Telemedicine Consultation for Emergency Trauma: Editor the 130 Million Square Foot Trauma Room 12 Linn Meyer Rafael J

JUNE 2011 Volume 96, Number 6

INSPIRING QUALITY: Highest Standards, Better Outcomes

FEATURES Stephen J. Regnier Telemedicine consultation for emergency trauma: Editor The 130 million square foot trauma room 12 Linn Meyer Rafael J. Grossmann Zamora, MD, FACS; Barbara Sorondo, MD; Director, Division of Robert Holmberg, MD, MPH; and Pret Bjorn, RN Integrated Communications Disclosing sleep: An ethical challenge from Tony Peregrin the e-FACS.org Ethical Issues in Surgery community 20 Associate Editor Jason D. Keune, MD; Ira J. Kodner, MD, FACS; Diane S. Schneidman and Gerald B. Healy, MD, FACS Contributing Editor Elias S. Hanna, MD, FACS, opens his heart to patients the world over 22 Tina Woelke Diane S. Schneidman Graphic Design Specialist Charles D. Mabry, Extremes of age: MD, FACS Surprising similarities of pediatric and geriatric surgery 24 Leigh A. Neumayer, Mark R. Katlic, MD, FACS; and J. Alex Haller, Jr., MD, FACS MD, FACS Health care integration: Will physicians lose their voice? 28 Marshall Z. Schwartz, MD, FACS Kevin Kavanagh, MD, FACS Mark C. Weissler, MD, FACS Editorial Advisors Tina Woelke DEPARTMENTS Front cover design

Looking forward 4 Editorial by David B. Hoyt, MD, FACS, ACS Executive Director Future meetings What surgeons should know about... 6 Clinical Congress Electronic prescribing in 2011 2011 San Francisco, CA, Caitlin Burley October 23-27 Advocacy advisor 31 2012 Chicago, IL, Running for political office September 30– Charlotte Grill October 4 2013 Washington, DC, October 6–10

Letters to the Editor should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to [email protected], or via mail to Stephen J. Regnier, Editor, Bulle- tin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or clarity. Permission to publish letters is assumed unless the On the cover: The emerging discipline of geriatric surgery shares many precedents, author indicates otherwise. symptoms, viewpoints, and treatment concerns with the specialty of pediatric surgery (see article, page 24). NEWS Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly JSAC focuses on imminent health policy changes 33 by the American College of Sur- geons, 633 N. Saint Clair St., Diane S. Schneidman Chicago, IL 60611. It is distrib- uted without charge to Fellows, Trauma surgeons discuss issues on Capitol Hill 36 Associate Fellows, Resident and Catharine Harris Medical Student Members, Af- filiate Members, and to medical Leadership conference focuses on effecting change at multiple levels 40 libraries and allied health person- Diane S. Schneidman nel. Periodicals postage paid at Chicago, IL, and additional mail- Did you know... 40 ing offices. POSTMASTER: Send address changes to Bulletin of the Fredric V. Price, MD, FACS, recognized American College of Surgeons, for commitment to global health 44 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian The ACS CoC ecognizesr 90 facilities with national award 45 Publications Mail Agreement No. 40035010. Canada returns to: Resident Research Scholarships for 2011 awarded 46 Station A, PO Box 54, Windsor, ON N9A 6J5. NCDB Research Fellow recognized by the Society of Surgical Oncology 47 The American College of Surgeons’ headquarters is lo- More women medical students select general surgery 49 cated at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. From Surgery News: Guidelines to prevent catheter infections 49 312-202-5000; toll-free: 800- 621-4111; e-mail:postmaster@ International Guest Scholarships available for 2012 50 facs.org; website: www.facs. org. Washington, DC, office is Trauma meetings calendar 50 located at 20 F Street N.W. Suite 1000, Washington, DC. 20001- A look at The Joint Commission: 6701; tel. 202-337-2701; web- Creating a culture of safety 51 site: www.tmiva.net/20fstreetcc/ home. Report on ACSPA/ACS activities, February 2011 53 Unless specifically stated oth- Timothy C. Flynn, MD, FACS erwise, the opinions expressed and statements made in this NTDB® data points: publication reflect the authors’ personal observations and do not The working wounded 62 imply endorsement by nor official Richard J. Fantus, MD, FACS; and John Fildes, MD, FACS policy of the American College of Surgeons. Chapter news 65 Rhonda Peebles ©2011 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment. Looking forward

ast month’s column centered on the retirement

of a key member of the American College of Surgeons’ Executive Staff—Linn Meyer,

Director of the Division of Integrated Com- munications. This month, I again focus on the retire- L ’’ ment of an individual who has contributed to this organization’s success in many ways and in multiple roles—Paul “Skip” Collicott, MD, FACS. Surgical career Dr. Collicott earned his bachelor’s of science and medical degrees at the University of Nebraska in The College owes a great debt Lincoln and Omaha, respectively. He completed a one-year rotating internship at Lincoln General Hos- of gratitude to Paul Collicott pital. His subsequent training was interrupted by two years of service as a general medical officer in the U.S. for his many contributions to Air Force during the Vietnam War. It was because of this experience that Skip decided to become a trauma the work of this organization. surgeon. He completed his surgical training at the University of Washington, Seattle. He built a robust peripheral vascular and trauma ’’ surgery practice in Lincoln and was on staff at five ACS-sponsored ATLS course was presented in Lin- Nebraska hospitals. Skip also served as a surgical coln, NE. Later that year, regional ATLS courses consultant for the Veterans Affairs Hospital, the were presented in eight more cities. The following University of Nebraska Student Health Center, and year, ATLS made its way into Canada, and in 1986, Lincoln Regional Center. He worked his way up the the course was introduced to the international com- academic hierarchy at the University of Nebraska munity at the Royal College of Surgeons in London, Medical College in Omaha and served as a trauma England. Skip proudly served as a national and in- consultant at that institution. ternational course director for many years. The ACS and other organizations have honored ATLS® Dr. Collicott for his important contributions to Skip will probably be best remembered as the the trauma and surgical communities. The ACS founding father of the Advanced Trauma Life Sup- COT accorded him its Trauma Achievement Award port® (ATLS) program, which is the internationally in 1982, its Service Award in 1987, and the ATLS recognized educational program on the initial evalu- Meritorious Service Award in 1988. In 1992, the ation and management of trauma patients. Dr. Colli- ACS, the American Association for the Surgery of cott introduced the ATLS concept to members of the Trauma, and the National Safety Council presented Committee on Trauma (COT) at their 1979 annual him with the Surgeon’s Award for Service to Safety, meeting in Houston, TX, after presenting a pilot and the American Trauma Society honored him with course to a group of family physicians in Auburn, NE, the presentation of the William A. Stone Lectureship. in 1978. That initial course was a response to a tragic plane crash involving James K. Styner, MD, FACS, ACS leadership an orthopaedic surgeon. Dr. Styner’s wife was killed In addition to serving on the COT for 10 years, and his children severely injured in the accident. The Dr. Collicott served on the ACS Board of Governors family had no access to appropriate medical care in from 1992 to 1994, the ACS Board of Regents from the rural area of southeast Nebraska where the plane 1993 to 2002, and the Executive Committee of the went down. Board of Regents from 1999 to 2001. In addition, he The members of the COT enthusiastically em- served on the Nominating Committee from 1997 to braced the proposal, and in January 1980, the first 1998, the Member Services Liaison Committee from 4

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 1993 to 1995, and the Central Judiciary Committee from 1995 to 1998. For his contributions to ATLS and to the ACS as whole, Skip was presented in 2008 with the College’s Distinguished Service Award—the highest of all ACS honors. For the last 10 years, Dr. Collicott has served as the Director of the ACS Division of Member Services. In this capacity, Skip has led substantial improvements in the College’s efforts to expand its membership. Under his watch, ACS membership climbed by 22 percent, from 64,000 to 78,000, and the number of residents joining the College nearly doubled. The College opened up membership to other health care professionals who are involved in the delivery of surgical services, including surgical nurses, anesthesiologists, and so on. He also oversaw the addition of a medical student Dr. Collicott category of ACS membership, the development of the ACS Resident and Associate Society (RAS), and the transformation of the Committee on Young Surgeons into the Young Fellows Association (YFA). Skip reached out to other divisions of the College to divide most of their time between their Lincoln, NE, collaborate on various projects. For example, the Divi- townhouse and their log cabin nestled in the middle sion of Member Services worked with the Division of of the Shoshone National Forest in northwest Wyo- Integrated Communications and Weber Shandwick ming. He intends to enjoy the wonders of nature by to develop a marketing strategy and to produce a fly fishing, hiking, and teaching his grandchildren to recruitment and retention DVD. Member Services appreciate wildlife and the great outdoors. and Integrated Communications also worked together The College owes a great debt of gratitude to Paul to develop more chapter websites, and electronic Collicott for his many contributions to the work of newsletters for the RAS and YFA. He worked with this organization. His warmth, his commitment to the ACS Foundation and the Finance area to ensure patient care, and his level-headed approach to resolv- the continued success of Operation Giving Back and ing issues will be sorely missed. to consolidate the College’s scholarship programs. Other accomplishments that Skip led include sub- stantially increasing the number of Central Judiciary Committee reviews by instituting standards for the behavior of a Fellow acting as an expert witness, ini- tiating a general membership survey, and fostering a Board of Governors study on surgeon burnout. David B. Hoyt, MD, FACS Retirement At press time, the College’s leadership was in- terviewing candidates to fill Skip’s post, which he intended to vacate May 31. However, I am pleased to report that he, like Linn, has agreed to serve as a consultant to his successor. Skip looks forward to retirement and spending If you have comments or suggestions about this more time with his wife, Irvene Hughes Collicott, or other issues, please send them to Dr. Hoyt at RN, who is also an ACS retiree. Skip and Irvene will [email protected]. 5

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

Electronic prescribing in 2011 by Caitlin Burley

he Medicare Improvements for Patients and Table 1. Providers Act of 2008 (MIPPA) authorized Annual e-prescribing incentives and penalties the Centers for Medicare & Medicaid Services T(CMS) to develop an incentive program for electronic Year Incentive Penalty prescribing, or e-prescribing. E-prescribing is defined as “the ability to electronically send an accurate, 2011 1.0% 0 error-free, and understandable prescription directly 2012 1.0 1.0% to a pharmacy from the point-of-care.”* Originally a quality measure in the 2008 Physician Quality 2013 0.5 1.5 Reporting Initiative (PQRI), CMS removed the e-prescribing measure and implemented a separate 2014 and beyond 0 2.0 pay-for-reporting incentive program in 2009, with the goal of advancing quality through safer, more coordinated prescription writing. The creation of Abbreviations and acronyms used in this article this pay-for-reporting program allows eligible professionals to potentially be able to qualify for two ASC X12N 837 electronic claim form incentive payments in 2011—one for e-prescribing and one for PQRI, which is now called the Physi- CMS Centers for Medicare & Medicaid Services cian Quality Reporting System (PQRS). Eligible professionals who successfully e-prescribe in 2011 standard claim form used by a non- qualify for an incentive payment of 1.0 percent; institutional provider or supplier to bill CMS 1500 however, Table 1 on this page shows the incentives Medicare carriers and durable medical and penalties for each year after 2011. equipment regional carriers

What are the benefits of e-prescribing? CPT Current Procedural Terminology

E-prescribing is designed to positively affect four EHR electronic health record stakeholder groups: patients, payors, providers, and pharmacies. An e-prescribing system should help e-prescribing electronic prescribing reduce patients’ out-of-pocket costs, improve their safety, and make filling prescriptions more conve- GPRO Group Practice Reporting Option nient, because they will no longer need to carry a Healthcare Common Procedure paper script, and pharmacies will have the prescrip- HCPCS tion in the system immediately. E-prescribing should Coding System benefit payors because safer outcomes with reduced Medicare Improvements for Patients and MIPPA adverse medication errors and increased formulary Providers Act of 2008 compliance will reduce costs. Providers are expected to gain time from e-prescribing, as the system should PFS Medicare Part B Physician Fee Schedule reduce administration issues, illegible scripts, and incorrect dosage, as well as expedite drug selection. PQRS Physician Quality Reporting System Lastly, e-prescribing should assist pharmacies by in- *Centers for Medicare and Medicaid Services. Available at: http:// QDCs quality data codes www.cms.hhs.gov/EPrescribing/. Accessed March 16, 2011. 6

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS creasing coordination and clarification with providers, • Provide information on formulary or tiered while decreasing dispensing errors and costs. formulary medications, patient eligibility, and autho- rization requirements received electronically from the Who is eligible to participate in this program? patient’s drug plan, if available. Eligible professionals are those for whom office vis- I think I’m an eligible professional; now what? its, eye exams, psychotherapy, or other services listed in the CMS E-Prescribing Measure Specifications To further determine eligibility for the incentive represent at least 10 percent of their Medicare charges: payment, the health care professional will need to physicians, physical and occupational therapists, consider the following questions: qualified speech-language pathologists, nurse practi- • Do I have an e-prescribing system/program and tioners, physician assistants, clinical nurse specialists, am I routinely using it? certified registered nurse anesthetists, certified nurse • Is my system capable of performing the func- midwives, clinical social workers, clinical psycholo- tions of a qualified system as described previously in gists, registered dietitians, nutrition professionals, and this article? qualified audiologists. • Do I expect my Medicare Part B physician fee Electronic prescribing should only be reported for schedule (PFS) charges for the codes in the denomina- office visits that are separately listed on Medicare tor of the measure (see Table 2, page 8) to comprise claims and separately payable by Medicare. Office at least 10 percent of my total Medicare Part B PFS visits provided as part of a global surgical package allowed charges for 2010? do not count toward calculations of penalties for Surgeons who answer “yes” to all of these questions not adopting e-prescribing. Only separately payable qualify for the incentive payment. Surgeons who office services count toward the 10 percent of Medi- answer “yes” to the first two questions, but “no” to care payments that determine a physician’s eligibility the third question, may not qualify for the incentive for the incentive payment, and toward the 25 office payment. However, it is important to be sure that services for which e-prescribing must be reported in your Medicare Part B PFS charges for the codes in the order to qualify for the incentive payment. (For more denominator of the measure do not make up at least information, refer to the section of this article titled 10 percent of your total Medicare Part B PFS allowed “What are the denominator codes?”) charges for 2011. If you answered “no” to either the Eligible professionals must have adopted a quali- first or second question, you are not eligible for the fied e-prescribing system in order to report the e- incentive payment. prescribing measure. There are two types of systems: one for e-prescribing only (stand-alone), and the How do I begin to participate for the 2011 incentive other is the electronic health record (EHR) with the payment? e-prescribing functionality. Regardless of the type of system selected, in order to be considered “qualified” There is no registration required to participate in it must meet the following criteria: the e-prescribing program. Simply begin reporting the • Generate a complete active medication list in- e-prescribing measure at any time in 2011. The sur- corporating electronic data received from applicable geon can report e-prescribing data using claims-based pharmacies and pharmacy benefit managers, if avail- reporting, registry-based reporting, or EHR-based able. reporting. For claims-based reporting, report the e- • Select medications, print prescriptions, elec- prescribing G-code (G8553) throughout 2011. For tronically transmit prescriptions, and conduct all registry-based reporting, report 2011 e-prescribing alerts. data using a CMS-qualified registry during the first • Provide information related to lower cost, quarter of 2012. For EHR-based reporting, report therapeutically appropriate alternatives (if any are 2011 e-prescribing data using a CMS-qualified EHR available). (The availability of an e-prescribing system product during the first quarter of 2012. to receive tiered formulary information, if available, It is important to note that only registries and EHR would meet this requirement for 2011). continued on page 9 7

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 2. Codes in the denominator that relate to surgeons

Code Descriptor

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or 99201 coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face- to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision 99202 making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care 99203 with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/ 99204 or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/ 99205 or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence 99211 of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision 99212 making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making 99213 of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling 99214 and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high 99215 complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

Source: CPT Manual data compiled by Division of Advocacy and Health Policy staff. 8

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Reporting an e-prescribing measure on CMS-1500

Available at: https://www.cms.gov/ERxIncentive/Downloads/2011_eRx_ClaimsBasedReportingPrinciples_111510.pdf.

vendors that have been vetted by CMS for the 2011 What is the reporting period for the 2011 incentive PQRS/e-prescribing incentive program are quali- payment? fied to report electronic prescribing information to CMS. These registries and EHR vendors are posted The e-prescribing incentive program reporting on the CMS website at https://www.cms.gov/ERx period is a full calendar year, January 1 to December Incentive/03_How_To_Get_Started.asp#TopOfPage. 31, 2011. Please note that these systems have not been checked for electronic prescribing functionality as defined in How can I e-prescribe successfully to receive the in- the specifications of the measure. centive amount? It is also important to note that eligibility and qualification for the 2011 incentive payment does not For the 2011 reporting period, an eligible profes- preclude the application of the e-prescribing penalty sional must report the e-prescribing numerator G- in subsequent years. code, which describes at least one prescription created 9

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS during the encounter that was generated and trans- charges, CMS will begin to apply a 1 percent penalty mitted electronically using a qualified e-prescribing across a surgeon’s total allowed charges. system. To qualify for the incentive payment, the e- prescribing G-code, G8553, must be reported at least When and where do I report the numerator and de- 25 times for Medicare office visits, as well as the other nominator codes? listed services for the calendar year for applicable Cur- rent Procedural Terminology (CPT)† codes included If you bill one of the CPT or HCPCS G-codes in the CMS e-prescribing measure specifications. (denominator codes) on the claim form that is sub- The specifications list the denominator codes, which mitted for the Medicare patient visit, and at least one are CPT or Healthcare Common Procedure Coding prescription was created during the patient encounter System (HCPCS) G-codes that represent eligible cases and transmitted electronically using a qualified e- on which surgeons may e-prescribe. prescribing system, report G8553 (numerator code) on the same claim form. An example of reporting What are the denominator codes? the e-prescribing measure on the Form CMS-1500 (Health Insurance Claim Form) is shown in the figure The denominator codes for the e-prescribing mea- on page 9. sure are as follows: What is the 2012 penalty for unsuccessful e-prescribing? 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, As required under Section 132 of MIPPA, CMS 96150, 96151, 96152, 99201, 99202, 99203, 99204, is required to implement a payment adjustment, or 99205, 99211, 99212, 99213, 99214, 99215, 99304, penalty, for those eligible professionals who are not 99305, 99306, 99307, 99308, 99309, 99310, 99315, successful e-prescribers. While the payment adjust- 99316, 99324, 99325, 99326, 99327, 99328, 99334, ment will not take effect until 2012, the penalty is 99335, 99336, 99337, 99341, 99342, 99343, 99345, based upon the January 1 through June 30, 2011, 99347, 99348, 99349, 99350, G0101, G0108, G0109 reporting period. The American College of Surgeons (ACS) encour- How do I avoid the 2012 penalty? ages surgeons to e-prescribe. The College realizes, given that narcotics cannot be e-prescribed and many To avoid the 2012 e-prescribing penalty, report of the denominator codes do not routinely apply to on a minimum of 10 unique visits via claims from surgeons, the opportunity to participate or avoid the January 1 through June 30. Each visit must be ac- penalty might seem limited. Based on the review of companied by the e-prescribing G-code attesting that data on evaluation and management (E/M) allowed during the patient visit at least one prescription was charges as a percent of total allowed charges, it ap- written electronically. Electronically generated refills pears that most surgical specialties meet or exceed do not count and faxes do not qualify as an electronic the required 10 percent of denominator codes as a prescription. New prescriptions not associated with a percentage of Medicare charges. Nevertheless, indi- code in the denominator of the measure specification vidual practices may vary significantly from national are not accepted as an eligible patient visit, and do data. In addition, the data review shows that cardiac not count toward the minimum unique electronic and thoracic surgery practices might fall below the prescribing events. However, unlike qualifying for 10 percent threshold of denominator codes as a per- the e-prescribing incentive, reporting physicians must centage of Medicare charges. For those specialties and report the 10 visits via claims and not via the registry- providers whose E/M charges are 10 percent or more based or EHR-based reporting methods. of their total allowed Medicare charges, it is important to note that if you do not correctly report E/M Are there any other exemptions for the 2012 penalty? †All specific references to CPT (Current Procedural Terminology) terminology and phraseology are © 2011 American Medical Association. To be an eligible professional to participate in the All rights reserved. e-prescribing incentive program, 10 percent of a sur- 10

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS geon’s Medicare Part B PFS charges must be composed The College will continue its efforts on all fronts of the codes in the denominator of the measure to and provide updates on changes to the e-prescribing be eligible for the penalty. Additional exemptions program as they become available. apply to the following: health care professionals For more information, go to http://www.cms.gov/ who are not physicians (MD, DO, or podiatrist), ERxIncentive/. If you have any further questions re- nurse practitioners, or physician assistants as of June garding e-prescribing, contact Bob Jasak at bjasak@ 30, 2011, based on primary taxonomy code in the facs.org.  National Plan and Provider Enumeration System; health care professionals who do not have prescribing privileges and report G-code G8644 (defined as not having prescribing privileges) at least once on an eligible claim before June 30; health care professionals who do not have at least 100 cases containing an encounter code in the measure denominator; or health care professionals who meet and report a significant hardship exemption.

