train residents and how to assess quality outcomes. Again what I was most struck by was that the issues discussed on nearly every level were simi- lar to talks or discussions that I had heard discussed at the American College of Surgeons’ Clinical Congresses over the last few years. It seems that the challenges facing Ameri- can surgery are not unique to us but rather to the practice of surgery in general. From what I heard in Sydney, there is much that we can learn and share with our colleagues Down Under. There were a number of high- lights for me at the congress. Certainly, the biggest was giv- ing the Chapter of the American College of Surgeons’ lecture at the President’s plenary session. I discussed the evolution of the The entrance of Christchurch Women’s Hospital in Christchurch, New ileal-pouch anal anastomosis Zealand. procedure and the current state of laparoscopy for this proce- dure. It was a distinct honor that I will always remember. knew in my specialty and many attended the Chapter of the Three other memorable high- of the famous—or, as they like American College of Surgeons lights occurred over food and to refer to themselves, “infa- luncheon. Here I met Stephen drink. I was asked to join the mous”—colorectal surgeons Deane, MBBS, FACS, the Past- colorectal surgeon’s banquet from Australia and New Zea- President of the chapter, and held in a facility overlooking land who I had known about Ross Blair, MB CHB, FACS, the Sydney skyline. Here I was from reading their multiple the current President. It was able meet with colleagues that I important publications. I also a wonderful lunch. Through 55

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS existence. The most fascinating thing I learned was that the founders of my institution, the Mayo Clinic, were personally involved in initiating the pro- cess that lead to the formation of the RACS.

Auckland After the Congress was over, I headed for Auckland, New Zealand. My host in Auckland was Dr. Eva Juhasz, FRACS, a colon and rectal surgeon at North Shore Hospital, one of three large public hospitals in the metropolitan area. I had contacted Dr. Juhasz because she had completed a portion of her colon and rectal surgery fellowship at the Mayo Clinic. During my day with Dr. Juhasz, I observed her doing a comple- tion proctectomy for Crohn’s disease, toured the hospital during her ward rounds, and attended the hospital’s multi- disciplinary colorectal tumor board. This experience was really my first opportunity to get a brief glimpse of operating The headquarters of the RACS in downtown Melbourne. room procedures and of the hospital system in Australia and New Zealand. Again, what impressed me was the emphasis our conversations, I discovered the view of the skyline, the fa- on measuring quality and ef- the members of the chapter mous harbor bridge, and opera ficiency for continuous process are particularly proud to be house at night was spectacular. improvement. The issues that members of the RACS as well The dinner was highlighted by were being discussed such as as the American College of performances by members of operating room safety and pa- Surgeons. the Sydney Opera. During this tient outcomes are all the same The last social function was a wonderful evening, I met Dr. things that U.S. surgeons are gala dinner for the congress. It John Royale, FRACS (retired), focusing on at this time. was a formal affair held across who was a former president of One of the many processes I Sydney Harbor at Luna Park. the RACS and is the current un- observed and internalized was We crossed the harbor at night official historian for the RACS. a specific method of “counting” on one of the harbor ferries. Al- It was a great opportunity to sponges, which I have brought though Sydney is a particularly learn about the structure of to my operating room to see beautiful city during the day, the RACS and how it came into if it might be a practice that 56

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS could be implemented to try to further improve our OR’s safety and quality. I spent two days in Auckland before driving south on the North Island. I spent a morn- ing visiting with Dr. Blair in Hamilton at his clinic and learning how the private versus public system of care works in New Zealand. We then went on a walking tour of the city. The highlight of the tour was visiting the Maori Heritage Museum. This was a fantastic place to learn about the exceed- ingly interesting history of the indigenous people of New Zealand and how their culture and way of life were changed by The three chairs given to the RACS by Dr. Charles W. Mayo to commemorate the establishment of European the formation of the RACS. settlements. After leaving Hamilton, I headed to the geothermal hot springs in Rotorura. This re- its wonderful white wines. of activity. As it turned out, gion is certainly worth the day However, I must say that I the weekend of my visit was and a half that I spent there, as found many of the red wines the same as the championship I have never visited any place to be outstanding, much to the rugby match for the Australia quite like it. I guess I could say dismay of many of my Austra- and New Zealand Rugby Union. that it is perhaps one of the lian colleagues who I was to The championship was between most geographically diverse meet later in the trip. two New Zealand teams, one and shockingly beautiful places from Christchurch and the I have ever visited. In a mat- Christchurch other from Wellington. Rugby ter of a few hours, I traveled Although I could have stayed was completely new to me but, through an arboreal forest, to in the wine region for a few as I quickly learned, this match a rain forest, finally arriving on more days, I pressed on south- was the equivalent of the Super a black sand beach. ward toward Christchurch, a Bowl, the World Series, and the My tour of the North Island beautiful city, to visit with Dr. National Collegiate Athletic As- ended in Wellington, the capital Frank Frizelle, FRACS. The sociation Final Four basketball of New Zealand. From Welling- Christchurch Hospital is a very tournament, all rolled up into ton, I took the car ferry across large tertiary referral center. I one. I enjoyed the match with to the South Island. Along the spent the day with Dr. Frizelle, Dr. Frizelle and his family after way, the ferry was accompanied touring the hospital, going on a delightful dinner, although I by dolphins that followed us all rounds with his fellows, and had no idea what was happen- the way to our port along an visiting the colorectal research ing on the field. inland waterway. As luck would facilities. have it, the ferry dropped me off My visit to Christchurch was Melbourne in one of the best wine regions a little different than the one Having finished my tour of of the world. The Marlborough others might experience. I ar- New Zealand, I headed to my region is world-renowned for rived in the city during a frenzy last stop, Melbourne. During 57

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS my brief stay in Melbourne, I the Mayo brothers, Charles similar to issues being dealt was scheduled to meet with the and William. Both brothers, with in Australasia. The RACS’ colorectal surgeons at Cabrini representing the American Col- past and current emphasis on Hospital. Two members of the lege of Surgeons, had toured the “audit” or surgeon-specific group had done a portion of Australia and New Zealand in outcomes measures should be their colorectal training at the 1924. The next year, Dr. Devine a model for the ACS’ push to- Mayo Clinic. After catching up spent time in Rochester, MN, ward outcomes analysis of its on some gossip, we set about at the Mayo Clinic, where he members in order to improve touring the hospital, the endos- traveled down the Mississippi quality of care. Although the copy suite, and the operating River on the Mayos’ riverboat. same problem may have differ- theaters. The day in the hos- To make the story complete, ent solutions or approaches for pital ended with a mixer with John showed me the chairs different groups, it is impor- surgeons from other hospitals presented to the RACS by the tant to note what others have in the city and the surgical clin- Mayo Clinic in honor of its for- done to determine if their solu- ical research staff at Cabrini. mation when Charles W. Mayo tion is appropriate for us. To end the evening, we enjoyed was made an honorary mem- Lastly, the most long-lasting a fabulous dinner at the home ber of the RACS. These three impact of this fellowship was of Dr. Paul McMurrick, FRACS. ceremonial chairs were for the the relationships formed. It is The food was outstanding, the president, vice-president, and one thing to fly into a country conversation was even better, secretary of the college. They to give a talk, but it is an en- and the Australian red wine currently sit in one of the large tirely improved experience to was superb. When I mentioned meeting rooms in the RACS also spend time “walking the my fondness for a number of headquarters in Melbourne. wards,” and sharing a meal New Zealand red wines, I was Again, this small bit of history turns colleagues into friends. quickly and loudly informed only further reinforced what I Already I was able to return the that obviously my ability to had learned since arriving in favor by hosting Dr. Deane at discern high-quality wine was Newcastle: although we may be my institution before his visit questionable. separated by more than half a to the Clinical Congress in Oc- I spent the next day touring world, we share more similari- tober. For these relationships the RACS headquarters. My ties than differences. and experiences I had while tour guide was Dr. Royale. We visiting Australia and New Zea- visited all the meeting rooms, Lessons learned land, I am truly grateful to the which housed a collection of Overall, my time in Austra- American College Surgeons beautiful antiques and paint- lia and New Zealand as the and the RACS Chapter of the ings given to the RACS. Every American College of Surgeons American College of Surgeons one of those items had a fasci- Australia and New Zealand for selecting me as the 2006 nating story. I was also allowed Travelling Fellow was one of ANZ Travelling Fellow. to browse through the Gordon the most rewarding personal Craig Library, which contains and professional experiences Dr. Cima is a consultant in the an extensive collection of an- that I have ever had. To be able division of colon and rectal sur- tique medical books. to see such beautiful places and gery at the Mayo Clinic, Rochester, Lastly, and most personally to interact with such wonder- MN. interesting to me, Dr. Royale ful people who happen to be laid out the history of how the very passionate about surgery RACS came into existence. and quality medical care was As it turns out, an important truly a unique opportunity. impetus to its formation came I learned that many of the from a deep friendship be- problems relative to medical tween the famous Australian care and surgery that we are surgeon, Hugh Devine, and dealing with in the U.S. are 58