What are the significant hardship exemptions?

CMS is allowing for two significant hardship exemptions: • G8642—eligible professionals, including physicians, who practice in a rural area without sufficient high-speed Internet access are exempt from penalties • G8643—eligible professionals, including physicians, who practice in an area without sufficient available pharmacies for electronic prescribing are exempt from penalties Eligible physicians must report the designated G- code at least once between January 1 and June 30 to avoid a penalty.

If I successfully participate in the EHR incentive program, am I exempt from the e-prescribing penalty?

No. The penalty applies regardless of whether an Ms. Burley is Quality Associate, Division of Advo- eligible professional is planning to participate in the cacy and Health Policy, EHR incentive program. However, if the physician Washington, DC. chooses to participate in the Medicare EHR incentive program and qualify for the bonus, he or she is not eligible to receive an incentive payment under the e-prescribing incentive program simultaneously in the same program year. If a physician chooses to participate in the Medicaid EHR incentive program, he or she can participate in the Medicare e-prescribing incentive program simultaneously. The ACS has been working diligently to address the implementation problems with both the incentive and penalty portions of the e-prescribing program. 11

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Telemedicine consultation for emergency trauma: The 130 million square foot trauma room

by Rafael J. Grossmann Zamora, MD, FACS; Barbara Sorondo, MD; Robert Holmberg, MD, MPH; and Pret Bjorn, RN

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS n rural areas, connecting patients with health care specialists in a timely manner remains a pressing concern. This is the case particularly for rural trauma patients, due to a shortage of trauma care providers in rural and sparsely populated areas.1-3 ThisI shortage specifically applies to Maine, where there are only three American College of Surgeons (ACS)-verified trauma centers covering an area of more than 35,387 square miles. Moreover, inclement weather, geographical impediments, and a relative lack of emergency medical service transportation services can make it difficult to transfer patients to trauma centers.2,3 Thus, telehealth technology provides an opportunity to efficiently improve quality of care in rural areas. In this article, which is based on a scientific exhibit winning entry from the 2009 Clinical Congress in Chi- cago, IL, the authors describe their experience implementing and evaluating a teletrauma network in rural Maine. Having an experienced trauma specialist assist with care is a benefit for rural emergency physicians that can potentially improve patient outcomes and reduce the cost of care.4 Typically, when a rural trauma event occurs, and immediate transfer to a trauma- certified hospital is not feasible, local hospital providers consult with trauma specialists via telephone.5-7 These conversations, however, suffer predictable limitations. First, they encourage a linear process—prior to the phone consultation, the local provider may be immersed in minutes or hours of single-handed direct care. Furthermore, this treatment interval must in turn be summarized and processed for the trauma center colleague—a crucial conversa- tion wholly reliant on the memory and mental organization of the rural provider. Perhaps most importantly, the consultation is neither contemporaneous nor usefully interactive, and is thus insensitive to inefficiency and error. Telemedicine for rural trauma health care Recent advances in technology and e-health have ushered in a new era—one in which the bridging of the rural health care dis- parities gap is becoming a distinct possibility. Telemedicine is one technological advance that is transforming the way rural health care is delivered. Emerging technologies in telemedicine offer increasingly affordable, high-definition multimedia systems that allow practitioners to share the patient care environment in real time. They permit clinicians to be “virtually” in the same room, across the geographical divide. For eastern and northern Maine, a largely rural area served by only one ACS-verified Level II trauma center— Eastern Maine Medical Center (EMMC), Bangor, ME— more than 200 miles away from some patients and local hospitals, telemedicine is intuitively an essential tool. The use of such technology in trauma, emergency medicine, and acute care is relatively recent.8,9 Logically, telemedicine and telepresence should be beneficial for rural areas. As Latifi and colleagues argue, emergency room staff in rural areas “often have 13

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 1 Current teletrauma sites in Maine

The EMMC (the “hub” site) is indicated on the map by the blue eagle; the 11 “spoke” sites are indicated by yellow dots. The locations of other hospitals in Maine are represented by red dots. Source: EMHS Planning Department, Brewer, ME.

limited experience with major traumas, which may savings have been found to accrue through more efficient lead to management errors and departures from the use of transportation services (for example, air transport), standard of care.”8 This lack of experience contributes reduction of unnecessary transfers, and reduction in to the poorer outcomes observed in trauma cases taking length of stay.8,17,18 Most of the studies demonstrating a place in rural as compared with urban areas.3,10 reduction in length of stay have examined institutions Several studies on the use of telemedicine consulta- before and after implementation of telemedicine. tion have indicated a positive impact on the quality of care.2,11,12 In certain cases, patients were able to stay in Teletrauma in eastern and northern Maine their local community rather than being transported The EMMC is a key participant in the northern to a larger institution. New England telemedicine system, which was initi- An early evaluation of telemedicine for emergency ated in 1996, long before most hospitals had adopted care found that it resulted in lifesaving care in two telemedicine technologies. Little systematic evalua- cases, and the researchers found that referring providers tion took place, however, until early 2006, when the overwhelmingly felt that telemedicine improved patient EMMC began an extensive project to expand its telecare.13 Other studies have found that telemedicine may medicine network. This project involved two major improve outcomes for patients with injury resulting departments: trauma surgery and pediatric intensive from burns.14,15 In addition, telemedicine consultation care. The following discussion will concentrate on in rural trauma cases can result in significant cost savings the authors’ teletrauma experience over the last four to patients and to health care systems.8,9,16-18 These cost years, comparing telemedicine consultations to our 14

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS facility with traditional telephone consultations. At the beginning of the study, we anticipated that access to trauma specialists through telemedicine would facilitate interventions for stabilizing patients, maximizing early care, and ultimately improving patient outcomes across the health care region. We thought that the teletrauma program would reduce the ratio of unnecessary transfers to the regional Level II trauma center, improve patient outcomes, and reduce medical errors, thus improving overall rural trauma care. The EMMC provides trauma consultations to the 11 community and critical access hospitals (CAHs) that participated, including Blue Hill Memorial Hos- pital, Charles A. Dean Memorial Hospital, Houlton Regional Hospital, Inland Medical Center, Mayo Re- A mobile camera site. gional Hospital, Millinocket Regional Hospital, Mount Desert Island Hospital, Penobscot Bay Medical Center, Redington-Fairview General Hospital, Sebasticook What have we found so far? Valley Hospital, and The Aroostook Medical Center. Our experience with teletrauma has been over- Figure 1, page 14, shows the teletrauma network, with whelmingly positive, both for providers and patients. the EMMC serving as the “hub hospital,” and outly- The data suggest that patient outcomes are improved ing facilities representing the “spokes.” The geographic when telemedicine is used (when appropriate) as region covers more than 126,000 square miles and compared with traditional telephone consultations. includes half of Maine’s 15 CAHs. This has inspired the We also asked referring and consulting providers about conceptualization of what could be thought of as the their experience using telemedicine, through a survey “130 million square foot trauma room.” Telemedicine administered within 48 hours of each telemedicine enables our specialists to work with providers at remote consultation (see Figure 2, page 16). hospitals in real time, as if we are all in the same room. We have gathered data on more than 700 transfer consultations between the EMMC’s trauma team and What did we look for? our network hospitals since mid-year 2007. Consulta- We utilized a non-equivalent, parallel, control group tions conducted by telemedicine account for 15 percent design to assess the impact of telemedicine trauma of these. Of the 105 telemedicine consultations, 55 consultations as compared with trauma cases using (52 percent) resulted in transfer of the patient to the telephone consultation in regard to patient outcomes, EMMC. A total of 192 surveys have been collected for clinical process, and physician satisfaction. Telemedi- each of the 105 telemedicine consultations recorded cine consultations were conducted using Tandberg to date, representing a 91 percent response rate when camera systems, such as the mobile unit shown in the at least one of the two providers completed a survey. photo on this page, which features a 20-inch wide- Patients transferred to the EMMC as a result of tele- screen LCD monitor with high-definition camera and medicine consultation were more likely to be slightly audio transmission. This system enables “continuous younger (36 years of age, compared with 45) and more presence” multipoint conference bridging between often male (84 percent compared with 66 percent) than sites, linking them in real time. The attending and were patients transferred to the EMMC after a tele- consulting physicians can see and speak with each phone consultation. The EMMC code green (trauma other, and the consulting physician is also able to see team) response was also more likely to be activated the patient. In all instances, the decision of whether or (22 percent versus 5 percent) when telemedicine was not to transfer a patient is made locally—for example, used. While the majority of trauma cases we have con- by the attending physician at the remote site—based sulted on involved motor vehicle crashes or falls, other on information and advice provided by the consultant mechanisms of injury included assault, watercraft inju- who actually “sees” the patient. continued on page 17 15

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 2. Telemedicine provider survey TELEMEDICINE: Transfer consultation survey Adult Trauma? PICU? Please rate your response only to those statements that apply (circle one).

Referring physician: Consulting physician: Referring CAH: Date/time of consult

1. It was my intention to transfer the patient prior to consultation. YES NO 2. The telemedicine process influenced patient disposition / transfer. YES NO 3. The telemedicine connection process was uncomplicated and efficient. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

4. The technical quality of the telemedicine connection (audio/visual) was optimal. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

5. The telemedicine process changed patient care management. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

6. The telemedicine process positively affected potential patient outcome. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

7. The telemedicine process better facilitated communication and decision making between clinicians. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

8. Telemedicine better facilitated communication and reassurance with family members (if appropriate). Strongly agree 5 4 3 2 1 Strongly disagree Comments:

9. My overall satisfaction with this telemedicine consult was high. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

10. I will use telemedicine again in the future. Strongly agree 5 4 3 2 1 Strongly disagree Comments:

11. A FOLLOW-UP consultation was done after the patient was transferred. YES NO 12. This FOLLOW-UP consultation served as an informative and effective training tool (if applicable). Strongly agree 5 4 3 2 1 Strongly disagree Comments:

PHYSICIAN'S SIGNATURE: ______

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ries, fire, explosion, and self-inflicted wounds. Use of demonstrate how telemedicine can offer benefits to the telemedicine system forces the early inclusion of a both referring and consulting medical providers. Thus, trauma surgeon in pre-transfer decision making—thus, this report provides a unique combination of quanti- patients transferred by telemedicine consult are likely tative and qualitative data to evaluate our experience to receive more appropriate and higher-quality care. with telemedicine. Telemedicine has had a substantial impact on clinical • A middle-aged patient presented in the evening process outcomes. For example, one of the outcomes to a rural emergency room with partial thickness burns we are tracking is the mode of transportation when to the face and both hands. An initial assessment de- a patient is transferred to the EMMC from a remote termined that a transfer to the Level II trauma center community. Our trauma coordinators review all pa- was warranted; however, a teletrauma consult with tients transferred from other facilities and determine an EMMC specialist resulted in the woman being whether or not a transfer was necessary. In cases where treated safely and effectively within her local hospital. the quality of patient management or transfer might The patient fully recovered from the burns without be improved, a coordinator then determines whether complications. Teletrauma was credited as eliminating or not telemedicine might have reasonably prevented an unnecessary 150-mile round-trip transport to the any such shortcomings. We have found that more EMMC. The referral physician stated, “Our patient is telephone consultations were deemed as a potentially impressed with both hospitals.” The consulting physi- “unnecessary transfer” compared with telemedicine. cian stated, “Teletrauma is great for assessing burn We also found that more telephone consultations patients.” resulted in an “inappropriate mode of transfer” com- • In a rural town, a motor vehicle crash occurred, pared with telemedicine consultations. The majority involving five individuals. Before transferring the five of these cases involved air transportation (at a much patients to the EMMC, a teletrauma consult was initi- higher expense), when ground transportation would ated with the EMMC trauma specialists. Additionally, have sufficed. Thus far, we have not identified a single the technicians, nurses, and physicians who took part case in which an inappropriate mode of transport was in the initial work-up of the patients were able to stay associated with a telemedicine case. We believe that the involved in the entire process of care—from transport more telemedicine is used, the better we will be able to to treatment at the EMMC via reverse telemedicine statistically demonstrate that this technology results in (referring hospital providers were able to observe the fewer transportation errors. treatment process after arrival at the trauma center). Notably, we have found that the incidence of medi- This event served as an important team-building and cal errors is lower when using telemedicine than for educational exercise for the referring rural health care telephone consultations. That is, according to the judg- providers. ment of our trauma coordinators, inappropriate clinical • The third case involved a female who had been management was more likely to be associated with burned during the evening. Providers at the rural com- telephone consultation cases than telemedicine cases. munity hospital contacted the EMMC for advice and Finally, while the mortality rate was higher for those assistance in transferring the patient to a Boston, MA, transferred after a telemedicine consultation, the Injury burn center. However, a trauma physician was able to Severity Score (ISS) was also higher. The median ISS of assess the injury and determine not only that a burn those greater than 15 was higher for the telemedicine center was not indicated, but indeed, that the patient group (25.0 compared with 18.0). While more data is could be safely treated at the CAH, with no threat of required for firm conclusions, the data thus far suggest morbidity or complication. that telemedicine can offer direct benefits for patient care. What do providers say about telemedicine? Clinical cases According to the surveys we disseminated after each When seeking to illustrate the benefits of telemedi- telemedicine consultation, providers (referring and cine, numbers may not tell the entire story. We have consulting) are supportive of—and wish to continue noted several cases in which telemedicine (subjectively) to use—telemedicine. For example, we found that resulted in more efficient and potentially life-saving referring and consulting providers in general felt that care. To convey this, we present three case studies that the technology was easy to use, and improved com- 17

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS munication between each other and providers and many services in which telemedicine can prove useful families. Providers also stated that they would be very in reducing costs and increasing access to care. willing to use telemedicine cameras in the future. Im- It is now, we believe, safe to say that telemedicine portantly, the majority of survey respondents felt that has a strong future in emergency and trauma care. the use of telemedicine improved the clinical care of the This is the case especially in rural areas where there patients involved. Several cases have been identified as is a shortage of specialists. It simply makes sense to having been impacted by telemedicine in a potentially use this technology in a way that links specialists to lifesaving way. providers in remote hospitals. After all, having a “30 million square foot trauma room” means that patients Conclusion in rural, remote locations no longer have to travel long Fifteen years ago, when telemedicine first made an distances to meet with specialists, and providers in appearance in the health care field, providers were trauma centers do not have to “fly blind” with respect reasonably skeptical. To see patients through a video to advice we give to rural referring physicians. screen seemed interesting, but somehow less clinical To be sure, challenges remain. Credentialing across than seeing them face-to-face. Also, providers won- facilities can be a difficult task, and ensuring compli- dered whether this technology would be feasible to ance with ever-changing regulations regarding patient use on a regular basis.19 Research has now shown that confidentiality will likely remain a barrier to full adop- telemedicine is accepted by providers and that there are tion of telemedicine services for many locations. Regu- latory conditions vary across localities, thus inhibiting Dr. Grossmann Zamora full adoption of telemedicine across the nation, and is a general and trauma according to the authors of a recent academic paper, surgeon at the Eastern Maine the existence of inconsistent regulations is unconstitu- Medical Center, Bangor. tional.20 Their point is that in order to make the best possible use of telemedicine, an infrastructure needs to be in place on the local, state, and federal levels. Another challenge has been the area of documentation and billing/reimbursement. We have a standardized process for dictation, coding, and charging payors in Maine for patients who receive telemedicine consultation and are not transferred. We have not, to date, researched the reimbursement aspect of the project. In addition, we have done a few trials of “tele-follow-up visits,” in which patients who reside long distances from the EMMC have been subsequently seen via Dr. Sorondo is director, telemedicine to evaluate their clinical progress. Eastern Maine Medical Cen- In our experience, telemedicine has had numerous ter Clinical Research Center, benefits both to patients and providers. Now, patients Bangor. have expanded access to specialists in a timely manner. In addition, preliminary analyses have shown that telemedicine could incur significant cost savings by averting unnecessary transfers to the EMMC. We are continuing our work with telemedicine in several areas (including TelePICU, TeleHomecare, Tele-ED Psychiatry, TeleNICU Stabilization, TeleStroke, TeleEndocrinology, and TelePsychiatry). We are also pursuing additional funding to expand our network in terms of geography and services. We hope that the national and world-wide trend toward increased use of telemedicine continues well into the future.  18

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Acknowledgments gionalization of trauma care using telemedicine feasible and desirable? Am J Surg. 2000;180(6):535-539. The authors acknowledge the significant contributions of the 17. Duchesne JC, Amber K, Simmons J, Islam S, Schmieg RE, Olivier J, McSwain NE. Impact of telemedicine upon rural following: Erik Steele, DO; David Burke, MD, FACS; Joanmarie trauma care. J Trauma. 2008;64(1):92-98. Pellegrini, MD, FACS; David Rydell, DO; Amy Fenwick, MD, 18. Zawada E Jr, Herr P, Larson D, Fromm R, Kapaska D, Erick- FACS; Rony Ramia, MD; Joseph Karem; Michael Rocque; Wanda son D. Impact of an intensive care unit telemedicine program Pacifici; and Karen Clements, RN. We also gratefully acknowledge on a rural health care system. Postgrad Med. 2009;121(3):160- the staff at the EMMC’s Emergency Department and staff at all 170. remote sites in the teletrauma network. 19. Wootton R. Telemedicine: A cautious welcome. BMJ. 1996;313(7069):1375-1377. 20. Gupta A, Sao D. The unconstitutionality of current legal bar- References riers to telemedicine in the United States: Analysis and future directions of its relationship to national and international 1. Ricketts T. Rural Health in the United States. New York, NY: health care reform. Available at: http://works.bepress.com/ Oxford University Press; 1999. deth_sao/2. Accessed March 22, 2011. 2. Rogers F, Ricci M, Caputo M, Shackford S, Sartorelli K, Callas P, Dewell J, Daye S. The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: Preliminary results. J Trauma. 2001;51(6):1037-1041. 3. Rogers F, Shackford S, Osler TM, Vane DW, Davis JH. Rural trauma: The challenge for the next decade. J Trauma. 1999;47(4):802-819. 4. Wyatt JP, Henry J, Beard D. The association between senior- Dr. Holmberg is a pediatri- ity of accident and emergency doctor and outcome following cian and director of clinical trauma. Injury. 1999;30(3):165-168. outreach, Eastern Maine 5. Car J, Sheikh A. Telephone consultations. BMJ. 2003;326(7396):966-969. Medical Center, Bangor. 6. Reisman A, Stevens D. Telephone Medicine: A Guide for the Practicing Physician. American College of Physicians, East Peoria, IL: Versa Press, 2002. 7. Sokol D, Car J. Patient confidentiality and telephone consultations: Time for a password. JME. 2006;32(12): 688-689. 8. Latifi R, Hadeed G, Rhee ,P O’Keeffe T, Friese RS, Wynne JL, Ziemba ML, Judkins D. Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients. Am J Surg. 2009;198(6):905-910. 9. Latifi R, einsteinW RS, Porter JL, Ziemba M, Judkins D, Ridings D, Nassi R, Valenzuela T, Holcomb M, Leyva F. Telemedicine and telepresence for trauma and emergency care management. Scand J Surg. 2007;96(4):281-289. 10. Baker S, Whitfield R, O’Neill B. Geographic variations in mortality from motor vehicle crashes. N Engl J Med. Mr. Bjorn is a registered 1987;316(22):1384-1387. nurse and trauma program 11. Lambrecht C. Telemedicine in trauma care: Description of manager, Eastern Maine 100 trauma teleconsults. Telemed J. 1997;3(4):265-268. Medical Center, Bangor. 12. Ricci MA, Caputo M, Amour J, Rogers FB, Sartorelli K, He is chair of the Maine Callas PW, Malone PT. Telemedicine reduces discrepancies Emergency Medical Services in rural trauma care. Telemed J E Health. 2003;9(1): 3-11. Trauma Advisory Committee. 13. Hicks LL, Boles KE, Hudson ST, Madsen RW, Kling B, Tracy J, Mitchell JA, Webb W. Using telemedicine to avoid transfer of rural emergency department patients. J Rural Health. 2001;17(3):220-228. 14. SaffleJ. Telemedicine for acute burn treatment: The time has come. J Telemed Telecare. 2006;12(1):1-3. 15. Saffle J,delman E L, Theurer L, Morris SE, Cochran A. Telemedicine evaluation of acute burns is accurate and cost- effective. J Trauma. 2009;67(2):358-365. 16. Aucar J, Granchi T, Liscum K, Wall M, Mattox K. Is re- 19

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Disclosing sleep: An ethical challenge from the eFACS.org Ethical Issues in Surgery community

by Jason D. Keune, MD; Ira J. Kodner, MD, FACS; and Gerald B. Healy, MD, FACS

recent publication by Michael Nurok, MD, who meet the professional and ethical standards of PhD, and colleagues in the New England the ACS should be able to address such a problem Journal of Medicine has caused a stir in individually, as a matter of delivering safe surgical the surgical community and beyond.* The care, and would likely view such a requirement as article,A entitled “Sleep deprivation, elective surgical “oppressive and insidious.” Next, they assert that a procedures, and informed consent,” appeared in the simple disclosure rule will not address the root of the December 30, 2010, issue. The article asserts that sur- problem, and surgeons should be trained in evaluating geons who are sleep deprived after a night of operating their own level of sleep deprivation as a component should be morally obligated to formally disclose their of providing excellent patient care. level of sleep debt to their elective patients who are Two of us (Drs. Kodner and Keune, co-authors of scheduled for surgery the next day. It is recommended this article), as the Co-Community Editors of the that this be done in the form of a standard informed Ethical Issues in Surgery community on the e-FACS. consent procedure. Furthermore, the authors call for org website, found this topic an apropos one for post- institutional changes that will prevent surgeons from ing as an “ethical challenge”: scheduling elective procedures on their post-call days. The authors include data published in a 2009 issue of An experienced surgeon has three elective proce- the Journal of the American Medical Association show- dures scheduled for Wednesday morning. As it hap- ing an “83% increase in the risk of complications (e.g., pens, on the night before, he performed emergency massive hemorrhage, organ injury, or wound failure) operations that kept him awake until 4 am. Although in patients who undergo elective daytime surgical tired, he is confident that he can complete the three procedures performed by attending surgeons who elective cases with the safety and efficiency that he is had less than a 6-hour opportunity for sleep between known for—after all, he was trained to be safe and ef- procedures during a previous on-call night.”† fective, even when fatigued. Is he morally obligated to A response from the American College of Surgeons disclose his level of sleep deprivation to these elective (ACS) leadership was printed as a letter to the editor patients? Should this disclosure be made as part of in the same issue. Carlos A. Pellegrini, MD, FACS, the informed consent process? Should his institution Chair, ACS Board of Regents; L.D. Britt, MD, establish rules that prevent elective cases from being MPH, FACS, ACS President; and David B. Hoyt, performed by surgeons who may be sleep deprived? MD, FACS, ACS Executive Director, agreed with the need for the problem of surgeon sleep deprivation The challenge was posted to the eFACS.org com- to be addressed fully.‡ They disagreed, however, with munity in early January, and the site has received a the proposed solution. First, they argued, surgeons variety of responses. Tyler G. Hughes, MD, FACS, *Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical of McPherson, KS, noted that “A patient is not a procedures, and informed consent. N Engl J Med. 2010; 363(27):2577-2579. competent judge of whether to proceed with surgery †Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, under these circumstances.” Dr. Hughes compared Salzberg CA, Yu T, Yoon CS, Williams DH, Wien MF, Czeisler CA, Bates the sleep-deprived surgeon with a sleep-deprived DW, Landrigan CP. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302:1565-1572. pilot, noting that if the crew is not fit, “[the pilot] ‡Pellegrini CA, Britt LD, Hoyt DB. Sleep deprivation and elective surgery. does not ask the passengers if it is alright to proceed, N Engl J Med. 2010; 363(27):2672-2673. he does not fly.” Allan L. Liefer, MD, FACS, of 20

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chester, IL, writes, “More rules is not the answer, To read all of the postings from the eFACS.org good judgment is the answer. Good judgment is the community, and to add your own view, visit http:// mark of a safe surgeon.” Alan Manning, MD, FACS, efacs.org/ethicalissues.  of Hammond, LA, wrote, “…no one [individual] or institution can make enough policies to replace our Dr. Keune is a resident in own personal professional responsibility.” the department of surgery, In partial agreement with Dr. Nurok and colleagues, Washington University, Todd C. Campbell, MD, FACS, of Coatesville, PA, St. Louis, MO. He is cur- wrote, “The surgeon is professionally but not mor- rently the Emerson Clini- ally obligated to disclose sleep deprivation. Thus, cal Scholar in Residence of this should be part of the informed consent process. the American College of All institutions should have rules and regulations in Surgeons. place governing the performance of all procedures and protecting the safety of public.” Similarly, Ramsey M. Dallal, MD, FACS, of Philadelphia, PA, noted, “If the data clearly documents that operative complications are increased if the surgeon has not slept, then we owe it to our patients to inform them.” The authors have a further concern about Dr. Nu- rok’s recommendation. It is possible that patients, for Dr. Kodner is the Solon & whom an elective operation may be a major life event, Bettie Gershman Professor of might not be able to incorporate information about Surgery, Washington Univer- a surgeon’s level of sleep into their decision-making sity, St. Louis, MO. process. As Dr. Pellegrini and colleagues noted, “Many other factors—including marital difficulties, an ill child, financial worries, and so on—negatively affect performance. Are we going to demand full disclosure of these problems as well?”‡ Just imagine trying to incorporate one of these mitigating factors into an informed consent procedure. In partial agreement with Dr. Nurok’s view, though, it is a concern that an individual surgeon will not have good insight into his or her own level of sleep deprivation. To be sure, fatigue can alter one’s nor- mally sound judgment. Such alteration of judgment Dr. Healy is professor of can obscure the ability of a surgeon to both police otology and laryngology, himself, and to obtain reasonable informed consent. Harvard Medical School, Moreover, physicians have many competing interests Boston, MA. He is a Past- such as self-image, peer pressure, and financial pres- President of the American sure that can be difficult to weigh in a state of fatigue. College of Surgeons. For these reasons, the authors have serious reserva- tions that self-regulation will be effective. Oversight should be at the institutional level, where the chance that a sleep-deprived surgeon might operate on an elective patient is more likely to be minimized. If such institutional oversight is not pursued at the level of a surgeon’s own department, then it is nearly inevitable that regulation will be imposed upon physicians from outside the surgical community. 21

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Elias S. Hanna, MD, FACS, opens his heart to patients the world over by Diane S. Schneidman

lias S. Hanna, MD, FACS, a retired cardiac lot of free equipment,” he said. In the course of his surgeon, spent most of his career using his one-year tour of duty in Vietnam, Dr. Hanna oper- talents to help underserved patients with ated on 89 Vietnamese children. Dr. Hanna received heart conditions throughout the world. His South Vietnam’s highest honor from the government’s recentE commitment of $160,000 to the American Ministry of Health for performing the first successful College of Surgeons (ACS) Foundation is earmarked heart operation on a Vietnamese citizen. to ensure that other international surgeons will have The operations that Dr. Hanna performed in every opportunity to do the same. Vietnam also afforded him the opportunity to train, Dr. Hanna emigrated to the U.S. from his native without charge, physicians in open-heart surgical Syria at age 17 to study at the University of Texas, techniques. “The most important thing, I think, is Austin. He received his medical degree in 1963 from that I showed the Vietnamese surgeons some simple Tulane University, New Orleans, LA, and currently cases that could be treated with their own [resources],” serves on the board of that institution. He went on he said. to complete his residency at Baylor University School According to Dr. Hanna, though, the highlight of Medicine, Houston, TX, where he trained under of his service in Vietnam was when he successfully Michael DeBakey, MD, FACS, and Denton Cooley, removed an enemy bullet from the heart of a 20-year- MD, FACS. old American soldier. “Although fragments of bullets Since then, Dr. Hanna has developed a reputation had been removed from soldiers in the past, the op- not only as an outstanding heart surgeon, but as a eration I performed that day was unprecedented in true humanitarian. the Vietnam War,” Dr. Hanna said. “The very next day, articles with pictures of me, the soldier, and the Service in Vietnam bullet I removed were published in newspapers all In 1969, he was drafted by the U.S. Army to per- over the world. I became a celebrity in the medical form surgery in Saigon, Vietnam. “I was the only community.” active heart surgeon in the program, which meant that I was able to get a great deal of experience,” “Fastest hands in the West” Dr. Hanna said. The operation on the soldier was just one of Dr. During “slow times” at the U.S. Army Third Field Hanna’s accomplishments to make the headlines. Hospital, Dr. Hanna created an important program After a stint at Fitzsimons Army Medical Center in that would have lasting positive effects on the lives of Aurora, CO, as an assistant heart surgeon and be- the Vietnamese people. “I would bring in Vietnamese coming familiar with aorta coronary bypass surgery, kids with congenital heart disease and help them if Dr. Hanna was named chief of thoracic surgery at I could. The hospital allowed me to use its facilities, St. Mary’s Hospital in San Francisco, CA, where he and medical supply companies in the U.S. sent me a started a new open-heart surgery program. It was there, in 1972, that he performed a triple Above: Dr. Hanna (right) with Thomas R. Russell, MD, FACS, bypass operation on a patient who was a Jehovah’s Chair of the ACS Foundation and former ACS Executive Director. Background: News clippings about Dr. Hanna’s Witness. Due to his religious beliefs, the man refused activities. a blood transfusion. Not to be deterred from saving 22

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS this patient’s life, Dr. Hanna put together an 11- my vineyards, I find balance, genuine peace, and a member operating team and successfully performed wonderful sense of completion,” Dr. Hanna said. His the procedure in approximately 75 minutes with no daughter, Christine, presently runs the winery. blood transfusion. This feat earned him a reputation for having the “fastest hands in the West.” Philanthropist After receiving international acclaim for both the Retirement from practice has done nothing to slow operation on the soldier in Vietnam and the triple Dr. Hanna’s efforts to ensure that patients in every bypass, “Countries all over the world asked me to nation have access to quality cardiothoracic care. He teach their surgeons various cardiac procedures, continues to serve as the founder and president of the concentrating mostly on bypass surgery,” Dr. Hanna Elias S. Hanna, MD, Cardiovascular Foundation, a said. In the course of his career, he took 48 medical charitable organization that assists countries that lack trips to 28 countries, including China, Syria, India, the resources necessary to perform open-heart surgery. Sri Lanka, Egypt, Iraq, Tunisia, Morocco, Saudi Dr. Hanna’s foundation recently gave $1.25 mil- Arabia, Lebanon, Taiwan, and the Philippines. “In lion to the Tulane University School of Medicine to each country, I was the first cardiac surgeon to ever establish the Elias S. Hanna, MD, Foundation Chair perform bypass surgery,” he noted. in Cardiovascular Surgery, and to enhance the activities By the time Dr. Hanna retired from operating, he of an outstanding faculty member in the department had performed more than 24,000 open-heart opera- of surgery. Thomas Yeh, Jr., MD, FACS, director of tions, completing several each operating day at five the Tulane Pediatric Heart Center, was installed as the cardiac surgery programs in northern California. chair in 2009. Last year, Dr. Hanna agreed to contribute $160,000 Winemaker to the ACS Foundation to sponsor an International A farmer’s son, Dr. Hanna now devotes much of his Guest Scholarship. Dr. Hanna said he decided to make time to the winery he established in Sonoma County, this donation because he greatly values the opportuni- CA. “Becoming a vintner has been a natural evolution ties that he had to teach surgical techniques to residents of my heritage,” he said. and surgeons in developing countries. Of course, one doesn’t go from operating to mak- “If I can extend those same opportunities to other ing fine wine without a little training. After reading residents and surgeons through the American College up on the subject extensively, he took his family on a of Surgeons, then I’m happy to do so,” Dr. Hanna trip to the legendary chateaux of France. “I talked to said. “I’m connected to institutions in 28 countries, winemakers whose families had been making wine for so I think through this partnership, we will be able to generations,” he said. He also observed their winemak- do a lot of good throughout the world.”  ing techniques and “the craft and artistry that went into every bottle of wine.” In 1985, he hired a professional winemaker and a consultant to help him establish the Hanna Winery, which has vineyards in the Russian River and the Ms. Schneidman is Manager of Special Projects, Division of Inte- Alexander Valley regions of Northern California. “In grated Communications, Chicago, IL. 23

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 24

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS by Mark R. Katlic, MD, FACS; and J. Alex Haller, Jr., MD, FACS

n 1951, when J. Alex Haller, Jr., MD, FACS, improvement. These operations, unfortunately, are of- a coauthor of this article, expressed an interest ten accompanied by increased length of stay, increased in pediatric surgery, his chief surgeon, Alfred cost, and increased complications. A number of centers Blalock, MD, responded, “I am not sure there have shown, however, that with a deeper knowledge of isI a future for a specialty of children’s surgery.”1 Pedi- geriatric physiology and compulsive attention to detail, atric surgeons were embraced first by the American results need not differ at all from those of the general Academy of Pediatrics, not the American College of population.4 Geriatric surgery is certainly a worthy area Surgeons (ACS). At that time, board certification was of study and of promulgating what we learn. an unmentioned dream. Sixty years later, thousands of surgeons have proven History of organized pediatric surgery Dr. Blalock wrong, as there are now more than 30 highly competitive training programs available, and Pioneers interested in children’s surgery in 1948 or- the American Board of Surgery (ABS) offers the im- ganized the Surgical Section of the American Academy primatur of certification. of Pediatrics (see Figure 1, page 26). Unlike the ACS, In similar regard, would any resident today tell his which initially feared the fragmentation of general chief that he or she is planning to be a geriatric surgeon? surgery, the pediatricians welcomed these sympathetic In fact, that is happening, and the state of geriatric surgeons. One unfortunate result, however, was the surgery as a discipline today is interestingly similar to perception that pediatric surgeons were the technical that of pediatric surgery a half-century ago. arm of pediatrics and not true surgeons themselves—an opinion that persisted for more than 20 years. Why geriatric surgery? Two events changed this impression and brought pediatric surgery into the camp with other types of The aging of the population will be the greatest surgery. In 1966, William Clatworthy, MD, of Co- force affecting health care—and affecting society as lumbus Children’s Hospital, Columbus, OH, led a a whole—in our lifetime. Already, the elder group is voluntary oversight committee of the Surgical Section experiencing near-exponential growth, with the most of the American Academy of Pediatrics—a committee explosive growth occurring in the older than 80 years charged with establishing strict training criteria that subset.2,3 In addition, the conditions that require surgery included board certification in general surgery and (atherosclerosis, cancer, arthritis, prostatism, cataract, two additional years in pediatric surgery. The second and others) increase in incidence with advancing age. event took place in 1970, when a new generation of Most surgeons operate on the elderly and believe that pediatric surgery leaders formed an independent orga- they are providing excellent care—but there is room for nization, the American Pediatric Surgical Association. 25

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Now in a stronger position, pediatric surgeons car- Figure 1. ried a petition to the Residency Review Committee History of specialty organizations and to the ABS, and in 1972, pediatric surgery was recognized with a Certificate of Special Competence Pediatric surgery in Pediatric Surgery. The ACS created an Advisory • 1948 Surgical Section of the American Academy of Council on Pediatric Surgery in 1969 (still in ex- Pediatrics istence today) which strengthened the position of • 1969 Advisory Council on Pediatric Surgery (American pediatric surgery within the surgical world. After College of Surgeons) a prolonged gestation, pediatric surgeons had been • 1970 American Pediatric Surgical Association reborn as “real” surgeons. • 1972 Certificate of Special Competence in Pediatric Surgery (American Board of Surgery) History of organized geriatric surgery Geriatric surgery When Mark R. Katlic, MD, FACS, a coauthor of this • 1994 Geriatrics for Specialists Initiative (American article, published the book Geriatric Surgery in 1990, Geriatrics Society) no organized group of geriatric surgeons existed, and • 1998 Section for Surgery and Related Specialties, now the list of chapter authors was composed of a large Section for Enhancing Geriatrics Understanding and subset of those willing to consider the appellation.5 Education, SEGUE (American Geriatrics Society) Many of these chapter authors went on to produce • 2004 Task Force on Geriatric Surgery (American Col- their own texts and to remain active in this nascent lege of Surgeons) area of knowledge.6-8 In 1992, however, a visionary geri- atrician—the late Dennis Jahnigen, MD, Goodstein Professor of Geriatric Medicine and director of the Center on Aging,University of Colorado Health Sci- and Related Specialties, and now it is referred to as ences Center, Denver, CO—recognized that geriatric the Section for Enhancing Geriatrics Understanding medicine alone could not improve care of the elderly. and Education (SEGUE). There are plans to transfer In 1994, he championed the Geriatrics for Specialists increased responsibility from the American Geriatrics Initiative (GSI) of the American Geriatrics Society (see Society to the 10 surgical and related specialty societies Figure 1, this page). that appoint representatives to this SEGUE council. The GSI was composed of representatives from 10 The College has had a Task Force on Geriatric Sur- surgical and related specialties for an organization origi- gery since 2004, and in 2010, the task force selected its nally known as the Interdisciplinary Leadership Group. first two-year surgical fellow to study geriatric surgical Later the organization was titled the Section of Surgical principles out of its Chicago, IL, headquarters. At least one general geriatric surgery clinical fellowship already Dr. Katlic is director of exists, at the Medical University of South Carolina, thoracic surgery, Geisinger Charleston. Health System, Wilkes-Barre, A discussion of certification would be premature; PA. however, the ABS has recognized the importance of geriatric surgical principles in its examinations, and recently has solicited a curriculum section for the Surgi- cal Council on Resident Education website. Other similarities

Both pediatrics and geriatrics deal with the extremes of age (see Figure 2, page 27). Organ system physiology may differ from the typical adult. Children are not just “little adults,” nor are the very elderly simply “old adults.” Both premature infants and octogenarians, for 26

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 2. through the first 50 years. Ann Surg. May 2003;237(5):597- Pediatric surgery and geriatric surgery: 606. 2. Kinsella K, He W. An Aging World: 2008. Available at: http:// Similarities through the decades www.afscmeinfocenter.org/2009/07/an-aging-world-2008. htm. Accessed May 12, 2011. • Extremes of age 3. World Population Ageing 1950-2050. Available at: http://www. • Two-decade age range of patients un.org/esa/population/publications/worldageing19502050/. Accessed December 31, 2010. • Organ system physiology may differ from general adult 4. Ghanta RK, Shekar PS, McGurk S, Rosborough DM, Aranki population SF. Nonelective cardiac surgery in the elderly: Is it justified? • Signs and symptoms subtle or different from general J Thorac Cardiovasc Surg.Jul;140(1):103-109, 109 e101. adult population 5. Katlic M. Geriatric Surgery: Comprehensive Care of the Elderly Patient. Baltimore-Munich: Urban & Schwarzenberg; 1990. • Attention to detail imperative 6. Rosenthal R, Zenilman M, Katlic M. Principles and Practice • Ageism exists in the surgery profession of Geriatric Surgery. New York: Springer-Verlag; 2001. • Initially embraced by non-surgical establishment 7. McLeskey C. Geriatric Anesthesiology. Baltimore: Williams and Wilkins; 1997. • Very young and very old patients need advocates 8. Zuckerman J. Orthopaedic Injuries in the Elderly. Baltimore- Munich: Urban & Schwarzenberg; 1990. 9. Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact of advanced age on trauma triage decisions and outcomes: A statewide analysis. Am J Surg. May 2009;197(5):571-574; example, are at risk for hypothermia; the former have discussion 574-575. 10. Randolph J. The first of the best. J Pediatr Surg. 1985;20(6):580- not yet developed stable temperature control and the 591. latter manifest an attenuated vasoconstriction response and less metabolic heat production through loss of lean muscle mass. Diminished immune defenses in each group may compromise response to bacterial infection. The signs and symptoms of surgical disease may be subtle or different from those in the general population. For example, a pseudo-stability after trauma may exist both in preschool children and the elderly. The young child might lose half its blood volume before there is any drop in blood pressure, preventing hypotension via vasoconstriction and increased heart rate. The elderly, with decreased response to catecholamines, and often taking beta-blocking medication, will not show tachy- cardia proportional to the degree of stress.9 Exceptional attention to detail in and out of the Dr. Haller is professor and operating room is crucial for both extremes of age. chief of pediatric surgery Ageism—prejudice based on chronologic age—is an emeritus, Johns Hopkins ugly reality of each specialty. Both age groups, coinci- University School of Medi- dentally spanning two decades each, need advocates; cine, Baltimore, MD. surgeons can and do embrace this role. Initially each specialty was considered a “hobby” for general surgeons. Now both pediatric surgeons and geriatric surgeons can reasonably be considered, in the words of Judson Randolph, MD, “general surgeons and something more, and something more.”10 