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Report of the 2006 ACS Traveling Fellowship to Germany Michael G. Franz, MD, FACS, Ann Arbor, MI

I was honored and thrilled considerate linguistic hosts, when chosen as the American often speaking in English for College of Surgeons Traveling the international audiences. Fellow to Germany for 2006. An international surgeon’s The opportunity to observe trick I witnessed for the first surgery as it is practiced in time was to present written Germany and to participate in text or images (for example, via the annual meeting of the Ger- PowerPoint) in German but lec- man Surgical Society was very ture in English, or vice versa. important to me. I have a strong Throughout the meeting, professional interest in surgical good food and refreshments science reported from Germany were aplenty. On the final eve- today and the history of Ger- ning of the German Congress, man surgical scholars. Most I was the guest of president agree that Theodor Billroth H. D. Saeger, MD, chief of vis- and his protégé, Emil Kocher, ceral surgery at the Technical who trained and practiced in University of Dresden. The Germany, are the founders of Dr. Franz black-tie affair was held in the modern abdominal and general beautifully renovated Deutsche surgery. The cornerstones of Telekom Building, inside what their approach to surgical prob- was formerly East Berlin. It was lems were clinical excellence often by cell phone, throughout exciting taking the Berlin Metro and investigative principles. the large, bustling city and im- into East Berlin and walking My journey actually began pressive surgical congress. past historic places like the during the ACS Clinical Con- Berlin is a beautiful European German State Opera House and gress in San Francisco, CA, city, with a long history and the Max-Planck Institute on the in October 2005, when I met a vibrant future. The people way to the president’s ball. my sponsor for the German were friendly and seemed very fellowship, Dr. Norbert Sen- cosmopolitan. Berlin is a true Being a tourist ninger, professor of surgery at international center. The DGC Saturday was my only agenda- the University of Muenster. was equally impressive. I was free day of the whole visit. I Dr. Senninger was a wonderful struck by the quality of the used the time to get an up- coordinator and host, who went presentations and the enthu- close look at the famous city out of his way to meet with me siasm of the attendees. Many of Berlin. I caught the U-Bahn ahead of time and made my visit sessions were standing-room (subway) at the Charlottenburg seamless and rewarding. When I only or completely filled. I was station and rode to the Bahnhof arrived in Berlin for the begin- privileged to present my latest Zoological Garden, affection- ning of the annual meeting of work and thoughts on incisional ately known as the “Bahnhof the German Surgical Society hernias during a general and Zoo.” The station and its street (Deutschen Gesellschaft fur laparoscopic surgery session side were bustling with young Chirurgie, or DGC), Dr. Sen- mid-week. The German and and old from around the globe. ninger kept in contact with me, other European presenters were I walked into the Tierpark, 59