References 1. Haller JA Jr. Why pediatric surgery? A personal journey 27

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ealth care integration is an often overlooked outcome of the health care reform process. For a physician, healthH care integration means (to paraphrase the U.S. White House) becoming employed by a hospital or joining a large group.1 Many view this as a development in the distant future associated with the planned implementation of accountable care organizations. Exactly how accountable care organizations will function is still Health care integration: not known. However, they will likely finance health care on a pay-per-event basis, where the insurance company assumes the risk of event occurrence and the health care delivery system assumes the risk of event treatment outcomes. Driving factors Health care integration is being driven by two factors. The first is related to the Medicare sustainable growth rate (SGR) physician Will physicians payment formula, which, if not changed, will cut the physician’s gross pay by almost 30 percent by lose their voice? the first of next year. It is estimated that it will cost $330 billion to correct this payment schedule over the course of 10 years—a daunting sum for a nation in an economic downturn.2 To make matters even worse, the Office of the Actuary of the Centers for Medicare & Medicaid has released a financial analysis on the effect of health care reform which is in line with the earlier Congressional Budget Office’s report. Medicare is widen- by Kevin Kavanagh, MD, FACS ing its deficit, and by 2019, health care costs in the U.S. will comprise 20 percent of the nation’s gross national product.2 The second factor driving health care integration is related to hospi- 28

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS tals charging a facility fee in addition to a physician visit fee.3 This policy places the facility at a competi- Differences in the increase in procedural tive advantage, as the facility can provide physician versus facility CPT code reimbursement services in a cost center that is profitable, compared Hospital with the ever-increasing unprofitable situations found CPT Surgery outpatient in private practice. In addition, facility-employed Year code center department Surgeon surgeons may be required to shift the performance of outpatient surgery from a freestanding outpatient 2008 42821 $768 $1,418 $282 surgery center to a hospital outpatient department 2010 42821 $920 $1,679 $299 to take advantage of the higher facility fee reimbursement. For example, in 2010, the facility fee at a freestanding outpatient surgery center for tonsil and adenoid surgery (CPT Codes 42820 to 42836) was of hospital governance. Similar to the banking indus- between $871 and $900, compared with $1,679 at an try, auditing and quality assurance functions should acute care hospital outpatient facility. This difference operate like a separate corporation in the hospital, is significantly more than the physician fee of between with staff being employed by, and reporting directly $184 and $299, depending upon the specific procedure to, the hospital’s board and not to the CEO. Hospital being performed.4 boards should be trained in issues of patient advocacy Comparison of these fees over time is also notewor- by independent training agencies and community thy. Most facility fees for these codes increased between board members should not have a conflict of interest 18 percent to almost 20 percent, compared with the with the facility. physician reimbursement, which only increased 5 per- • Physicians need to be permitted the freedom to cent to 10 percent. The table on this page shows the counsel their patients, patients’ families, and medical reimbursement for CPT* code 42821, tonsillectomy decision makers regarding health care quality and and adenoidectomy, age 12 years or older. where the patient can receive the best value of health Health care integration is well under way, with care, regardless of the facility that is recommended more than 50 percent of physician practices owned to the patient or the facility that currently employs by hospitals, and the number is increasing fast.5 Ad- the physician. Gag clauses and any form of retaliation ditional practices have integrated through contractual against the physician regarding discussions of facility arrangements. Once 50 percent employment occurs quality need to be strictly prohibited, provided that in a facility, a tipping point is reached and hospital- Health Insurance Portability and Accountability Act employed physicians, who report to the chief execu- regulations are followed. tive officer (CEO), comprise the majority of members • Most importantly, physicians need to develop on hospital committees. an independent voice. Integration not only affects Physicians who were members of an independent hospital governance but also medical trade organi- medical staff that oversaw hospital functions were the zations. Being a patient advocate means more than most common governance structure prior to health telling the patient to stop smoking and lose weight. care integration. Now, the majority of these physicians It means more than making sure health care is well report to the CEO, and independence is lost. Some funded so the doctor’s medical bills are paid. It means facilities even require the signing of “gag clauses” as ensuring the patient is able receive the highest value they relate to the discussion of facility quality issues. health care in both cost and quality. To this end, transparency and public reporting What needs to be done are very important to health care integration. Public There are three goals that need to be supported by reporting of infections is currently supported by the physicians: Centers for Disease Control, the Association for Pro- • Physicians should be advocates of a new model fessionals in Infection Control, the Infectious Disease †All specific references to CPT (Current Procedural Terminology) Society of America, the Society for Healthcare Epi- terminology and phraseology are © 2011 American Medical Association. demiology of America, the Council of State and Ter- All rights reserved. ritorial Epidemiologists, and the Trust for America’s 29

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Health.6-8 In addition, at least 27 states now mandate 4. 2010 Tonsil & Adenoidectomy Reimburse- 9 ment Fact Sheet. Ethicon Endosurgery. Available at: public reporting of health care-acquired infections. http://www.ethiconendosurgery.com/sites/default/files/ Placing a guarantee on services is something that Fact_Sheet_2010_Tonsil_and_Adnoid.pdf. Accessed March is common in other industries and is expected by 14, 2011. the public.10 This guarantee includes support of non- 5. Mathews AW. When the doctor has a boss: More physicians payment of hospital-acquired conditions—a policy are going to work for hospitals rather than hanging a shingle. Wall St J. Available at: http://online.wsj.com/article/SB10001 which was universally applied to surgeons when 424052748703856504575600412716683130.html?KEYW global surgical fees were introduced in the mid 1980s. ORDS=hospital+ownership+of+physicians. Accessed March Global surgical fees have been viewed as good policy 18, 2011. for the surgeon and the patient. Certainly, it is also 6. CDC Statement: Public Reporting of Healthcare Acquired Infections. Media Statement. Centers for Disease Control and good policy for facilities. The concern of inhibiting Prevention, U.S. Dept. of Health and Human Services. Feb 2, health care for the sickest patients is not valid due 2010. Available at: http://www.cdc.gov/media/pressrel/2010/ to the fact that it is the doctor, not the facility, who s100202.htm. Accessed March 14, 2011. determines which patients are admitted. Under the 7. Srinivasan A. Media Telebriefing on State Healthcare- current diagnosis-related groups system, facilities Associated Infection Data. Centers for Disease Control May 27, 2010. Available at http://www.cdc.gov/media/ that treat the sickest patients who are at the greatest transcripts/2010/t100527.htm. Accessed March 14, 2011. risk of developing hospital-acquired conditions will 8. Experts Support National Public Reporting of Healthcare- often still receive the maximum payment because of Associated Infections. Available at: http://www.healthwatchu- the presence of other coexistent, co-morbidity factors. sa.org/mrsa/pdf_downloads/20090722-Experts_Public- Reporting-HAIs.pdf. Accessed March 14, 2011. The Geisinger Health System adopted this payment 9. Frieden TR. Maximizing infection prevention in the next policy in February of 2006 for coronary artery bypass decade: Defining the unacceptable. Infect Control Hosp Epi- graft and currently with other ProvenCare procedures demiol. 2010 Nov;31 Suppl 1:S1-3. Available at: http://www. covered by its Geisinger Health Plan Insurance.11,12 journals.uchicago.edu/doi/full/10.1086/656002. Accessed Soon, this payment policy may become standard in May 16, 2011. 10. Employers support nonpayment for “never events.” News in accountable care organizations, which may receive brief. Am Med News. Available at: http://www.ama-assn.org/ one fee for all services related to an event. amednews/2009/03/23/gvbf0323.htm. Accessed March 14, 2011. Conclusion 11. Abelson R. In bid for better care, surgery with a warranty. New York Times. Available at: http://www.nytimes. Physicians have their work cut out for them to com/2007/05/17/business/17quality.html. Accessed March regain the leadership position in our health care 14, 2011. delivery system. Physicians are at risk of belonging 12. Giesinger Health System. Frequently Asked Questions. to a trade, as opposed to a profession, and therefore, Available at: http://www.geisinger.org/provencare/faq.html. they need to develop an independent voice, apart Accessed March 14, 2011. from the facility administration, a voice that truly  advocates for patients. Dr. Kavanagh is a non- practicing otolaryngologist in References: Somerset, KY, and founder of Health Watch USA, a 1. Lowes R. Physicians say White House should not write off 501(c)3 organization whose small practices. Medscape Med News. Available at: http:// mission is to promote health www.medscape.com/viewarticle/727420. Accessed March care transparency and value- 14, 2011. Login required. purchasing. 2. Alonso-Zaldivar R. Gov’t: Spending to rise under health care overhaul. Associated Press. Available at: http://www.realclearpolitics.com/news/ap/politics/2010/ Sep/09/gov_t__spending_to_rise_under_health_care_over- haul.html. Accessed March 14, 2011. 3. Mathews AW. When hospital fees catch you off guard. Wall St J. Available at: http://online.wsj.com/article/SB1000142 4052748703819904574555723216593610.html. Accessed March 14, 2011. 30

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Advocacy advisor

Running for political office by Charlotte Grill

unning for, and holding, political office is or state level because those contests are usually less still one of the most powerful ways to expensive, have smaller campaign territories, and of- contribute to our society and to influence fer credible political experience for individuals who legislative issues and decisions. Surgeons decide to pursue higher offices at a later date. Rserving in public offices are greatly needed and can • Step two: File with the appropriate agency. make the critical difference in ensuring that legisla- Most offices require, at minimum, that candidates tion reflects the needs of the profession, patients, and are registered voters in the district of the office be- the health care system. Although being a candidate ing sought. Additional requirements may include a for elective office can be emotionally and physically certain number of signatures on petitions, a level of draining and time-consuming, it affords those who money, a minimum age, or other experience qualifica- are elected the opportunity to direct systemic changes tions. in government and opens doors to future political If running for a state seat, the candidate should con- opportunities. This article summarizes the steps for tact the secretary of state office to file; for a federal seat launching a campaign for office, and is intended to he or she should contact the Federal Election Com- make the process less daunting. mission (FEC). The FEC requires that candidates Before moving forward, though, an honest personal register within 15 days of raising $5,000, although assessment is in order. Candidates should think about most nominees register before they reach that total their involvement in a local political party and the because the registration process usually takes longer connections they have within the existing political than 15 days.* All federal elections require candidates establishment. They also should consider whether to be registered to comply with federal fundraising they can sacrifice time away from their practices and regulations. At this stage in a campaign, it is neces- families for a campaign that will take energy, commit- sary for the candidate to create a political fundraising ment, and resources, and whether their families are name because it needs to appear on all fundraising equally committed. They should determine whether and political materials. they truly enjoy community involvement and have • Step three: Determine political party affiliation. personalities that can handle the level of socializing By this point in the process, or long before, candidates and “politicking” needed to become successful elected already know the political party with which they officials. identify and will declare. Although declaring party affiliation seems like a fairly obvious point, in many Steps to getting a campaign started state and local races, independents are more likely to • Step one: If all factors indicate that someone run, and party affiliation is less important than it is is in a position to launch a political campaign, the at the federal level. It also is a good idea to declare potential candidate should research different offices a party affiliation because political party offices have and positions in government. The candidate should access to data on donors, volunteers, and experienced explore elected positions at municipal, county, state, campaign personnel, and may be in the process of and federal levels to get an idea of the various time recruiting candidates. commitments, requirements for running, and respon- • Step four: Recruit staff and volunteers. All cam- sibilities to find the best fit for his or her lifestyle and paigns require, at the very minimum, a treasurer and goals. Upon settling on a seat to pursue, the candi- a campaign manager. Treasurers are essential in terms date should get details on filing deadlines, as well of balancing campaign budgets, keeping records up as residency and other requirements. For first-time to date on donors, and filing the proper fundrais- campaigns, it probably is best to start at the local ing reports. Campaign managers handle scheduling *Complete Campaigns. You’re running for office…Now what? Available at: events, writing speeches, recruiting volunteers, and http://www.completecampaigns.com. Accessed March 22, 2011. reaching out to donors. When running for higher 31

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS state and federal offices, campaign staff tends to be Being in the public eye will help the candidate garner much larger. new supporters and volunteers, and will provide op- • Step five: Focus on fundraising efforts. It takes portunities for him or her to meet with the press and a lot of time and energy to call and reach out to get the candidate’s name out. people who can support candidates with financial contributions. Special events, such as teas, pig roasts, Conclusion and party-affiliated dinners, can also “bring home the Campaigns are a very different experience for most bacon” for a campaign fund. surgeons who don’t interface with politicians or cam- • Step six: Create the campaign website. The In- paigns regularly. Running for office, however, is a ternet has become the hub for campaigns to access manageable undertaking for anyone with the interest and reach the public. Websites are no longer just a and passion to be involved in the public service sec- forum for relaying a candidate’s message and talk- tor. Organization and a good support staff can make ing about the issues; most campaigns post videos of all the difference in running a smooth and successful speeches and links for contributors. Websites are an campaign. Starting in smaller races also is a great en- easy format for creating a strong campaign message trée to getting involved without biting off more than and relaying biographical information and personal is manageable for a first-time candidate. Although anecdotes. Moreover, they are particularly effective in starting a campaign may be a stressful or unknown reaching younger voters, who are more comfortable endeavor, the reward is getting into office and having using technology on a daily basis. a direct impact on the legislative process.  • Step seven: The candidate should file papers to get his or her name on the ballot. Candidates are given instructions on this process when they register to enter a race, and these guidelines should be followed care- fully; one small misstep may prevent a candidate from getting on the ballot. • Step eight: Poll of voters in the district. The purpose of conducting polls is to find out how many voters in the district recognize the candidate’s name, are willing to vote for that individual, and what the top priorities are for voters in the district. Many companies and websites carry out these polls. Results from polls will show the candidate’s viability, if the campaign’s message and issues resonate with the public, and the public’s perception of the candidate. Polls will also help campaigns set strategy and develop a concise and clear message. • Step nine: Communicate with the voters. Deliver a coherent, understandable, and accessible message that summarizes the candidate’s beliefs and objectives if elected. Several approaches are effective in disseminating a campaign message—from grassroots efforts, to using Web-based initiatives, to working with local media outlets. All of these approaches will get the word out about the candidate’s qualifications, expertise, and political agenda. • Step 10: Interact with the public as much as possible. Canvas the district by handing out yard signs, bumper stickers, and other campaign materi- Ms. Grill is State Affairs Associate, Division of Advocacy and Health als. Attend public events and be as visible as possible. Policy, Chicago, IL. 32

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

JSAC focuses on imminent health policy changes by Diane S. Schneidman

JSAC participants gather in Freedom Plaza before departing for Capitol Hill to meet with their federal legislators.

Approximately 297 surgeons ACOs ment reform leadership group. and surgical staff representing the Four panelists addressed the This group will be responsible American College of Surgeons development of ACOs and other for developing bundled payment, (ACS) and 17 surgical specialty new health care delivery and pay- pay for performance, ACO, and societies participated in the fourth ment models, as well as how these other “shared savings group” plans annual Joint Surgical Advocacy emerging systems will affect surgi- for pilot testing. “Ultimately, all Conference March 27–29 at the cal practice. specialty societies will be invited JW Marriott Hotel in Washing- Sandra S. Marks, assistant di- to participate in this group to ton, DC. Highlights of this year’s rector, division of federal affairs, learn about what works and what conference include the following: American Medical Association doesn’t,” and to explore other col- • A continuing medical educa- (AMA) Washington Office, gave laborative initiatives, Ms. Marks tion session on accountable care a brief overview of how medical said. organizations (ACOs) and surgical organizations are ad- Harold D. Miller, executive di- • An overview of legislative dressing the innovative methods rector of the Center for Healthcare issues important to surgery and of providing health care services. Quality and Payment Reform, the surgical patient She noted that the AMA House Washington, DC, addressed the • Comments from three new of Delegates has adopted a set of development of ACOs more physician members of the U.S. principles on ACOs, and that the specifically. Mr. Miller defined Congress AMA and the ACS are working an ACO as “a group of providers • Advocacy training together to form a physician pay- who are responsible for the overall 33

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cost and quality of care delivered ACA allows Medicare to project reliable information from trusted to patients.” spending for these programs. No databases, performance measure- Some patients fear that be- upfront money would be paid to ment, cost estimation, promulga- cause one objective of ACOs is providers, so “it doesn’t change tion of guidelines or “dashboards,” to control costs, they will ration fee-for-service at all,” he added. The processes for controlling care, and care, said Mr. Miller, who also is law also “makes doctors liable for the provision of incentives for high president and chief executive of- any spending increases and forces performance, Dr. Speir said. ficer of the Network for Regional hospitals to hire and/or acquire Surgeons are uniquely positioned Healthcare Improvement, Pitts- physicians.” to lead the movement toward burgh, PA. However, ACOs are Anthony T. Petrick, MD, FACS, value-based care because they designed to reduce costs through director of minimally invasive and already measure outcomes. “We the provision of more coordinated, bariatric surgery at Geisinger Medi- need surgeons to stand up and safer, better quality care without cal Center, Danville, PA, talked be accountable,” he added. The rationing, he explained. about how the accountable care movement toward value-based care “It’s really physicians who need model has been implemented at will require time. “It’s not a mara- to take the lead” in the develop- that institution. thon so much as a death march,” ment of ACOs, he continued, Dr. Petrick said Geisinger’s Dr. Speir quipped. because they have first-hand ProvenCare system has been suc- knowledge about how to deliver cessful due to “motivated physi- Key issues more cost-effective and higher- cians and enthusiastic leadership.” Lobbyists from three of the or- quality care. Also, physicians and It was developed through a col- ganizations that cosponsored the other providers will feel the big- laboration of physicians and the JSAC—the ACS, the American As- gest effects of the new payment institution and focused on the sociation of Neurological Surgeons/ systems that will be implemented coordination of resources. “Every- Congress of Neurological Surgeons through the ACOs. body’s got to be all in on this,” he (AANS/CNS), and the American Two proposed reimbursement explained. Academy of Otolaryngology-Head models are episodic payment and ProvenCare uses the episodic and Neck Surgery (AAO-HNS)— comprehensive care payment. payment approach that Mr. Miller briefed the meeting attendees on Under the episodic payment ap- described. For bariatric surgery, key legislative issues in surgery. proach, patients would be pro- Geisinger physicians and adminis- Kristen Hedstrom, MPH, As- vided with a “warranty” on their trators developed 35 benchmarks, sistant Director, Legislative Af- care. In other words, if a patient which are actionable and mea- fairs, ACS Division of Advocacy experiences a complication af- surable. Since then, the bariatric and Health Policy, Washington, ter an operation, the ACO will surgery department has increased DC, spoke about payment and provide the necessary additional the value of care and fundamen- quality issues. With regard to care at no charge to the patient tally altered the payment system, Medicare payment, she noted that or payor. The comprehensive care Dr. Petrick said. the flawed sustainable growth rate concept calls for making “global” According to Alan Speir, MD, (SGR) formula used to calculate payments for treating a patient’s a cardiac surgeon and founding reimbursement for physicians will health condition. Payment would partner of Cardiac, Vascular, and force a 29.5 percent cut in payment be adjusted for the complex- Thoracic Surgery Associates in Falls starting January 1, 2012. Given the ity of care and bonuses would Church, VA, “Alternative [health enormity of these potential reduc- be provided based on outcomes, care delivery and payment] meth- tions, “Our focus is not on fixing Mr. Miller explained. odologies are now a reality. Not the SGR. The bottom line is that Mr. Miller noted that the Af- only are they are here now, but they we have to get rid of the SGR,” said fordable Care Act (ACA) does have been here for years.” Ms. Hedstrom. The SGR should be not refer specifically to ACOs and The strategic building blocks of replaced with a new system that in- instead calls for the establishment value-based health care systems are cludes a stable mechanism for up- of “shared savings programs.” The as follows: collaboration, analysis of dating Medicare reimbursement, 34

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Resident attendees prepare for meetings on Capitol Hill.

preserves the patient-physician ACA to conduct comparative • Application of the Federal relationship, and ensures that pa- effectiveness research Tort Claims Act to cases involving tients have access to the physicians • Continue voluntary par- Emergency Medical Treatment of their choice. ticipation in the Physician Qual- and Active Labor Act-mandated With respect to quality im- ity Reporting System (formerly services provement initiatives, the surgi- known as the Physician Quality • Liability protection for phy- cal community agrees with the Reporting Initiative) sicians who follow evidence-based concept of improving the value of • Delay electronic prescribing practice guidelines health care, Ms. Hedstrom said. In and electronic health record penal- • Protections for physicians order to reach this goal, a system ties who volunteer their services in must be in place to reward physi- • Postpone public reporting disaster or emergency situations cians who take steps to improve until risk-adjusted clinical out- • Exploration of alternatives the quality and cost-effectiveness comes data are available to tort reforms of care. Surgical associations also Another key issue for the surgi- Ms. Orrico also said that sur- recommend that the government cal community is liability reform, gical associations support the take the following steps: noted Katie Orrico, JD, director Provider Shield Act, H.R. 816, • Provide incentives and sup- of the AANS/CNS Washington which would clarify that nothing port for the development of spe- Office. Legislativeeforms r that in the ACA creates a new cause of cialty and/or condition-specific, surgical associations support to action, such as the establishment outcomes-centered clinical data make compensating patients for of health care provider standards registries medical injuries more efficient and of care in medical liability cases. • Fully fund the Patient Cen- equitable are as follows: Joy Trimmer, JD, director of tered Outcomes Research Insti- • Caps on noneconomic dam- the government affairs at the tute, which is established in the ages AAO-HNS, Washington, DC, 35

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS addressed the concerns that physi- The most significant problems without approval from the Senate cians’ groups have about the ACA’s with the IPAB are as follows: and House majority and minority establishment of the Independent • The 15 members will be leaders Payment Advisory Board (IPAB). appointed solely by the president • Fewer than half of the IPAB members can be health care providers, and none may be in active practice or otherwise employed Trauma surgeons • The IPAB will be required to recommend cuts based on unreal- discuss issues on Capitol Hill istic spending targets starting in 2014 by Catharine Harris • Because hospitals, hospices, and other health care institutions Three weeks prior to the Joint Surgical Advocacy Conference (JSAC), are exempt from IPAB cuts until 25 members of the American College of Surgeons Committee on Trauma 2020, payment reductions will (COT) traveled to Washington, DC, from all regions of the U.S. to discuss disproportionately fall on health trauma-specific issues with their senators and representatives. The COT’s care professionals Advocacy Day took place March 9 at the ACS Washington Office. Without a permanent solution to The program began with a legislative and political update from Division the SGR, physicians essentially are of Advocacy and Health Policy staff and advocacy training with Chris subject to “double jeopardy” with Huckleberry, legislative director for Rep. Kurt Schrader (D-OR), and Josh cuts stemming from both the SGR Martin, chief of staff to Rep. Mac Thornberry (R-TX). Attendees also and the IPAB’s recommendations. heard from keynote speaker Rep. Joe Heck, DO (R-NV), an osteopathic According to Ms. Trimmer, there physician elected to Congress last November. is “broad-based bipartisan opposi- Speakers from Capitol Hill addressed the “dos and don’ts” of lobbying— tion” in Congress to the IPAB. including keeping their requests brief, using personal stories to illustrate In addition, Ms. Trimmer en- published data, and talking to challenging staffers. Mr. Huckleberry, couraged JSAC participants to ask Mr. Martin, and Representative Heck also emphasized the importance of their legislators to support H.R. ongoing advocacy, made possible through building personal relationships 451, the Healthcare Truth and with legislators. Surgeon advocates can form these relationships by invit- Transparency Act of 2011. This bill ing their legislators to tour their practices or hospitals, hosting in-district is designed to improve transpar- fundraisers, and frequently visiting legislators’ DC and district offices. ency in the marketing materials Following these sessions, COT members met with 53 senators and of all health care providers and representatives or their health policy staff to request that Congress include requires that all health care profes- $224 million in trauma funding in the fiscal year 2012 Labor/Health and sionals appropriately identify the Human Services/Education Appropriations Act, as authorized by the Af- field and specialty in which they fordable Care Act. They also advocated for the Health Care Safety Net are licensed. Enhancement Act of 2011 (H.R. 157), which would provide liability protections for physicians providing care in compliance with the Emergency Physicians in Congress Medical Treatment and Active Labor Act. Another topic of discussion was Three newly elected physician Medicare physician payment reform. members of Congress spoke at COT Advocacy Day participants also reached an important milestone by the JSAC—Rep. Larry Bucshon, achieving 100 percent participation in, and raising more than $10,000 for, MD (R-IN), a cardiothoracic the American College of Surgeons Professional Association-SurgeonsPAC surgeon; Rep. Dan Benishek, MD, (political action committee). FACS (R-MI), a general surgeon; and Rep. Andrew Harris, MD Ms. Harris is Legislative Assistant, Division of Advocacy and Health Policy, Washington (R-MD), an anesthesiologist (see DC. photos, page 37). Representative Bucshon said he 36

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Representative Bucshon Representative Benishek Representative Harris

ran for Congress because “I really and Washington than the passage Representative Harris spoke. Judy felt like we needed more physi- of the ACA,” he said. “The IPAB Schneider, a specialist on Congress cians in office,” especially in light is just a disaster,” he added. at the Congressional Research of the passage of the ACA. “As The motivating factor for Rep- Service, Library of Congress, time goes by, I think we’re going to resentative Benishek’s bid for Washington, DC, led the session see the ACA having fundamentally Congress dates back to 2009 and on advocacy for residents and detrimental effects on surgical the enactment of the American first-time JSAC attendees. Other care.” Consequently, he spon- Recovery and Reinvestment Act, speakers for this program were as sored the bill calling for repeal of also known as the stimulus bill. He follows: John H. Armstrong, MD, the ACA. He said he believes the said that law represented a nega- FACS, Chair, American College ACA mandate that all Americans tive turning point in the direction of Surgeons Professional Asso- have health insurance coverage is of the nation. ciation (ACSPA)-SurgeonsPAC unconstitutional and “should be Representative Harris’s political Board of Directors; Sara Morse, expedited to the [U.S.] Supreme career began in 1998 when he ran Manager of Political Affairs, ACS Court.” In addition, Representa- for and won a seat in the Mary- Division of Advocacy and Health tive Bucshon said he opposes land State Senate. He encouraged Policy; Megan Marcinko, program the ACA for the provisions it is surgeons who are interested in manager, Congress and political lacking, including repeal of the effecting health policy changes affairs, AAO-HNS; and Adrienne SGR and tort reforms. (For more to run for Congress. At the very Roberts, senior manager, legisla- information on Representative least, he recommended that JSAC tive affairs, AANS/CNS. Bucshon, see the May 2011 issue participants use their Capitol Hill An advanced advocacy training of the Bulletin.*) visits wisely. “It takes effective workshop for all attendees includ- Representative Benishek also advocacy to get your issues before ed opportunities for role-playing believes the ACA should be re- the legislature,” Representative with a former member of Congress pealed. “There has been no better Harris said. and a discussion of grassroots example of the ‘disconnect’ be- advocacy. But first, Patricia A. tween the people [of this nation] Advocacy training Clark, a communications consul- *Friesen S. Rep. Larry Bucshon, MD, brings The JSAC comprised two ses- tant for a number of medical and surgical perspective to public policy. Bull Am sions designed to help surgeons surgical organizations, offered tips Coll Surg. 2011;96(5)16-20. hone the advocacy skills of which on persuading legislators to take 37

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS action on issues of concern to for surgeons to build a relationship PAC receptions surgery. Ms. Clark recommended with legislators is to offer site visits JSAC participants also were that surgeons communicate their of their institutions to congres- invited to attend a fundraising message as concisely as possible, sional staff. reception for the ACSPA-Surgeons- using sound bites. They can leave Dr. Fitch also noted, “There are PAC. More than $27,000 was more detailed, written information four things candidates want and raised during that event. High-level behind at the meeting or send it need” from physician constituents, donors—individuals contributing subsequent to the discussion. including the following: $1,000 or more—were invited to Meeting participants then had • They want money. Host a a private reception with Rep. Pete the opportunity to practice for fundraiser. Sessions (R-TX). The congressman their Capitol Hill visits with Steve • They want their supporters’ serves on the powerful House Rules Buyer, a former Republican U.S. time. They need volunteers to stuff Committee and chairs the National representative from Indiana. While envelopes and canvas neighbor- Republican Congressional Com- in Congress from 1993 to 2011, hoods. mittee. Mr. Buyer served on the House • They want surgeons’ knowl- Energy and Commerce Commit- edge about health care issues. Capitol Hill visits tee, including the Subcommittee “Physicians have a unique skill set, On the final day of the JSAC, on Health. unique knowledge, and we need meeting participants had the op- Next, Jane C.K. Fitch, MD, to share that with our legislators,” portunity to put their freshly cul- professor and chair, department Dr. Fitch noted. tivated advocacy skills to the test. of anesthesiology, University of • They want support. Vote and Most of the attendees met with Oklahoma Health Science Center, assist with campaigns. their legislators on Capitol Hill to Oklahoma City, and chair of the Echoing Dr. Harris’s sentiments, discuss their concerns about imple- American Society of Anesthesiolo- Dr. Fitch said that physicians who mentation of the ACA, Medicare gists Committee on Government want to play an active role in ad- payment reform, medical liability, Affairs, provided helpful hints on vocating on behalf of the medical the surgical workforce shortage, successful grassroots advocacy. She community also should write to and other issues that affect surgical encouraged physicians to speak in their newspapers and, perhaps, run patient care. layperson’s language during infor office. “Short of that, we have district meetings and to cultivate a to take responsibility to educate Ms. Schneidman is Manager, Special Proj- relationship with their members of legislators about the issues of im- ects, Division of Integrated Communications, Congress. She noted that one way portance to us,” she added. Chicago, IL.

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS KZA/ACS2011ad:Layout 1 3/18/11 11:05 AM Page 1

NASHVILLE, TENNESSEE — AUGUST 18-19, 2011 Big Bang Coding and Reimbursement

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AMERICAN COLLEGEOF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes © 2011 KarenZupko & Associates, Inc. Leadership conference focuses on effecting change at multiple levels by Diane S. Schneidman

“Leading with impact” was the Defining leadership most important leaders, Rev. Mar- theme of this year’s American Col- Offering the opening remarks tin Luther King, Jr., Dr. Britt said, lege of Surgeons (ACS) Leadership for the meeting was L.D. Britt, “Our lives begin to end the day Conference for Young Surgeons MD, MPH, FACS, President of we become silent about the things and Chapter Leaders, which took the College. Dr. Britt encouraged that matter.” place March 26 and 27 at the JW the young surgeons and chapter He noted that most of the great Marriott in Washington, DC. officers to speak out and influence leaders in history assumed their Members of the College’s Young change in their institutions and in positions of power in times of up- Fellows Association developed and the public policy sector. Quoting heaval, yet they managed to leave moderated the program. one of this nation’s historically their countries in better condition. He cited Queen Elizabeth I as the exemplar of leadership because of the profound changes she led in England, which left the nation Did more stable and respected than it was when she was crowned. you know...that the College has The best leaders of organizations endorsed Partnership for Patients: Better Care, also leave a lasting impression. Lower Costs—a new public-private partner- “When a leader departs and the ship aimed at helping to improve the quality, safety, and affordability organization continues to pros- of health care for all Americans? per, then that leader succeeded,” On April 12, U.S. Department of Health and Human Services (HHS) Sec- Dr. Britt said. retary Kathleen Sebelius and Centers for Medicare & Medicaid Services (CMS) Administrator Donald Berwick, MD, announced a new national Leading during crisis partnership to stop millions of preventable injuries and complications in Kenneth L. Mattox, MD, the next three years. The American College of Surgeons and other major FACS, professor of surgery at stakeholders endorsed the effort and pledged to join with CMS in the Baylor University School of Med- initiative to improve patient care. icine, Houston, TX, found him- Using $1 billion in new funding provided by the Affordable Care Act, self leading a medical response HHS will work with a variety of public and private partners to accomplish team after Hurricane Katrina. the following two core goals: Dr. Mattox and his colleagues • Keep hospital patients from getting injured or sicker, so that by the developed a strategy for trans- end of 2013, preventable hospital-acquired conditions will decrease by porting more than 27,000 evacu- 40 percent ees from New Orleans, LA, to • Help patients heal without complications, so that by the end of 2013, Houston, developing an incident preventable complications during a transition from one care setting to command and medical team, another and all readmissions will be reduced by 20 percent as well as policies about whom For more information about the Partnership for Patients, visit http:// among the incoming would be www.HealthCare.gov/center/programs/partnership. admitted as patients. According to Dr. Mattox, the six phases of leadership during 40

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS disaster response are as follows: the other person feel appreciated,” • Lack of trust. “For many (1) assess the problem; (2) make a he said. Also, remember that “the mid-level physicians and surgeons plan; (3) implement the plan; (4) problem is not the other person. in this country, their trajectory in anticipate surprises; (5) finish the It’s the situation.” Try to find com- terms of how they view their ca- plan; and (6) review results. Sur- mon ground. reer is not going up. It is, in fact, geons are particularly qualified to Dr. Mahuad explained how he going down,” Dr. Evans said. This lead in times of crisis because they applied these principles in his situation has led some surgeons to are problem solvers and possess a negotiations with Peru’s president view government payors, hospital “unique genome,” which makes at the time, Alberto Fujimori, administrators, insurance compa- them believe they are the only a man whom most Ecuadorans nies, and so on, skeptically. ones who can resolve the situa- viewed as the enemy due to • Surgeons are data-driven tion. Surgeons also are familiar the many years of armed con- decision makers, but they believe with making decisions based on flicts between the two nations. the data that are used for physi- the existing data and decisively Dr. Mahuad’s goal was to win cian profiling misrepresent the dealing with diversions, Dr. Mat- back territory that Ecuador had realities of practice. However, tox said. He encouraged surgeons lost to Peru over the course of there are measurement instru- to “go to the heart of danger, and nearly a half century. ments on which surgeons can rely. there you will find safety.” To find common ground, the The College’s National Surgical Dr. Mattox added, “You will two presidents went on a raft- Quality Improvement Program face a time soon when you’re in ing trip on the Amazon River to (ACS NSQIP®) is “by far and charge of making things happen.” discuss how the surrounding land away the best database going” for When that time comes, “it is could be divided more equitably. analyzing surgical outcomes, Dr. absolutely amazing what a small, In October of 1998, Dr. Mahuad Evans said. dedicated group of people can do and Mr. Fujimori signed the Bina- • Surgeons and other physi- to change the course of the world.” tional Plan for the Development of cians “live in a world of technical the Border Area, with former U.S. challenges” rather than adaptive Negotiating with feeling President Bill Clinton serving as a challenges. They are uncom- People often view negotiation mediator. Under the agreement, fortable dealing with cultural as a rational process in which the two countries declared a recip- changes. two or more people are trying to rocal free navigation zone on the • Surgeons greatly value their reach a compromise on competing Amazon River in the region and independence. They typically and varying objectives. However, ceded certain disputed territories have preferred to avoid working negotiation is not a strictly logical to one another. in teams. process. It has an emotional ele- • Physician leaders are not visi- ment as well, according to Jamil Failing to follow ble. “Surgeons want other surgeons Mahuad, PhD, president of Ec- According to Stephen R.T. Ev- leading them,” Dr. Evans said. uador from 1998 to 2000, and ans, MD, FACS, vice-president of • Lack of urgency. “Surgeons an academic fellow at the Center medical affairs and chief medical operate only in crisis mode,” Dr. for Public Leadership, Kennedy officer at Georgetown University Evans observed. To get surgeons School of Government, Harvard Medical Center, Washington, DC, involved in an endeavor, leaders University, Cambridge, MA. the trend in health policy has been need to create a sense of urgency Before entering into a negotia- toward less physician control of and make it time-sensitive. tion, Dr. Mahuad recommended patient care. As the government • Time constraints create a that people complete a self- implements the Accountable Care barrier to participation. inventory to determine their emo- Act, this drift will gain speed. • Intellectual elitism. “Sur- tional triggers and how they will Many surgeons balk at following geons are highly trained to prac- react to hot-button issues. Once policymakers’ lead with regard to tice medicine,” but not necessarily a dialogue gets under way, “Read these sorts of changes for the fol- to resolve conflict by working with the other person’s emotions. Make lowing reasons: people of different backgrounds. 41

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Impaired physicians duce these problems, “we need to know which road you need to take Like Dr. Evans, Michael R. promote a culture of medicine that to get there. Dream. Oreskovich, MD, FACS, clinical values work-life balance,” he said. • Deal with perceived trans- professor of psychology at the “The things that make surgeons gressions. “Forgive, forget, and University of Washington, Seattle, surgeons are also the things that file” when someone does some- noted that surgeons like to be in make us more likely to be im- thing that you find upsetting. control. Consequently, “there has paired,” added Krista Kaups, MD, “Don’t let someone else control never been a surgeon born who FACS, health sciences clinical pro- your happiness,” he said. wished to be an impaired sur- fessor of surgery at the University • Be approachable. Listen geon,” he said. of California, San Francisco. Such attentively, be flexible, and be vis- “Physician impairment is de- characteristics include compul- ible. fined as the inability to practice siveness and perfectionism, she • Be accountable. with reasonable skill and safety,” said as a lead into an interactive • Expand your limits. Take Dr. Oreskovich said. Causes of discussion of impairment. some risks. impairment include neurodegen- • Behave ethically. Exude in- erative disease, substance abuse, Departmental leadership tegrity. mental health issues, stress, and J. Patrick O’Leary, MD, FACS, • “Exercise good judgment, burnout. Indicators of potential executive associate dean for clini- but avoid being judgmental.” impairment among physicians cal affairs at Florida International • Be good at your job. include isolation, conflicts with University College of Medicine, • Be nice. colleagues, disorganization, inac- Miami, discussed the activities cessibility, frequent absences, and and qualities of successful surgery Leadership in the ACS rounding at odd hours. department chairs. Dr. O’Leary, Two surgeons who currently Physicians with substance abuse who for many years chaired the serve on several ACS standing problems also may have a chaotic department of surgery at Loui- committees—Hilary Sanfey, MD, lifestyle and poorly explained ac- siana State University School of FACS, and Patricia Turner, MD, cidents and injuries. Dr. Oreskov- Medicine, New Orleans, cau- FACS—presented a session titled ich suggested that physicians and tioned surgeons who are being Moving up the College Leadership other health professionals who considered for chairmanships to Ladder. believe a coworker has an alcohol make certain they understand the Dr. Sanfey, professor of sur- or drug problem conduct an in- expectations of deans and other gery and vice-chair of education tervention, which he described as institutional leaders. at Southern Illinois University “a life-saving event.” “Start off understanding and School of Medicine, Carbondale, Meanwhile, surgeons suffering enforcing the status quo. Then be said attaining leadership posi- from burnout may show signs creative,” he said. “Pick the area tions requires preparation. She of depersonalization (such as that needs the most attention encouraged young surgeons to no longer connecting with their and do it first.” Understand the do their homework and to attend patients), emotional exhaustion, mission, identify goals, gather the College’s leadership training low personal accomplishment, the right people, communicate programs. and cynicism. Surveys conducted responsibilities, and measure Young surgeons can get lead- by the ACS Board of Governors’ outcomes. ership experience through their Committee on Physician Com- Dr. O’Leary listed his 10 per- College membership by joining petency and Health indicate that sonal keys to success as follows: their local chapter, participating in 40 percent of Fellows meet the • Know yourself. Conduct an the medical student program, and criteria of suffering from burnout, honest inventory of your strengths inquiring about openings on other Dr. Oreskovich said. In addition, and weaknesses, likes and dislikes, ACS committees. Once involved, 30 percent screen for depression and so on. stay involved, Dr. Sanfey said. Ac- and one in six demonstrate signs • Have a destination. Know cept criticism, follow through on of suicidal ideation. To help re- where you want to end up and activities, and promote yourself. 42

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS She also recommended finding a During the gathering for young est from the public. “I think we’re mentor. surgeons, Scott Coates, MD, on the threshold of moving for- Surgeons who enter into lead- FACS, a member of the ACS ward with our College” through ership positions need to manage Young Fellows Association, pro- our ongoing commitment to qual- their time wisely. Leaders need to vided an “insider’s guide” to the ity and to our patients, Dr. Hoyt delegate, schedule “closed door” work and functions of that group. said. The College is starting to time, develop a strategy for deal- At the luncheon for chapter lead- roll out its new Inspiring Quality ing with e-mail, and “say ‘no’ to ers, Jon Sutton, Manager of State program, and “what we’re seeing requests that aren’t going to help Affairs, ACS Division of Advocacy is that people really are starting to your career,” Dr. Sanfey said. They and Health Policy, presented an listen to us,” he noted. also need to achieve balance be- update on state legislation. Mr. Shalgian agreed with Dr. Hoyt tween their professional and their and stated that the message of the personal lives. Town hall meeting Inspiring Quality program—that Patricia Turner, MD, FACS, an As in years past, this year’s Lead- reducing health care costs is not assistant professor of medicine at ership Conference ended with a about reducing payment, but the University of Maryland Medi- town hall meeting with the follow- rather about improving quality— cal Center, Baltimore, acknowl- ing ACS leaders: Dr. Britt; Carlos is resonating in Washington. edged that getting involved in A. Pellegrini, MD, FACS, Chair, In addition, Dr. Armstrong professional organizations can seem ACS Board of Regents; John H. encouraged participation in the burdensome to residents and young Armstrong, MD, FACS, Chair, ACSPA-SurgeonsPAC. This group surgeons who already are pressed American College of Surgeons advocates for surgeons in two for time and money. However, the Professional Association Political ways: (1) by making bipartisan, benefits of membership in these as- Action Committee (ACSPA- pro-surgery campaign contribu- sociations outweigh the drawbacks. SurgeonsPAC) Board of Directors; tion to candidates for Congress; Active participation in professional David B. Hoyt, MD, FACS, ACS and (2) by providing education organizations provides surgeons Executive Director; and Christian that elevates surgical practice. with networking and educational Shalgian, Director, ACS Division opportunities. Professional associa- of Advocacy and Health Policy. tions advocate for their members at Dr. Pellegrini emphasized the the federal and state levels, provide importance of the College’s mis- practice management tools, and sion of providing optimal care offer scholarships and grants for to patients. He also encouraged scientific inquiry, she noted. young surgeons to get involved Dr. Turner also offered several in the College and to seek out pieces of advice to young sur- positions on committees that fo- geons who are looking to take cus on matters that are of special on leadership positions in their relevance to them personally and professional groups or their insti- professionally. tutions, including the following: Dr. Britt emphasized the ben- (1) be timely; (2) pay attention to efits of ACS membership and detail; (3) accept new responsibili- asked the chapter leaders and ties when they are presented; and young surgeons to find out what (4) “view every opportunity as a factors may deter surgeons in their stepping stone.” communities from joining the organization. Networking Dr. Hoyt said that the College’s The program included separate ongoing efforts in advocacy and Ms. Schneidman is Manager, Special networking luncheons for young quality improvement will help it Projects, Division of Integrated Communi- surgeons and chapter leaders. to draw more members and inter- cations, Chicago, IL. 43