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the Berlin equivalent of New laparoscopic surgeon who has Aachen, I had the opportunity York’s Central Park but with led clinical trials validating to present data from my own a famous zoo within, until I minimally invasive inguinal wound healing laboratory and arrived at the Siegessäule (Vic- hernia repair. He has devel- subject the work to the rich tory Column). The Siegessäule oped a technique, with great criticism of the Aachen surgical is one of the more famous attention to anatomic de- scientists. I was also impressed sights of Berlin, designed by tail, that results in outcomes by the high volume of opera- Heinrich Strack in 1864 to equivalent to any of the open tions performed at the Univer- commemorate the victory of operations with the advan- sity of Aachen and the talented Prussia in the Danish-Prus- tages of minimal incisions. team of junior staff surgeons sian war. His scientific approach to this (Oberarzten) who support Dr. Further along my long walk, common surgical problem will Schumpelick. The evening was I approached the center of contribute to the advance of spent on the center square, the German government, the laparoscopic surgery in gen- enjoying Aachen beer and more newly renovated Reichstag. eral. Dynamic reconstruction white asparagus. Aachen also Berlin was reestablished as the of the abdominal wall during has a rich history, including capital of the reunified Ger- ventral hernia repair and housing the site of the 9th cen- many soon after the fall of The the importance of the linea tury winter home of Karl the Wall in 1989. I was intrigued alba was another principle I Great (Charlemagne). by the juxtaposition of a large appreciated in observing Dr. Soviet military cemetery and Koeckerling. Germany’s impact on surgery memorial shrine immediately In the end, my traveling adjacent to the center of the Aachen fellowship to Germany was a German government. A little My next stop was the Uni- success and exceeded all of my further into my walk, I stood versity of Aachen, tucked in goals. The chance to witness beneath the equally famous the western border of Germany surgical art and science first- Brandenburg Tor, the historic where Germany, Belgium, and hand confirmed my belief that eastern gateway to Berlin. the Netherlands come together. modern surgery owes a great In fact, my hotel was in the debt of gratitude to its German Hannover Netherlands, whereas my visit roots. And today, modern Ger- On Sunday, I traveled by to the University of Aachen was man surgical scientists carry on train to the University of Han- in Germany. The department of that important tradition. I also nover. There, my host, Prof. surgery is led by Prof. Volker respected the ability of German Ferdinand Koeckerling, chief Schumpelick. Dr. Schumpelick surgeons to balance a rigorous surgeon (Chef Arzt), arranged is chief surgeon and renowned day’s work with the apprecia- for me to stay at a beautifully for his academic approach to tion of good food and friends. renovated hotel, the Kaiser- surgical problems. The offices From the impressive German hof, right on the main square and hallways around the surgi- Surgical Congress to the in- in the center of Hannover, cal wards proudly display post- ner laboratories of Aachen, conveniently located across ers outlining state-of-the-art German surgeons continue to from the main train station scientific presentations made serve society with competent (Hauptbahnhof). That eve- by the Aachen group around and compassionate care and a ning, I joined Dr. Koeckerling the world. Dr. Schumpelick is continual drive to innovate and and his family and friends for also the incoming president of improve. a wonderful German meal on the German Surgical Society. the shores of Lake Machsee. Surgeons in Aachen are espe- Dr. Franz is an associate profes- Traditional white asparagus cially well-known for their basic sor of surgery at the University of was in season and prepared in descriptions of collagen isoform Michigan in Ann Arbor. many different ways. expression during wound heal- Dr. Koeckerling is a skilled ing and hernia formation. In 60