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Fredric V. Price, MD, FACS, recognized for commitment to global health

Health Volunteers Overseas (HVO) is pleased to announce that Fredric V. Price, MD, FACS, a gynecologic oncologist, is a recipient of the sixth annual Golden Apple Award. As part of its World Health Day observances, HVO created this award to recognize the extraordinary educational contributions of volunteers to international program sites. Each volunteer honored with this award has demonstrated a strong commitment to HVO’s educational mission by working on curriculum development, teacher training, didactic or clinical train- Dr. Price with a patient. ing, or the enhancement of educational resources. As vice-chair and then chairman mitted to improving health care in Since 1950, World Health Day of the International Network of the developing countries. (April 7) has been celebrated an- Society of Gynecologic Oncolo- A graduate of Yale University, nually by the World Health Or- gists, Dr. Price led efforts to provide New Haven, CT, and University ganization and the international gynecologic oncology to women of Louisville School of Medicine, community. This year’s theme in developing countries, and es- Louisville, KY, Dr. Price did his was “Antimicrobial resistance: No tablished a program to send U.S. residency at Magee-Womens Hos- action today, no cure tomorrow,” gynecologic oncologists to Hon- pital of the University of Pittsburgh which promotes the safeguarding duras, where such specialized care Medical Center, and completed his of medicines for future generations. was unavailable. He established clinical fellowship at Yale. Dr. Price For more information on World a partnership with HVO to help is in private practice in Pittsburgh, Health Day 2011, visit http://www. maintain the Honduran program, PA. who.int/world-health-day/2011/en/ and began recruiting oncologists “I am very pleased that the con- index.html. throughout the U.S. to serve as tributions made by Dr. Fredric A private, not-for-profit organi- visiting specialists in Honduras. Price towards improving gyneco- zation, HVO was founded in 1986 Training Honduran residents logic oncology services are being to improve global health through and physicians through lectures, recognized with this award,” said education. HVO designs and surgery, hospital teaching rounds, Nancy Kelly, executive director implements clinical education pro- and interdisciplinary tumor con- of HVO. “By highlighting the ac- grams in child health, primary care, ferences raises the standard of care complishments of volunteers like trauma and rehabilitation, essential available to women in Honduras. Dr. Price, we hope to raise aware- surgical care, oral health, blood Dr. Price’s dedication to helping ness of global health issues and disorders and cancers, infectious cancer patients in Honduras, and encourage others to work towards disease, nursing education, and in future HVO sites, makes him better health care around the wound care. For more information, a role model for physicians com- world.” go to http://www.hvousa.org/. 44

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The ACS CoC recognizes 90 facilities with national award

The Commission on Cancer designated comprehensive cancer data are reported by each CoC- (CoC) of the American College centers, pediatric, and network accredited cancer program to of Surgeons (ACS) has granted cancer programs also received the the CoC’s National Cancer Data its Outstanding Achievement award. Base, a joint program with the Award (OAA) to a select group of Established in 1922 by the ACS, American Cancer Society. These 90 currently accredited and newly the CoC is a consortium of pro- data account for approximately accredited cancer programs across fessional organizations dedicated two-thirds of all newly diagnosed the U.S. as a result of surveys to improving the survival and cancer cases in the U.S. each year, performed during 2010. The list quality of life for cancer patients and are used regularly to monitor of cancer facilities that received through standard-setting, preven- the quality of patient care deliv- the award can be found online tion, research, education, and the ered in CoC-accredited cancer at http://www.facs.org/cancer/coc/ monitoring of comprehensive programs and to improve cancer outstandingachievement2010list. quality care. Its membership care outcomes at both the national html. includes Fellows of the College and local level. Established in 2004, the CoC and representatives of 47 national The CoC provides the public OAA is designed to recognize organizations that reflect the full with information on the resources, cancer programs that strive for spectrum of cancer care. services, and cancer treatment ex- excellence in providing quality The CoC’s core functions in- perience for each CoC-accredited care to cancer patients. The award clude setting standards for qual- cancer program. This informa- is granted to facilities that dem- ity, multidisciplinary cancer tion is shared with the public on onstrate a commendation level of patient care; surveying facilities the Cancer Programs page of the compliance with seven standards to evaluate compliance with the American College of Surgeons that represent six areas of cancer 36 CoC standards; collecting website at http://www.facs.org/ program activity: cancer commit- standardized, high-quality data cancer/index.html and through the tee leadership, cancer data man- from accredited facilities; and American Cancer Society National agement, clinical management, using the data to develop effective Cancer Information Center at research, community outreach, educational interventions to im- 800-ACS-2345. and quality improvement. prove cancer care outcomes at the For more information about The level of compliance with national, state, and local levels. the Commission on Cancer, visit the seven standards is determined There are currently more than www.facs.org/cancer/index.html. during an on-site evaluation by a 1,500 CoC-accredited cancer pro- physician surveyor. In addition, grams representing 25 percent of facilities must receive a compli- all hospitals in the U.S. and Puer- ance rating for the remaining 29 to Rico. These CoC-accredited cancer program standards. The facilities diagnose and/or treat 90 programs that received the 71 percent of all newly diagnosed OAA, following surveyor visits cancer patients each year. Receiv- in 2010, represent approximately ing care at a CoC-accredited can- 17 percent of programs surveyed cer program ensures that a patient during this period. A majority of will have access to the full quality recipients are community-based spectrum of comprehensive can- facilities; however, teaching hos- cer care close to home. pitals, National Cancer Institute- In addition, cancer patients’ 45

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Resident Research Scholarships for 2011 awarded

Five American College of Sur- of two years, beginning July 1, Pittsburgh Medical Center, Pitts- geons Resident Research Scholar- 2011. These scholarships are burgh, PA. ships for 2011 were awarded by sponsored by the Scholarship Research project: Targeting IRF1 the Board of Regents in February. Endowment Fund of the College. as a potential therapeutic target in The scholarships are offered to The recipients for these scholar- liver ischemia/reperfusion injury. encourage residents to pursue ships are as follows: • Greta V. Bernier, MD, careers in academic surgery and • John R. Klune, MD, resi- resident in surgery, University of carry awards of $30,000 for each dent in surgery, University of Washington, Seattle, WA. Research project: Discovery of new genes for inherited predispo- sition to breast cancer by exome sequencing in high-risk families. • Erik G. Pearson, MD, resident in surgery, University of Utah Health Sciences Center, Salt Lake City. (Research to be performed at Children’s Hospital of Philadelphia, PA.) Research project: Understanding the risk of graft versus host disease after in utero hematopoietic stem cell transplantation. • Serena Tan, MD, resident in surgery, Stanford Hospital and Clinics, Stanford, CA. Dr. Klune Dr. Bernier Research project: A novel injury

Dr. Pearson Dr. Tan Dr. Burke

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS model of acute respiratory dis- notch in medullary thyroid can- of the Bulletin. This information tress syndrome. cer. will also appear on the College’s • Jocelyn Burke, MD, resi- The requirements for these scholarships Web page, at http:// dent in surgery, University of research-oriented scholarships www.facs.org/memberservices/ Wisconsin, Madison. offered by the College for 2012 research.html. Research project: Targeting will be published in a later issue

NCDB Research Fellow recognized by the Society of Surgical Oncology

Richelle Williams, MD, a mend needle biopsy (fine needle third-year surgical resident from aspiration or core) as the initial the University of Chicago, IL, diagnostic procedure of choice recently received the Resident for breast lesions. Needle biopsy Essay Award for the best clinical is almost as accurate as, and offers research presentation from the several advantages over, surgical Society of Surgical Oncology biopsy (for example, decreased (SSO). The award was presented cost and fewer complications). to Dr. Williams at the SSO’s 64th As a result, there are initiatives annual meeting in San Anto- under way to make needle biopsy nio, TX. Dr. Williams is in her for diagnosis of breast cancer prior first of two years as a Research to surgery a quality indicator in Fellow with the Commission breast cancer care. on Cancer’s National Cancer Dr. Williams’ analysis revealed Data Base (NCDB), which is a steady increase in utiliza- housed at the headquarters of the tion of needle biopsy over time American College of Surgeons (73.8 percent in 2003 to 86.7 per- (ACS). Mitchell C. Posner, MD, cent in 2008), with a concomitant FACS, program director and vice- Dr. Williams decline in excisional biopsies. The chairman of surgery at the Uni- three most important predictors of versity of Chicago Medical Cen- excisional biopsy use were disease ter, said of the award, “This is an stage, hospital location, and hos- extraordinary achievement and diagnostic procedure for breast le- pital case volume. Rates of needle prior winners read as a virtual sions. The literature on current bi- biopsy utilization in high-volume Who’s Who in academic surgi- opsy utilization rates is sparse, and centers suggested that a goal rate cal oncology. Congratulations to Dr. Williams’ study sought to of 85 to 90 percent should be rea- Richelle and her co-authors.” evaluate trends in utilization pat- sonable whenever needle biopsy The award was given in rec- terns and the factors driving these rate is implemented as a quality ognition of Dr. Williams’ work trends in a large (n=373,837) con- improvement measure. The full examining temporal trends in temporary (2003–2008) cohort of paper reporting these results has the utilization of needle versus patients with breast cancer. been submitted for publication excisional biopsy as the initial Consensus guidelines recom- in the Annals of Surgical Oncology. 47

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The AmericA n c ollege of SurgeonS • DiviS ion of eDucATion ACS Multimedia Atlas of Surgery

Editor-in-Chief: Horacio J. Asbun, MD, FACS Foreword by Ajit K. Sachdeva, MD, FACS, FRCSC, Director, Division of Education, American College of Surgeons

Pancreas surgery Volume Editors: Pascal R. Fuchshuber, MD, PhD, FACS Horacio J. Asbun, MD, FACS colorectal surgery Volume Editors: Tonia M. Young-Fadok, MD, MS, FACS, FASCRS Horacio J. Asbun, MD, FACS

The interactive Multimedia Atlas of Surgery volumes present a step-by-step guide to both To order, open and laparoscopic procedures. Each chapter call 800-633-0004 is authored by a leading surgeon in the field, or visit and includes: www.cine-med.com • Narrated surgical video • Medical illustrations • Tips to prevent errors Pricing: • DVD-ROM with book and online access Regular price Member price Pancreas $360 $299 Colorectal $325 $270 • One-year online access only Pancreas $240 Colorectal $180 • Individual chapters CD-ROM with PDF chapter $35 each Online only $20 each

Published by

American College of Surgeons InSpIrIng QuAlIty: Highest Standards, Better Outcomes

Atlas of Surgery (P&C) ad - BULLETIN final.indd 1 4/11/2011 11:31:33 AM More women medical students select general surgery

The gender gap among U.S. all USMG from academic years “The make-up of residents en- medical graduates (USMG) in the 1999–2000 through 2004–2005; tering general surgery each year traditionally male-dominated spe- (2) USMG applicants for posi- consists of medical graduates from cialty of general surgery is shrink- tions at Accreditation Council the U.S. and abroad. By examining, according to study results for Graduate Medical Education ing these populations separately, published in the March issue of (ACGME)-accredited general we were able to provide a more the Journal of the American College surgery residency programs for ap- definitive analysis of those ap- of Surgeons. These findings align plicant years 2000 through 2005; plying to, and entering, general with the overall trend of increas- and (3) USMG entering positions surgery training,” said Elisabeth ingly equal gender enrollment of at ACGME-accredited general C. Davis, Education Research medical students. surgery training programs be- Associate, Division of Education, The study found a 22 percent tween academic years 2000–2001 American College of Surgeons, relative increase in the percentage to 2005–2006. and the study’s lead author. “Fur- of women among USMG appli- During the six-year study pe- ther research should examine cants to general surgery programs riod, the percentage of women residency programs on a national between application years 2000 entering training increased not scale with respect to factors sug- (n = 506; 27 percent) and 2005 only in general surgery, but also in gested in previous studies that (n = 754; 33 percent). Addition- the surgical specialties of obstetrics may be associated with women’s ally, there was a 25 percent rela- and gynecology, ophthalmology, decisions to enter surgery. These tive increase in the percentage of orthopaedic, otolaryngology, urol- factors include the percentage of women among USMG who began ogy, and plastic surgery. At the women on the surgical faculty, the general surgery training between end of the study period, general presence of on-site childcare, and academic years 2000–2001 (n = surgery had the second highest policies regarding gender-based 282; 32 percent) and 2005–2006 percentage of women among discrimination and maternity (n = 384; 40 percent). USMG entering surgery training leave.” The study authors analyzed (40 percent), behind obstetrics three related populations: (1) and gynecology (82 percent). From Surgery News: Guidelines to prevent catheter infections

Officials at the Centers for Dis- are responsible for surveillance N. Olmsted, MPH, president of ease Control and Prevention have and control of infections in the the Association for Professionals released updated guidelines for hospital, in outpatient settings, in Infection Control and Epide- the prevention of catheter-related and in home health care settings. miology. Furthermore, the De- bloodstream infections, report The release of the guidelines partment of Health and Human staff of Surgery News, the official comes at a critical time. Starting Services has set a national goal of newspaper of the American Col- this year, hospitals must track and reducing central line-associated lege of Surgeons. report on central line-associated bloodstream infections by 50 Last updated in 2002, the bloodstream infections in their percent by 2013. guidelines are aimed at health intensive care units or risk los- To learn more about the up- care providers who insert intra- ing 2 percent of their Medicare dated guidelines, go to http://www. vascular catheters and those who payments, according to Russell facs.org/surgerynews. 49

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS International Guest Scholarships available for 2012

The American College of Surgeons is offering In- their intended permanent location. Applications will ternational Guest Scholarships in 2012 to competent be accepted for processing only when the applicants young surgeons from countries other than the U.S. have been in surgical practice, teaching, or research for or Canada who have demonstrated strong interests in a minimum of one year at their intended permanent teaching and research. The scholarships, in the amount location, following completion of all formal training of $8,000 each, provide the International Guest Schol- (including fellowships and scholarships). ars with an opportunity to visit clinical, teaching, and • Applicants must have demonstrated a commit- research institutions in North America and to attend ment to teaching and/or research in accordance with and participate fully in the educational opportunities the standards of their respective home country. and activities of the ACS Clinical Congress in Chicago, • Applicants whose careers are in the developing IL, in 2012. stage are deemed more suitable for receipt of this schol- This scholarship endowment was originally provided arship than those who are serving in senior academic through the legacy left to the College by Paul R. Haw- appointments. ley, MD, FACS (Hon), former Director of the College. • Applicants must submit a fully completed ap- More recently, gifts from Fellows and their families and plication form provided by the College on its website. associates have expanded the roster of International The application and accompanying materials must be Guest Scholarships. The ACS Foundation website submitted in English. Submission of a curriculum vitae features additional information about these benefactors without a completed application is not acceptable. and the awards they support. • Applicants must provide a list of all of their The scholarship requirements are as follows: publication credits and must submit three complete • Applicants must be medical school graduates. publications (reprints or manuscripts) of their choosing • Applicants must be at least 35 years of age, but from that list. younger than 45, on the date that the completed ap- • Applicants must submit letters of recommenda- plication is filed. tion from three of their colleagues. One letter must be • Applicants must submit their applications from from the chair of the department in which they hold academic appointment or a Fellow of the ACS residing in their country. The chair’s or the Fellow’s letter must include a specific statement detailing the nature and extent of the teaching and other academic involvement Trauma meetings calendar of the applicant. • The International Guest Scholarships must be The following continuing medical education used in the year for which it is designated. The scholar- courses in trauma are cosponsored by the Ameri- ship cannot be postponed. can College of Surgeons Committee on Trauma • Applicants who are awarded scholarships are ex- and Regional Committees: pected to provide a full written report of the experiences • Point/ Counterpoint, June 13–15, 2011, provided through the scholarships upon completion of National Harbor, MD. • Advances in Trauma, December 9–10, their tours. 2011, Kansas City, MO. • An unsuccessful applicant may reapply only Complete course information can be viewed twice, and only by completing and submitting a cur- online (as it becomes available) through the Ameri- rent application form provided by the College, together can College of Surgeons’ website at http://www. with new supporting documentation. facs.org/trauma/cme/traumtgs.html, or contact International Guest Scholarships provide successful the Trauma Office at 312-202-5342. applicants with the privilege of participating in the College’s annual Clinical Congress in October, with public recognition of their presence. They will receive 50

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS gratis admission to selected postgraduate courses, plus Kate Early, International Liaison, American College of admission to all lectures, demonstrations, and exhibits, Surgeons, 633 N. Saint Clair St., Chicago, IL 60611- which are an integral part of the Clinical Congress. 3211 USA; [email protected]. Assistance will be provided in arranging visits (fol- Completed applications, including all the support- lowing the Clinical Congress) to various clinics and ing documentation, for the 2012 International Guest universities of the scholars’ choosing. Scholarships must be received no later than July 1, To qualify for consideration by the selection com- 2011. All applicants will be notified of the selection mittee, all of the requirements must be fulfilled. The committee’s decision in November 2011. Applicants application form for the ACS International Guest are urged to submit their completed application pack- Scholarship is available online on the College’s website age as early as possible in order to provide sufficient at http://www.facs.org/memberservices/igs.html. Sup- time for processing. porting materials and questions should be directed to: A look at The Joint Commission Creating a culture of safety

The concept of a culture of an indispensable role in creating port such events to demonstrate safety is based on the idea that a a culture of safety in a health the value of reporting health care organization cannot care organization. Surgeons and • Communication with pa- truly improve patient safety if it other organizational leaders must tients about their care outcomes, waits for adverse events to occur frequently communicate the im- including outcomes that were not before taking action to address portance of safety and encourage anticipated unsafe system issues. Waiting until everyone in the organization to • Support for staff involved in an unwanted patient outcome oc- focus on safety improvement as adverse events curs typically results in a reaction an ongoing concern. Safety is not • Teamwork among caregivers in which a caregiver is blamed for a one-time-only effort. • Engagement of patients as an event. That caregiver is then It is important for surgeons and active members of the care team ordered to receive training or other organizational leaders to ac- • Risk assessment before ad- counseling, or is fired. knowledge that adverse events can verse events occur and adverse Although this type of approach occur because of a human error, event prevention is often seen in events such as but that “to err is human.” There- Organizations should also ac- wrong site surgery, safety experts fore, reporting of adverse events tively search for information in the believe that this approach is least is encouraged, not punished. It is professional literature about how effective in producing successful, important to avoid intimidating to do things safely. In addition, long-term results that truly im- behavior that can result in staff not sharing information about safety prove safety. Instead, creating an speaking up when they see some- efforts with others at conferences, environment or culture in which thing that could undermine team through published articles, and safety is the focus is recognized as effectiveness and compromise the through informal communication the most effective way to achieve safety of patients. help to create an environment that positive change. In addition, a culture of safety supports safety. “Culture” refers to the attitudes, includes the following compo- For more information about values, and behaviors shared by a nents: patient safety, visit The Joint group of people, in which leaders • Routine reporting and open Commission at http://www.joint influence the group. Surgeons discussion of adverse events commission.org/topics/patient_safe- are leaders in the operating room • Analysis of all such events ty.aspx. and beyond, which gives them • Feedback to those who re- 51

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS So, You Want to Be a Surgeon...

Medical student guide to residency training

The online resource, So, You Want to Be a Surgeon…A Medical Student Guide to Finding and Matching with the Best Possible Surgery Residency, is now available on the American College of Surgeons Web site at:

http://www.facs.org/residencysearch

This online, contemporary version of the popular “Little Red Book” has proved to be an invaluable resource for medical students seeking opportunities in graduate medical education. The revised online version of this helpful reference includes a searchable database containing a complete list of accredited surgical specialty residency programs, as well as a section devoted to assisting students in choosing a residency program that is their best match.

For further information, contact Elisabeth Davis, MA, Education Research Associate, Division of Education, at 312-202-5192, or via e-mail at [email protected].

AmericA n c ollege of SurgeonS ● DiviS ion of eDucA tion

Little Red Book-Bulletin (rev 06-07).indd 1 3/2/2010 3:16:34 PM American College of Surgeons Professional Association (ACSPA)

The ACSPA-SurgeonsPAC (political action committee) raised $1,345,374 for the 2009/2010 election cycle. Of this amount, approximately $735,805 was raised in 2010. A total of 78 percent of the U.S. Governors contributed, and 100 percent of the U.S. Officers and Regents contributed as well. Plans for the ACSPA-SurgeonsPAC for 2011 include a two-day strategic planning meeting with the specific aim of assessing where the ACSPA- SurgeonsPAC stands, and determining new goals and the most effective means of achieving them. The ACS-SurgeonsPAC remains committed to increasing its overall market share of Fellows and Resident members. The approval process is under way for the addition of a named lecture sponsored by the ACSPA- SurgeonsPAC during the 2011 Clinical Congress program. The lecture would capture multiple dimensions of advocacy in the public and private sectors, and would merit continuing medical education credit. American College of Surgeons (ACS) Board of Governors The Board of Governors presented suggestions to the Board of Regents regarding College initiatives. The recommendations/suggestions came from the Governors during their October meetings, and included the following, among others: Report on • The College should remain extremely active in issues related to new reimbursement paradigms, such as hyper-bundling ACSPA/ACS • Public outcomes and cost-effectiveness reporting should be based on systems that have been thor- activities oughly tested, vetted, and validated regarding metrics and systems that will be used to assess clinical skills • Regarding graduating surgical residents who February 2011 seem unprepared for practice, Governors would urge the College to develop a questionnaire for distribution to the Fellowship to begin to understand the problem, and perhaps, begin to develop solutions by Timothy C. Flynn MD, FACS • The ACS should assign resources to develop and test alternative payment models that will ultimately replace the sustainable growth rate (SGR)

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • The ACS should investigate and develop action Operation Giving Back (OGB) plans to deal with issues that impact the surgeon’s Kathleen M. Casey, MD, FACS, Director, ACS relationship to integrated health care systems Operation Giving Back, received the American • Consider adopting dues increases gradually and Medical Association (AMA) Nathan Davis Inter- in small increments more frequently, going forward national Award in Medicine during the AMA’s National Advocacy Conference in February in Public profile and communications Washington, DC. Work has progressed on the College’s brand/ The Resident and Associate Society of the Ameri- reputation-building campaign. The slogan/ can College of Surgeons (RAS-ACS) is soliciting tagline for the campaign—Inspiring Quality: High- input on resident involvement in global surgery est Standards, Better Outcomes—was selected. The work. This input will be shared with the OGB for core attribute and focal point of the campaign will planning and programming purposes in support of be to communicate the power, scope, and ongoing resident opportunities in this realm. achievements of the ACS quality programs. The Other OGB news as of January 19 included: focus on quality is intrinsic to the College’s mission • A total of 48 new and updated opportunities and agenda, and reflects the most positive and im- posted on the OGB website portant contributions the College makes on behalf • Number of surgeons enrolled in My Giving of surgical patients. Back increased to more than 1,625 • A 30 percent increase in page views of the Global Health Service Corps (GHSC) OGB website The Board of Regents endorsed a proposal to cre- • More than 48,000 site visits from 174 coun- ate a U.S. GHSC (the equivalent of a Marshall Plan tries for health) that would train and fund local providers and U.S. health care professionals to work, teach, American College of Surgeons Foundation learn, and enhance the health care workforce and The Foundation had a relatively good year in infrastructure in low-income countries. It would be 2010. Its primary mission is voluntary philanthropy designed and implemented as a federal international from Fellows and friends to support the College’s health service program to support skilled health goals, especially quality patient care. The Founda- professionals who work in developing countries tion’s goals for 2011 include the following: through loan forgiveness and scholarships. The • Increasing unrestricted gifts to the College proposal would be based on the following: • Beginning to use social media • Loan forgiveness and scholarships for health • Soliciting more invitations to present at chap- professionals who commit to a minimum of one ter meetings year of service The oundation’sF industry breakfast this year will • Emphasis on long-term partnership and sus- feature John F. Stossel. Mr. Stossel will speak on the tainability very delicate balance of corporate support of CME. • Provision of direct medical care in parallel to education and training of local providers and invest- Education ment in infrastructure and human resource capacity  A letter from the College articulating specific • Commitment to service to the vulnerable and solutions to concerns about delivery of safe care poor by PGY-1 surgery residents, especially during long • Support of established academic, non- periods of duty, was sent by the College to the Ac- governmental and governmental programs creditation Council for Graduate Medical Education This grassroots effort would occur concurrently (ACGME). The letter focused on the following with the 50th anniversary of the U.S. Peace Corps, specific solutions: with a new form of investment in development, • Establishment and enforcement of stringent public diplomacy, and the global community. supervision standards

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • Improved education and training of PGY-1 of formats that are especially designed to address dif- residents prior to, and subsequent to, starting resi- ferent learning needs. The evidence-based content of dency training using standardized and structured SESAP 14 addresses principally the core competen- experiences based on pre-determined standards cies of medical knowledge and patient care, and also This letter from the College was very well- focuses on the other core competencies, as defined received by the ACGME and in a variety of national by the American Board of Medical Specialties and forums. During the annual meeting of the Asso- the ACGME. The 15 content categories correspond ciation of American Medical Colleges (AAMC) in with the content categories defined by the ABS for November 2010, a meeting was convened by the the recertification examination in surgery. SESAP leadership of the AAMC with surgical leaders and 14 offers the opportunity to earn a maximum of 70 educators to discuss better preparation of medical Category 1 continuing medical education (CME) students for surgery residency training. The AAMC credits, 10 credits more than previous editions of remains very interested in collaborating in the SESAP. design and implementation of new educational  The ACS Comprehensive General Surgery interventions to better prepare fourth-year medical Review Course is specifically designed to help students to enter residency education in surgery. The practicing surgeons fulfill requirements for Part 2 aforementioned letter and the educational programs of MOC, and also to prepare for the recertification of the Division of Education were the central focus examination in surgery, in order to fulfill Part 3 of of discussions in all the forums mentioned in this MOC. The course includes a robust educational section. design, with online pre- and post-tests.  Based on a strategic agenda, the Council Two Comprehensive General Surgery Review of Medical Specialty Societies (CMSS) endorsed Courses were approved for 2011. These will be held simulation-based education and training as a key May 19–22 and June 23–26, in Chicago, IL. new strategic imperative for the CMSS. The aim  Selected Readings in General Surgery (SRGS) is of the CMSS is to coordinate efforts to advance a preeminent, evidence-based educational program simulation-based education and training across all in surgery designed to meet the learning needs of surgical and medical specialties, pursue new models practicing surgeons and surgery residents. The SRGS for telemedicine and telementoring, cross-fertilize is recognized by the ABS as an educational program ideas, and define opportunities to share expensive that may be used to fulfill the requirements for Part 2 resources across specialty societies. of MOC. A forthcoming issue will focus on clinical  The 2010 Clinical Congress program included problems encountered by general surgeons engaged 11 named lectures, 117 panel presentation sessions, in rural practice. The SRGS offers the opportunity 24 didactic and skills-oriented postgraduate courses, to earn a maximum of 10 Category 1 CME credits 334 Surgical Forum presentations, 128 scientific per issue (80 Category 1 CME credits per year). paper presentations, 242 scientific exhibits (includ- The SRGS Connect is an online publication that ing 74 from outside the U.S. and Canada), and 204 is based on SRGS, and is available in three different video-based education presentations. formats:  The Surgical Education and Self-Assessment Pro- • SRGS Connect–Resident is currently available gram (SESAP) remains the premier self-assessment to residency programs and cognitive skills education program for practicing • SRGS Connect–Practicing Surgeon is available surgeons. It is also used widely by surgery residents. to individual practicing surgeons The American Board of Surgery (ABS) recognizes • SRGS Connect–Premium is available to individ- SESAP as an educational program that may be used ual practicing surgeons who prefer the convenience to fulfill the requirements for Part 2 of Maintenance of receiving with their subscriptions full-text reprints of Certification (MOC). of the most important articles from the overview SESAP 14 was released during the 2010 Clinical The SRGS Connect–Practicing Surgeon and the Congress in Chicago, IL, and is available in a variety SRGS Connect–Premium may be used to earn up to

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 80 Category 1 CME credits per subscription year, in the United States. Published in 2010, this report or 10 Category 1 CME credits per issue. provides a picture of the surgical workforce in  A number of sessions from the 2010 Clinical practice as well as in training in the U.S. Each of Congress program were selected for webcasting in an the ACS HPRI reports has been made available on effort to offer convenient access to these important the ACS Web portal (e-FACS.org), and the ACS sessions. A total of 25 sessions from the 2010 Clini- HPRI website. The fact sheets have been adapted cal Congress were bundled with 45 sessions from and published in the ACS Bulletin. previous Clinical Congress meetings to produce a Thomas C. Ricketts, PhD, MPH, Managing complete webcast package that offers the opportu- Director of the ACS HPRI, was appointed to the nity to earn 121 Category 1 CME credits. National Health Care Workforce Commission in October 2010. Dr. Ricketts was one of 15 experts Journal of the American College appointed to the new commission. The commis- of Surgeons (JACS) sion was established under the Affordable Care The JACS Category 1 CME program continues to Act (ACA). It is an independent body that advises be popular among Fellows and subscribers. In 2010, Congress and the White House on health work- 71,982 credits were earned, and 2,593 individual force policy. It will also serve as a national resource surgeons participated in the Journal’s CME program. for states and localities to evaluate education and training activities, identify and recommend ways ACS Health Policy Research Institute to address barriers to improved coordination, and (ACS HPRI) encourage innovations that address population A hotline for workforce data or policy advice, the needs, changing technology, and other environ- ACS HPRI is committed to providing reliable and mental factors. useful data to support policymaking for health care The ACS HPRI is currently engaged in multiple in the U.S. Queries about data, provision of existing workforce-related projects with three tasks forming literature, and reports, slides, and maps are available the core of this work, as follows. to individual Fellows by request. In addition, the • Atlas of Surgical Workforce. Version 1 of the ACS HPRI has generated slide presentations that online Atlas was released at the ACS Clinical Con- are available on the portal for use by the Fellows. gress in October 2010. The Atlas provides a picture Compiling and analyzing the AMA and the of the supply and geographic distribution of physi- AAMC data, the ACS HPRI has developed a lon- cians and institutions providing surgical services in gitudinal database that provides surgical specialist an effort to help practitioners, policymakers, and workforce trends, demographic characteristics, patients anticipate current and future distribution geographic distribution, and training background. and identify places with limited access to surgical These data can, and have been, used to develop a services. forecasting model that compares the effect of po- • Longitudinal Database of Physicians. The Cecil tential policy scenarios. With this information, we G. Sheps Center for Health Services Research, have provided a series of documents for distribution Chapel Hill, NC, and the HPRI have developed among members of Congress, the White House, and a longitudinal database of physicians in the U.S. other relevant stakeholders. Among these documents This file links annual files of physicians and allows are six fact sheets available in print and on the ACS analysts to track the changes physicians make in HPRI website. The most recent fact sheet, Inde- their practice location, activity status, and, to a pendent Practice Becoming Increasingly Rare Among lesser extent, residency or fellowship training. These Surgeons, provides some foreshadowing to what we data have been used to determine the migration might expect to see in the future as Accountable Care patterns of physicians and surgeons over time by Organizations (ACOs) become more clearly defined age, gender, specialty, and training status. and organized. Another more comprehensive report • Surgical Workforce Projection Model. The developed from this data is The Surgical Workforce model is a user-friendly prediction model of the

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS supply of surgeons in the U.S. It will allow users to sive specialization (voluntary narrowing of scope of forecast future supplies of surgeons by head count, practice over time) of general surgeons in response and full-time equivalent by age, gender, race, geo- to the increased numbers of trainees pursuing fel- graphic location, and specialty. The model is primar- lowship training in surgical subspecialties. While this ily intended to be a tool for policy analysis. occurs in all specialty areas of surgery, it is especially The HPRI research includes, but is not limited problematic in general surgery. to, the following: • Rural surgery. The Sheps Center has a long • Innovative models of surgical staffing. Rural involvement in rural health, and due to the fact that communities across the U.S. have long struggled it houses an Office of Rural Health, it is an obvious to maintain surgical services in local hospitals, and topic for in-depth analysis of critical access hospitals recent data show further contraction of the rural and surgical services. A total of 58 million Americans surgical workforce. Using a semi-structured case- live in what is classified by the U.S. Census Bureau study approach, the HPRI is examining surgical as rural America. Drafting criteria for health policy staffing models of rural hospitals. The goal is to shortages of surgeons is in progress. In addition, produce information that is useful to communi- analysis continues to examine and clarify differences ties, especially rural ones, in addressing current or between rural and urban surgical practice locations. anticipated shortages in the surgical workforce. Developing projects for the HPRI include the ACS National Surgical Quality following: Improvement Program (ACS NSQIP®) • ACOs and regionalization. The final rules that On January 1, 2011, the ACS NSQIP launched will guide the development of Medicare-ACOs are several important changes to advance the program. under development in the Centers for Medicare The ACS NSQIP Generation Two has updated the & Medicaid Services (CMS). There is guidance as program to address the variety of hospital types that to the ACO’s eventual design provided by prior have variable needs, have variable resources, perform demonstrations that suggest these entities will be variable case mixes, and so forth. The following areas hospital-centered, will make use of bundled pricing, are where changes are occurring and are a reflection will aggregate multiple physician groups, and will of input from a variety of sources: increase the trend toward organizational affiliation • Information technology platform flexibility for surgeons. On the surgical side, less attention has • Case collection options been paid to the coordinating and integrating work • Data variables—both content and number of on surgical services including burn care, wound care, variables collected pediatric surgery, oncology, thoracic, and transplant • Statistical methods advancing in line with the surgery that can be used as guidance for how to advancing science organize coordinated systems integrating primary • More meaningful data reports care and post acute care to reduce costs and improve • “Closing the loop” materials (for example, best quality. practices, case studies) • Surgical service areas and underservice. Health The ACS NSQIP has already developed a number Profession Shortage Areas (HPSA) were defined and of evidence-based best practices guidelines. Several are administered by the U.S. Health Resources and new guidelines have been created and have been Services Administration (HRSA) based on primary posted on the ACS NSQIP secure website. The care resources. Primary care HPSAs do not ad- best practices guidelines summarize key evidence- equately define all health professional shortage areas. based recommendations from professional societies’ To address this problem for surgeons, the HPRI has guidelines approved by an expert panel. Hospitals developed a proposal for a HPSA designation for or individual practitioners are using these concise areas that have critical shortages of general surgeons. guidelines as a framework to prioritize and direct • Subspecialization trends and training. This efforts for addressing postsurgical complications. project builds on work that investigated the progres- • Collaboratives: Collaboratives allow participat-

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ing sites to compare outcomes and share best prac- recognized vendor, implementation on a large scale tices in a cooperative, noncompetitive environment, would be more possible. and provide for data sharing opportunities beyond International interest in the ACS NSQIP con- the scope of the standard ACS NSQIP participation. tinues to rise. The ACS NSQIP currently has two The Florida Surgical Care Initiative is in the final sites outside of the U.S. and Canada. Because of the stages of development and will soon be the largest high interest of several international sites in joining ACS NSQIP collaborative, with nearly 100 sites. the ACS NSQIP, the possibility of an international • National conference: More than 700 individu- pilot is being evaluated. The ACS NSQIP is cur- als attended the ACS NSQIP National Conference rently in the process of gathering information from in 2010. Peter Pronovost, MD, of Johns Hopkins international sites interested in joining the Global School of Medicine, Baltimore, MD, served as the Surgical Quality Initiative pilot. keynote speaker and delivered a presentation on bloodstream infections. Attendees also enjoyed pre- Advocacy sentations from ACS leaders and the ACS NSQIP  The ACS responded to the CMS’ request for participating sites on a variety of program updates information regarding the ACOs and the implemen- and surgical quality improvement topics, including tation of the Medicare Shared Savings Program. The the ACS NSQIP’s role in health care reform. The ACS provided feedback on various issues, including 2011 ACS NSQIP national conference will take policies and standards to ensure that groups of solo place at the Westin Copley Place in Boston, MA, or small practice providers have the opportunity to July 24–26. The ACS NSQIP is currently in the participate in the ACOs—specifically, the impor- process of finalizing the agenda for the upcoming tance for the CMS to address legal concerns that conference. might arise for the ACS members, and to imple- As the ACS NSQIP becomes increasingly multi- ment effective risk adjustment methodologies. The specialty, the ACS continues to collaborate with comments also addressed the need for prospective specialty experts from a number of different special- attribution of beneficiaries to the ACOs, assessment ties and surgical societies. The addition of specialty- of beneficiary and caregiver experience of care using specific data variables and modules will continue to the Consumer Assessment of Healthcare Provid- enhance the ACS NSQIP targeted procedure dataset ers and Systems Surgical Care Survey, the use of and the overall program. patient-centeredness criteria for assessment of the Building on a successful partnership, the CMS ACOs, and what quality metrics an ACO should approached the College to develop additional out- meet. The comment letter emphasized that a new come measures. The CMS recognizes the strong delivery system must focus on promoting quality understanding and acceptance by providers of the care, improving patient access, and, ultimately, ACS NSQIP data collection and statistical method- providing cost-efficient care. ology. The ACS NSQIP data were used to develop  The ACS met with staff members of Senate risk-adjusted hierarchical models for four clinical, Finance Committee Chair Max Baucus (D-MT) to outcome-based, performance measures. These discuss the implementation of provisions included measures were submitted to the National Quality in the ACA (P.L. 111-148) to provide 10 percent bo- Forum (NQF) for evaluation and endorsement, nus payments under Medicare for general surgeons and two measures have passed through the NQF care for patients in HPSAs. The ACS staff discussed committees; they are now out for public comment. how to best ensure that the bonus payments are The remaining two measures have started the NQF being delivered to those general surgeons who are process, and, thus far, have been favorably discussed. caring for patients in underserved areas where there In 2011, the CMS is planning to release an- are demonstrated shortages of general surgeons. other request for applications to become a CMS- Based on the meeting, the ACS staff is working recognized vendor. The ACS expects to submit an with Finance Committee staff to secure a meeting application. If the ACS were able to be a CMS- with the HRSA to discuss the possibility of creating