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS WHAT SURGEONS SHOULD KNOW ABOUT, from page 11 to increase opportunities for collaboration. References As a member of the National Quality Forum (NQF), an organization that endorses perfor- 1. Institute of Medicine Committee on Quality of mance measures for public reporting, the Col- Health Care in America. Crossing the Quality lege comments and votes on many quality initia- Chasm: A New Health System for the 21st Cen- tury. Washington, DC: National Academies Press; tives and is actively involved in NQF projects. 2001. ACS Executive Director Thomas R. Russell, 2. Rand Health Research Highlights. The First Na- MD, FACS, serves on the steering committee of tional Report Card on Quality of Health Care in the AQA (formerly the Ambulatory Care Qual- America. Santa Monica, CA: Rand Health; 2004. ity Alliance), a multistakeholder organization 3. U.S. House of Representatives, Committee on concerned with the implementation of perfor- Energy and Commerce, Subcommittee on Health. Medicare Physician Payment: How to Build a mance measures, and Dr. Opelka chairs the AQA Payment System that Provides Quality, Efficient surgery/procedure performance measurement Care for Medicare Beneficiaries. Testimony workgroup. As mentioned previously, the Col- from Day 1 (July 25, 2006). Available at: http:// lege has been involved in measure development energycommerce.house.gov/108/Hearings/ as a lead organization in the PCPI and serves 07252006hearing1993/hearing.htm. Accessed September 7, 2006. on the PCPI Executive Committee. 4. Opelka FG. Medicare Physician Payment: How The College continues to advocate that P4P to Build a Payment System that Provides Qual- programs should include evidence-based mea- ity, Efficient Care for Medicare Beneficiaries. sures, improve quality for the surgical patient, Testimony before U.S. House of Representatives, Committee on Energy and Commerce, Subcom- reduce data collection and submission burden mittee on Health. July 27, 2006. Available at: for the surgeon, and adequately reimburse sur- http://www.facs.org/ahp/testimony/opelka0707. geons for the additional obligations. E html. Accessed September 7, 2006.

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NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2008 ACS ANZ Chapter Travelling Fellowship available

The International Relations Committee of In the event that the selected applicant is from the American College of Surgeons announces a surgical specialty that is not participating in the availability of a travelling fellowship, the the RACS Congress, specific negotiations will Australia and New Zealand (ANZ) Chapter of be necessary to ensure the Travelling Fellow’s the American College of Surgeons Travelling participation in a national meeting of that spe- Fellowship. cialty. The academic and geographic aspects of the Purpose itinerary will be finalized in consultation and The purpose of this fellowship is to encourage mutual agreement between the Fellow and the international exchange of information concern- president or designated representative of the ing surgical science, practice, and education and ANZ Chapter of the ACS. The surgical centres to to establish professional and academic collabora- be visited depend to some extent on the special tions and friendships. interests and expertise of the Fellow and his or her previously established professional contacts Basic requirements with surgeons in Australia and New Zealand. The scholarship is available to a Fellow of The successful applicant’s spouse is welcome the American College of Surgeons in any of the to accompany him or her. There will be many surgical specialties who meets the following opportunities for social interaction in addition requirements: to these professional activities. • Has a major interest and accomplishment in basic sciences related to surgery Financial support • Holds a current full-time academic appoint- The Australia and New Zealand Chapter and ment in Canada or the U.S. the College will provide a sum of $12,000 U.S. • Is younger than 45 years on the date the to the successful applicant, who will also be application is filed exempted from registration fees for the An- • Is enthusiastic, personable, and possesses nual Scientific Congress. He or she must meet good communication skills all travel and living expenses. Senior chapter representatives will consult with the Fellow Activities about the centres to be visited in Australia and The Fellow is required to spend a minimum of two New Zealand, the local arrangements for each or three weeks in Australia and New Zealand: centre, and other advice and recommendations • To attend and participate in the Annual about travel schedules. The Fellow is to make Scientific Congress of the Royal Australasian his or her own travel arrangements in North College of Surgeons (RACS), which will be held America, as this makes available reduced fares in Hong Kong, China (May 12–15, 2008) and travel packages for travel in Australia and • To participate in the formal convocation New Zealand. ceremony of that congress • To attend and address the ANZ Chapter Applications meeting during that congress The ACS International Relations Committee • To visit at least two medical centres in will select the Fellow after review and evaluation Australia and New Zealand before or after the of the final applications. A personal interview Annual Scientific Congress of the RACS to lec- may be requested before the final selection. ture and to share clinical and scientific expertise The closing date for receipt of completed ap- with the local surgeons plications is November 15. The successful ap- 62

VOLUME 91, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS plicant and an alternate will be ling fellowship may be obtained Section, American College of selected and notified by March from the College’s Web site, Surgeons, 633 N. Saint Clair St., 2007. www.facs.org, or by writing Chicago, IL 60611-3211. Applications for this travel- to the International Liaison

A look at the Joint Commission Wrong site surgery and the Universal Protocol

Surgeons are vital partners the Joint Commission database components of the Universal in efforts to eliminate surger- are orthopaedic surgery, gen- Protocol include the following: ies on the wrong site or on the eral surgery, and neurosurgery; (1) a preoperative verification wrong patient, or performance the most frequent anatomical process, (2) marking the opera- of a wrong procedure on a pa- site of wrong site surgeries tive site, and (3) taking a “time tient. among cases in the Joint Com- out” immediately before start- The Joint Commission on Ac- mission database are knee, ing the procedure. creditation of Healthcare Orga- foot/ankle, and hand/wrist. For The Universal Protocol is en- nizations’ Sentinel Event Da- example, an operating room dorsed by more than 50 of the tabase receives approximately may be set up for a right-sided nation’s leading health care and nine voluntary reports per knee arthroscopy on Patient medical associations, including month of wrong site surgeries. A. Patient A is delayed, but the American College of Sur- This rate has increased since Patient B—who is also sched- geons. Its strategies represent the July 2004 implementation uled for knee arthroscopy, but the consensus of the leading of the Universal Protocol for on the left knee—is ready and names in health care—the Col- Preventing Wrong Site, Wrong is brought into the operating lege, the Joint Commission, the Procedure and Wrong Person room. The equipment setup is American Medical Association, Surgery™. The Joint Commis- not changed, and the patient the American Hospital Associa- sion reviewed 83 cases of wrong is prepped and draped and the tion, the American College of site surgery in 2005. procedure is started based on Physicians, the American Den- The top three root causes the arrangement of the arthros- tal Association, the American of wrong site surgery in 2005 copy equipment. Academy of Orthopaedic Sur- were communication (70%), The hospitals and ambu- geons, the Association of peri- procedural compliance (64%), latory surgery centers that Operative Registered Nurses, and leadership (46%). Com- reported wrong site surgeries the American Nurses Associa- munication was also the main to the Joint Commission in tion, and many others. root cause of wrong site surgery 2005 frequently identified sur- Each month, this column fo- (78%) from 1995 through 2004; geon override of the Universal cuses on activities of the Joint orientation/training (45%) Protocol’s strategies as a con- Commission that are relevant and procedural compliance tributing factor. If wrong site to surgeons. For more informa- (30%) were the other top root surgeries are to be eliminated, tion on the Joint Commission, causes. surgeons must strive to achieve and to sign up for Joint Com- The specialties most com- 100 percent adherence with the mission e-mail newsletters and monly involved in wrong site Universal Protocol’s multiple, announcements, visit www. surgeries that are recorded in redundant strategies. The main JointCommission.org. 63

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Career Opportunities The American College of Surgeons’ online job bank

A unique interactive online recruitment tool provided by the American College of Surgeons, a member of the HEALTHeCAREERSJ Network

An integrated network of dozens of the most prestigious health care associations.

Candidates: • View national, regional, and local job listings 24 hours a day, 7 days a week--free of charge. • Post your resume, free of charge, where it will be visible to thousands of health care employers nationwide. You can post confidentially or openly— depending on your preference. • Receive e-mail notification of new job postings. • Track your current and past activity, with toll-free access to personal assistance.

Employers: • Nationwide market of qualified surgical candidates. • Resume Alert automatically e-mails notices of potential candidate postings. • Exceptional customer service and consultation. • Online tracking.

Questions? Contact HealtheCareers Network at 888/884-8242 or [email protected] for more information.

HEALTHeCAREERSad.indd 1 8/23/2006 10:26:46 AM Operation Giving Back Volunteer opportunities available

Beginning with this issue, we will be publishing volunteer opportunities in the Bulletin, as provided by Operation Giv- ing Back (OGB). OGB is the volunteerism initiative of the American College of Surgeons launched in 2004 to encourage and support surgeons in their volunteer efforts. One of OGB’s from all specialties to travel times a year in San Diego, CA. goals is to provide surgeons with the DOCS’ continuing • The New Orleans, LA, with information to assist them medical education team to pro- area continues to have pressing in finding opportunities aligned vide teaching and training for needs for medical assistance, with their personal talents, in- African physicians in Rwanda and surgeons of all special- terests, beliefs, and lifestyles. and the Democratic Republic ties are welcomed at the clinic This column will help to serve of Congo. conducted jointly by Operation that purpose. • Domestic volunteer op- Blessing and International The Operation Giving Back portunities include Fresh Start Medical Alliance. database continues to be aug- Surgical Gifts, which coordi- For more information on mented with new volunteer nates actively practicing plas- these and other surgical vol- agencies, including the follow- tic, maxillofacial, and pediatric unteer opportunities, visit the ing: surgeons; ophthalmologists; and Operation Giving Back Web • Lumiere Medical Minis- otolaryngologists to serve during site at www.operationgiving tries is looking for urologists, “surgery weekends” held seven back.facs.org. obstetricians/gynecologists, and orthopaedic and general surgeons to provide clinical and teaching services at hos- pitals located in Aux Cayes, Bonne Fin, and Port-au-Prince, Senior civilian surgeons sought Haiti. for combat trauma care program • Health Volunteers Over- seas provides training and clinical opportunities for ortho- The American Association from Iraq and Afghanistan. paedic, maxillofacial, and hand for the Surgery of Trauma and Volunteer participants are being surgeons (general, plastic, and the ACS Committee on Trauma sought to travel to Landstuhl orthopaedic surgeons with spe- have developed the Senior Visit- Regional Medical Center in cialty training in hand surgery) ing Surgeon in Combat Trauma Germany to lend expertise and in Cambodia, China, Costa Care Program. to gain insight into the military Rica, Ethiopia, Honduras, Ni- This program is designed to effort to reduce combat mortal- caragua, Peru, Samoa, South develop a collaboration between ity. Africa, St. Lucia, and Uganda. civilian trauma surgeons and Fo r m o r e d e t a i l s , v i s i t • Doctors On Call for Ser- military surgeons caring for http://www.facs.org/trauma/ vice (DOCS) invites physicians wounded soldiers returning combattrauma.html. 65

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS PG 22: Principles of cancer Surgery

PG 23: the Hernia course (Parts i & ii)

Nine Courses PG 24: update on mechanical ventilation

for Surgeons on the Go PG 25: unresolved issues in trauma and critical care The American College of Surgeons’ Division of PG 27: minimally invasive esophageal Education is pleased to make available the content Surgery of nine postgraduate courses on a CD-ROM, Syllabi Select 2006. This CD-ROM is able to run in the PG 28: Benign Disease of the gastrointes- tinal tract (Parts i & ii) PC and Mac environments and offers you the ability to word-search throughout the CD, along with the PG 29: Surgery of the Pancreas

convenience of accessing any of the courses when you PG 32: What’s new in vascular Surgery want and where you want. 2006: update on management of common vascular Problems These syllabi can be purchased by calling 312/202-5474 PG 33: minimally invasive Surgery: or through the College’s Web site at www.facs.org. the next Steps

$69 for Fellows of the American College of Surgeons; $45 for Resident or Associate Members; $99 for nonmembers; $60 for surgical resident nonmembers* (Additional $16 shipping and handling charge for international orders.)

*Nonmember residents must supply a letter confirming status as a resident from a program director or administrator and are limited to one CD-ROM.

AmericAn college of SurgeonS • DiviSion of eDucAtion

Syllabi Select - 2006.indd 1 9/7/2006 12:12:05 PM NTDB® data points Horse sense by Richard J. Fantus, MD, FACS, Chicago, IL, and John Fildes, MD, FACS, Las Vegas, NV

Ancestors of the horse once Mortality rate by helmet use in animal rider injuries roamed the earth with dino- Mortality rate by helmet use in animal rider injuries saurs. Over millions of years, the animal evolved into the 1.58 modern horse that can weigh close to 1,100 pounds and travel 1.6 upwards of 40 miles per hour. 1.4 History is full of the varied 1.2 roles the horse has played in 1 transportation, battle, industry, sport, and recreation. In the 0.8 U.S., approximately 30 million 0.6 0.43 people are involved in eques- 0.4 trian activities each year.* This synergistic relationship with 0.2 equines is not without conse- 0 quence, however. No Helmet Helmet Throughout time, many well- known figures have found their demise on the back of a horse. In 1227, Genghis Kahn died injuries were sprains, strains, animal riders that include all from a fall off a horse. Five and fractures, but there are horseback riders. This group centuries later, William III of several thousand brain inju- of patients were on average 37 England died from injuries ries each year. Brain injuries years of age, and had an aver- sustained after his horse tripped account for 17 percent of sig- age length of stay of 4.1 days, on a molehill. Recent history re- nificant equestrian injuries but an intensive care unit length minds us of the late Christopher are responsible for 60 percent of stay of slightly more than Reeve, the actor who suffered of equestrian-related fatalities. one day, and an average injury a severe neck injury during an The American Medical Eques- severity score of 9.6. There was equestrian sporting activity. trian Association Safe Riders a total of 88 deaths for an over- According to the U.S. Consumer Foundation (http://www.amea- all mortality of 1.5 percent. Product Safety Commission, online.org/) refers to a reduction Helmets were worn by 469 and more than 200,000 people were in head injury fatalities through among those cases, two resulted treated for horseback riding the use of riding helmets. in death (.43%) whereas the injuries in 2004. Many of these To examine the occurrence of non-helmeted group accounted these injuries in the National for 5,444 records and 86 deaths *According to the Web sites of the Trauma Data Bank® Dataset (1.58%). These data are depicted American Academy of Orthopaedic 5.0, we used the cause of injury in the figure on this page. S u r g e o n s ( www.aaos.org ), t h e code (E code) E 828.2 for an With a fourfold greater mor- Children’s Safety Network (www. childrenssafetynetwork.org), and the accident involving the rider of tality for the non-helmeted Hughston Sports Medicine Foundation an animal being ridden. There group, horse sense would tell (http://www.hughstonfoundation.com). were 5,913 records that contain us to wear a helmet when rid- 67

NOVEMBER 2006 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ing a moving object that puts us brief monthly reports in the If you are interested in sub- almost eight feet off the ground Bulletin. The full NTDB Annual mitting your trauma center’s while traveling close to 40 miles Report Version 5.0 is available on data, contact Melanie L. Neal, per hour. the ACS Web site as a PDF file Manager, NTDB, at mneal@ Throughout the year, we will be and a PowerPoint presentation facs.org. highlighting these data through at http://www.ntdb.org.

Trauma meetings calendar

The following continuing December 8–9, Kansas City, becomes available) through the medical education courses in MO. American College of Surgeons trauma are cosponsored by the • Trauma and Critical Web site at: http://www.facs. American College of Surgeons Care—2007, March 26–28, org/trauma/cme/traumtgs.html, Committee on Trauma and Re- 2007, Las Vegas, NV. or contact the Trauma Office at gional Committees: Complete course informa- 312/202-5342. • Advances in Trauma, tion can be viewed online (as it

The Residency Assist Page of the American College of Surgeons offers a medium for program directors to acquire updates and advice on topics relevant to their needs as administrators and teachers.

Our goals are to offer practical information and approaches from summaries of published articles, invited editorials, and specific descriptions of lessons learned from program directors’ successful and not-so-successful strategies. Through the development of the Residency Assist Page, the ACS intends to support program directors and faculty by providing succinctly presented information helpful in addressing the challenges associated with administering state-of-art residency education. www.facs.org/education/rap

For additional information, please contact Linda Stewart, at [email protected], or tel. 312/202-5354.

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