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS a HPSA for general surgery. At present, the CMS consistently out of compliance, and the ACGME is implementing the bonus payment by providing continues to strengthen and enhance its enforcement bonuses to general surgeons for major procedures procedures. performed in already existing primary care and  Regarding the Independent Payment Advi- mental health HPSAs. This definition fails to take sory Board, the ACS was among a select group of into account the unique requirements of surgery, stakeholders and patient advocacy groups, includ- and, therefore, the provision is poorly targeted. ing representatives from the disability and senior General surgeons operating in urban and suburban citizen communities, to participate in a roundtable hospitals that provide care to underserved areas and discussion hosted by the Aspen Institute. The Aspen populations could be excluded from receiving bonus Institute is a widely respected nonpartisan organi- payments. The College’s Division of Health Policy zation and think tank that hosts a wide variety of and Advocacy staff continues efforts initiated early policy forums, seminars, conferences, and events last year to improve the incentive payment through on numerous public policy issues. Among these creation of surgery-specific HPSAs. programs is the Aspen Health Stewardship Project,  The College was joined by several surgical which is a bipartisan effort that seeks to inform the organizations in sending a letter to the Occupational policymaking process and to refocus the national Safety and Health Administration regarding the dialogue on health reform legislation. petition filed by Public Citizen addressing regula-  The ACS was among a select group of physi- tion of resident duty hours. The College strongly cian organizations who met with policy leaders at believes that the federal government should not the Blue Cross/Blue Shield Association offices in regulate medical resident and fellow training educa- Washington, DC, to discuss priorities and con- tion, including duty hours, outside of the currently cerns with the implementation of health insurance existing ACGME structure. Resident hours are one exchanges, which were created by the ACA and will of many factors that impact quality and safety of begin operation in 2014. Even though the exchanges patient care and the well-being of residents. Severe will not be operational until 2014, state legislatures restrictions on resident duty hours without support- are beginning to consider how to draft legislation ing evidence of corresponding benefits will result in to implement exchanges at that time. a host of unintended negative consequences.  The ACS co-hosted a briefing for House and  The College, along with a variety of other Senate staff in conjunction with the AAMC and the constituencies, provided significant input following National Association of Children’s Hospitals. The the ACGME’s most recent 18-month evaluation briefing, entitled Addressing the Physician Shortage of resident duty work hours. The comprehensive Post Health Care Reform, was attended by more analysis addressed the full spectrum of issues with than 60 individuals from approximately 45 House (1) a thorough review of the current scientific lit- and Senate offices, as well as several congressional erature; (2) testimonies from key representatives committees and other health organizations. The from medical and surgical specialties, residents, briefing featured presentations from Atul Grover, medical students, and the public; and (3) expert MD, PhD; Patricia Hicks, MD; and Thomas Rick- opinion from leading authorities on sleep research, etts, PhD, MPH. The briefing was organized to help physiology, and fatigue management. The new duty raise awareness on Capitol Hill about physician hour requirements include increased safeguards shortages in areas other than primary care (espe- to address the well-being and safety of residents. cially in surgical fields and pediatric subspecialties), Over the past years, the ACGME has continued and how these shortages might be affected by the to rigorously monitor resident duty hours through recently enacted health reform law. the respective residency review committees that  Regarding trauma funding, the College, along include individuals with the requisite expertise from with representatives of the Trauma Coalition, met the various specialties. Punitive actions have been with Mary Wakefield, administrator of HRSA, and taken against institutions that were found to be her staff to discuss funding of the trauma provisions

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS as authorized in the ACA. The College, represented The ACS signed on to two letters to CMS stating by staff and Edward E. Cornwell III, MD, FACS, concerns with the e-prescribing payment adjust- emphasized the tremendous opportunity to lower ment for 2012. Highlighted in these letters were costs and improve outcomes by including funding issues related to the reporting period ending June for the trauma and emergency programs. Dr. Corn- 30, 2011, and the exceptions. The letters urged well also highlighted the unique workforce shortages CMS to extend the reporting period and add more confronting trauma and emergency medical services, exception categories, such as those physicians who and the need to address those issues at all caregiver attest to meaningful use in 2011 or 2012. The levels. The groups asked that funding be included in ACS continues to represent surgery at all meetings the President’s budget, or by utilizing discretionary regarding the future of e-prescribing, and possible dollars. changes to the program. (For more information on A similar meeting took place January 27 with the e-prescribing incentive program, see the “What Nicole Lurie, MD, Assistant Secretary for Prepared- surgeons should know about” column on page 6 of ness and Response at the U.S. Department of Health this issue of the Bulletin.) and Human Services. At the meeting, the group  On the political side, state elections strongly also emphasized the need to utilize the trauma and reflected the Republican wave that struck at the emergency programs for disaster preparedness. federal level. From a medical liability reform per- The College is simultaneously working with spective, these elections may result in a couple of ad- House and Senate appropriators to secure funding ditional states considering comprehensive reforms. for these programs. It is very early in the appropria-  The ACS continues to provide a series of cod- tions process, and it promises to be an extremely ing workshops. Physicians receive CME credits for challenging appropriations cycle. The College, each workshop completed and certified professional however, is working hard to secure funding for these coders receive continuing education units through vital programs. the American Academy of Professional Coders.  CMS finalized various other proposed The 2011 coding workshop schedule includes the changes to the 2011 Physician Quality Reporting following: April 28–29, Chicago, IL, and August System (PQRS). The ACS supported a proposal 18–19, Nashville, TN. that—for registry-based reporting of measures  Several commissions have announced various groups in 2011—the minimum patient numbers appointments. Robert M. Zwolak, MD, FACS, a or percentages must be met by Medicare Part B member of the ACS General Surgery Coding and fee-for-service patients exclusively, and may not in- Reimbursement Committee, was appointed to the clude data on non-Medicare Part B fee-for-service Patient Centered Outcomes Research Institute. patients. CMS finalized this proposal. In addition,  The ACS prepared two comment letters re- CMS finalized the ACS-supported proposal to lated to the ACOs. The first letter addressed legal reduce the reporting threshold for eligible profes- issues related to the implementation of the ACOs, sionals who report individual quality measures specifically with respect to the antitrust, anti- using the claims-based mechanism from 80 percent kickback, physician self-referral, and civil monetary to 50 percent. Lowering this reporting threshold penalty laws. The ACS expressed concern that a to 50 percent will ideally increase the likelihood general waiver will not adequately protect providers for successful reporting in the PQRS and increase of care within the context of an ACO; rather, CMS participation in 2011. (For more information, must create explicit protection from these laws. The refer to the series of “What surgeons should know second ACO comment letter was a joint specialty so- about…” columns on PQRS reporting published ciety comment letter prepared in response to a CMS in the Bulletin earlier this year.) request for information regarding the ACOs. The  The ACS continues to educate members and ACS provided feedback on various issues, including their staff about the e-prescribing incentive program policies and standards to ensure that groups of solo through our website, meetings, and publications. or small practice providers have the opportunity to

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS participate in the ACOs, the need for prospective Young Fellows Association (YFA) attribution of beneficiaries to the ACOs, assessment During the YFA’s 2010 annual meeting, mem- of beneficiary and caregiver experience of care, the bers discussed mentoring activities. Based on the use of patient-centeredness criteria for assessment of discussions, it was agreed that the YFA Governing the ACOs, and quality metrics that an ACO should Council members would seek to establish mentoring meet. relationships with well-established members of the  The ACS continues to call on Congress to take College, including Officers, Regents, Governors, action to stop cuts to Medicare reimbursement and so forth. Also, the YFA Governing Council will mandated by the SGR and to replace Medicare’s seek to identify the YFA members of the College who broken payment system with reforms that will are interested in establishing mentor relationships preserve Americans’ access to quality surgical care. with residents.  The ACS prepared a joint specialty society comment letter regarding the ACA’s provisions ACS Advisory Councils for screening to prevent fraud, waste, and abuse for the Surgical Specialties in Medicare, Medicaid, and the Children’s Health All Advisory Councils routinely discuss the Jacob- Insurance Program. The comment letter agreed with son Innovation Award, Sheen Award, and Honorary CMS that the screening mechanisms applied should Fellowship. The nominations are forwarded to the be based on provider type, and that physicians be- ACS Honors Committee for its consideration. long in the “limited risk” category. The letter did The Advisory Councils continue to propose express concern that the application of screening specialty-sponsored programming for the Clinical provisions to physicians who also enroll as durable Congress. Following the recommendation of the medical equipment, prosthetics, orthotics, and ACS Program Committee, several sessions are co- supplies suppliers would result in physicians being sponsored by two specialty Advisory Councils or by a categorized as “high risk.” The ACS also supported specialty Advisory Council and an ACS committee. the CMS position that would prevent physicians from being required to pay an application fee for HealtheCareers (Job Bank) carrying out the screenings and other program As of January 20, there were 568 active jobs listed integrity efforts carried out under these sections of on the website, with 359 posted resumes. This is a the law. valuable service for all members of the College (and is free for Resident Members). Resident and Associate Society (RAS) The RAS had a very productive 2010 meeting. New projects for 2011 include the following: Dr. Flynn is senior • Exchange program with the Royal College of associate dean, clinical Surgeons in Ireland affairs, University of • Revitalization of liaisons to residency programs Florida College of Medi- • Evaluation of the ACS resident membership cine, Gainesville, FL. data to evaluate retention trends He is Chair of the ACS • Resident needs assessment Board of Governors. • Program director survey to better understand recruitment and retention opportunities • Increased advocacy outreach through the ACS State Affairs staff andCS A chapters • Annual scholarship competition for the ACS- sponsored courses (five to be granted) • Increased contact with international surgical trainee organizations

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NTDB® data points The working wounded by Richard J. Fantus, MD, FACS; and John Fildes, MD, FACS

According to the U.S. Census Source of payment Bureau, the number of uninsured Source of payment Americans rose to 50.7 million 4,500

in 2009. That figure is equivalent 4,000 to approximately one in six U.S residents. Meanwhile, the per- 3,500 centage of Americans with private 3,000 insurance was at its lowest since 2,500

1987—the first year that the U.S. 2,000 government began keeping this Cases Number of statistic. The reason for this stag- 1,500 gering increase in the uninsured 1,000 population is multi-factorial. 500

There was a segment of workers 0 who lost their employee benefits 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 when the recession eliminated Age their job, but there were also a Blue Cross/Blue Shield Medicaid Medicare Private/Commercial Insurance Self Pay significant number of companies that dropped employee health benefits. Additionally, there were families that went without coverage to cut household costs, since by primary method of payment. viduals who in 2009 were not able the average cost to insure a family There were 103,483 records that to be covered under their parents’ of four is estimated at $14,000 had primary payor source as self- insurance policies. It will be inter- per year. Workers between the pay. 79,088 records had discharge esting to see over the ensuing years ages of 18 and 64 were the biggest status recorded, including 70,340 how this peak or line may change losers, as public programs such as discharged to home, 3,717 to as health care coverage according the Children’s Health Insurance acute care/rehab, 2,143 to nursing to the Affordable Care Act is finally Program, Medicare, and Medicaid homes; 2,888 died. These patients implemented. (These data are de- protected only the very young were 78 percent male, on average picted in the figure on this page.) and the elderly portion of the 34.2 years of age, had an average There is partisan rhetoric on population (http://www.usatoday. length of stay of 4.5 days, and both sides of the health care crisis com/news/nation/2010-09-17- an average injury severity score in an effort to fix this national uninsured17_ST_N.htm). of 9.55. public health crisis. To date, there In order to examine the oc- When looking at the distribution are a few improvements, and there currence of those workers in the of records by payor source, it is is much that has yet to be finalized overall group of individuals pay- interesting to note that the self-pay or realized. Unfortunately, the ing out of pocket for their health peak occurs in an age bracket that bottom line is that, at present, care in the National Trauma Data would not only include working more individuals in the produc- Bank® research dataset 2009, Americans without employee tive years of their lives—often admissions records were searched coverage, but also college-age indi- from working families—will re- 62

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS main without coverage or be sig- for more detailed study. If you and clinical professor of surgery, University nificantly under-covered as health are interested in submitting your of Illinois College of Medicine, Chicago, insurance remains unobtainable, trauma center’s data, contact IL. He is Past-Chair of the ad hoc Trauma unavailable, or unaffordable for Melanie L. Neal, Manager, NTDB Registry Advisory Committee of the Com- the “working wounded.” at [email protected]. mittee on Trauma. Throughout the year, we will be Dr. Fildes is chair, department of trauma, highlighting data through brief Acknowledgment University Medical Center, Las Vegas, and reports that will be found monthly director for general surgery, surgical critical in the Bulletin. The NTDB Annual Statistical support for this article has care, and acute care surgery; professor of sur- Report 2010 is available on the been provided by Chrystal Price, data gery and vice-chair, department of surgery; ACS website as a PDF file and a analyst, NTDB. and chief, division of trauma/critical care, PowerPoint presentation at http:// University of Nevada School of Medicine, www.ntdb.org. In addition, infor- Dr. Fantus is director, trauma services, Las Vegas. He is Trauma Medical Director mation is available on our website and chief, section of surgical critical care, for the American College of Surgeons. about how to obtain NTDB data Advocate Illinois Masonic Medical Center,

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JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Who will help you help them? Patients and their families frequently look to surgeons for guidance and advice—especially when dealing with life-limiting illness.

Now a new curriculum from the American College of Surgeons and the Cunni - Dixon Foundation o ers surgeons-in-training and practicing surgeons guidance for the management of problems encountered in palliative care, including advice on personal awareness, self-care, and the surgeon-patient relationship.

Surgical Palliative Care: A Resident’s Guide can help surgeons learn what their judgment and skill in the art of surgery can provide for their patients’ comfort, function, and longevity.

To review the content of the manual and discover how it can help you deal with the challenges of life-limiting illness, visit: http://www.facs.org/palliativecare/ surgicalpalliativecareresidents.pdf

A Resident’s Guide Surgical Palliative Care:

Single copies of the manual are available at no cost by contacting [email protected] or by calling 312-202-5311. Multiple copies are also available— you only pay postage costs.

| Editor-in-Chief | Associate Editor Geoffrey P. Dunn, MD, FACS | Associate Editor Robert Martensen, MD, PhD David Weissman, MD, FACP Chapter news

by Rhonda Peebles

To report your chapter’s news, contact Rhonda Peebles toll-free at 888-857-7545, or via e-mail at [email protected]. Peru Chapter co-hosts VII Congress The Peru Chapter co-hosted the VII Congress February 17–19, which was held in conjunction with the XII International Congress of General Surgeons Peruvian Society. More than 700 surgeons and surgical academicians attended the education program, which was held at the Lima Sheraton Ho- tel and Convention Center. Frederick. L. Greene, MD, FACS, the College’s Second Vice-President, presented four cancer-related lectures: (1) Anatomical and Molecular Staging of Cancer: 2011 and Beyond; (2) Laparoscopic Management of Abdominal Malig- nancy; (3) Management of Carcinoid Tumors of the Large Bowel; and (4) Staging of Colorectal Cancer. In addition, Dr. Greene presented an update on Peru Chapter, left to right: David Ortega, MD, FACS, Governor; College activities to the Peru Chapter members (see Dr. Greene; and Danilo Bambaren Gastelumendi, MD, FACS, photo, right). President. North Texas Chapter meets in Dallas The North Texas Chapter held its 2011 annual meeting February 18–19 at the City Place Conference Center in Dallas. In addition to numerous presentations by residents, the meeting featured three notable lectures: The Robert S. Sparkman Memorial Lecture, the Harry M. Spence Memorial Lecture, and the Ethics Lecture. Presentations by residents were a major component of the meeting (see photo, this page), and included the following: • Best Paper—Trauma: Child Abuse: A Significant Etiology of Mortality in Pediatric Trauma Patients. Jordan Estroff, MD, Children’s Medical Center, Dal- las North Texas Chapter: left to right: Michael Truitt, MD, FACS, • Best Paper—Oncology: Long-Term Outcome Co-Program Chair; Dr. Roe; Dr. Wishnew; and Chris Bell, MD, Analysis In Patients With Breast Cancer and a Positive FACS, Co-Program Chair. Axillary Micro Metastases Who Did Not Undergo Axillary Dissection. Elise Roe, MD, Baylor University Medical Center, Dallas • Best Paper— Mini Talks: Pericaval Mass: A Time • Best Overall Paper: Who Will Cover the Cost to Reflect On Vena Cava Aneurysms. Jenna Wishnew, of Undocumented Immigrant Trauma Care? Christo- MD,* Texas Tech University, Lubbock. pher Mitchell, MD, Dallas Methodist Medical Center Also, this year, the winner of the Resident Jeopardy *Denotes Resident Membership in the College. Competition was Baylor University, Dallas. 65

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Florida Chapter leaders, members, and staff posed in the rotunda of the state capitol in Tallahassee.

Virginia Chapter, left to right: Samuel J. Williams II, MD, FACS; Georgia Society-ACS, left to right: Stephan Jerrard, MD, Craig S. Derkay, MD, FACS, FAAP, President; G. Wilkins Hubbard FACS; Harold L. “Hal” Kent, MD, FACS, President; Elizabeth II, MD, FACS, Past-President; James E. Foster II, MD, FACS, Morgan, MD, PhD, FACS; and Kathy Browning, Executive Vice-President; and Barry E. Roper, MD, FACS. Director.

Advocacy days for chapters initial grants: Alabama, Northern California (with In 2010, a grant program to assist chapters with involvement of Southern California and San Diego advocacy efforts was created. The grants for 2011 Chapters), Connecticut, Florida, Georgia, Indiana, averaged approximately $2,500 per chapter and were Massachusetts, New York, Ohio, and Virginia. intended to help support Lobby Day events and educa- The following are Lobby Day summaries from three tion programs for chapter leaders and state legislators. of the selected chapters: A total of 10 chapters were selected to receive these continued on page 68 66

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chapter meetings For a complete listing of the ACS chapter education programs and meetings, visit the ACS website at http://www.facs. org/about/chapters/index.html. (AP) following the chapter name indicates that the ACS is providing AMA PRA Category 1 Credit™ for this activity.

Date Chapter Location/Information Location: Grove Park Inn, Asheville, NC July 15, 2011 - North Carolina Contact: Brad Feldman, MPA, CAE, IOM, 877-859-4561 July 17, 2011 and South Carolina (AP) e-mail: [email protected] ACS Representative(s): Julie A. Freischlag, MD, FACS Location: Memphis, TN July 29, 2011 - Contact: Wanda Johnson, 931-967-4700 Tennessee (AP) July 31, 2011 e-mail: [email protected] ACS Representative(s): David B. Hoyt, MD, FACS Georgia Society of the Location: Atlanta, GA August 27, 2011 - American College of Surgeons Contact: Kathy Browning, 404-625-1520 August 28, 2011 (AP) e-mail: [email protected] Location: Omni Mt. Washington Hotel, Bretton Woods, NH Contact: Brad Feldman, MPA, CAE, IOM, 877-867-8712 August 27, 2011 New Hampshire (AP) e-mail: [email protected] ACS Representative(s): Thomas V. Whalen, MD, FACS Location: Doubletree Hotel, Overland Park, KS September 10, 2011 - Contact: Gary Caruthers, 785-235-2383 Kansas (AP) September 11, 2011 e-mail: [email protected] ACS Representative(s): Mark A. Malangoni, MD, FACS Location: Baltimore Intercontinental Hotel, Baltimore, MD Contact: Brad Feldman, MPA, CAE, IOM, 877-904-1915 September 17, 2011 Maryland (AP) e-mail: [email protected] ACS Representative(s): Charles D. Mabry, MD, FACS Location: Boone Faculty Center, Lexington, KY October 14, 2011 Kentucky (AP) Contact: Linda Silvestri, 859-323-6346 e-mail: [email protected] Location: Holiday Inn, Waterbury, CT November 03, 2011 - Contact: Chris Tasik, 203-674-0747 Connecticut November 05, 2011 e-mail: [email protected] ACS Representative(s): L.D. Britt, MD, MPH, FACS Location: American Club, Kohler, WI November 04, 2011 - Wisconsin Surgical Society– Contact: Terry Estness, 414-453-9957 November 05, 2011 A Chapter of the ACS e-mail: [email protected] ACS Representative(s): David B. Hoyt, MD, FACS

Location: Tokyo, Japan November 18, 2011 Japan Contact: Kyoichi Takaori, MD, FACS, 81-75-751-4323 e-mail: [email protected]

JUNE 2011 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The Louisiana Chapter met and elected leaders for 2011: Left to right (all MD, FACS): Benjamin D. Li, Immediate Past-President, John Hunt III, LA Committee on Trauma Chair; Barry G. Landry, Commission on Cancer State Chair; Charles D. Knight Jr., Governor; Daniel J. Frey, Governor, and Gazi B. Zibari, President-Elect. Pictured separately at right is Joseph F. Uddo, Jr., President.

• The Florida Chapter held its Lobby Day on Feb- Month Chapter Years ruary 8, and topics discussed with legislators included the following: Maintaining the Office of Trauma within June Alberta, Canada 21 the state Department of Health, granting sovereign Arkansas 36 immunity for emergency services and Medicaid, and Connecticut 44 raising the minimum personal liability insurance cover- Metropolitan Washington (DC) 37 age (see photo, page 66). Ecuador 44 • The Virginia Chapter held its Lobby Day on Feb- Germany 21 ruary 9, and topics discussed with legislators included Greece 25 the following: Protecting physician Medicaid payments Idaho 61 from further cuts, supporting the agreement between Ireland 28 the Medical Society of Virginia and the Virginia Trial Israel 14 Lawyers to maintain the medical malpractice cap for at Maine 60 least the next 20 years, and protecting services provided Mexico–Northeast 37 through Medicaid and the Family Access to Medical Mexico–Nor-Occidental 40 Insurance Security—the state’s health insurance pro- Minnesota 39 gram for children (see photo, page 66). New Mexico 26 • The Georgia Society of the ACS held its Lobby New York 45 Day on March 2. In addition to meeting with several Western New York 46 key state legislators, the Georgia Society–ACS members North Dakota 56 also examined and studied the day-to-day workings of Oregon 46 the state capitol (see photo, page 66). Philippines 40 Spain 28 Chapter anniversaries Wisconsin 40 Month Chapter Years

May Colorado 54 Maryland 54 Ms. Peebles is in the Division of Member Services, Chicago, IL. 68

VOLUME 96, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS