NOVEMBER 2017 | VOLUME 102 NUMBER 11 | AMERICAN COLLEGE OF SURGEONS Bulletin

Should your health care system invest in an ambulatory surgery center? A decision-making framework Contents

FEATURES COVER STORY: Should your health care system invest in an ambulatory surgery center? A decision-making framework 12 Sean M. O’Neill, MD, PhD; Stanley K. Frencher, MD, MPH; Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon); and David R. Flum, MD, MPH, FACS

Frank R. Lewis, Jr., MD, FACS: 15 years of visionary leadership at the American Board of Surgery 24 Lena Napolitano, MD, FACS, FCCP, FCCM; Anne Rizzo, MD, FACS; and Christine Shiffer, MBA

A history of health information technology and the future of interoperability 29 Mark Lukaszewski

Nursing workforce in surgery and trauma care delivery: A global call to action 34 | 1 Gregory L. Peck, DO, FACS; Jessica Badillo, MSN, RN; Margot Consuelo Burbano, MSN, Enf. Esp.; Isabelle Citron, MD, BM BCh; Cristiane de Alencar Domigues, PhD, RN; Richard W. Lang III; Lisa A. Falcón, MSN, RN, TCRN, NE-BC; Kathleen Martin, MSN, RN; Sol Angelica Muñiz, MSN, RN, FN; Timothy Murphy, MSN, RN, ACNP-BC, TCRN, CEN, FAEN; Nobhojit Roy, MD, PhD; and Suzanne Willard, PhD, APN, FAAN

RAS-ACS Symposium essays: Residents debate the future of leadership in surgery 43 Naveen F. Sangji, MD, MPH

Reframing surgical leadership in 2017: Surgeon-scientist or surgeon-advocate? Surgeon-scientist 44 Kunal Jatin Patel, MD

Reframing surgical leadership in 2017: Surgeon-scientist or surgeon-advocate? Surgeon-advocate 46 Neeraja Nagarajan, MD, MPH

NOV 2017 BULLETIN American College of Surgeons Contents continued

COLUMNS NEWS Citation for Prof. Clare L. Marx, CBE, DL, MB, BS, FRCS 80 Looking forward 10 Barbara Lee Bass, MD, FACS, Hilary A. Sanfey, MB, BCh, MHPE, FRCS(Hon), installed as 98th David B. Hoyt, MD, FACS FACS, FRCSI ACS President 63 What surgeons should know about... Citation for Prof. Orgoi Sergelen, The New Medicare Card Project 49 Dr. Mary Edwards Walker Award presented to Dr. Kuy 67 MD, PhD, FACS 81 Lauren Foe, MPH, and Raymond R. Price, MD, FACS Sadhana Chalasani Honorary Fellowship in the ACS awarded to 10 prominent Citation for Prof. Fu-Chan Wei, MD 82 ACS NSQIP best practices case surgeons 69 Kant Y. Lin, MD, FACS studies: Quality improvement in imaging strategies for pediatric Citation for Prof. Patrick J. Broe, Call for nominations for the ACS appendicitis 51 MCh, FRCSI, FRCSEd(Hon) 73 Board of Regents and ACS Officers- Ilan I. Maizlin, MD, MSPH; A. Brent Eastman, MD, FACS, Elect 83 Michelle C. Shroyer, MPH; FRCSI(Hon), FRCSEd(Hon) ACS accepting 2018 Jacobson Tal Koppelmann, MD; and Robert Citation for Prof. Miguel A. Promising Investigator Award T. Russell, MD, MPH, FACS Cainzos, MD, PhD, FACS 74 applications 84 ACS Clinical Research Program: Mark Malangoni, MD, FACS Making quality stick: Optimal 2 | Induction chemotherapy and Citation for Prof. Francisco J. F. Resources for Surgical Quality minimally invasive transanal Castro Sousa, MD, FACS 75 and Safety: The SQO and review surgery to increase organ processes: Keys to staying Enrique Moreno González, MD, preservation in rectal cancer 55 on track 86 FACS(Hon) Hagen Kennecke, MD, MHA, Coming next month in JACS and FRCPC; Y. Nancy You, MD, MHSc, Citation for Prof. Renzo Dionigi, MD, online now 86 FACS, FRCSEd(Hon), ASA(Hon) 76 FACS; and Judy C. Boughey, MD, Associate Fellows: Apply now for FACS L. D. Britt, MD, MPH, DSc(Hon), ACS Fellowship 87 FACS, FCCM, FRCSEng(Hon), From the Archives: President FRCSEd(Hon), FWACS(Hon), Eisenhower and his bowel SCHOLARSHIPS FRCSI(Hon), FCS(SA)(Hon), obstruction 57 FRCSGlasg(Hon) Traveling Fellow to Japan reports Justin Barr, MD, PhD, and on experience 88 Citation for Prof. Juan Hepp, MD, Theodore N. Pappas, MD, FACS Elizabeth C. Wick, MD, FACS FACS 77 A look at The Joint Commission: Patricia J. Numann, MD, FACS Joint Commission details new pain MEETINGS CALENDAR Citation for Prof. Valerie J. Lund, assessment, management standards Calendar of events 92 in R3 Report 59 CBE, MB, BS, FRCS, FRCSEd 78 Carlos A. Pellegrini, MD, Gerald B. Healy, MD, FACS, FACS, FRCSI(Hon), FRCS(Hon), FRCS(Hon), FRCSI(Hon) FRCSEd(Hon) Citation for Prof. Masatoshi NTDB data points: Distraction: Makuuchi, MD, PhD 79 Driving and cell phone use 61 Junji Machi, MD, PhD, FACS Richard J. Fantus, MD, FACS

V102 No 11 BULLETIN American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient Join the and to safeguarding standards of care in an optimal and ethical practice environment. conversation.

EDITOR-IN-CHIEF Letters to the Editor Diane Schneidman should be sent ACS Communities allow you with the writer’s to tap into the College’s collective DIRECTOR, DIVISION OF name, address, INTEGRATED COMMUNICATIONS e-mail address, and knowledge anytime, anywhere, Lynn Kahn daytime telephone and on any device. SENIOR GRAPHIC DESIGNER/ number via e-mail to PRODUCTION MANAGER dschneidman@facs. Tina Woelke org, or via mail to Diane S. Schneidman, SENIOR EDITOR Editor-in-Chief, Tony Peregrin Bulletin, American Upload and access NEWS EDITOR College of Surgeons, Matthew Fox 633 N. Saint Clair St., documents, photos, Chicago, IL 60611. EDITORIAL AND PRODUCTION Letters may be edited and videos ASSISTANT for length or clarity. Kira Plotts Permission to publish letters is assumed EDITORIAL ADVISORS unless the author Find and Charles D. Mabry, MD, FACS indicates otherwise. Leigh A. Neumayer, MD, FACS connect with your Marshall Z. Schwartz, MD, FACS colleagues Mark C. Weissler, MD, FACS

FRONT COVER DESIGN Tina Woelke Engage with the experts Bulletin of the American College of Surgeons (ISSN 0002-8045) is Participate in published monthly by the American College of Surgeons, 633 N. discussions relevant Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, to your specific Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional interests mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ acscommunities.facs.org personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. ©2017 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.

2017_CO_Ad_Communities_Halfpage_v02.indd 1 8/9/2017 10:06:56 AM Officers and Staff of the American College of Surgeons

Timothy J. Eberlein, MD, FACS Nicole S. Gibran, MD, FACS Patrick V. Bailey, MD, FACS Officers St. Louis, MO Seattle, WA Medical Director, Advocacy James K. Elsey, MD, FACS S. Robert Todd, MD, FACS, FCCM Christian Shalgian Courtney M. Townsend, Atlanta, GA Houston, TX Director Jr., MD, FACS Galveston, TX Henri R. Ford, MD, FACS AMERICAN COLLEGE OF PRESIDENT Los Angeles, CA Advisory Council SURGEONS FOUNDATION J. David Richardson, MD, FACS Gerald M. Fried, MD, FACS, FRCSC Shane Hollett Louisville, KY Montreal, QC to the Board Executive Director IMMEDIATE PAST-PRESIDENT James W. Gigantelli, MD, FACS of Regents ALLIANCE/AMERICAN Hilary A. Sanfey, MB, Omaha, NE COLLEGE OF SURGEONS (Past-Presidents) CLINICAL RESEARCH PROGRAM BCh, MHPE, FACS B. J. Hancock, MD, FACS, FRCSC Kelly K. Hunt, MD, FACS Springfield, IL Winnipeg, MB Kathryn D. Anderson, MD, FACS Chair FIRST VICE-PRESIDENT Eastvale, CA Enrique Hernandez, MD, FACS Mary C. McCarthy, MD, FACS CONVENTION AND MEETINGS Philadelphia, PA W. Gerald Austen, MD, FACS Robert Hope Dayton, OH Boston, MA SECOND VICE-PRESIDENT Lenworth M. Jacobs, Jr., MD, FACS Director L. D. Britt, MD, MPH, Edward E. Cornwell III, Hartford, CT DIVISION OF EDUCATION FACS, FCCM Ajit K. Sachdeva, MD, MD, FACS, FCCM L. Scott Levin, MD, FACS Norfolk, VA Washington, DC Philadelphia, PA FACS, FRCSC SECRETARY John L. Cameron, MD, FACS Director Mark A. Malangoni, MD, FACS Baltimore, MD William G. Cioffi, Jr., MD, FACS Philadelphia, PA EXECUTIVE SERVICES Providence, RI Edward M. Copeland III, MD, FACS Maxine Rogers TREASURER Fabrizio Michelassi, MD, FACS Gainesville, FL New York, NY Director, Leadership Operations David B. Hoyt, MD, FACS A. Brent Eastman, MD, FACS FINANCE AND FACILITIES Chicago, IL Linda G. Phillips, MD, FACS Rancho Santa Fe, CA Galveston, TX Gay L. Vincent, CPA 4 | EXECUTIVE DIRECTOR Gerald B. Healy, MD, FACS Director Gay L. Vincent, CPA Valerie W. Rusch, MD, FACS Wellesley, MA New York, NY HUMAN RESOURCES Chicago, IL AND OPERATIONS CHIEF FINANCIAL OFFICER R. Scott Jones, MD, FACS Marshall Z. Schwartz, MD, FACS Charlottesville, VA Michelle McGovern Philadelphia, PA Edward R. Laws, MD, FACS Director Anton N. Sidawy, MD, FACS Boston, MA INFORMATION TECHNOLOGY Officers-Elect Washington, DC LaSalle D. Leffall, Jr., MD, FACS Brian Harper (take office October 2017) Beth H. Sutton, MD, FACS Washington, DC Director Wichita Falls, TX Barbara L. Bass, MD, FACS LaMar S. McGinnis, Jr., MD, FACS DIVISION OF INTEGRATED Houston, TX Courtney M. Townsend, Jr., Atlanta, GA COMMUNICATIONS PRESIDENT-ELECT MD, FACS Lynn Kahn Galveston, TX David G. Murray, MD, FACS Director Charles D. Mabry, MD, FACS Syracuse, NY Pine Bluff, AR Steven D. Wexner, MD, FACS JOURNAL OF THE AMERICAN FIRST VICE-PRESIDENT-ELECT Weston, FL Patricia J. Numann, MD, FACS COLLEGE OF SURGEONS Syracuse, NY Timothy J. Eberlein, MD, FACS Basil A. Pruitt, Jr., MD, Editor-in-Chief FACS, FCCM, MCCM Carlos A. Pellegrini, MD, FACS San Antonio, TX Board of Seattle, WA DIVISION OF MEMBER SERVICES SECOND VICE-PRESIDENT-ELECT Richard R. Sabo, MD, FACS Patricia L. Turner, MD, FACS Governors/ Bozeman, MT Director Executive Seymour I. Schwartz, MD, FACS M. Margaret Knudson, MD, FACS Board of Regents Rochester, NY Medical Director, Military Health Committee Systems Strategic Partnership Michael J. Zinner, MD, FACS Diana L. Farmer, MD, Frank C. Spencer, MD, FACS Miami, FL New York, NY Girma Tefera, MD, FACS FACS, FRCS Director, Operation Giving Back CHAIR Sacramento, CA Andrew L. Warshaw, MD, FACS Leigh A. Neumayer, MD, FACS CHAIR Boston, MA PERFORMANCE IMPROVEMENT Tucson, AZ Steven C. Stain, MD, FACS Will Chapleau, RN, EMT-P VICE-CHAIR Albany, NY Director Anthony Atala, MD, FACS VICE-CHAIR Executive Staff DIVISION OF RESEARCH AND Winston-Salem, NC OPTIMAL PATIENT CARE Susan K. Mosier, MD, MBA, FACS EXECUTIVE DIRECTOR Lawrence, KS Clifford Y. Ko, MD, John L. D. Atkinson, MD, FACS David B. Hoyt, MD, FACS MS, MSHS, FACS Rochester, MN SECRETARY DIVISION OF ADVOCACY Director James C. Denneny III, MD, FACS Daniel L. Dent, MD, FACS AND HEALTH POLICY Alexandria, VA San Antonio, TX Frank G. Opelka, MD, FACS David P. Winchester, MD, FACS Medical Director, Cancer Margaret M. Dunn, MD, FACS Francis D. Ferdinand, MD, FACS Medical Director, Quality Dayton, OH Wynnewood, PA and Health Policy Michael F. Rotondo, MD, FACS Medical Director, Trauma

V102 No 11 BULLETIN American College of Surgeons Author bios*

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

a b c

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MRS. BADILLO (a) is a doctoral nursing MS. BURBANO (d) is associate DR. DOMIGUES (g) is bachelor of research student and graduate research professor and director of graduate nursing program coordinator, Faculdade assistant, Rutgers University, Newark, NJ. programs, School of Nursing, das Américas, São Paulo, Brazil; board Universidad del Valle, Cali, Colombia. member, Brazilian Committee on Trauma DR. BARR (not pictured) is a general and Panamerican Trauma Society; and surgery resident, Duke University MS. CHALASANI (e) is Regulatory regional director for Advanced Trauma Medical Center, Durham, NC. and Quality Affairs Coordinator, Care for Nurses in Latin America. ACS Division of Advocacy and DR. BOUGHEY (b) is professor of surgery Health Policy, Washington, DC. DR. EASTMAN (h) is former corporate and vice-chair, research, department senior vice-president and chief medical of surgery, Mayo Clinic, Rochester, DR. CITRON (f) is a surgical resident and officer, Scripps Health; N. Paul Whittier MN. She is Chair, American College of a Ronda Stryker and William Johnston Endowed Chair of Trauma, Scripps Memorial Surgeons Clinical Research Program Global Surgery Research Fellow, Program Hospital, La Jolla, CA; and clinical professor (ACS CRP) Education Committee. for Global Surgery and Social Change, of surgery-trauma, University of California, Harvard Medical School, Boston, MA. San Diego. He is a Past-President of the ACS. DR. BRITT (c) is the Henry Ford Professor and Edward J. Brickhouse Chairman, department of surgery, continued on next page Eastern Virginia Medical School, Norfolk. He is a Past-President of the ACS.

NOV 2017 BULLETIN American College of Surgeons Author bios continued

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MS. FALCÓN (i) is director, trauma MS. FOE (l) is Regulatory Associate, ACS DR. KENNECKE (o) is medical oncologist and injury prevention, and trauma Division of Advocacy and Health Policy. and medical director, The Virginia Mason program manager, Level I Trauma Cancer Institute, Seattle, and associate Center, Robert Wood Johnson University DR. FRENCHER (m) is medical director, professor of medicine, University of Hospital, New Brunswick, NJ. surgical quality, Martin Luther King, British Columbia, Vancouver. He is Jr. Community Hospital, and assistant recto-anal subcommittee chair, Canadian DR. FANTUS (j) is vice-chairman, professor, department of urology, Cancer Trials Group–Gastrointestinal department of surgery; medical director, University of California, Los Angeles. Disease Site Committee. trauma services; and chief, section of surgical critical care, Advocate Illinois Masonic DR. HEALY (n) is Emeritus Gerald B. DR. KOPPELMANN (p) is pediatric Medical Center. He is clinical professor of Healy Chair in Otolaryngology, Children’s endoscopic and minimally invasive surgery, University of Illinois College of Hospital, Boston; professor of otology and surgery fellow, Children’s of Alabama, Medicine, Chicago, and Past-Chair, ad hoc laryngology, Harvard Medical School; University of Alabama at Birmingham. Trauma Registry Advisory Committee, and member, Board of Directors, Council ACS Committee on Trauma (COT). on Surgical and Perioperative Safety. MR. LANG (q) is a medical student, Rutgers He is a Past-President of the ACS. Robert Wood Johnson Medical School. DR. FLUM (k) is associate chief medical officer, UW Medicine, and associate chair for research, UW department of surgery, continued on next page University of Washington, Seattle.

V102 No 11 BULLETIN American College of Surgeons Author bios continued

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DR. LIN (r) is professor and chief, DR. MALANGONI (v) is associate executive MS. MUÑIZ (y) is a Minority Biomedical division of plastic surgery, University director, American Board of Surgery (ABS). Research Support Scholar-doctoral nursing of Kentucky, Lexington. research student, and global trauma MS. MARTIN (w) is trauma program nurse coordinator, department of global MR. LUKASZEWSKI (s) is manager, Lankenau Medical Center, health nursing, Rutgers University. Congressional Lobbyist, ACS Division Wynnewood, PA, and chair, Society of Advocacy and Health Policy. of Trauma Nurses, International MR. MURPHY (z) is trauma performance Trauma Outcomes Performance improvement coordinator, Robert DR. MACHI (t) is professor of surgery and Improvement Course Subcommittee. Wood Johnson University Hospital. assistant director, Office of Global Health & Medicine, John A. Burns School of Medicine, DR. MORENO GONZALEZ (x) is emeritus DR. NAGARAJAN (aa) is a postgraduate University of Hawaii, Honolulu. He is a professor of surgery; and director, department year (PGY)-2 surgery resident, Brigham founder of the JrSr Corporation, Tokyo, Japan. of oncology, hepato-bilio-pancreatic surgery, and Women’s Hospital, Boston, MA. and organ transplantation, Complutense DR. MAIZLIN (u) is pediatric surgery University, Madrid, Spain. He is a member continued on next page research fellow, Children’s of Alabama, of the Royal Academy of Medicine of Spain. University of Alabama at Birmingham.

NOV 2017 BULLETIN American College of Surgeons Author bios continued

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DR. NAPOLITANO (bb) is director, DR. PAPPAS (ee) is vice-dean, medical DR. PRICE (ii) is clinical professor, trauma and surgical critical care, and affairs, and professor of surgery, department of surgery; director, Center for professor of surgery, University of Duke University Medical Center. Global Surgery; adjunct associate professor, Michigan Health System, Ann Arbor. division of public health, department of She is a past-director of the ABS and DR. PATEL (ff) is a PGY-3 research family and preventive medicine, University Past-Chair, ACS Board of Governors. fellow, Medical University of of Utah, Salt Lake City; and director, South Carolina, Charleston. graduate surgical education, Intermountain DR. NUMANN (cc) is Lloyd S. Rogers DR. PECK Medical Center, Intermountain Healthcare, Professor of Surgery Emeritus, Upstate (gg) is assistant professor of Salt Lake City. He serves on the ACS Medical University, Syracuse, NY, and State surgery, division of acute care surgery, International Relations Committee, and University of New York Distinguished Rutgers Robert Wood Johnson Medical is Vice-Chair, International Advocacy Teaching Professor Emeritus. She School. He is a member, ACS Young Committee, Operation Giving Back. is a Past-President of the ACS. Fellows Association and Education Workgroup, the Panamerican Trauma DR. RIZZO (jj) is a trauma and critical DR. O’NEILL (dd) is Veterans Affairs (VA)/ Society Trauma Systems Committee, and care surgeon, Inova Fairfax Hospital, Falls Robert Wood Johnson Foundation Clinical Co-Chair, Indicators Working Group. Church, VA; professor of surgery, Uniformed Scholar, VA Health Services Research DR. PELLEGRINI Services University of the Health Sciences, and Development Center for the Study of (hh) is chief medical Bethesda, MD; and director, ABS. Healthcare Innovation, Implementation officer, UW Medicine, and vice-president for and Policy, and general surgery resident, medical affairs, University of Washington, University of California, Los Angeles. Seattle. He is a Past-President of the ACS. continued on next page

V102 No 11 BULLETIN American College of Surgeons Author bios continued

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DR. ROY (kk) is head of the World DR. SANGJI (nn) is a surgical critical DR. WILLARD (rr) is associate dean Health Organization Collaborating care fellow, Massachusetts General of global health and clinical professor, Center for Research in Surgical Care Hospital, Boston, and Chair, Resident Rutgers School of Nursing, Newark. Delivery in Low and Middle Income and Associate Society of the ACS Countries, Mumbai, India, and a Lancet Advocacy and Issues Committee. DR. YOU (ss) is associate professor, Commissioner of Global Surgery. section of colorectal surgery, department MS. SHIFFER (oo) is director, of surgical oncology, medical director, DR. RUSSELL (ll) is assistant professor communications and public affairs, ABS. Familial High-Risk Gastrointestinal of surgery, Children’s of Alabama. Cancer Clinic, University of Texas MD MS. SHROYER (pp) is a research associate Anderson Cancer Center. She is Vice- DR. SANFEY (mm) is professor of for pediatric surgery, Children’s of Alabama. Chair, ACS CRP Education Committee. surgery and vice-chair, educational affairs, department of surgery; and associate DR. WICK (qq) is associate professor of director, Academy for Scholarship and surgery, University of California, San Education, Southern Illinois School of Francisco, and co-principal investigator, Medicine, Springfield. She is Immediate Agency for Healthcare Research and Past First Vice-President of the ACS. Quality Safety Program for Improving Surgical Care and Recovery.

NOV 2017 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

ew topics are more controversial today than for every for $1 spent on health care, about 55 cents is health care reform. An individual’s feeling about spent on social services.3 Fhow to fund health care and whether health care In addition, we tax approximately 18 percent of the is a right or a privilege is generally rooted in a com- GDP. Medicare, Social Security, and interest on con- bination of philosophic, political, and moral values. sumer debt accounts for a total of 16 percent of taxes And while most Americans would agree that reining on GDP—meaning 2 percent in taxes is left for educa- in health care spending is a worthy goal, these per- tion and other social welfare programs. 3 sonal beliefs affect our perspective regarding the best approach to achieving this aim. They add an emo- tional element to an issue that truly is an economic Health care reform proposals problem. Health care financing has been at the heart of every major effort to reform the nation’s health care system, and it remains the case in the most recent debate over the The economics of health care future of the Affordable Care Act (ACA). The increase So, what are some key facts about the economics of in Medicaid spending and the decline in the number health care? First, according to the Centers for Medi- of Americans who are uninsured noted previously are care & Medicaid Services (CMS), national health care both attributable to the implementation of the ACA, 10 | expenses grew 5.8 percent to $3.2 trillion in 2015—about which expanded access to care primarily by increas- $9,990 per person—and accounted for 17.8 percent of ing the affordability of individual/non-group health the gross domestic product (GDP). CMS projects that care plans and expanding Medicaid eligibility. How one health care spending will grow 1.2 percentage points feels about these developments, again, is traceable to faster than the GDP per year between 2015 to 2025. As a the individual’s philosophic, political, and moral beliefs. result, health care’s share of GDP spending is expected In fact, approaches to addressing the shortcomings in to rise to 19.9 percent by 2025.1 the ACA and health care reform in general are divided Medicare spending grew 4.5 percent in 2015, which along partisan lines. Approximately 85 percent of Demo- was a slight dip from the 4.8 percent growth in 2014. crats indicate that the government should have a role in Medicaid spending, however, has risen steeply in recent health care delivery and favor leaving the ACA largely years. More specifically, federal Medicaid expenditures intact or replacing the legislation with a single-payor sys- increased 12.6 percent in 2015.1 tem. Meanwhile, 65 percent of Republicans state that The number of uninsured individuals has dropped government should not have a significant role in health dramatically since the advent of Medicare and Medic- care, and the Republican-controlled Congress and White aid. In 1963, 23.4 percent of Americans were uninsured. House have sought to repeal and replace the ACA.4 That percentage dropped to approximately 10 or 11 per- Republican proposals to replace the ACA tend to fo- cent after Medicare and Medicaid were instituted.2 That cus on cutting taxes and reducing health care spending. number rose to about 16 percent in 2010 and dropped Initial efforts called for cutting Medicare and Medicaid to approximately 9 percent in 2015. spending, as well as subsidies for individual insurance Despite all the money funneled into health care and plans. More recent efforts would shift all the cuts to Med- the expanded availability of health insurance coverage, icaid and to subsidies. For example, the Senate version of some individuals argue that patients in other devel- the American Health Care Act (AHCA) would eliminate oped countries experience better outcomes with less the ACA’s marketplace subsidies and enhanced matching spending per capita. However, this argument does not rate for the Medicaid expansion and replace them with a capture the full spending picture. In other economi- block grant. This legislation also would convert Medic- cally developed countries, for every $1 spent on health aid’s federal-state financial partnership to a per capita cap care, about $2 is spent on social services. In the U.S., and allow states to waive the ACA’s prohibition against

V102 No 11 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Health care financing has been at the heart of every major effort to reform the nation’s health care system, and it remains the case in the most recent debate over the future of the ACA.

charging higher premiums for individuals with preexisting conditions. It also REFERENCES would eliminate the controversial individual mandate that requires all Ameri- 1. Centers for Medicare & cans to either purchase health insurance or pay a penalty. Medicaid Services. NHE Fact Sheet. Available at: www.cms.gov/research- statistics-data-and-systems/ Expanding access while controlling cost statistics-trends-and-reports/ So the question now comes down to, are we going to dismantle the ACA and nationalhealthexpenddata/ get tax relief, or are we going to move further in the direction of universal nhe-fact-sheet.html. Accessed coverage? And, if we move to expand access, how are we going to pay for it? September 27, 2017. The good news is that some health policy experts argue that the U.S. could 2. Obama B. United States health care reform progress to date and pay for expanded coverage by eliminating waste. Former CMS Administrator next steps. JAMA. 2016;316(5):525- Don Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil, 532. for example, contend that the following forms of waste account for at least 3. Bradley EH, Taylor LA. The 21 percent of U.S. health care spending:5 American Healthcare Paradox: Why Spending More Is Getting Us Less. New York, NY: Public Affairs, • Failures of care delivery 2013. • Failures of coordinated care 4. Bialik K. More Americans say • Overtreatment government should ensure | 11 • Administrative complexity health care coverage. FactTank: • Pricing failures News in the Numbers. Available at: www.pewresearch.org/ • Fraud and abuse fact-tank/2017/01/13/more- americans-say-government- In the aggregate, elimination of these forms of waste would reduce health should-ensure-health-care- care spending by as much as $1.3 trillion annually. coverage/. Accessed October 2, Surgeons can contribute to waste reduction through excellent performance 2017. 5. Berwick DM, Hackbarth AD. and by questioning the pricing structures and for-profit approaches applied Eliminating waste in U.S. health in many of our institutions today. We can help policymakers develop alter- care. JAMA. 2012;307(14):1513- native payment methodologies and commit to providing value-based care. 1516. These are challenging times, and the American College of Surgeons has 6. American College of Surgeons. voiced its concerns about the potential effects of the AHCA on patient ac- Letter to Sens. Mitch McConnell and Charles Schumer. Available cess to high-quality and safe surgical services and is committed to helping at: www.facs.org/~/media/ surgeons engage in the quality improvement activities and the educational files/advocacy/federal/acs%20 programs they need to provide high-quality, cost-effective care.6 Our com- grahamcassidy%20hr%20 mitment to improving efficiency and reducing waste will help to establish 1628%20092217.ashx. Accessed the economic platform on which it will be possible to expand access to care September 28, 2017. for all Americans. We assume this responsibility as advocates for each of our patients and for our profession. ♦

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at look- [email protected].

NOV 2017 BULLETIN American College of Surgeons AMBULATORY SURGERY CENTERS

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Should your health care system invest in an ambulatory surgery center? A decision-making framework

by Sean M. O’Neill, MD, PhD; Stanley K. Frencher, MD, MPH; Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCSEd(Hon), FRCS(Hon); and David R. Flum, MD, MPH, FACS

V102 No 11 BULLETIN American College of Surgeons AMBULATORY SURGERY CENTERS

HIGHLIGHTS mbulatory surgery centers (ASCs) offer the opportu- nity for surgeons to perform specific procedures more • Looks at the factors that may favor Aefficiently and conveniently than they can in hospital- health system investment in an ASC, based operating rooms (ORs). Consequently, health care including lower operating costs, increased systems are increasingly interested in ASCs as a strategic market share and footprint, increased option for delivering surgical services. Although the long- patient satisfaction, and improved term value proposition of a more efficient cost structure capacity to serve community needs might appear compelling to individual health care systems, • Describes factors that may make ASC the decision to add an ASC must be made wisely based on investment less favorable, including local circumstances. lower revenue in the short term, This article is intended for surgeon leaders and hospital upfront cost requirements, case executives who are considering building or buying an ASC, volume thresholds, and specific market and provides a framework for assessing such an ASC invest- conditions that may constrain choices ment opportunity. The authors examine why a health care • Outlines the initial steps that should be system should consider investing in an ASC and when to taken in the decision-making process, avoid such an investment. This article describes fundamental including examining outpatient case investment options and offers a practical guide for establish- | 13 volume, assessing reimbursement trends, ing the viability of a health care system’s ASC opportunities. and developing an investment cost break- As with any major health care investment, numerous finan- even period based on these projections cial, legal, and regulatory intricacies are involved in fully realizing an ASC from start to finish. This article will help health care system leaders, particularly surgeons, perform the initial assessment necessary to guide ASC investment decision making.

Trends in ambulatory surgery An ASC is a freestanding facility that “operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, and in which the expected duration of services would not exceed 24 hours following an admis- sion.”1 Conversely, hospital ORs provide surgical services to both inpatients and outpatients who may require hospitaliza- tion and for whom the duration of services may exceed 24 hours. Nearly half of all operations performed in U.S. hospitals and ASCs are provided on an ambulatory basis.2,3 Surgical techniques, payment models, and regulations have evolved as this ambulatory surgery model has become more established.4-6 Reimbursement rates for facility fees reflect hospitals’ higher overhead costs, and are typically higher—up to 40–70 percent higher—for hospital-based surgery than for procedures performed in ASCs.7 Recent estimates suggest that more than half of all outpatient procedures occur in hospital

NOV 2017 BULLETIN American College of Surgeons AMBULATORY SURGERY CENTERS

FIGURE 1. ASC MARKET SHARE BY PROCEDURE TYPE (RELATIVE TO HOSPITAL-BASED ORs) AND ASC ORs PER CAPITA, 2000–2009

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ORs, but up to 40 percent of these operations could Given their competing objectives, health care sys- safely be shifted to ASCs.8 ASC market share trends for tems and ASCs have had an affiliation characterized four common procedures in the Medicare population much more by competition and contentiousness than are outlined in Figure 1, this page. The long-term value by cooperation.10,11,14 This relationship has been chang- proposition for the overall health care system is com- ing, however, as health care systems increasingly turn pelling; such a shift from hospitals to ASCs could result to the ASC model.15,16 Investment options for health in a $25 billion savings to Medicare over 10 years.9 care systems include building a new ASC or acquir- At the local level, negotiating this shift is com- ing an existing one.17 Additionally, health care systems plicated and involves understanding the often can choose to invest as a solo venture or in partner- competing priorities of health care systems, ASCs, ship with outside investors, typically a physician group. surgeons, and patients. Independent ASCs and larger The U.S. has more than 5,000 ASCs, and more than 90 health care systems are frequently in direct compe- percent are at least partially owned by physicians or tition for surgical cases.9 Surgeons and patients can physician groups.18,19 As of 2007, only a small minority both exert influence over whether an equivalent pro- was partially (16 percent) or fully (3 percent) owned by cedure will be performed in a hospital or an ASC, hospitals, but by 2015, some estimates had the total at but little research is available to identify consistent 20–25 percent.17,19 preferences among either group. Convenience, habit, The settings in which future surgical care is pro- and familiarity likely play as strong a role as any other vided will continue to evolve, and both hospitals and factor. Financially, surgeon-investors with an interest ASCs will be part of that evolution. The role of surgeons in an ASC are strongly incentivized to drive cases to in this process is yet to be defined, but they are often their facility.4,10,11 Hospitals and health care systems at least partial investors in new ASCs. Non-investor cannot legally offer this financial incentive to non- surgeons may find they are being expected to perform investor surgeons.12,13 more outpatient cases in a nonhospital OR.

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Reasons to invest in an ASC research is available to confirm that patients do prefer A health care system might consider investing in an the ASC setting.20,23 ASC for various reasons, including those described in the following paragraphs. (For a brief overview of the Improved access to meet community needs advantages and disadvantages of investing, see Table 1, Health care systems are increasingly coming to view page 16.) local or regional population health as part of their core mission.24,25 For hospitals and health care systems that Improved cost structure comprise the health care safety net, meaning those with A growing body of published evidence shows that a high proportion of Medicaid and uninsured patients, low-risk surgical procedures can be performed more the care of vulnerable populations is even more central efficiently in ASCs than in hospitals.7,8,20 Because ASCs to the organizational mission.26 From this standpoint, are designed to deliver a narrow range of outpatient the efficiency gains that can be realized by an ASC rela- surgical services, they can be more efficient than hospi- tive to hospital-based care may allow a safety net health tals in several significant ways, such as room turnover care system with constrained resources to better serve and facility overhead costs, and have greater flexibility community needs. Traditional models have largely in terms of staffing.21 Because surgeons at ASCs often failed to eliminate disparities; albeit unproven, it is pos- perform the same types of cases repeatedly, ASCs only sible that the ASC model implemented in the safety net | 15 need to purchase a subset of the equipment and sup- would improve access to surgical care for vulnerable plies. If these repetitive cases are frequently performed populations.27-29 Revenue creation in this setting will in hospital-based ORs, a health care system may have a be a steep challenge, which is the primary reason very significant opportunity to improve their cost structure few safety net ASCs exist today. Additionally, coor- by shifting those cases to an ASC.17 dinating the multiple functions needed to efficiently execute ambulatory surgical care (for example, preop- Increased market share erative evaluation, transportation, pharmacy, follow-up When procedures that once took place in a hospital visits) with vulnerable populations may be more chal- are performed in an independently owned ASC, those lenging and require more investment relative to those cases represent a loss of market share for the health care with a high commercial payor mix. However, for a system, and the resulting revenue impact on the hos- system focused on population health, increasing access pital can be substantial.10,11,14 Therefore, when a health to and efficiency of care for its population at the cost care system invests in an ASC, it can gain back that lost of a financial loss in one business unit may be a worth- market share or head off potential threats from future while tradeoff. independent ASC competition.22

Increased patient convenience/satisfaction Reasons not to invest Aside from lower operating costs, an improved patient There are numerous reasons not to invest in an ASC, experience is often offered as a reason to shift cases including decreased revenue, upfront costs, case- from the hospital to an ASC. Improved patient satis- volume requirements, and hesitancy to switch to ASC faction can be attributed to variables such as greater care on the part of patients and providers (see Table 1). accessibility, more convenient parking, and quieter and less-confusing facilities. Compared with visiting a large Decreased revenue hospital full of acutely ill patients, an ASC may project Because hospital-based ORs can charge higher facility a more relaxed environment. The appeal of this image fees than ASCs for equivalent procedures, if a health is self-evident; interestingly, however, little published care system shifts those procedures out of the hospital

NOV 2017 BULLETIN American College of Surgeons AMBULATORY SURGERY CENTERS

TABLE 1. ADVANTAGES AND DISADVANTAGES OF INVESTING IN AN ASC

Advantages Disadvantages

Improved cost structure for equivalent procedures Decreased revenue for equivalent procedures

Increased market share Upfront investment/purchase costs

Improved patient experience Case volume threshold for financial sustainability

Surgeon/physician preference for ASC setting Surgeon/physician preference for hospital setting

Improved access to care for patients Limited opportunity due to regulations

Opportunity to “start clean” with innovations to improve Limited opportunity due to local market factors workflow, management, scheduling, staffing

and into an ASC, it will see an immediate drop in rev- Case volume requirement enue. This differential reimbursement has an uncertain Because ASCs have high fixed costs relative to marginal future, however. Some payors already refuse hospital- costs, the most important factor in achieving positive based facility charges for procedures that could be done financial margins is revenue.33 While contracts, reim- in an ASC.30 In the long run, trends that incentivize cost bursement rates, and payor mix can sometimes be reduction and value improvement are likely to become renegotiated to increase revenue, the primary strategy more, rather than less, common. For many health care that ASCs use to achieve optimal revenue is maximiz- 16 | systems, then, the question is not whether to buy or ing surgical case volume and throughput.9 Financial build an ASC, but when. stability thus depends almost entirely on reaching a Of note, prior to January 1, hospitals could actually minimum annual case volume threshold, and achiev- purchase an existing ASC and then convert it to “hos- ing it can be a challenge. pital-based” status, making it possible for hospitals to Higher margin procedures, such as orthopae- start charging higher facility fees despite lower over- dics, will have a relatively lower threshold, and lower head costs. This loophole, however, was eliminated margin procedures, such as ophthalmology, a higher with passage of the Bipartisan Budget Act of 2015.6,31 threshold. As a general rule, depending on the proce- Although the specifics of future health care regula- dure and payor mix, this margin is typically somewhere tion are uncertain, health care systems that are able between 2,000 and 4,000 cases annually for an average to deliver quality services in the most cost-effective, ASC with four ORs.9 If a health care system chooses to efficient, and patient-centered settings will be well- build a new ASC, increased volume has to come from positioned to thrive.8 a combination of its present hospital-based procedures and from new sources, such as additional surgeons Upfront costs or new referral networks. Hundreds of independent Construction or purchase prices for ASCs are often ASCs fail financially each year, and not achieving this in the single- to double-digit millions.32 Purchasing volume threshold is often the critical factor.34 Addi- land, contracting with physician groups and ASC tionally, when a health care system shifts procedures staff, and fulfilling licensing and regulatory require- from a hospital to an ASC, this reduction in hospi- ments also consume significant amounts of money tal-based procedures must be replaced to maintain and time. A pro forma financial analysis can produce financial margins. cost estimates for specific potential sites, plans, and opportunities. This step provides great clarity by Patient and surgeon choices grounding conceptual plans in reality. Not all health A health care system theoretically can shift all of its systems are financially strong enough to pursue an ASC-appropriate procedure volume out of hospital ASC opportunity; a joint venture may mitigate this ORs; however, in practice, this move rarely occurs due cost to some degree. to both patient and surgeon preferences. Typically, only

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40–60 percent of ASC-appropriate procedures end up these factors may impair the ASC’s ability to realize shifting to a new ASC. an optimal cost structure. As part of a recent study comparing the cost of care for identical procedures performed in different settings, patients were allowed to independently choose a hos- Assessing investment options pital or ASC for outpatient orthopaedic surgery, based In general, health care systems have two fundamental on availability and convenience. As a result, 63 percent investment options—build or buy. The investment of all procedures (854 of 1,365) wound up being per- can be pursued as a solo venture, or as a partnership formed in the hospital, meaning only a minority of with an outside investor group, typically a group of patients opted for the ASC when given a choice.20 As physicians. Table 2, page 18, summarizes the advan- noted previously, little research into patient preferences tages and disadvantages of each option. has been conducted, but it is safe to assume that not To navigate these complex influences in a practi- every patient will opt for an ASC if given the choice. cal way, the following framework can guide a health Likewise, surgeons may prefer to schedule pro- system in systematically considering the most salient cedures in the hospital, whether for convenience, issues in an ASC investment decision (see Table 3, habit, or a sense of security. Depending on the loca- page 19). The entire exercise may not need to be com- tion, placing an ASC in a geographically separate site pleted before a clear recommendation is apparent, | 17 may significantly affect a surgeon’s daily or weekly but proceeding through the entire set of questions workflow. If a new ASC is inconvenient for physi- can be helpful in understanding a health system’s cians, forcing them to schedule procedures at this unique circumstances and limitations with respect facility will prove to be a leadership challenge. How- to ASC investment. ever, mutually satisfactory arrangements can often be achieved, such as locating an ASC near surgeons’ Examine ASC-appropriate case volume clinics or offices. Eliminating logistical barriers will First, determine the number of ambulatory procedures improve the chances of successfully shifting proce- performed annually in the health system and examine dures from the hospital to the ASC. trends over the past five years. Determine what frac- Additionally, surgeons who have practiced their tion of those procedures are ASC-appropriate. Which entire career in a tertiary care setting may be uncom- ones could safely be performed in the ASC setting? fortable operating without immediate higher-level Remembering that typically only 50 percent of these backup, even if the likelihood of needing it is very procedures are successfully shifted to an ASC, cut the low. Anesthesiologists, for example, have developed total number of ASC-appropriate procedures in half contingency plans for rare and catastrophic compli- to arrive at an initial estimate of internally generated cations.35 Although many surgeons are early adopters case volume. of new innovations, even relatively minor changes in If the total is more than 4,000–5,000 cases, pro- practice can be challenging to implement.36,37 Finally, cedure volume is likely to be less of a concern. If the the lower costs of an ASC may not be fully realized total is between 2,000 and 4,000 cases, achieving the if surgeons practice in exactly the same way. In com- threshold to maintain a positive financial margin will parison with hospital ORs, ASCs have more efficient likely require adding new sources of volume to the cost structures derived from streamlined supply pur- system, either through additional physicians or refer- chasing, faster case length and turnover, and typically ral networks. If the total is below 2,000, achieving the limited focus on resident education. Surgeons who volume threshold may prove challenging. The precise come from a tertiary care environment and do not threshold will depend on procedure and payor mix, alter their practices and preferences to accommodate however. In any case, a health system should have a

NOV 2017 BULLETIN American College of Surgeons AMBULATORY SURGERY CENTERS

TABLE 2. ADVANTAGES AND DISADVANTAGES OF DIFFERENT INVESTMENT AND PARTNERSHIP TYPES

Investment type Advantages Disadvantages

Build new ASC • Choice of location • Certificate of need requirements • Choice of physicians may limit options • Choice of referral network • Process can be prolonged (from decision to opening typically at least 18 months • Choice of building design, layout, features for the smallest, simplest ASCs) • Must acquire land • Architecture, construction, licensing costs

Purchase • Faster than building • Facilities and locations are limited to existing ASC • May avoid certain regulatory the existing ASCs in the local market requirements and processes • May have limited ability to redesign facilities • May have a baseline level of referrals and cases • May have limited ability to change that are independent of the health system existing routines and workflows • May need to retain current physicians and staff

Partnership type Advantages Disadvantages

Solo venture • Full management control (strategy, • Fully bear downside financial risk marketing, location, case selection, • Health system surgeons may have no purchasing, staffing, recruitment) 18 | incentive to shift practice to ASC setting • No profit-sharing • Does not require finding a joint venture partner group

Joint venture • May reduce initial investment cost • Management decisions must be negotiated/settled with partners • Partially mitigates downside financial risk • Profits shared with partners • If joint venture partners are physicians, they will be incentivized to shift case volume to the ASC • Options for partnership groups limited by market conditions • Health system brand can be valuable to partners, may help facilitate favorable agreements

high degree of confidence in these projections when these numbers will provide a realistic range of rev- moving forward with an investment decision. enue expectations.

Examine current reimbursement levels and trends Assess barriers to shifting cases For these ASC-appropriate cases, calculate average from hospitals to ASCs reimbursement given the procedure and payor mix. Surveying the surgeons who will be practicing in It will be necessary to adjust current reimburse- the proposed ASC can be done relatively quickly and ments by replacing hospital-based facility fees with inexpensively, and is critically important. Making a lower, ASC-level facility fees. Examine trends from large investment decision without knowing what payors over the last five years and develop a sense of the surgical staff expect can be very risky. Given the the volatility in reimbursement rates and likelihood preferences of the health care system’s surgeons, how of significant changes in the future.17 Generating continued on page 20

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TABLE 3. DECISION-MAKING FRAMEWORK: SHOULD THIS HEALTH CARE SYSTEM INVEST IN AN AMBULATORY SURGERY CENTER?

Step Description Objectives/Deliverables

1. Estimate case Estimate ASC case volume Annual/quarterly estimates of ASC- volume • Obtain current volume for ASC- possible cases at current and future • Current possible cases, and divide in half volume, by specialty and procedure volume • Project future volume for ASC cases • Future based on internal trends, market projections trends, and acquisition options 2. Estimate Examine ASC case revenue Annual/quarterly estimates of ASC revenue • Current reimbursement for revenue, based on projected procedure procedure and payor mix mix, case volume, payor mix, reimbursement trends • Assess likelihood of changes for future reimbursement trends 3. Assess barriers Assess barriers to converting current hospital- • Results from survey of surgeons to achieving based outpatient surgery to the ASC setting expected to practice at the ASC case volume • Internal: Surgeon or patient preferences • Estimate of local market ambulatory • Internal • External: Degree of local market surgery capacity and volume • External saturation, applicable regulatory • Summary of applicable regulations limitations such as CON and salient limitations 4. Develop Explore local health care market to Enumerate specific alternatives with investment understand realistic options to: locations, expected barriers, and options projected procedure volume • Build: Locations and construction options | 19 • Buy: Existing ASCs, likelihood of acquisition • Solo: Financial resources and options • Partner: Potential investor groups 5. Obtain formal Develop financial projection(s) for: • Formal assessment of financial • ASC purchase options investment cost options projection • ASC construction options • Formal assessment of • Operating costs projected operating costs 6. Calculate Calculate expected average contribution Annual/quarterly estimates of CM expected margin (CM) • Aggregate average margin • Financial • By specialty and procedure • Consider community needs (identify strategic priorities) 7. Calculate Calculate: • Break-even case volume break-even • Time frame to break even • Break-even case volume* point • ROI over salient time (for • Time frame to break even† • ROI over fixed time‡ example, five years) 8. Synthesize Use findings to inform decision making Decision findings • Proceed: Decide investment type (purchase versus build) and partnership (solo versus joint venture) • Study further: Investigate areas in analysis with high uncertainty • Decline and reassess periodically

*Break-even = Total investment cost/average contribution margin per case †Time frame to break even = Break-even case volume/expected cases per month ‡ROI: Total revenue over fixed time period – total investment cost – total operating cost over fixed time period/ total investment cost – total operating cost over fixed time period

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REFERENCES many ASC-appropriate procedures can be expected 1. Code of Federal Regulations 416.2.B. Ambulatory Surgical to actually shift to the ASC? Survey and interview Services—Definitions. Available at www.ecfr.gov/cgi- questions should specifically identify any particular bin/text-idx?node=pt42.3.416&rgn=div5#se42.3.416_12. advantages or disadvantages unique to the health Accessed May 6, 2017. 2. Wier LM, Steiner CA, Owens PL. Surgeries in hospital- care system, assess opinions on any specific loca- owned outpatient facilities, 2012. Healthcare Cost and tions or facilities under consideration, and elicit as Utilization Project Statistical Brief #188. Rockville, honestly as possible the surgeons’ interest in practic- MD: Agency for Healthcare Research and Quality; ing in an ASC. The answers will help a health care February 2015. Available at: www.hcup-us.ahrq.gov/ system understand to what degree internal proce- reports/statbriefs/sb188-Surgeries-Hospital-Outpatient- Facilities-2012.jsp. Accessed September 14, 2017. dure volume can supply an ASC, and to what degree 3. Weiss AJ, Elixhauser A, Andrews RM. Characteristics procedure volume will need to be augmented by of operating room procedures in U.S. hospitals, 2011. new sources. Healthcare Cost and Utilization Project Statistical Brief Local health care market factors, including #170. Rockville, MD: Agency for Healthcare Research and total case volume at competing institutions and Quality; February 2014. Available at: www.hcup-us.ahrq. regulatory requirements, may present barriers to 20 | gov/reports/statbriefs/sb170-Operating-Room-Procedures- United-States-2011.pdf. Accessed September 28, 2017. successfully realizing an ASC. For each institution 4. Casalino LP, Devers KJ, Brewster LR. Focused factories? in the local market, obtain estimates of annual case Physician-owned specialty facilities. Health Aff (Millwood). volume and breakdown by specialty and location 2003;22(6):56-67. (hospital versus ASC). Although many counties 5. Plummer E, Wempe W. The Affordable Care Act’s effects on 22 the formation, expansion, and operation of physician-owned in the U.S. have ASCs, some have relatively few. hospitals. Health Aff (Millwood). 2016;35(8):1452-1460. Assessing the degree of market oversaturation will 6. Dentler J. Impact of Budget Act on ASC to HOPD influence decision making. conversions: Four FAQs. Becker’s ASC Review. November 19, After assessing the local health care market, 2015. Available at: www.beckersasc.com/asc-transactions- obtain a basic understanding of state regulatory and-valuation-issues/impact-of-budget-act-on-asc-to-hopd- conversions-4-faqs.html. Accessed March 6, 2017. requirements. Certificate of need requirements exist 7. Mitchell JM, Carey K. A comparison of ambulatory surgery in 34 states, which can limit ASC growth in satu- center production costs and Medicare payments: Evidence rated markets.38 However, loopholes and exceptions on colonoscopy and endoscopy. Med Care. 2016;54(2):126-132. can often be found.39 8. Erhun F, Malcolm E, Kalani M, et al. Opportunities to improve the value of outpatient surgical care. Am J Manag Develop options for acquisition and partnership Care. 2016;22(9):e329-335. 9. Establishing an ambulatory surgery center: A primer from The opportunities available for building or purchas- A to Z. Becker’s ASC Review. March 12, 2008. Available at: ing an ASC, as well as proceeding as a solo or joint www.beckersasc.com/news-analysis/establishing-an- venture, will depend on the circumstances of the ambulatory-surgery-center-a-primer-from-a-to-z.html. local health care market. Each option should be Accessed March 6, 2017. 10. Lynk WJ, Longley CS. The effect of physician-owned explored and developed with realistic, specific alter- surgicenters on hospital outpatient surgery. Health Aff natives enumerated. Generally speaking, if a health (Millwood). 2002;21(4):215-221. care system is in a relatively ASC-dense market, 11. Kahn CN. Intolerable risk, irreparable harm: The legacy of acquiring one or several ASCs will likely be a realistic physician-owned specialty hospitals. Health Aff (Millwood). option. Land acquisition costs will vary by market. 2006;25(1):130-133. Co-investment partners may be groups of local sur- continued on next page geons, or even national ASC firms.40 Keep in mind that if the health care system’s brand is strong locally

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(such as an academic medical center), it may have REFERENCES, CONTINUED a competitive advantage in bidding for ASC acqui- 12. U.S. Department of Health and Human Services. Office of sition targets.15 Inspector General. A roadmap for new physicians: Fraud and abuse laws. Available at: https://oig.hhs.gov/compliance/ Obtain a financial projection physician-education/01laws.asp. Accessed March 9, 2017. 13. Department of Health and Human Services, Office of Formally develop upfront cost estimates for all Inspector General. 42 CFR Part 1001: Medicare and state of the options described in this article—specific health care programs: Fraud and abuse; clarification of alternatives for building versus buying and solo the initial OIG safe harbor provisions and establishment investment versus partnership. Generate estimates of additional safe harbor provisions under the anti- kickback statute; final rule. Federal Register. Vol 64, No. 223. of operating costs, which can often be adapted November 19, 1999. Available at: https://oig.hhs.gov/fraud/ from an existing local ASC cost structure. docs/safeharborregulations/getdoc1.pdf. Accessed March 7, 2017. Calculate contribution margin and break-even 14. Grant J. Specialty hospitals: Pro and Kahn. Health Aff Calculate the expected average revenue and (Millwood). 2006;25(3):880-881. Available at: http://content. expected average cost per procedure. Develop a healthaffairs.org/content/25/3/880.1.full. Accessed October 16, 2017. | 21 range for these values depending on the number 15. Ishii L, Pronovost PJ, Demski R, Wylie G, Zenilman M, of procedures expected per year. Ambulatory Surgery Coordinating Council. A model Next, calculate the average contribution for integrating ambulatory surgery centers into an margin, which is total projected revenue minus academic health system using a novel ambulatory surgery coordinating council. Acad Med. 2016;91(6):803-806. total projected cost, divided by total number of 16. Koenig L, Gu Q. Growth of ambulatory surgical centers, expected procedures. A positive contribution surgery volume, and savings to Medicare. Am J Gastroenterol. margin predicts whether the venture will be 2013;108(1):10-15. financially successful, and the higher the contri- 17. Becker S, Rechtoris M. 14 Observations and thoughts and bution margin, the greater the degree of financial issues for ASCs 2015–2016. Becker’s ASC Review. July 15, 2015. Available at: www.beckersasc.com/asc-turnarounds-ideas- safety. A negative contribution margin makes any to-improve-performance/14-observations-and-thoughts-and- investment opportunity financially inadvisable, issues-for-ascs-2015-2016.html. Accessed May 6, 2017. unless it can reasonably be expected to turn posi- 18. Medicare Payment Advisory Commission. Report to the tive in the future. Although health care systems Congress: Medicare payment policy. Washington, DC; are better able than independent ASCs to absorb 2012. Pages 115–137. Available at: http://medpac.gov/docs/ default-source/reports/march-2012-report-to-the-congress- significant financial shocks, independent ASCs medicare-payment-policy.pdf?sfvrsn=0. Accessed September are typically advised to maintain a contribution 14, 2017. margin of 30 percent or more to guard against 19. Ambulatory Surgery Center Association. Ambulatory unexpected changes in procedure volume or reim- surgery centers: A positive trend in health care. bursement policy. Alexandria, VA; 2007. Available at: www.ascassociation. org/advancingsurgicalcare/aboutascs/industryoverview/ Dividing the upfront investment cost by con- apositivetrendinhealthcare. Accessed September 14, 2017. tribution margin yields the investment break-even 20. Fabricant PD, Seeley MA, Rozell JC, et al. Cost savings from point; that is, the number of procedures that need utilization of an ambulatory surgery center for orthopaedic to be performed to pay off the original investment. day surgery. J Am Acad Orthop Surg. 2016;24(12):865-871. In general, if there is a high degree of confidence in projected future revenue and cost, a longer continued on next page break-even period may be acceptable. When there is less certainty about future projections, a shorter

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REFERENCES, CONTINUED break-even period is more desirable, as debts will be paid off more quickly. 21. Pash J, Kadry B, Bugrara S, Macario A. Scheduling of Return on investment (ROI) can be calculated procedures and staff in an ambulatory surgery center. Anesthesiol Clin. 2014;32(2):517-527. over a fixed period, which can be useful for boards 22. Carey K. Ambulatory surgery centers and prices in hospital and executive groups working within specific time outpatient departments. Med Care Res Rev. March 2016 [Epub horizons (such as a three-year plan). This is calcu- ahead of print]. lated as the total revenue minus total cost over a 23. Gardner TF, Nnadozie MU, Davis BA, Kirk S. Patient fixed period, divided by the total cost over that same anxiety and patient satisfaction in hospital-based and freestanding ambulatory surgery centers. J Nurs Care Qual. period (including investment costs). 2005;20(3):238-243. 24. DiSesa VJ, Kaiser LR. What’s in a name? The necessary Synthesis transformation of the academic medical center in the A health care system’s decision on whether to invest era of population health and accountable care. Acad Med. in an ASC will be based on the following factors: 2015;90(7):842-845. 25. Gourevitch MN. Population health and the academic projecting expected case volume and revenue; medical center: The time is right. Acad Med. 2014;89(4):544- assessing internal and external barriers; exploring 22 | 549. realistic investment options; and calculating the 26. Wakeam E, Hevelone ND, Maine R, et al. Failure to rescue average contribution margin, investment costs, and in safety-net hospitals: Availability of hospital resources and break-even period for these alternatives. differences in performance. JAMA Surg. 2014;149(3):229-235. 27. Hayanga AJ, Kaiser HE, Sinha R, Berenholtz SM, Makary For some, achieving a threshold procedure M, Chang D. Residential segregation and access to surgical volume may appear unrealistic, and for others, their care by minority populations in U.S. counties. J Am Coll Surg. ORs may be over capacity. Depending on proce- 2009;208(6):1017-1022. dure and payor mix, attaining a positive financial 28. Zak Y, Rhoads KF, Visser BC. Predictors of surgical margin may be too uncertain. The surgeon work- intervention for hepatocellular carcinoma: Race, socioeconomic status, and hospital type. Arch Surg. force may be enthusiastic and willing to work 2011;146(7):778-784. around challenges to shift procedures to the ASC 29. Hong Y, Zheng C, Hechenbleikner E, Johnson LB, Shara setting; alternatively, such a change may be so dis- N, Al-Refaie WB. Vulnerable hospitals and cancer surgery ruptive that physicians are unlikely to alter their readmissions: Insights into the unintended consequences practice patterns. Some health care systems may of the Patient Protection and Affordable Care Act. J Am Coll Surg. 2016;223(1):142-151. have multiple acquisition targets, and others may be 30. Adamopoulos H. The outpatient payment rate debate: What limited to building on their own. Working through lower reimbursement would mean for hospitals. Becker’s this framework systematically will help health care Hospital CFO. Available at: www.beckershospitalreview. system leaders to understand whether investing in com/finance/the-outpatient-payment-rate-debate-what- an ASC is a realistic and prudent strategic option, lower-reimbursement-would-mean-for-hospitals.html. Accessed March 9, 2017. and if so, why. Areas of low precision or confidence 31. U.S. Government. Public Law 114–74: Bipartisan Budget Act can be identified for further investigation. of 2015, Section 603: Treatment of Off-Campus Outpatient Given the overall trend of shifting surgical Departments of a Provider. Nov. 2, 2015. Available at: www. care to lower acuity settings, if a health care sys- congress.gov/114/plaws/publ74/PLAW-114publ74.pdf. tem’s initial assessment recommends against ASC investment, this exercise should be reevaluated peri- odically, especially if significant changes occur in continued on next page the health care market. If the question of whether a health care system should invest in an ASC is

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actually a question of when, and not if, continuing REFERENCES, CONTINUED to reassess the situation as circumstances evolve is prudent. 32. Dyrda L. 10 new outpatient surgery center plans, openings—May 2, 2015. Becker’s ASC Review. June 2015. Available at: www.beckersasc.com/asc-transactions-and- valuation-issues/10-new-outpatient-surgery-center-plans- Conclusion openings-may-2-2015.html. Accessed March 6, 2017. In the long run, shifting appropriate surgical cases 33. Vaidya A. Ensuring ASC profitability in a value-based to ASCs is likely to be advantageous for health care world. Becker’s ASC Review. November 2, 2016. Available at: www.beckersasc.com/asc-turnarounds-ideas-to-improve- systems in an environment dominated by value-based performance/ensuring-asc-profitability-in-a-value-based- 17,41 care efforts. The decision to invest in a specific world.html. Accessed May 7, 2017. ASC, however, will be informed by the specific cir- 34. Burger J. Why do ASCs fail? Outpatient Surgery cumstances faced by the health care system making Magazine. August 2015. Available at: http://magazine. the decision. The fundamentals of good business will outpatientsurgery.net/i/553403-why-do-ascs-fail-august- 2015-subscribe-to-outpatient-surgery-magazine/. Accessed always hold true: in the future, the health care sys- April 9, 2017. tems that can manage to deliver the highest quality 35. Larach MG, Dirksen SJH, Belani KG, et al. Special article: surgical services, at the most reasonable prices, will Creation of a guide for the transfer of care of the malignant | 23 be the ones most likely to thrive. ♦ hyperthermia patient from ambulatory surgery centers to receiving hospital facilities. Anesth Analg. 2012;114(1):94-100. 36. Putnam LR, Chang CM, Rogers NB, et al. Adherence to surgical antibiotic prophylaxis remains a challenge despite Acknowledgments multifaceted interventions. Surgery. 2015;158(2):413-419. Dr. O’Neill was supported by the Veterans Affairs (VA) 37. Parsons Leigh J, Niven DJ, Boyd JM, Stelfox HT. Office of Academic Affiliations through the Robert Wood Developing a framework to guide the de-adoption of low- Johnson Foundation Clinical Scholars Program and the Uni- value clinical practices in acute care medicine: A study protocol. BMC Health Serv Res. 2017;17(1):54. versity of California, Los Angeles, Gerald R. Levey Surgical 38. National Conference of State Legislatures. CON- Resident Research Award. This article does not represent Certificate of need state laws. August 2016. Available at: the views of the U.S. Department of Veterans Affairs or www.ncsl.org/research/health/con-certificate-of-need- the U.S. government. state-laws.aspx. Accessed March 7, 2017. 39. Becker S, Lundeen R, Mikula A. Developing an ambulatory surgery center: Understanding the key legal issues and the essential elements of an ASC operating agreement. Becker’s ASC Review. 2006;5:1,4-10. Available at: www.beckersasc.com/pdfs/past-issues/091006_ASC_ Review.pdf. Accessed March 7, 2017. 40. Rechtoris M. The 5 ASC powerhouses: 35 things to know about the largest surgery center chains. Becker’s ASC Review. December 2016. Available at: www.beckersasc. com/asc-transactions-and-valuation-issues/the-5-asc- powerhouses-35-things-to-know-about-the-largest-surgery- center-chains.html. Accessed March 9, 2017. 41. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood). 2008;27(3):759- 769.

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24 |

Frank R. Lewis, Jr., MD, FACS: 15 years of visionary leadership at the American Board of Surgery

by Lena Napolitano, MD, FACS, FCCP, FCCM; Anne Rizzo, MD, FACS; and Christine Shiffer, MBA

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rank R. Lewis, Jr., MD, FACS, has just completed overall teaching efforts, Dr. Lewis received the UCSF a 15-year term (2002–2017) as executive director Surgery Residents’ Excellence in Teaching Award in Fof the American Board of Surgery (ABS), with 1990 and 1991, as well as the 1991 Alpha Omega Alpha numerous remarkable accomplishments during his Honor Medical Society Chapter Award for Outstand- tenure. At the winter ABS meeting, Dr. Lewis also ing UCSF Faculty Teacher. announced his retirement effective at the end of 2017. He then moved east, and from 1992 to 2002, he Hence, it is fitting to chronicle the life and career of served as chair, department of surgery, Henry Ford this surgical leader, who has played such an important Hospital, Detroit, MI, and professor of surgery, Case and dominant role in surgical education, training, Western Reserve University, Cleveland, OH. and certification in the U.S. and around the world. Dr. Lewis’ clinical interests have centered on trauma and critical care, and his research has focused on car- diopulmonary physiology, cardiopulmonary effects of Education and training sepsis, and acute respiratory failure. He collaborated Dr. Lewis graduated cum laude with a bachelor of phys- with Virgil Elings, MD, University of California, Santa ics from Princeton University, NJ, and was inducted Barbara, to develop the lung water computer, which into Sigma Xi, the Scientific Research Honor Society. allowed the quantitation of pulmonary edema using the He received his medical degree in 1965 from the Uni- double indicator technique. They established the valid- | 25 versity of Maryland Medical School, Baltimore. ity of the technique in both human and animal models. His initial goal was to be an internist. However, a Dr. Lewis’ more recent work has focused on critical one-year internship (six months medicine, six months care physiology and specifically the cardiopulmonary surgery) at San Francisco General Hospital, CA, effects of sepsis and of vascular resistance on cardiac resulted in a change of heart. After a few weeks on output. In the course of more than 40 years, Dr. Lewis the internal medicine service at San Francisco Gen- has published more than 175 articles in peer-reviewed eral, he recognized that managing chronic disease was journals. not what he really wanted to do. During Dr. Lewis’ surgical training under the leadership of J. Englebert Dunphy, MD, FACS, chairman, department of surgery, Leadership roles and F. William Blaisdell, MD, FACS, chief of trauma Dr. Lewis has served in numerous leadership roles and founder of the first U.S. trauma program in 1968, in the course of his surgical career. In addition to he was drawn to the excitement of the nascent field of his roles as chief of surgery at San Francisco Gen- acute care surgery, caring for patients with acute sur- eral from 1986 to 1992 and chair of surgery at Henry gical issues and traumatic injuries. Ford Hospital for a decade, he has held many national It was too late to apply for surgical residency that leadership roles in surgery. Most notably, he served year, but he was accepted into the surgical residency as Chair of the American College of Surgeons (ACS) program at the University of California, San Francisco Board of Governors, ACS First Vice-President, pre- (UCSF), the following year in 1966. After completing sident of the American Association for the Surgery his residency training in 1972, Dr. Lewis completed a of Trauma, president of the Shock Society, and chair National Institutes of Health trauma research fellowship of both the ABS and the Residency Review Commit- with his mentor, Dr. Blaisdell, at San Francisco General. tee for Surgery (RRC-Surgery). The highlight of his Dr. Lewis served on the faculty of the UCSF from career in surgery has been the last 15 years, during 1973 to 1992, rising from assistant professor to profes- which he served as executive director of the ABS, sor and vice-chair, department of surgery, and to chief promoting pivotal changes in surgical training and of surgery at San Francisco General Hospital. For his certification and lifelong learning.

NOV 2017 BULLETIN American College of Surgeons FRANK R. LEWIS AND THE ABS

Dr. Lewis speaking at his retirement dinner in April 2017 (left), and receiving a commemorative bowl from Dr. Hunter at the event

ABS Henry Ford Health System, succeeding him as public Dr. Lewis’ accomplishments during his tenure as ABS member this past July. executive director are numerous, and all of the ABS directors hold Dr. Lewis in high esteem. According to The first ABS mission statement ABS chair John G. Hunter, MD, FACS, “There are not As a means to further focus the goals and future direc- enough words in the English language to describe the tion of the ABS, Dr. Lewis and ABS leaders sought to service and contributions made by Dr. Lewis to Ameri- develop a mission statement for the organization. In can surgery over his 15 years as ABS executive director. 2014, the first mission statement of the ABS was intro- We are deeply indebted to him for his visionary guid- duced, with a focus on the board’s duty to the public. ance and dedication to the mission of the board.” The It reads as follows: “The American Board of Surgery following summarizes some of the numerous advances serves the public and the specialty of surgery by pro- and major developments that occurred at the ABS viding leadership in surgical education and practice, by 26 | during Dr. Lewis’ tenure. promoting excellence through rigorous evaluation and examination, and by promoting the highest standards At-large ABS director positions for professionalism, lifelong learning, and the continu- Dr. Lewis is an advocate for surgeons in clinical prac- ous certification of surgeons in practice.” tice. In 2005, Dr. Lewis and the ABS announced the creation of three at-large director positions to better SCORE reflect the diversity of the surgical community in the An unwavering advocate for surgical residents and resi- U.S. These positions were in addition to the ABS board dency education, Dr. Lewis led an important effort as of directors’ representation from 26 U.S. surgical orga- ABS executive director in the establishment of the Sur- nizations. This change has allowed surgeons in private gical Council on Resident Education (SCORE). or group practice to have greater representation on On November 20, 2006, the ABS hosted the inaugu- the board and, thereby, ensure its standards align with ral meeting of SCORE, to examine the state of surgical the needs of today’s practicing surgeons and myriad training and develop a new national curriculum for practice environments. The inclusion of ABS at-large general surgery residency training in the U.S. SCORE directors has been highly successful in further broad- is composed of representatives from the principal orga- ening the board’s representation. nizations involved in surgical education: the ACS, the American Surgical Association (ASA), the Association The first ABS public member role of Program Directors in Surgery, the Association for Under Dr. Lewis’ leadership, a public member was Surgical Education, the RRC-Surgery, the Society of added to the ABS board of directors to represent the American Gastrointestinal and Endoscopic Surgeons, public in its deliberations. In 2010, the first ABS public and the ABS. The meeting was organized by Dr. Lewis member, William Scanlon, PhD, a consultant and and ABS assistant executive director Richard H. Bell, commissioner for the Medicare Payment Advisory Jr., MD, FACS, as a first step toward developing a com- Commission, was added to provide a public voice in prehensive program to improve the training of U.S. all ABS deliberations. Dr. Scanlon just completed his surgeons. term on the ABS, with Nancy M. Schlichting, MBA, SCORE emerged from the growing concern among immediate past-president and chief executive officer, the leadership of the ABS and other organizations that

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SCORE member organization representatives at its inaugural November 2006 meeting. Front row, from left: Thomas Biester, MS (ABS); Robert Rhodes, MD, FACS (ABS); Richard Bell, MD, FACS (ABS); Hiram Polk, MD, FACS (ASA); Doris Stoll, PhD (RRC-S); Dr. Lewis (ABS); Joseph Cofer, MD, FACS (APDS); J. David Richardson, MD, FACS (RRCS); Carlos A. Pellegrini, MD, FACS (ASA); Ajit Sachdeva, MD, FACS (ACS); and Donald Risucci, PhD (ASE). Back row: Timothy Flynn, MD, FACS (ABS); L. D. Britt, MD, FACS (RRC-S); Barbara Bass, MD, FACS (ACS); Gary Dunnington, MD, FACS (APDS); R. James Valentine, MD, FACS (APDS); David Feliciano, MD, FACS (ABS); and Patrice Blair, MPH (ACS). Not pictured: John Potts, MD, FACS (APDS). traditional surgical training no longer could respond 750 learning modules and is used by 98 percent of the sufficiently to the pressures of the modern health care general surgery residency programs accredited by the environment and that the quality of graduate surgi- Accreditation Council for Graduate Medical Educa- cal education and the overall attractiveness of surgery tion (ACGME). as a specialty were threatened. The rapid growth of new technology and surgical knowledge, along with Resident education limits on residency work hours and a projected short- Dr. Lewis has led many initiatives that have shaped | 27 age of surgeons in the near future, were all factors U.S. surgical training and certification, including the that prompted the creation of SCORE and inspired design and implementation of the FIRST (Flexibility in its objective of a new, innovative curriculum for sur- Duty Hour Requirements for Surgical Trainees) Trial, gery residency training. The ABS had seen firsthand an which Dr. Lewis initiated in partnership with ACS Exe- undesirable high degree of variability in the knowledge cutive Director David B. Hoyt, MD, FACS, and Ajit K. of graduated surgery residents, particularly regarding Sachdeva, MD, FACS, FRCSC, Director, ACS Division of complex trauma and gastrointestinal cases. Education. The study was funded by the ABS, the ACS, At the November 2006 meeting, SCORE representa- and ACGME, and was organized and directed by Karl tives reviewed the efforts of member organizations in Y. Bilimoria, MD, MS, FACS, John Benjamin Murphy improving surgical education and the attractiveness of Professor of Surgery, Northwestern University, Chi- surgery as a career choice. They also reviewed the pro- cago, IL. The trial went from conception to initiation in posals of the ASA Blue Ribbon Panel (2005) regarding seven months and to initial results 18 months later. The the restructuring of surgical training and ultimately findings of the study led directly to changes in resident decided that SCORE would focus on opportunities for work hours as announced by the ACGME in March 2017. improving the traditional five-year surgery curriculum. Under Dr. Lewis’ leadership, the ABS has worked The members of SCORE also agreed to move ahead with all major organizations engaged in surgical edu- with the development of a website dedicated to the cation and quality improvement to foster education, provision of comprehensive, high-quality educational training, and assessment that reflects best practices. A materials that would be available at a reasonable cost central focus of the ABS since 2013 has been to critically to all surgical residents. evaluate general surgery residency training, related to The SCORE curriculum is now a national stan- renewed concern about lack of autonomy afforded to dard for defining what a surgeon should know and general surgery residents, and to ensure that residents be able to do by the end of general surgery residency, are fully prepared to enter independent practice at the and SCORE is a critical element in shaping the future completion of residency. of general surgery residency training. The SCORE The ABS has convened multiple daylong retreats to portal (www.surgicalcore.org) comprises more than review associated issues in surgical training, including

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resident work-hour limits, the reduction in open operative procedures BIBLIOGRAPHY performed during training, and the dramatic growth of post-residency American Association for the Surgery of fellowships. This critical evaluation led to a recommendation to pursue Trauma. Past presidents. Frank R. competency-based training as the ultimate goal, similar to the plan for Lewis MD 1999–2000. Available at: implementation across all Canadian training programs by the Royal www.aast.org/About/PastPresidents. College of Physicians and Surgeons of Canada. aspx. Accessed September 8, 2017. When asked in an interview with the AAST what advice he would The American Board of Surgery. Available at: www.absurgery.org. Accessed give to students and residents interested in surgery as a career goal, September 8, 2017. Dr. Lewis said, “The most important thing is to really have a passion- ate interest in what you do. When you figure that out, jump into it and do it as well as possible to advance the science of it wherever you can, to constantly look at how you can do things in the best way. If you do that, it’s hard for anything else to be a problem.”

Maintenance of Certification With Dr. Lewis’ guidance, the ABS has sought to optimize lifelong learning and certification to best serve both diplomates and the public. 28 | In a memorandum sent July 7 to all diplomates from ABS chair Mary E. Klingensmith, MD, FACS, and Dr. Lewis, the ABS announced that Maintenance of Certification (MOC) reporting requirements would be changed to require reporting only every five years instead of three, and that the required Self-Assessment Continuing Medical Education credits would be reduced by 50 percent. The ABS also announced that in 2018 diplomates would be offered alternatives to the traditional 10-year recertification exam. The ABS MOC Program will continue to evolve in response to diplomate feedback under Jo Buyske, MD, FACS, who assumed the role of ABS executive director September 1.

Conclusion As ABS executive director, Dr. Lewis has been a visionary leader in many areas of surgical training and certification, including the devel- opment of a primary certificate in vascular surgery, the establishment of “flexible rotations” in surgical residency training, and the restructur- ing of the ABS to encompass advisory councils and component boards covering all areas of general surgery. His numerous accomplishments during his tenure as ABS executive director have clearly changed the landscape of general surgery in the U.S. ♦

Acknowledgements The authors would like to thank Dr. Lewis’ wife, Janet Christensen, and the American Board of Surgery for contributing the photos published with this article.

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A history of health information technology and the future of interoperability

by Mark Lukaszewski | 29

ealth information technology (HIT), particu- Act was passed as part of the larger American Recovery larly the electronic health record (EHR), plays and Reinvestment Act of 2009.2 In 2011, the meaningful Han important role in how payors measure use (MU) component of HITECH was implemented quality, and therefore, in how surgeons are reim- to expand the adoption of HIT and facilitate the use bursed. This article looks at the evolving role of HIT, of EHRs.2 the challenges of achieving interoperability, and The HITECH Act authorized CMS to establish how Congress is working to ensure improved data the Medicare and Medicaid EHR Incentive Programs. exchange. It describes surgeons’ frustrations with the These programs paid approximately $35 billion in current data exchange system and what the Ameri- incentive payments to eligible professionals, hospi- can College of Surgeons (ACS) Division of Advocacy tals, and critical access hospitals to adopt, implement, and Health Policy is doing to address these concerns. upgrade, and demonstrate the use of certified EHR It outlines the significant amount of time the ACS technology (CEHRT).3 The reporting requirements has spent educating members of Congress, Health involve the ability of an EHR to perform such func- and Human Services (HHS), the Centers for Medi- tions as generating problem lists, exchanging patient care & Medicaid Services (CMS), and the Office of the clinical data, or e-prescribing.3 National Coordinator (ONC) about the challenges The MU program launched in stages beginning in related to EHR interoperability. 2011. The focus of Stage 1 was data capture and shar- ing. In 2014, the ONC created Stage 2, which sought to extend the requirements of Stage 1 and promote Background on meaningful use more advanced clinical processes. Stage 3 began this In 2004, President George W. Bush created the ONC for year and extends into 2018. Its focus is on improv- HIT, which is charged with synchronizing HIT in the ing overall outcomes, and the MU program is now U.S. health care sector.1 The Health Information Tech- a component of the Merit-based Incentive Payment nology for Economic and Clinical Health (HITECH) System—specifically the Advancing Care Information

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performance category—under the Quality Payment and that would enhance care, aid research, and pro- Program (QPP).3,4 vide cost savings. Even the simplest data exchanges can prove to be challenging. Imagine trying to identify a patient with Data blocking, or a language problem? the most common surname in the U.S., “Smith.” To EHRs have remained siloed in their data exchanges ensure that patient Smith is the same patient so that and have proven highly inefficient for machine- information can be transferred from one EHR to the readable information shared among providers caring next requires identification matching and a secure trust for a patient. The real impact of digital information framework.5 At present, no HIT industry standards has yet to reach a level adequate to enrich patient for reliable patient identification matching have been care outcomes or greatly increase surgical decision established. making. Some EHR systems have been accused of Many members of Congress believe most interop- data blocking and adding service costs for providers erability shortfalls are associated with data blocking. seeking more effective means of data sharing. Although data blocking is a concern, most EHR vendors When digital systems seamlessly exchange data meet the minimum requirements for sharing informa- with each other, it is referred to as interoperability. tion. However, the evidence suggests that even though 30 | More specifically, true interoperability occurs when EHR vendors are meeting these minimum require- information held in one EHR transfers through a ments, they are not optimally facilitating the data standardized wire format to a separate EHR in such exchanges to accelerate interoperability.6 Complexity, a way that the information exchanged proves to be lack of standards, and costs are the primary roadblocks machine readable by the accepting EHR. Once that vendors offer when asked to expedite interoperabil- information is accepted in transfer, the receiving EHR ity solutions. To comply with the law, vendors often should have enough appreciation of the content and provide even the most basic information in PDF files, the context of the data shared to be able to represent which are not easily interpreted by other EHRs, for the information appropriately in the workflow of the transfer. Such transfers may be interpreted as minimum clinicians using the transferred information. compliance with patient needs and may be viewed as The challenge is that each EHR vendor presents an element of data blocking. information in its own way, using its own terminol- It is more likely that the complexity of informa- ogy and values. High-level exchange information tion necessary to exchange has resulted in a lack of requires a decoding function that translates the send- agreement over standards. The ONC, therefore, is ing EHR’s terminology and values along with the unprepared to set such standards as requirements for clinical context into a standard that crosses the wire CEHRT. The sooner the health information profes- format for the receiving EHR to read. The accept- sion and clinical aspects of medicine come together ing EHR must interpret and represent the content and standardize the information fit for transfer, the in the right context using its own terminology and more promptly the ONC can act to require standards values. However, for many different reasons, often in CEHRT that facilitate interoperability. EHR developers, hospitals, health care organizations, and even providers intentionally and unintentionally block the exchange of electronic health data. The Government fixes result is that digital health information is not seam- Members of Congress realize that interoperability is lessly available for the multiple-use cases a surgeon crucial in today’s health care environment. On April could imagine for shared information. Fully shared 16, 2015, President Obama signed the Medicare Access information would increase physicians’ workflows, and CHIP (Children’s Health Insurance Program)

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Reauthorization Act (MACRA) of 2015 into law.4 The • Measure 2: Proportion of health care providers who primary purpose of this legislation was to permanently report using the information that they electronically repeal the flawed sustainable growth rate formula receive from outside providers and sources for clinical used to calculate Medicare physician payment updates decision making4 and replace it with the QPP. However, Congress also declared achieving widespread exchange of health On December 13, 2016, Congress passed the 21st information through interoperable certified EHR Century Cures Act, which revised a definition of technology by December 31, 2018, as a national objec- interoperability with three characteristics:7 tive in MACRA. MACRA states that there shall be “widespread interoperability” and established metrics • Enables the secure exchange of electronic health infor- to determine whether, and to what extent, objectives mation with, and use of electronic health information have been met by this time.4 from, other HIT without special effort on the part of MACRA defined interoperability as “the ability the user of two or more health information systems or com- ponents to exchange clinical and other information • Allows for complete access, exchange, and use of all and use the information that has been exchanged electronically accessible health information for autho- by means of common standards to provide access to rized use under applicable state or federal law | 31 longitudinal information for health care providers to facilitate coordinated care and improve patient • Does not constitute information blocking as defined outcomes.”4 in section 3022(a) Specifically, MACRA defines “widespread interop- erability” as interoperability between CEHRT systems Like MACRA, the 21st Century Cures Act man- employed by meaningful EHR users under the Medi- dates support for interoperable network exchange to care and Medicaid EHR Incentive Programs and other be spearheaded by the ONC in collaboration with the clinicians and health care providers on a nationwide National Institute of Standards and Technology and basis.4 other divisions of HHS. This work includes establish- The Secretary of HHS delegated authority to carry ing and publishing details about a trusted exchange out this section of MACRA to the ONC. If the Secre- framework along with a directory of participating tary determines that these objectives have not been health information networks and rules for these net- reached by December 31, 2018, the Secretary must works to apply. It also calls for the establishment of a submit a report to Congress identifying barriers and new HIT Advisory Committee to make recommen- provide recommended actions the federal govern- dations to the ONC on the development of a policy ment can take to achieve them by December 31, 2019. framework to advance an interoperable HIT infra- In addition, the ONC has determined that two mea- structure. The new committee will replace the existing sures are the most appropriate indicators of having HIT Policy and Standards Committees.7 fulfilled the widespread interoperability MACRA This new committee also will be responsible for requirement: submitting annual progress reports on interoperabil- ity advancements to HHS and Congress, including • Measure 1: Proportion of health care providers who are recommendations for realizing improvements to electronically engaging in the following core domains interoperability in the health care industry. One new of interoperable exchange of health information: send- feature is that the ONC must implement a standard- ing; receiving; finding (querying); and integrating ized process for receiving complaints about HIT lack information received from outside sources4 of interoperability, and report those individuals or

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groups responsible for information blocking. The bill anesthesia. Often, these roles extend beyond the day of also requires HHS to designate standards for health surgical care into the postoperative recovery period. data exchange that improve interoperability.7 Patients receive care longitudinally over time, and not The 21st Century Cures Act takes aim at several always in one facility or under one EHR. Complex policy changes and gives authority to the HHS Office clinical care models track patients over time and space. of the Inspector General to investigate and penalize To fix this problem, Congress and regulatory agen- information blocking.7 cies have tapped EHR vendors for solutions. However, Both MACRA and 21st Century Cures have the this is a costly misstep, as interoperability problems potential to improve interoperability. Both mandate cannot solely be solved by developing a better EHR. that if interoperability goals are not accomplished in Many clinical institutions are looking beyond the a timely manner, the HHS Secretary shall submit a EHR and are considering cloud-based solutions that report to Congress identifying barriers and provide operate outside the EHR firewalls. These cloud solu- recommendations to correct them. tions enable tracking of patients across the continuum, providing inputs from patients, clinicians, insurers, and others. Interoperability could extend to medical Effects on practice devices, smartphones, laptops, and so on. If all digital 32 | Surgeons are frustrated when EHR requirements health information partners complied with the same demand more data entry, leaving less face time with strict standards and terminologies for data elements, patients. More and more, surgeons find themselves interoperable data would be more than just EHR. It managing digital health information from all its would, in turn, encompass clinical data to move in various sources. Many surgeons point to EHR frus- EHRs, mobile devices, clouds, patient records, regis- trations as a large contributor to burnout, adding to tries, and more. This level of interoperability would the physician wellness conundrum. EHRs should have enable the industry to leverage digital health infor- workflow services built for patients and surgeons that mation for better health, improved care, and optimal fit the clinical circumstances and advance care. cost-effectiveness. Clinical care models are growing increasingly complex. The continuum of care for a patient fre- quently crosses several phases provided by multiple ACS action clinicians, each with unique EHRs. In surgery, these The ACS is working with Health Level Seven (HL7), phases include preoperative evaluation, preoperative an American National Standards Institute-accredited readiness, intraoperative care, postoperative care, and standards developing organization, and the Health postdischarge follow-up care. To realize the full ben- Services Platform Consortium (HSPC) to create a efit of digital health information, we will need truly framework for working interoperability in order to meaningful data following the patient through this track patients across their care continuum with digi- continuum. tal health information specific to their care needs.8,9 Information flows that track patients across these This interoperability framework is extremely complex. phases are now key to optimal quality and safe, afford- Individual patient models must define all workflows able surgical care. The surgical care team involves a for clinical care, step by step. The care models must be broad array of providers acting over time across the mapped out for every instance and option for care. Each care continuum beginning with the decision to oper- element of these models must be translated into specific ate, long before the day of an operation. Complex clinical definitions all providers agree to accept. Then patients require a team of physicians playing definitive those definitions are assigned machine-readable ter- roles in readying a patient for a surgical procedure and minologies from known standards held in recognized

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libraries such as the Systematized Nomenclature REFERENCES of Medicine–Clinical Terms (SNOMED CT), and 1. The American Presidency Project. Executive Order 13335— assigned logical observation identifiers names and Incentives for the Use of Health Information Technology and codes (LOINC) and RXNorm.10-12 When appro- Establishing the Position of the National Health Information Technology Coordinator. Available at: www.presidency.ucsb.edu/ priate, those terminologies need to be bound ws/?pid=61429. Accessed September 22, 2017. to a value set from the U.S. National Library 2. U.S. Department of Health & Human Service. HITECH Act of Medicine.13 Upon completion of these steps, Enforcement Interim Final Rule. Available at: www.hhs.gov/ the ACS plans to ask HL7 to accept these clini- hipaa/for-professionals/special-topics/HITECH-act-enforcement- cal definitions with their assigned terminologies interim-final-rule/index.html. Accessed September 22, 2017. 3. Centers for Medicare & Medicaid Services. Electronic Health and bound value sets to become an acceptable Records (EHR) Incentive Programs. Available at: www.cms.gov/ standard. Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Once acceptable standards are agreed upon index.html?redirect=/ehrincentiveprograms. Accessed September by the clinical community and the HL7 technol- 22, 2017. ogy community, the final step will depend on the 4. Congress.gov. H.R.2—Medicare Access and Chip Reauthorization Act of 2015. Available at: www.congress.gov/bill/114th-congress/ ONC and CMS requiring that these standards house-bill/2/text. Accessed September 22, 2017. be part of EHR certification so that the informa- 5. National HIE Governance Forum: Trust Framework for Health tion is available for an interoperable wire format Information Exchange. Available at: www.healthit.gov/sites/ | 33 exchange.8 The ACS believes that this affirmation default/files/trustframeworkfinal.pdf. Accessed September 22, by CMS should be at a scale large enough to set 2017. 6. The Office of the National Coordinator for Health Information the de facto standard for EHR interoperability Technology (ONC) Department of Health and Human Services. across payors. Report on Health Information Blocking. Available at: www. Even though Congress has developed many healthit.gov/sites/default/files/reports/info_blocking_040915. pieces of legislation and programs to address pdf. Accessed September 22, 2017. interoperability concerns, our clinical care 7. Congress.gov. H.R.34—21st Century Cures Act. Available at: www.congress.gov/bill/114th-congress/house-bill/34. Accessed models remain complex and in need of change. September 22, 2017. The digital health care information needed to 8. Health Level Seven International. Introduction to HL7 standards. optimize modern care models must use standard- Available at: www.hl7.org/implement/standards/. Accessed ized data that operates between EHRs, registries, September 22, 2017. and other smart HIT devices across the surgical 9. Healthcare Services Platform Consortium. Our approach. Available at: http://hspconsortium.org/about/our-story/. care continuum. Clinicians and HIT engineers Accessed September 22, 2017. across the clinical domains must come together to 10. U.S. National Library of Medicine NIH. Health IT Home. ascribe clinical definitions that map to machine- SNOMED CT. Available at: www.nlm.nih.gov/healthit/ readable formats using common terminologies snomedct/. Accessed September 22, 2017. and values. Additionally, the government must 11. LOINC. The Universal standard for identifying health measurement, observations, and documents. Available at: h t t p s :// demand these aspects of interoperability be loinc.org/. Accessed September 22, 2017. mandated as nationally required standards. To 12. U.S. National Institutes of Health National Library of Medicine. achieve this goal, the ACS will work with both Unified Medical Language System (UMLS). RxNorm. Available the regulatory and legislative sides of government at: www.nlm.nih.gov/research/umls/rxnorm/. Accessed to implement effective, meaningful change. ♦ September 22, 2017. 13. U.S. National Institutes of Health National Library of Medicine. Databases. Available at: www.nlm.nih.gov/. Accessed September 22, 2017.

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Nursing workforce in surgery and trauma care delivery: A global call 34 | to action

by Gregory L. Peck, DO, FACS; Kathleen Martin, MSN, RN; Jessica Badillo, MSN, RN; Sol Angelica Muñiz, MSN, RN, FN; Margot Consuelo Burbano, MSN, Enf. Esp.; Timothy Murphy, MSN, RN, ACNP-BC, Isabelle Citron, MD, BM BCh; TCRN, CEN, FAEN; Cristiane de Alencar Domigues, PhD, RN; Nobhojit Roy, MD, PhD; Richard W. Lang III; and Lisa A. Falcón, MSN, RN, TCRN, NE-BC; Suzanne Willard, PhD, APN, FAAN

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his article is part of a series that describes literature highlighting the benefits of systems-based efforts to improve global trauma care in Latin interprofessional health care approaches to patient TAmerica. The first article in the series—“Using care, Working Together for Health highlights the need global surgical indicators to improve trauma care in to enhance current healthcare member teamwork, Latin America”—was published in the April issue of with noted emphasis on the teamwork core skills sets the Bulletin.* In this article, the authors look at how of communication and leadership as a key mecha- improving nursing workforce can improve the avail- nism in overcoming health care shortfalls.2-3 These ability of trauma care in low- and middle-income concepts are consistent with the conclusions of various countries (LMICs). As in the other articles in this U.S. health care organizations that are documenting series, the authors describe efforts in Latin Amer- that teamwork—a critical component of interprofes- ica that support the World Health Assembly (WHA) sional surgical teams—mitigates medical error and Resolution 68.15. can be linked directly to improved patient outcomes and patient safety.4-7 The Agency for Healthcare Research and Quality | 35 The need for interprofessional care (AHRQ) and The Joint Commission indicate that low In the last 15 years, significant work has been conducted expectations, poor communication and teamwork, to quantify the global health care workforce burden. and authority gradients can inhibit effective team- The World Health Report (WHR), a November 2006 work in health care environments, and remain key expert assessment of shortfalls in global health care underlying reasons for underdeveloped health care workforce, described the global health care workforce safety cultures.6-7 AHRQ further indicates that hier- crisis and its massive effect in 57 countries and on 1 bil- archical structures, such as those potentially related lion people, indicating that there is a global deficit of to gender or professional differences on a health care “2.4 million doctors, nurses, and midwives.”1 An addi- team, are well-documented obstacles to teamwork tional 4.3 million health care workers were needed to and patient safety.6 fulfill the Millennium Development Goals established by the United Nations in 2000, which include eight anti- poverty targets in the identified countries outlined in Nursing workforce disparities the WHR. The report also documented variances in Regional differences, as well as disparities in training, geographical workforce density ranging from 2.3 in qualifications, gender, and profession, emphasize the Africa, to 4.3 in Southeast Asia, to as high as 24.8 in imbalances in health care provider workforce short- the U.S. (numbers per thousand population). In fact, age around the globe. Although almost two-thirds countries with fewer than 2.3 skilled health care work- of all health care workers are women, data accen- ers per 1,000 population were observed to have poor tuates that women nurses are often underutilized primary health care intervention coverage.1 and relegated to bed-making and other nonclinical The document, Working Together for Health, indicates tasks.8-11 These differences, combined with variances that maximizing the capacity of the existing health care in employment credentialing requirements, and barri- workforce is a key mechanism in decreasing the global ers that inhibit standardization of the trauma nursing health care burden.1 In alignment with comprehensive specialty paradigm among LMICs can have a negative *Peck G, Saluja S, Blitzer DN, et al. Using global surgical indicators to im- effect on care and management of the injured patient prove trauma care in Latin America. Bull Am Coll Surg. 2017;102(4):11-16. (see Table 1, page 36).12

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TABLE 1. SUMMARY OF BARRIERS According to the Center for Projects Developments study THAT INHIBIT TRANSLATION OF published in 2013, Colombia had 7,872 medical specialists, TRAUMA NURSING SPECIALTY 1,471 surgeons, 1,977 anesthesiologists, and 1,008 specialists AMONG LMICs in trauma and orthopaedics.13 Colombia’s workforce density numbers were 1.5 for physicians and 0.8 for nurses per 1,000 • Regional disparities affecting 1 health care workforce population. The National Association of Nurses in Colombia (ANEC) states Colombia had 44,520 registered nurses from • Differences in health care training 1997 to 2015, of which 93 percent were women (see Table • Nonstandardized nursing 2, page 37, for other supporting data).14 However, in the 72 education curriculums nursing graduate programs offered in Colombia, nursing cur- • Minimal leadership training ricula are not designed to prepare nurses for advanced roles for nursing personnel in trauma nursing leadership, surgical systems enhancement, or interprofessional team-based care paradigms.15 36 | • Gender barriers, professional barriers, Brazil, the largest and most populous country in Latin and clinical underutilization America, offers free universal health coverage to all of its • Lack of trauma nursing specialists 207 million residents.16 According to the Federal Councils • Lack of clarity in trauma nurse specialty of Nursing and Medicine, the provider-to-patient ratio per 10,000 population is 22.9 for nurses and 21.4 for physicians, • Scarcity in literature regarding workforce whereas the ratios for surgeons and anesthesiologists are capacity shortfalls, systems strengthening 10.8 and 8.8 per 100,000 population, respectively, with mal- roles, and nursing advanced degree distribution of health care professionals to the southeast requirements specific to trauma region overall.17,18 Qualifying and quantifying the surgery • Under-designation of trauma and trauma nurse specialty in Brazil’s health system (see programs/systems Table 3, page 38) has proven difficult, as a higher level of • Underdevelopment of grassroots education or training to work in specialty areas is neither performance improvement mandated nor easily assessed. structure and processes Much like Latin America, regional maldistribution in • Early stages of surgery-championed total health care workforce is addressed in the literature policy (such as LCoGS trauma/surgical from other areas of the world, as well. For example, a 2009 nursing workforce density indicator) survey in India estimated health care density in urban areas at 42 health workers per 10,000 population and 11.8 per 10,000 population in rural areas.19 This imbalance was even more exaggerated when levels of qualification and training are considered: physicians, 13.3 urban/3.3 rural; nurses and mid- wives, 15.9 urban/4.1 rural per 10,000 population.19 Similarly, geographic areas that the World Bank has not classified as a LMIC—such as Puerto Rico, an unincorporated area of the U.S.—faced the same financial challenges and lack of human and material resources as those countries that the World Bank does classify as low-income.20 Here, health care

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TABLE 2. AGE DISTRIBUTION OF HEALTH CARE PROFESSIONALS WITH NURSING TRAINING IN COLOMBIA Age group Women Men Total Women Men (percent) (percent) 16–20 2 0 2 ~0% ~0% 21–25 2,362 263 2,625 ~10 ~1 26–30 8,018 958 8,976 ~34 ~4 31–35 6,130 878 7,008 ~26 ~4 36–40 2,026 366 2,392 ~9 ~2 41–45 1,080 158 1,238 ~5 ~1 46–50 694 67 761 ~3 ~0 51–55 416 31 447 ~2 ~0 56–60 174 20 194 ~1 ~0 = or > 61 40 10 50 ~0 ~0 Total 20,942 2,751 23,693 90% 12%

Source: Ortiz LC, Cubides H, Restrepo DA. Labour Characterization of Health Human Talent in Colombia: Approach from Quotation Base Wages to the General System and Social Security of Health. Ministry of Health and Protection: Social Management of Human Talent Development in the Republic of Colombia, 2012.

provider-to-patient ratio was affected when interna- proposing six core indicators to target the magni- | 37 tional migration occurred, increasing the impact of tude of the surgery and trauma burden by the year nursing shortages and specialty gaps on the island.20 2030.26 Specifically, the LCoGS indicated that there This type of shifting in the nursing workforce stem- is a need for global surgical workforce expansion to ming from international migration, as well as a lack 20−40 surgery, anesthesia, and obstetrician physi- of global standardization in nursing education, licen- cian specialists (SAOs) per 100,000 population by the sure, and regulation, affects the quality of care and year 2030. Although SAO roles are clearly delineated, organizational performance globally.21 This drives nursing was more broadly categorized within the regional disparities in care and nursing competen- larger category of “allied health professionals,” and cies.22-23 When specialty specific disparities exist as in a “surgery and/or trauma nursing specialty” work- the example of the trauma nursing specialty, middle- force density indicator was not delineated. However, and high-income countries also experience challenges this may require an adjustment because surgeons are in health care delivery.24 unable to safely, consistently, and repeatedly execute surgical care delivery without nursing specialty pro- fessionals in surgery disciplines that are represented Importance of nurses in surgical by the SAO density. and trauma care delivery Since 2015, Rutgers Global Surgery has partnered Nursing has the largest workforce of any health care with Rutgers School of Nursing, the Panameri- profession and, therefore, may be a solution to provid- can Trauma Society (PTS) nursing leadership, and ing emergency and essential surgical care globally.22-23 select nursing professionals from Latin America to The International Council of Nurses recognized the develop a support system for the role of nursing critical nature and positive health care impact pro- leadership in surgery and trauma nursing special- vided through nursing in its report, Nurses: A Force for ization. The academic interprofessional support Change: Improving Health Systems’ Resilience.25 system intends to empower and enhance interpro- The Lancet Commission on Global Surgery fessional injury care in LMICs through education, (LCoGS) put forth recommendations for implemen- training, networking, and team implementation for tation and evaluation of national surgical systems by continued on page 39

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TABLE 3. BRAZILIAN NURSING IN NUMBERS Nursing Nursing Nurses/ Nurses/ Population Nurses auxiliaries technicians inhabitants 100,000 Rondônia 1,787,279 2,970 8,975 3,309 0.0019 185.14 Acre 816,687 672 4,613 2,050 0.0025 251.01 Amazonas 4,001,667 3,364 27,326 8,731 0.0022 218.18 Roraima 514,229 1,397 4,522 1,394 0.0027 271.09 North Pará 8,272,724 8,326 41,391 10,537 0.0013 127.37 Amapá 782,295 911 8,937 1,748 0.0022 223.45 Tocantins 1,532,902 1,030 10,751 4,712 0.0031 307.39 TOTAL 17,707,783 18,670 106,515 32,481 0.0018 183.43 Maranhão 6,954,036 4,214 32,773 12,090 0.0017 173.86 Piauí 3,212,180 5,832 17,119 8,471 0.0026 263.71 Ceará 8,963,663 14,250 33,747 17,474 0.0019 194.94 Rio Grande do Norte 3,474,998 6,226 18,259 7,931 0.0023 228.23 Paraíba 3,999,415 4,185 20,547 11,223 0.0028 280.62 Northeast Pernambuco 9,410,336 13,015 55,794 20,443 0.0022 217.24 Alagoas 3,358,963 5,606 11,398 5,608 0.0017 166.96 Sergipe 2,265,779 6,811 8,767 4,360 0.0019 192.43 Bahia 15,276,566 14,860 70,334 32,465 0.0021 212.52 38 | TOTAL 56,915,936 74,999 268,738 120,065 0.0021 210.95 Minas Gerais 20,997,560 23,947 103,872 45,542 0.0022 216.89 Espírito Santo 3,973,697 4,164 23,895 8,069 0.0020 203.06 Southeast Rio de Janeiro 16,635,996 51,350 148,805 49,604 0.0030 298.17 São Paulo 44,749,699 192,374 183,090 118,853 0.0027 265.60 TOTAL 86,356,952 271,835 459,662 222,068 0.0026 257.15 Paraná 11,242,720 24,687 44,094 23,074 0.0021 205.24 Santa Catarina 6,910,553 6,902 34,556 13,200 0.0019 191.01 South Rio Grande do Sul 11,286,500 15,207 81,903 23,476 0.0021 208.00 TOTAL 29,439,773 46,796 160,553 59,750 0.0020 202.96 Mato Grosso do Sul 2,682,386 3,576 12,042 5,995 0.0022 223.50 Mato Grosso 3,305,531 2,783 15,228 7,935 0.0024 240.05 Midwest Goiás 6,695,855 5,265 33,762 13,977 0.0021 208.74 Distrito Federal 2,977,216 3,351 31,731 12,101 0.0041 406.45 TOTAL 15,660,988 14,975 92,763 40,008 0.0026 255.46 Brasil 206,081,432 427,275 1,088,231 474,372 0.0023 230.19

Sources:

Brazilian Institute of Geography and Statistics. Estimates of the resident population in Brazil and Federative Units with reference date on July 1, 2016. Available at ww2.ibge.gov.br/home/estatistica/populacao/estimativa2016/estimativa_tcu.shtm. Accessed August 30, 2016.

Federal Council of Nursing. Nursing in numbers. Available at: www.cofen.gov.br/enfermagem-em-numeros. Accessed August 21, 2017.

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defining trauma nursing workforce and expansion of the specialty TABLE 4. (see Table 4, this page). 2016 AND 2017 NURSING When we combine the LCoGS report and these symposia/ SYMPOSIA AND WORKSHOP AIMS workshop goals, the aim of improving surgical care delivery through maximizing the capability of existing workforce through • Effectively promote nursing roles in: improved nursing education, teamwork, and leadership begins ȖȖ Trauma program leadership to take shape in the international settings mentioned previously. Ȗ Performance improvement Surgery and trauma nursing leadership could allow for an inter- Ȗ professional establishment and continued development of data ȖȖ Data management registry, performance improvement, and quality assurance initia- ȖȖ Systems strengthening tives, and be critical to decreasing perioperative mortality rates Ȗ Modeling of interprofessional and increasing the total number of surgical interventions (LCoGS Ȗ team-based care surgical care delivery indicators 3 and 4; see Table 5, page 40). To achieve LCoGS national surgery/trauma qualification and • Provide interprofessional forums | 39 quantification of LCoGS surgery care delivery indicators and for sharing global perspectives World Development Indicator targets by 2030, nursing leader- on existent barriers ship and task-sharing in these systems administrative roles may • Enhance understanding of nursing prove to be pivotal. perspectives on respective trauma hospital and program landscapes in LMICs Promoting the role of the trauma nurse Globally, there is documented confusion about the role, impor- tance, and the conceptual application of the trauma nurse specialty.12 The role of the trauma program manager (TPM), a nursing leadership position required for trauma center des- ignation in North America, evolved as a result of inputs from the Society for Trauma Nurses and the American College of Surgeons (ACS) Committee on Trauma. Crouch and col- leagues explained how a trauma nurse coordinator role in one country held 17 titles, and Walter and Curtis explained global variance between the context, scope, and impact of trauma practice.12,27 Barleycorn and colleagues discussed the differ- ences in trauma training and education within LMICs, stating, “trauma education should be differentiated for newly qualified nurses and those with experience,” and “advanced-level train- ing should focus on teamwork, trauma nurse leadership, and crisis-management skills.”24 Promotion of nursing leadership skills within every stage of the trauma program may foster intrapersonal and interper- sonal consistency in various trauma nursing specialty roles,

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TABLE 5. LCoGS CORE INDICATORS AND ASSOCIATED TRAUMA PROGRAM/SYSTEM ELEMENT LCoGS Proposed trauma program/ Category indicator Description system element focus The geographic accessibility Prehospital system 1 of surgical facilities and integration with hospital registry Preparedness The density of specialist Acute care surgeon/fellowships; trauma 2* surgical providers program manager The number of surgical procedures Trauma and emergent/essential hospital/ 3* provided per 100,000 population societal registries Trauma and emergent/essential Delivery hospital/societal registries, formal 30-day perioperative 4 trauma performance improvement mortality rates and patient safety, and trauma morbidity/mortality review process The risk of impoverishing Future work—ministries of health/ 5* expenditure when education/finance and trauma/acute care surgery is required surgery divisional business administration Impact The risk of catastrophic Future work—ministries of health/ 6* expenditure when education/finance and trauma/acute care surgery is required surgery divisional business administration *World development indicators

40 | enable systems workload task sharing, promulgate training that could promote this simple paradigm interprofessional care, increase cost-effectiveness, in the LMICs seemingly perpetuates professional and diversify the talents of existing human capital. and gender disparities in surgery and trauma work- Nursing leadership and collaboration with surgeons force leadership. within surgery/trauma program process improve- ment (PI) activities is a process that improves surgery care delivery by identifying preventable Call for action or potentially preventable complications and partici- To meet the metrics set forth within the 2030 LCoGS pating in loop closure after collaborative nurse and document, the present generation of nurses must be surgeon identification of opportunities for improve- systemically educated, trained, and empowered in ment. However, there is no evidence to suggest this leadership positions around the world. A focused occurs on a regular basis, or with interprofessional engagement of an interprofessional workforce participation, in the LMICs. PI directorship is an may stimulate systems enhancement and assist in example of a leadership responsibility that a TPM addressing the global surgical burden. could fulfill in an international application of the Surgical care is in a period of marked transition. TPM role. As the TPM oversees the trauma program The burden imposed by professional, economic, in its entirety, unit or departmental trauma nurse social, and surgery’s gender culture barriers exac- managers can distribute capacity in order to pri- erbates global surgical care deficits. The need to oritize growth of other components of the trauma transition from a traditional hierarchical to a team- program (for example, injury prevention, trauma based interprofessional care model is evident.4 The registry, trauma education, and so on). Another transition in Latin America requires collaborative trauma nurse specialist role includes the PI coor- interprofessional and multinational action between dinator, who may fulfill a PI leadership role, that advocacy groups such as the ACS and the PTS, and allows off-loading from the TPM during the early linkage to national surgical societies in LMICs. For stages of TPM leadership. However, the underde- this type of evolution to be successful, an earnest velopment of affordable and quality education/ evaluation of any individual and organizational

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gender and professional-based gaps must REFERENCES be conducted together and transparently. 1. World Health Organization. Working Together for Health: World Health The extension of qualified nursing Report 2006. Available at: www.who.int/whr/2006/en/. Accessed specialty roles into hospital, national, September 15, 2017. societal, and ministerial leadership 2. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaén CR. Journey to the patient-centered medical home: A qualitative analysis positions will require formal policy of the experiences of practices in the National Demonstration Project. development and action. The authors Ann Fam Med. 2010;8(Suppl 1):S45-S56. doi:10.1370/afm.1075. advocate for the delineation of a spe- 3. Palese A, Mesaglio M, De Lucia P, et al. Nursing effectiveness in Italy: cific nursing specialty workforce density Findings from a grounded theory study. J Nurs Manag. 2013;21(2):251- alongside the physicians’ specialist SAO 262. 4. Banki F, Ochoa K, Carrillo ME, et al. A surgical team with focus on indicator. The modification of SAO to staff education in a community hospital improves outcomes, costs and include nursing specialists will aid in patient satisfaction. Am J Surg. 2013;206(6):1007-1014, disc. 1014-1015. achieving the intent specified within 5. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Working Together for Health and be instru- Harris M. Nurse staffing and inpatient hospital mortality. N Eng J Med. | 41 mental in crossing professional and 2011;364(11):1037-1045. 6. Agency for Healthcare Research and Quality. Safety Culture. AHRQ gender chasms to properly align surgi- Patient Safety Network. June 2017. Available at: https://psnet.ahrq. cal care delivery and successful national gov/primers/primer/5/safety-culture. Accessed April 22, 2017. surgical planning in LMICs that achieves 7. The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors the WHA Resolution 68.15. ♦ that undermine a culture of safety. July 2008. Available at: www. jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_ undermine_a_culture_of_safety/. Accessed August 4, 2016. 8. Australian Government. Workforce Gender Equality Agency. Gender Acknowledgements composition of the workforce: By industry. Available at: www.wgea. The authors would like to thank the fol- gov.au/sites/default/files/Gender%20composition-of-the-workforce- lowing individuals for their contributions by-industry.pdf. Accessed September 15, 2017. to this article and the work described in 9. Catalyst Inc. Women in male-dominated industries and occupations. May 2017. Available at: www.catalyst.org/knowledge/women-male- it: Jorge Esteban Foianini, MD, FACS, sec- dominated-industries-and-occupations. Accessed September 15, 2017. retary-treasurer, Panamerican Trauma 10. World Health Organization. Gender and health workforce statistics. Society; Jasmine Garces-King, DNP, RN, 2008. Available at: www.who.int/hrh/statistics/spotlight_2.pdf. CCRN, TCRN, ACNP-BC, trauma program Accessed September 21, 2017. director, Orange Regional Medical Center, 11. Roy N, Gerdin M, Ghosh SN, et al. The Chennai consensus on in- hospital trauma care for India. J Emerg Trauma Shock. 2016;9(2):90-92. Middletown, NY; chair, leadership commit- 12. Walter E, Curtis K. The role and impact of the specialist trauma nurse: tee, Society of Trauma Nurses; and course An integrative review. J Trauma Nurs. 22(3):153-169. director, trauma nursing course, Panameri- 13. Amaya Lara LJ, Chavarro D, Romero Silva G, et al. Study of can Trauma Society; Allissa Gerdes, MPH, availability and distribution of the specialist doctors offered in services global surgery program coordinator, Rut- of high and medium complexity in Colombia. Center for Project Development. Bogota: Pontifica University Javeriana; 2013. gers Robert Wood Johnson Medical School 14. Carvallo Suárez B. Social-labor indicators of Registered Nurse (RWJMS) acute care surgery division, Professionals by ANEC. Official Publication of National Association of New Brunswick, NJ; Vicente H. Gracias, Nurses in Colombia. 2016;81:66-68. MD, FACS, senior vice-chancellor, clinical continued on next page affairs, Rutgers Biomedical Health Sciences,

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president and chair of Rutgers Health Group; REFERENCES, CONTINUED and professor of surgery, Rutgers University 15. Carvallo Suárez B. Participation of ANEC in the forum about RWJMS; John G. Meara, MD, DMD, MBA, Advanced Practice Nursing. Official Publication of the National FACS, director, Program in Global Surgery Association of Nurses in Colombia. 2016;81:14-16. and Social Change, Harvard Medical School; 16. Brazilian Institute of Geography and Statistics. Estimates of the resident population in Brazil and Federative Units with reference chair, department of plastic and oral surgery, date on July 1, 2016. Available at: https://ww2.ibge.gov.br/home/ Boston Children’s Hospital; and co-chair, The estatistica/populacao/estimativa2016/estimativa_tcu.shtm. Accessed Lancet Commission on Global Surgery; Edgar August 30, 2016. Rodas, MD, FACS, associate professor of sur- 17. Federal Council of Medicine. Medical Portal: Statistics, Federal gery, division of acute care surgery, Virginia District, 2017. Available at http://portal.cfm.org.br/index. php?option=com_estatistica. Accessed August 21, 2017. Commonwealth University School of Medi- 18. Federal Council of Nursing. Nursing in numbers. Available at: www. cine, Richmond; member of the Panamerican cofen.gov.br/enfermagem-em-numeros. Accessed August 21, 2017. Trauma Society Trauma Systems Committee; 19. Rao K. Bhatnagar A, Bernman P. India’s health workforce: Size, 42 | and co-chair of the Panamerican Trauma Sys- composition, and distribution. India Health Beat. 2009;1(3). Available at: tems Committee’s Indicators Working Group; http://documents.worldbank.org/curated/en/928481468284348996/ Indias-health-workforce-size-composition-and-distribution. Accessed and Yuly Andrea Santa Mejia, Enf. Esp., nurse September 21, 2017. specialist in adult critical care, La Universidad 20. Patron M. Puerto Rico’s exodus of doctors adds health care strain to de Antioquia; and an emergency nurse, Hospital dire financial crisis. Available at: www.nbcnews.com/news/latino/ San Vicente Fundación, Medellin, Colombia. puerto-rico-s-exodus-doctors-adds-health-care-strain-dire-n783776. Accessed September 21, 2017. 21. Jones CB, Sherwood GD. The globalization of the nursing workforce: Pulling the pieces together. Nurs Outlook. 2014;62(1):59-63. 22. World Health Organization. Global initiative for emergency and essential surgical care. Available at: www.who.int/surgery/ globalinitiative/en/. Accessed September 21, 2017. 23. World Health Organization. Managing the healthcare workforce migration. Global Code of Practice. May 2010. Available at: www.who. int/hrh/migration/code/practice/en/. Accessed Septembers 21, 2017. 24. Barleycorn D. Trauma nursing development in England: Insight from South Africa. Int Emerg Nurs. 2013;21(3):190-193. 25. International Council of Nurses. 2016–Nurses: A Force for Change: Improving Health Systems’ Resilience. Available at: www.icn.ch/ publications/2016-nurses-a-force-for-change-improving-health- systems-resilience/. Accessed September 2, 2017. 26. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569-624. 27. Crouch R, McHale H, Palfrey R, Curtis K. The trauma nurse coordinator in England: A survey of demographics, roles and resources. Int Emerg Nurs. 2015;23(1):8-12.

V102 No 11 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

RAS-ACS Symposium essays: Residents debate the future of leadership in surgery

by Naveen F. Sangji, MD, MPH

ach year, the Advocacy and Issues Commit- health care policy and advocacy, business, and regula- | 43 tee of the Resident and Associate Society of the tion. Other surgeons want to refresh the traditional EAmerican College of Surgeons (RAS-ACS) hosts roles of service, education, and innovative research. a symposium at the Clinical Congress that features a What should surgical leadership look like in the 21st debate on a current and controversial issue relevant to century? Should we strive for a seat at the table of surgeons in training and in practice. The committee business and politics? Or should we strengthen our members selected Reframing Surgical Leadership in commitment to direct patient care, surgical educa- 2017: Surgeon-Scientist or Surgeon-Advocate? as this tion, and research? year’s theme. Surgical residents from across the country par- A changing regulatory and social environment has ticipated in this discussion by submitting essays led to diminished individual surgeon autonomy in the describing the future of leadership in surgery. We operating room (OR) and in patient care. Historically, received a number of impressive entries. The first- the surgeon has been the “captain of the ship” inside place winners, Ciara Huntington, MD, postgraduate and outside the OR. In 2017, the surgeon is one of the year (PGY)-5, general surgery resident, Carolinas many members of a health care team, often with lim- Medical Center Charlotte, NC, and Jeffrey Howard, ited autonomy. MD, PGY-4, general surgery resident, University of In today’s environment, with an ever-increasing Louisville, KY, were invited to present their views focus on quality, safety, and outcomes, every aspect of at the ACS Clinical Congress 2017. Leading the dis- surgical care is scrutinized—from our training models, cussion at the meeting were Amalia Cochran, MD, to our patient care practices, to our OR attire. Although FACS, FCCM, Chair, ACS Professional Association surgeons welcome changes that improve patient out- political action committee Board of Directors, and comes, many are troubled by the increasing regulatory an ACS Governor; Caprice C. Greenberg, MD, MPH, and administrative burdens that lead to further loss of FACS, immediate past-president of the Association for autonomy. How can surgeons preserve their role as Academic Surgery; and David A. Spain, MD, FACS, leaders in patient care? an ACS Governor. Some members of the surgical community advo- Following are the second-place entries on the cate for increased surgeon involvement in the world of topic. ♦

NOV 2017 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

Reframing surgical leadership in 2017: Surgeon-scientist or surgeon-advocate? Surgeon-scientist

by Kunal Jatin Patel, MD

et me start this response by saying that I see recently published an editorial commenting on this absolutely no reason why the answer to this trend, and it is not the only prominent media outlet to Lprompt should not be “both.” However, in the do so.* Keswani and colleagues have gone further in spirit of fostering discussion and debate, I take the characterizing the issue of the diminished focus of basic 44 | viewpoint that the future of surgical leadership science research by the surgical community. In a survey should actually be a return to the roots of surgery and of 2,500 academic surgeons, they identified the factors a return to the prominence of the surgeon-scientist. at play: “pressure to be clinically productive, excessive As a current research fellow in the midst of pursu- administrative responsibilities, difficulty obtaining ing a PhD, I feel particularly compelled to make the extramural funding, and desire for work-life balance.”† case that further deterioration of the traditional roles As a resident, I have the advantage of being on the of the academic surgeon (that is, patient care, surgi- outside looking in, so to speak. Despite what some cal education, and surgical research) can only serve to attending surgeons may think, residents do pay atten- stunt the frequency and magnitude of surgical break- tion when attendings comment (and complain) about throughs. their lives, their pressures, and the inadequate amount of time allocated for the academic opportunities they must and want to pursue. Research can bring acco- Contributing factors lades and prestige to departments and hospitals, but it Much has recently been made of the precipitous decline requires a long-term investment. I do not believe it is of the surgeon-scientist, which is a discussion that cynical to say that most hospital administrators do not appears to largely revolve around the abandonment take a 30,000-foot view of research, which is precisely of research, and especially basic science research, by what is required for basic science. This shortsighted- the surgical community. As such, I believe the discus- ness is driving the shift in mentality across the country. sion should begin there. The scientific journal Nature What I take from all this is an academic environ- ment that views surgical research as an extracurricular *More surgeons must start doing basic science. Nature. 2017;544(7651):393- activity. It is almost as if administrators have the atti- 394. Available at: www.nature.com/news/more-surgeons-must-start- tude of, “You can go out and play after you’ve finished doing-basic-science-1.21874. Accessed September 13, 2017. †Keswani SG, Moles CM, Morowitz M, et al. The future of basic sci- your RVUs [relative value units] for today.” Perhaps ence in academic surgery: Identifying barriers to success for surgeon- most concerning is the fact that this is a trend that has scientists. Ann Surg. 2017;265(6):1053-1059. ‡ been going on for decades and appears to be worsen- Ko CY, Whang EE, Longmire WP, Jr., McFadden DW. Improving the ‡ surgeon’s participation in research: Is it a problem of training or priority? ing. This reduced emphasis on research will not work J Surg Res. 2000;91(1):5-8. in modern-day science. National Institutes of Health

V102 No 11 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

I do not believe it is cynical to say that most hospital administrators do not take a 30,000-foot view of research, which is precisely what is required for basic science. This shortsightedness is driving the shift in mentality across the country.

funding is on the decline, and the direct consequence research do not warrant the effort. The traditions of is an increasingly competitive environment in which surgical research—established over the course of hun- night and weekend science will get one nowhere. We dreds of years—no longer seem worth it. I emphasize live in a world where information and knowledge are the history of surgical research here in an appeal to the changing at an unprecedented rate. Internists, pedi- surgical psyche. For reasons I do not fully understand, atricians, pathologists—these physicians get weeks surgeons, perhaps more than any other specialty, revere allocated out of every month to focus on grant-writ- the history of their field. ing and research. At my institution, we have an entire society dedi- This forum is not intended to attack other spe- cated to the celebration of surgical history and surgical cialties, but it does not take a highly critical mind to breakthroughs. The residents and attendings alike fawn identify the patterns emerging when it comes to the over the giants of surgery. Physicians such as Alexis inequities in supporting research and grant writing Carrel, MD; Joseph Lister, MD; Ephraim McDowell, | 45 activity. Procedure-based specialties are invariably seen MD; or Norman Shumway, MD, PhD, FACS, are cel- as the revenue generators. However, there are no “off- ebrated for lifetimes worth of achievement, and yet we service” weeks for surgeons. Maybe there are some simultaneously abandon their legacies when we deem- days where your partners begrudgingly round on your phasize the essential role of surgeons in modern-day patients, but those never seem to happen as often as research. The need for more surgical breakthroughs they should, or as often as your contract had promised. will never disappear as long as surgical disease exists. Given these circumstances, how exactly do you write More to the point, the need for surgeons to make those a $1 million basic science grant with outdated knowl- breakthroughs will never disappear. edge of the field in your “free time?” We have all been on the receiving end of consults from services that have little-to-no understanding of surgical disease or operational processes. Basic science Making surgical science appealing again research is the same story in a different setting. How While the problem is clear, the solution is perhaps less can we expect physicians or basic scientists to address obvious. Nevertheless, the value of supporting basic the problems of transplant-related ischemia reperfusion science research needs to be emphasized. I want to be injury if they have never even witnessed an organ pro- a purely academic surgeon, with a productive lab and curement? I have classes with graduate students and a robust practice. Admittedly, these professional goals pre-clinical MD/PhD students who have never set foot may seem increasingly ridiculous considering the asser- near a patient, and it is painfully obvious that, while tions I’ve made in this essay. they can regurgitate the appropriate words and phrases, In fact, many of my co-residents and colleagues the real burdens of these diseases are lost on them. To across the country have different visions for their lives. resolve the causes of and treatments for surgical dis- The same factors identified as hindering academic ease, we need the involvement of surgeons. Bench to success are identified for avoiding academic surgery bedside only works when you have a foothold in both. altogether: pressures, responsibilities, lack of balance. The abandonment of the bench by surgeons is surely While few would argue against the importance of an abandonment of surgical progress. Society cannot research, many would argue the current barriers to afford for us to shirk this responsibility.♦

NOV 2017 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

Reframing surgical leadership in 2017: Surgeon-scientist or surgeon-advocate? Surgeon-advocate

by Neeraja Nagarajan, MD, MPH 46 |

“Medicine is a social science, and politics is nothing else but medicine on a large scale.” — Rudolf Virchow1

ate last week, I was struck with a familiar sense of helplessness. My patient, Mr. J, a gentleman in his L30s, had a piece of his skull missing, was nonver- bal, and scored a three on the Glasgow Coma Scale. He was admitted for injuries sustained after being brutally assaulted while in prison. Having already undergone multiple operations, the prognosis for the return of his neurological function was close to zero. As surgeons, we are trained to solve the problems in front of us—to work with our minds and hands to “fix” issues. However, we often care for patients like Mr. J for whom we have little to offer, those we cannot help get better using only our surgical skills. The issues that affect the care of these surgical patients are complex and run along society’s fault lines—imperfect health care delivery systems, unequal access to care, gun violence, homelessness, structural racism, and institutionalized sexism. As such, the solutions need to go beyond the traditional definitions of surgical care and straddle the social, economic, and the political.

V102 No 11 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

It is clear that for surgeons to continue to provide excellent clinical care, remain relevant in today’s health care environment, and strive for societal well-being as a whole, we have to be prepared to fully engage with health care in its entirety and lend ourselves to being not just clinicians and scientists, but also strident health care advocates.

The evolving role of the surgeon-advocate A curious mix of naivety and arrogance has kept The history of surgery illustrates the ever-changing surgeons from engaging in policy work and politi- role and scope of the surgeon and what they can cal discourse. There is a tendency to view the study do—from the “minimally educated, itinerant barber and practice of policy, advocacy, and public health as surgeons” of lore to today’s highly respected surgeon- incompatible with real surgery, and that contributing scientists who practice evidence-based medicine.2 to policymaking is something we only do when we can The surgeon-scientist has, over the last century, no longer perform surgery and engage in hard science. built an impressive body of work that often exists at The reality is, health care and health policy experts the intersection of the social sciences and surgical care. exert influence over what kind of operations we can Rigorous scientific inquiry has helped determine the perform, the setting in which we perform them, who causes of disease processes, while research has helped has access to our services, what our remuneration will quantify the effect of socioeconomic determinants on be, and ultimately, how well we can do our jobs, and individual and community health.3 However, today’s how satisfied we are performing them. As the surgeon- | 47 health care climate and its unique challenges mean scientists among us well know, political will is linked that surgeon-leaders are called upon to take on new to priority setting in biomedical research, and influ- roles that move beyond well-established clinical and ences what kinds of research gets bankrolled, which research frameworks. disease studies are funded, what research methods Whereas health care problems are myriad, there are we use, and which regions of the U.S. and around the striking commonalities in the reasons that contribute world receive allocated resources. to their continued prevalence. For example, smoking, a known carcinogen, is staging a comeback among young adults, especially in low- and middle-income Engagement at all levels countries.4 Obesity, a leading modifiable cause of mor- It is clear that for surgeons to continue to provide excel- tality and morbidity, remains difficult to prevent and lent clinical care, remain relevant in today’s health treat despite scientific advancements.5 Gun violence, care environment, and strive for societal well-being with well-understood links to lax gun control laws, as a whole, we have to be prepared to fully engage continues unabated in the U.S.6 with health care in its entirety and lend ourselves to The disparities in health care outcomes for racial, being not just clinicians and scientists, but also stri- ethnic, and sexual minorities are documented exten- dent health care advocates. In doing so, we may seek sively but have yet to be dismantled.7-9 There is little inspiration from those among us who have already scientific uncertainty about the efficacy of vaccines mastered working across disciplines and outside of or the inevitability of global warming—yet we live established paradigms. Surgeons such as Atul Gawa- in interesting times, where scientific evidence is no nde, MD, MPH, FACS, a general and endocrine longer correlated with public opinion or reflected in surgeon, Brigham and Women’s Hospital, Boston, policy change. The failure to find workable solutions MA, and a leader in the discussion of surgical qual- in health care today has not been due to a dearth of ity improvement, have reached millions through the knowledge, but rather to a lack of effective health care written word and focused national attention on topics policies, consensus among stakeholders, targeted heath as varied as surgical safety and end-of-life decisions.10 education, and political action. Others like Dorry Segev, MD, PhD, FACS, a transplant

NOV 2017 BULLETIN American College of Surgeons RAS-ACS SYMPOSIUM: REFRAMING SURGICAL LEADERSHIP

surgeon at Johns Hopkins University, Balti- REFERENCES more, MD, and an internationally recognized 1. JRA. Virchow misquoted, part‐quoted, and the real McCoy. J Epidemiol expert in the area of organ allocation, have Community Health. 2006;60(8):671. Available at: www.ncbi.nlm.nih. taken their research to Capitol Hill and spear- gov/pmc/articles/PMC2588080/. Accessed October 13, 2017. 2. Evers BM. The evolving role of the surgeon scientist. J Am Coll Surg. headed the passage of legislation that allows 2015;220(4):387-395. for human immunodeficiency virus-positive 3. Marmot M. Social determinants of health inequalities. Lancet. organ transplant.11 Other physicians, such as 2005;365(9464):1099-1104. Melina Kibbe, MD, FACS, chair, department 4. World Health Organization. Tobacco fact sheet. May 2017. Available of surgery, University of North Carolina at at: www.who.int/mediacentre/factsheets/fs339/en/. Accessed September 13, 2017. Chapel Hill, have harnessed the power of the 5. U.S. Department of Health and Human Services. National Institute of media to draw attention to gender disparities Diabetes and Digestive and Kidney Diseases. Overweight & Obesity in research and the widespread implications Statistics. Available at: www.niddk.nih.gov/health-information/ 48 | it has for efficacy and safety of treatment health-statistics/overweight-obesity. Accessed September 13, 2017. modalities in the market.12 Along with these 6. Center for Gun Policy and Research, Johns Hopkins Bloomberg School of Public Health. Webster DW, Vernick JS (Eds). Reducing gun high-profile examples of surgeon-advocates in violence in America: Informing policy with evidence and analysis. action, there are many others who are quietly The Johns Hopkins University Press. 2013. Available at: h t t p s :// collaborating with and leading stakeholders, jhupress.files.wordpress.com/2013/01/1421411113_updf.pdf. Accessed including patients, patient advocates, policy- September 13, 2017. makers, public health professionals, the media, 7. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley and others through this turbulent era in health BD, Stith AY, Nelson AR (Eds). Unequal treatment: Confronting care. racial and ethnic disparities in health care. Washington, DC: National As surgeons, we prize single-minded Academies Press; 2002. focus and a certain insularity in our dedica- 8. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, tion to our craft, but we should vigilantly Landers S. Sexual and gender minority health: What we know and what needs to be done. Am J Public Health. 2008;98(6):989-995. stand guard against this single-mindedness 9. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care blinding us to the struggles of the patients we by race, ethnicity, and language among the insured: Findings from a serve. Surgery is responsibility—our careers national sample. Med Care. 2002;40(1):52-59. and our lives are built upon this foundation. 10. Sandhu S. Atul Gawande: If I haven’t succeeded in making you itchy, But how far does this responsibility go? Does disgusted or cry I haven’t done my job. The Guardian. October 11, 2014. Available at: www.theguardian.com/books/2014/oct/11/atul- it stop with caring for Mr. J as he is now, or gawande-surgeon-author-interview. Accessed September 13, 2017. does it extend to preventing this situation 11. Victor D. Johns Hopkins to perform first H.I.V.-positive organ from happening to others? Should a surgeon transplants in U.S. New York Times. February 10, 2016. Available at: try to address the issues related to mass incar- www.nytimes.com/2016/02/11/health/johns-hopkins-wins-approval- ceration, the disproportionate arrests of men to-perform-hiv-positive-organ-transplants.html?mcubz=3&_r=0. Accessed September 13, 2017. of color, and the effects of structural vio- 12. CBS News. Sex differences in medical research 2014. Available at: lence on patients and their families? The www.cbsnews.com/videos/sex-differences-in-medical-research/. answer, I realized, captures the essence of Accessed September 12, 2017. what I believe is the role and future of sur- geons as leaders. ♦

V102 No 11 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

The New Medicare Card Project

by Lauren Foe, MPH, and Sadhana Chalasani

he New Medicare Unlike HICNs, which Card Project, which list patients’ SSNs, MBIs are What is the timeline for the Twas established in the generated as “non-intelligent” New Medicare Card Project? Medicare Access and CHIP unique identifiers, so they do CMS will begin mailing the (Children’s Health Insurance not have any special meaning new cards in April 2018 and will Program) Reauthorization Act specific to beneficiaries. replace all old Medicare cards of 2015, requires the Centers Although MBIs are “non- by April 2019. To help practices for Medicare & Medicaid intelligent,” they are still successfully convert to the Services (CMS) to remove confidential identifiers and MBI system, CMS will offer a Social Security numbers (SSNs) should be used only for transition period, beginning from all Medicare cards by Medicare-related business. April 1, 2018, and ending April 2019. CMS will issue new December 31, 2019, during which Medicare cards that will feature providers will be allowed to a Medicare Beneficiary Identifier How does CMS plan to submit either the HICN or MBI (MBI) in place of the SSN-based implement the New when billing Medicare. Providers Health Insurance Claim Number Medicare Card Project? should not submit both numbers (HICN), which is used to track CMS has a three-step on the same transaction. | 49 Medicare billing, eligibility plan to execute the New After the 21-month transition status, and claim status. Medicare Card Project: period, CMS will not accept claims that include HICNs. 1. Generate MBIs for all CMS requires that all providers Why is CMS issuing new beneficiaries. MBIs will be who submit or receive Medicare Medicare cards? assigned to existing (active, transactions containing HICNs In addition to meeting a deceased, or archived) modify their processes and requirement mandated by and new beneficiaries. electronic systems and be ready statute, CMS is issuing new to accept MBIs by April 1, 2018. Medicare cards to combat 2. Educate stakeholders and While providers must use identity theft and illegal use distribute new Medicare MBIs after December 31, 2019, of Medicare benefits. The new cards. CMS will mail the new HICNs may still be used in the Medicare cards will feature Medicare cards in geographical following Medicare transactions: the MBI, which is a randomly waves. CMS will conduct assigned number integral to targeted local outreach to • Claims appeals: CMS will accept this fraud-prevention effort. patients, caregivers, and appeals requests and related forms MBIs will comprise a mix providers before the new that contain either a HICN or MBI. of 11 uppercase alphabetic cards are due to arrive in and numeric characters. The a geographical area. • Claims status queries: Providers second, fifth, eighth, and can use either HICNs or MBIs to ninth characters of the MBI 3. Modify the systems and business check the status of a claim with will always be alphabetic. processes. CMS will provide a date of service on or before The use of several alphabetic regular updates to accommodate December 31, 2019. characters makes MBIs visibly receipt, transmission, distinguishable from HICNs, display, and processing of • Span-date claims: Providers can which are primarily numeric. the newly assigned MBI. submit claims using either the

NOV 2017 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

HICN or MBI for patients who is intended for providers to be asp?questionID=3704) and update began receiving services in an able to access a beneficiary’s MBI their Medicare records, which inpatient hospital, home health, or at the point of service without may require coordinating between religious nonmedical health care disrupting the clinical workflow. billing and office staff. institution before December 31, CMS encourages practices to 2019, but stop receiving such subscribe to their MAC’s portal • Work with CMS to help Medicare services after December 31, 2019. to ensure that providers have a patients adjust to their new mechanism to access patients’ Medicare cards. CMS will produce MBIs. CMS has created a list of posters and other educational Will these new Medicare cards MAC websites (www.cms.gov/ materials (www.cms.gov/Medicare/ affect Medicare benefits? Medicare/New-Medicare-Card/ New-Medicare-Card/New-Medicare- No, the new Medicare cards Providers/MACs-Provider-Portals- Card-Messaging-Guidelines-July-2017. and MBIs will not affect by-State.pdf) to help providers pdf) that providers can share with the benefits that a Medicare locate their MAC’s portal. patients to educate them about beneficiary receives. New Medicare Card Project- related changes. What steps can providers What resources will be take to prepare for the • Prepare to use the new MBI 50 | available for providers to new Medicare cards? format by asking billing and office look up patient MBIs? • Visit the CMS provider website staff to ensure that the practice Starting in April 2018, when (www.cms.gov/Medicare/New- management systems being providers input a HICN into Medicare-Card/Providers/Providers. used can accept the 11-character the HIPAA (Health Insurance html) and sign up for the weekly alphanumeric MBI. In addition, Portability and Accountability Medicare Learning Network (MLN) providers should confirm that Act) Eligibility Transaction Connects newsletter (www.cms. vendors used to bill Medicare are System (also known as HETS) gov/Outreach-and-Education/ ready for the change. to check a patient’s Medicare Outreach/FFSProvPartProg/Provider- eligibility status, the system Partnership-Email-Archive.html) will indicate whether CMS to receive updates on the New Where can I go for more has mailed a new Medicare Medicare Card Project. information or questions on card to the beneficiary. CMS the New Medicare Card Project? will begin including both the • Participate in CMS quarterly calls More information about the New HICN and MBI on every claims to get additional New Medicare Medicare Card Project is available processing decision sent to Card Project information. CMS on the CMS website (www.cms. providers in October 2018. will let providers know when calls gov/Medicare/New-Medicare-Card). In June 2018, CMS will release are scheduled in MLN Connects. Surgeons who have an MBI look-up tool in Medicare questions about complying Administrative Contractor (MAC) • Verify all Medicare patient with the New Medicare Card secure web portals that will allow addresses. If the addresses on file Project may contact CMS at providers to look up MBIs for are different from the addresses NewMedicareCardSSNRemoval@ Medicare beneficiaries. To find listed on electronic eligibility cms.hhs.gov, or the American a beneficiary’s MBI in the MAC transactions, providers should College of Surgeons Division of portal, providers must know the ask patients to contact the Social Advocacy and Healthy Policy patient’s first name, last name, Security Administration (https:// at [email protected]. ♦ date of birth, and SSN. This tool faq.ssa.gov/ics/support/KBAnswer.

V102 No 11 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

Quality improvement in imaging strategies for pediatric appendicitis by Ilan I. Maizlin, MD, MSPH; Michelle C. Shroyer, MPH; Tal Koppelmann, MD; and Robert T. Russell, MD, MPH, FACS

ppendicitis is the most and risk of removing a normal outlier for compliance with common abdominal appendix, there exists a great the ACR guidelines. The rate Asurgical procedure in the variation among children’s of preoperative CT scan use pediatric population, yet diagnosis hospitals in US and CT use and at Children’s of Alabama was can prove challenging in many negative appendectomy rates.4 70 percent of all appendicitis cases.1 Standard diagnostic This variance remains a critical admissions, which is well above approaches include history and problem in pediatric surgery, the aggregate cohort rate of physical exam, white blood cell in light of extensive literature approximately 25 percent. count, and diagnostic imaging. detailing the adverse effects of Similarly, only 30 percent of Both ultrasound (US) and increased CT scan usage, such as appendicitis admissions at computed tomography (CT) exposure to ionizing radiation, Children’s of Alabama had scans have been reported to and risk of future malignancies preoperative US scans in contrast improve diagnostic accuracy in the pediatric population.5 to an aggregate cohort rate of in appendicitis. Although CT approximately 85 percent. has a higher sensitivity for | 51 diagnosing appendicitis than The local problem: US, ongoing concerns have Overuse of CT scans How was the QI activity been raised about the radiation Children’s of Alabama, put in place? exposure and increased costs Birmingham, is a tertiary care, To address the overuse of CT associated with CT scans.2 freestanding children’s hospital. scans, Children’s of Alabama The American College of It is a 380-bed facility, which created a multidisciplinary Radiology (ACR) has published provides services to all pediatric focus group comprising senior guidelines that state, “In patients in the state of Alabama, members of the department children, US is the preferred resulting in approximately 15,000 of pediatric surgery, pediatric initial examination as it is nearly annual overall admissions and emergency medicine, and as accurate as CT for diagnosis 6,200 annual surgical admissions. pediatric radiology. This group of appendicitis but is without Approximately 75 percent of was charged with establishing ionizing radiation exposure.”3 surgical admissions present the best clinical and radiological Without diagnostic imaging, directly to the children’s hospital, approach to evaluating pediatric misdiagnosis of appendicitis can whereas 25 percent are transferred appendicitis. The group met carry significant consequences, from other facilities in the state. three times over the period of including progression to In a recent comparative several months in order to direct perforated disease in a case of analysis of 29 children’s hospitals its focus to specific issues. missed appendicitis; and in a case participating in the American The first meeting centered of a “negative appendectomy,” the College of Surgeons National on initial exploration. Group considerable cost and morbidity Surgical Quality Improvement members discussed and described of undergoing an unnecessary Program Pediatric (ACS NSQIP® current methods of evaluating a operation. Although the goal Pediatric), Children’s of Alabama child with suspected appendicitis. of evaluating patients with was noted to be a high outlier Specific topics of focus were suspected appendicitis is timely for preoperative CT scan use perceived barriers for use of US in diagnosis with minimal CT use for appendicitis and a low suspected appendicitis, perceived

NOV 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 1. CLINICAL DECISION ALGORITHM BASED ON THE PAS

52 | radiological challenges, and to gather feedback from all can use when faced with diagnosis specific populations that may clinicians, house staff, nurses, of a child with appendicitis need to forgo imaging or need CT and radiology technicians prior imaging. As part of this meeting, to implementation. At the final • Create a standard template the workgroup created a standard meeting, which occurred mid- for reporting of US findings in template for the reporting of implementation, the group children with appendicitis to aid US findings in children with addressed challenges with the physician in deciding whether appendicitis to aid the physician implementation of the algorithm, to pursue surgery or additional in making a decision about adherence to the algorithm, diagnostic imaging whether to operate or perform and suggested changes to additional diagnostic imaging. improve the algorithm. • Attempt to achieve a significant At the second meeting, This meeting occurred four reduction in the baseline rate of the group focused on the months after initiation of the CT scan use for children with development of an evidence- algorithm-based approach. suspected appendicitis while based algorithm for the improving the US utilization rate initial evaluation of children with suspected appendicitis, Description of the QI activity To develop the algorithm, a incorporating the barriers Children’s Hospital of comprehensive literature search discussed in the previous Alabama sought to improve was performed to determine the meeting. Following this meeting, the imaging strategies for most appropriate clinical risk the workgroup created an pediatric appendicitis by stratification tool. We opted to algorithm based on the Pediatric concentrating on the following use the PAS developed by Samuel, Appendicitis Score (PAS) as three actionable goals: considering its validation in the described later in this column. literature.2 The PAS allowed for During the third meeting, • Develop an algorithm based on initial patient risk-stratification the group met with the best practices in the literature, into low, moderate, or high risk members of each department which health care professionals for appendicitis. Based on this

V102 No 11 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

FIGURE 2. IMAGING MODALITY USE PRE- AND POST-PROTOCOL IMPLEMENTATION

initial classification, imaging both the implementation and all appendicitis admissions were modalities and other diagnostic success of the QI program. evaluated for demographics, interventions were determined clinical characteristics, use of according to the algorithm diagnostic imaging, and rates outlined in Figure 1, page 52. Necessary resources and skills of negative appendectomies. This algorithm was further Engagement of all pediatric Those variables were then linked with a web-based surgeons, radiologists, and compared with all appendicitis order set in the electronic emergency physicians was crucial admissions in the eight months health record for emergency to the success of this initiative. prior to implementation. medicine providers to enable For that purpose, specific The changes in imaging a “point and click” interface. department-level meetings were modality rates before and after Based on a classification held in each of the specialties protocol implementation are | 53 system developed by Nielsen involved. During those meetings, illustrated in Figure 2, this page. and colleagues, all patients members of the department Since initiation of the PAS-based were grouped into the were encouraged to contribute protocol, the rates of CT scans following categories:6 to the formation of the pathway among appendicitis admissions and were queried regarding the almost halved to 35 percent of • Normal appendix obstacles or difficulties they could admission, while the rates of foresee in its implementation. US studies more than doubled • Appendix not visualized or Consequently, when the to 65 percent of admission. partially visualized without pathway was implemented, Concurrently, no differences secondary signs of appendicitis those individuals were vested were noted in length of hospital in its successful launch. stay; postoperative complication • Appendix not visualized or No additional direct rates; rates of intraoperative partially visualized with clinical costs were incurred. findings of complicated secondary signs of appendicitis The only additional expenses appendicitis (perforation, for this project were in the abscess, and so on); or rates • Acute appendicitis employment of a statistician of negative appendectomy and data entry personnel for between the pre-protocol and Patients in the first two the quarterly evaluations the post-protocol cohorts. categories were considered of US and CT use rates. Approximately 25 percent negative for appendicitis, while of appendicitis admissions those matching the description presented to our institution as in the latter two categories Results transfers from other hospitals were considered positive. The PAS algorithm and throughout the state. Those All data were evaluated on a radiological reporting template patients overwhelmingly quarterly basis to follow trends in were implemented September 1, underwent CT imaging in the use of US and CT, thus monitoring 2016. For the next eight months, referring facilities. To address this

NOV 2017 BULLETIN American College of Surgeons ACS NSQIP BEST PRACTICES CASE STUDIES

Institutions considering undertaking a similar QI activity should evaluate the rates of different imaging modalities used in the appendicitis admissions in their facility and compare them with the ACS NSQIP Pediatric cohort to determine the extent of deviation from the national standard.

problem, Children’s is presenting cohort to determine the extent REFERENCES its protocol and data at local, of deviation from the national 1. Miglioretti DL, Johnson E, Williams regional, and state meetings in an standard. Involve collaborators A, et al. The use of computed effort to increase the rate of US from radiology and emergency tomography in pediatrics and the evaluations in referring facilities. medicine departments at an early associated radiation exposure and estimated cancer risk. JAMA Pediatr. Another setback that stage of planning and create a 2013;167(8):700-707. Children’s of Alabama faced in standardized protocol for clinical 2. Samuel M. Pediatric appendicitis implementing this algorithm is evaluation of right lower quadrant score. J Pediatr Surg. 2002;37(6):877-881. that US scans are not performed pain, which takes into account 3. American College of Radiology, ACR overnight at the facility. Following history, physical findings, and lab appropriateness criteria. Expert panel on gastrointestinal imaging. 2013. a meeting with the pediatric values. Furthermore, evaluate the Available at: https://acsearch.acr. radiology department, the exact radiological capabilities of your org/docs/69357/Narrative/. Accessed timing of US availability was institution when establishing October 3, 2017. determined. That information your clinical pathway. 4. Quigley AJ, Stafrace S. Ultrasound was then disseminated to the To ensure successful assessment of acute appendicitis in paediatric patients: Methodology and house staff in pediatric surgery implementation, the authors pictorial overview of findings seen. 54 | and pediatric emergency recommend interval audits of Insights Imaging. 2013;4(6):741-751. medicine. If individuals with US and CT rates. Arrange a 5. Lee JH, Jeong YK, Park KB, et al. PAS score >3 are evaluated at mid-implementation meeting Operator-dependent techniques for times when US is unavailable, to discuss any concerns or graded compression sonography to detect the appendix and diagnose they are admitted overnight complications, as well as receive acute appendicitis. Am J Roentgenol. for imaging in the morning. feedback on the pathway. 2005;184(1):91-97. Assuming an approximate cost Conduct individual meetings 6. Nielsen JW, Boomer L, Kurtovic K, et of $697 for a limited abdominal US as necessary to address al. Reducing computed tomography and an approximate cost of $3,889 identified barriers created by scans for appendicitis by introduction of a standardized and validated for a CT scan of abdomen/pelvis system process changes. ultrasonography report template. with intravenous contrast, the As final words of advice, J Pediatr Surg. 2015;50(1):144-148. hospital’s pre-protocol imaging Children’s of Alabama found that costs for the monitored period a multidisciplinary effort and was $201,309. Post-protocol the collaboration between surgical, cost was $133,176, yielding a net radiological, and emergency cost savings of $68,133, or a 33.8 medicine specialists is absolutely percent decrease in imaging costs. necessary for such a program to be implemented and maintained. And lastly, create posters of the Lessons learned clinical pathway to be displayed Institutions considering in physician work areas of the undertaking a similar QI activity surgical and emergency house- should evaluate the rates of staff. Those materials can be different imaging modalities used useful in facilitating calculation in the appendicitis admissions in of the PAS score and improving their facility and compare them compliance with the pathway. ♦ with the ACS NSQIP Pediatric

V102 No 11 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Induction chemotherapy and minimally invasive transanal surgery to increase organ preservation in rectal cancer

by Hagen Kennecke, MD, MHA, FRCPC; Y. Nancy You, MD, MHSc, FACS; and Judy C. Boughey, MD, FACS

atients diagnosed with minimally invasive transanal following criteria: T1, T2, or rectal cancer often face the surgery. Study objectives are T3a/b but extend less than 5 mm Ppossibility of complete organ to establish the feasibility and beyond the muscularis propira; loss, and 25 percent of patients safety of this approach to allow amenable to minimally invasive with stage II/III rectal cancer sphincter preservation. transanal excision; and exhibit require a permanent colostomy. Current treatment of T1- no high-risk pathology features. Improvements in systemic T3 rectal tumors includes Patients are treated with therapy and use of neoadjuvant radical surgery with an open or three months of neoadjuvant | 55 treatment have encouraged efforts laparoscopic total mesorectal chemotherapy with FOLFOX to avoid radical resections. This excision (TME), while (Oxaliplatin, Leucovorin, and trend has been seen with other preoperative chemoradiation 5-Fluorouracil) or CAPOX solid malignancies including is added for patients with T3- (Capecitabine and Oxaliplatin). breast, anal, and head and T4 or N+ tumors. Population- If evidence of tumor regression neck cancers. For rectal cancer, based studies in the U.S. have is found on rectal endoscopy there is ongoing investigation documented an increasing use of and MRI, patients proceed to regarding whether preoperative local excision/transanal surgery tumor excision by surgeons chemotherapy along with less in the treatment of T1 or T2 rectal experienced in transanal aggressive surgical resection tumors.1 However, a significant endoscopic microsurgery will allow preservation of the proportion of T1-T2 tumors are (TEMS) or transanal minimally rectum and rectal function and pathologically node-positive and invasive surgery (TAMIS). avoid the need for a stoma. the literature demonstrates an Participating surgeons must have increased rate of local relapse performed at least 20 TEMS/ when patients are treated with TAMIS procedures and must The NEO Trial (CCTG CO28) transanal local excision alone.2-4 submit an unedited video of The CCTG (Canadian Clinical the first patient they enroll. Trials Group) CO28 Neoadjuvant Local excision is permitted chemotherapy, Excision and Staging and treatment for very low tumors when Observation (NEO) Trial has Patients enrolled in CO28 are appropriate. Subsequent been activated at designated staged with pelvic magnetic treatment is determined on centers in the U.S. and Canada. It resonance imaging (MRI) and the basis of tumor pathology aims to treat patients diagnosed endoscopy (see Figure 1, page on the resected specimen. with T1-T3a/b, low- to mid- 56). Clinically node-negative Completely resected tumors rectal tumors with neoadjuvant tumors that are eligible for downstaged to pT0 or pT1 chemotherapy followed by the NEO trial must meet the without any histologic high-

NOV 2017 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

FIGURE 1. STUDY SCHEMA OF THE NEO TRIAL, CO28

The primary endpoint is the rate of downstaging to pT0 or pT1 upon excision after neoadjuvant chemotherapy. The study will be considered successful if at least 65 percent of patients are managed with rectal organ preservation.

risk factors have a low risk of nodal involvement and REFERENCES 5,6 are treated with observation. Endoscopic and cross- 1. Stitzenberg KB, Sanoff HK, Penn DC, Meyers MO, sectional imaging is repeated every four to six months Tepper JE. Practice patterns and long-term survival for 56 | for 36 months and annually in years four and five. early-stage rectal cancer. J Clin Oncol. 2013;31(34):4276- It is recommended that patients with tumors that 4282. 2. Salinas HM, Dursun A, Klos CL, et al. Determining do not achieve downstaging to pT1 after systemic the need for radical surgery in patients with T1 rectal chemotherapy proceed directly to standard TME cancer. Arch Surg. 2011;146(5):540-543. surgery. Preoperative pelvic radiation is recommended 3. Sajid MS, Farag S, Leung P, Sains P, Miles WF, Baig MK. only for patients with ypT3+ or node-positive tumors. Systematic review and meta-analysis of published trials Study leads are Hagen Kennecke, MD, MHA, comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management FRCPC, co-author of this column, and Carl J. of early rectal cancer. Colorectal Dis. 2014;16(1):2-14. Brown, MD, FACS, colon and rectal surgeon, 4. You YN, Baxter NN, Stewart A, Nelson H. Is the Providence Health Care, Vancouver, BC. The study increasing rate of local excision for stage I rectal cancer will be run by the Canadian Clinical Trials Group in the United States justified?: A nationwide cohort at select Canadian and U.S. cancer centers. Per- study from the National Cancer Database. Ann Surg. 2007;245(5):726-733. case funding will be provided and chemotherapy 5. Monson JR, Weiser MR, Buie WD, et al. Standards supply is expected to be commercially available. practice task force of the American Society of Colon and Contact [email protected] Rectal Surgeons. Dis Colon Rectum. 2013;56(5):535-550. for study information and participation. ♦ 6. Greenberg JA, Shibata D, Herndon JE 2nd, Steele GD Jr, Mayer R, Bleday R. Local excision of distal rectal cancer: An update of cancer and leukemia group B 8984. Dis Colon Rectum. 2008;51(8):1185-1191.

V102 No 11 BULLETIN American College of Surgeons FROM THE ARCHIVES

President Eisenhower and his bowel obstruction

FRANKLIN MARTIN, MD, FACS, by Justin Barr, MD, PhD, and Theodore N. Pappas, MD, FACS FOUNDER OF THE AMERICAN COLLEGE OF SURGEONS

he 34th president of the U.S., complicated by bilious vomiting. and Dr. Ravdin as first assistant, Dwight D. Eisenhower, As President Eisenhower’s heart the operation commenced.4 Tunderwent surgery on rate climbed and his blood In the early morning hours June 9, 1956, to treat a small bowel pressure dropped, Dr. Snyder of June 9, the team explored obstruction. After a distinguished initiated intravenous hydration, President Eisenhower’s abdomen career in military and public consulted surgery, and transferred through a right paramedian service, Mr. Eisenhower assumed the president to Walter Reed incision. After lysing adhesions, the presidency in 1952 at age Army Hospital, Washington, DC, they found 30–40 cms of 62.1 A debilitating myocardial where his vital signs stabilized. thickened, indurated, contracted infarction in 1955 had already Once the president was admitted terminal ileum resulting complicated his tenure when to the hospital, a nasogastric tube from Crohn’s, the source of he began experiencing severe was placed that promptly drained the obstruction. They did not abdominal pain on June 8, 1956, voluminous gastric fluid, and observe any active inflammatory after a dinner soirée featuring radiographs confirmed the clinical bowel disease and elected to | 57 Jane Powell and Bob Hope. diagnosis of bowel obstruction. bypass the obstruction with an President Eisenhower had ileocolostomy rather than resect suffered bouts of intestinal the diseased bowel. Intestinal discomfort throughout his life, The surgical team assembles bypass was a common operation with severe symptoms in 1923 The surgical team consisted of in the 1950s, but the choice resulting in an uncomplicated Leonard Heaton, MD, FACS, nonetheless precipitated much appendectomy. After another Surgeon General of the U.S. controversy from physicians episode in May 1956, his Army; Isidor Ravdin, MD, FACS, who believed it left the president physicians diagnosed him with chairman of surgery, University of at increased risk for recurrence. Crohn’s disease, a pathology Pennsylvania, Philadelphia; Brian Subsequent events proved the only recently described in Blades, MD, FACS, chairman team’s decision correct.5 the medical literature.2,3 of surgery, George Washington President Eisenhower’s As President Eisenhower’s University, Washington, DC; recovery was essentially condition degenerated, bowel and John Lyons, MD, FACS, the unremarkable except for a minor obstruction from postoperative premier private practice surgeon wound infection. His prolonged adhesions versus Crohn’s in Washington at the time. convalescence in the hospital disease were the diagnoses When the president’s condition and at his Gettysburg, PA, farm debated among his physicians. failed to improve and follow-up did complicate foreign relations This abdominal pain began radiographs evidenced worsening and arguably contributed to the just after midnight on June 8. The obstruction, the surgical 1956 Suez crisis among Egypt, president’s personal physician, team unanimously agreed to Israel, Great Britain, and France. Howard Snyder, MD, initially operate. President Eisenhower’s President Eisenhower’s incapacity assumed this episode would pass cardiologists concurred that he following the operation and his like the others and prescribed could tolerate a laparotomy, albeit heart attacks eventually led to Milk of Magnesia and a tap water at higher risk. With Dr. Heaton the 25th Amendment, which enema. The pain worsened, designated as primary surgeon established contingency plans

NOV 2017 BULLETIN American College of Surgeons FROM THE ARCHIVES

President Eisenhower receiving his honorary ACS Fellowship in the White House with his medical team, February 6, 1958 From left: Dr. Snyder; Dr. Blades; Dr. Heaton; Dr. Lyons; President Eisenhower; Dr. Ravdin; Frank Berry, MD; and Robert Cutler Source: University Archives, University of Pennsylvania, Ravdin Papers, Box 14, Folder 4

for presidential disability and was ratified in 1967.6 REFERENCES His health continued to deteriorate, with a major 1. Ambrose S. Eisenhower. New York, NY: Simon and stroke in his second term and multiple myocardial Schuster; 1983. 58 | infarctions and bowel obstructions through the 1960s. 2. Crohn BB, Ginzburg L, Oppenheimer GD. Regional A severe obstruction in February 1969 required a ileitis: A pathological and clinical entity. Am J Med. subsequent operation for adhesive disease. President 1952;13(5):583-590. 3. Mulder DJ, Nobel AJ, Justinich CJ, Duffin JM. A tale Eisenhower died on March 28 following this of two diseases: The history of inflammatory bowel 7 surgery from yet another myocardial infarction. disease. J Crohns Colitis. 2014;8(5):341-348. The American College of Surgeons (ACS) provided 4. Heaton LD, Ravdin IS, Blades B, Whelan TJ. President a supporting role throughout President Eisenhower’s Eisenhower’s operation for regional enteritis: A footnote treatment for his small bowel obstruction. In fact, to history. Ann Surg. 1964;159:661-666. 5. Pappas TN. President Eisenhower’s bowel obstruction: Dr. Ravdin was presiding over an ACS Board of The story of his surgeons and their decision to operate. Regents meeting in Chicago, IL, when his wartime Ann Surg. 2013;258(1):192-197. friend Dr. Heaton summoned him to the nation’s 6. Gilbert RE. The impact of presidential illness on the capital. Dr. Ravdin decamped mid-meeting, leaving administration of Dwight D. Eisenhower. Politics Life Loyal Davis, MD, FACS, the 43rd President of Sci. 2012;31(1-2):16-35. 7. Hughes CW, Baugh JH, Mologne LA, Heaton the College, in charge. The day after President LD. A review of the late General Eisenhower’s Eisenhower’s operation, the Board of Regents sent operations: Epilogue to a footnote to history. Ann Surg. Dr. Ravdin a formal letter of reprimand for practicing 1971;173(5):793-799. itinerant surgery.8 In this same, contradictory missive, 8. Ravdin IS. Letter to the American College of Surgeons the Regents simultaneously complimented Dr. Ravdin Board of Regents. June 10, 1956. University of Pennsylvania Archives and Records Center. I.S. (Isidor on “the honor he brought” to the College; it has Schwaner) Ravdin Papers 1912–1972. Box 14, Folder 7. been this panegyric narrative that has endured. In 9. Ravdin IS. Telegram to the American College of 1960, Dr. Ravdin served as President of the ACS. Surgeons from President Eisenhower. October 5, 1956. President Eisenhower formally acknowledged University of Pennsylvania Archives and Records the College for its leader’s assistance, and the College Center. I.S. (Isidor Schwaner) Ravdin Papers 1912–1972. 9,10 Box 12, Folder 6. inducted him as an Honorary Fellow in 1957. ♦ 10. Six distinguished men receive honorary fellowships. Bull Am Coll Surg. 1958;43(1):16-17. Available at: facs.org/about- acs/archives/acshistory/honoraryfellows. Accessed August 1, 2017.

V102 No 11 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Joint Commission details new pain assessment, management standards in R3 Report

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

n late August, The Joint • Visited hospitals to research programs to improve pain Commission released an leading practices on pain assessment, pain management, IR3 Report, also known as assessment and management, and the safe use of opioid the Requirement, Rationale, particularly the safe use of opioids medications based on the and Reference Report, on the identified needs of its patient development of new and revised • Formed a standards review panel population. Joint Commission pain assessment to appraise draft standards and management standards for ȖȖ EP 4: The hospital provides hospitals. The standards are the information to staff and result of an 18-month standards Requirements that may LIPs on available services for revision project that included a affect surgeons consultation and referral of focus on the safe and judicious These pain assessment and patients with complex pain prescribing of opioids. The management standards, which management needs. project was part of a national take effect January 1, 2018, are effort to address the opioid crisis designed to improve the quality ȖȖ EP 6: The hospital facilitates in the U.S., which is designed and safety of care provided by practitioner and pharmacist to ensure that physicians assess Joint Commission-accredited access to the prescription drug | 59 and treat pain appropriately, and hospitals. They require hospitals monitoring program databases. that patients have a substantial to make pain assessment and involvement in pain assessment, management, as well as safe ȖȖ EP 7: Hospital leadership works treatment, and goal setting and opioid prescribing, a priority. with its clinical staff to identify an understanding of the safety What do these standards mean and acquire the equipment issues associated with the use of for surgeons? The hospitals where needed to monitor patients analgesics of all kinds. Surgeons surgeons hold privileges will have who are at high risk for adverse are, of course, deeply involved to meet new requirements that outcomes from opioid treatment. in this issue, given that pain is so will affect pre- and postoperative central to pre- and postoperative activities. Even if these • Medical Staff 05.01.01—The patient management. requirements have no direct effect organized medical staff has a To develop these new on surgery, surgeons will want leadership role in the organization and revised standards, The to be fully informed about the performance improvement Joint Commission engaged standards, which are as follows: activities to improve quality of in the following activities: care, treatment, and services and • Leadership 04.03.13—Pain patient safety. • Conducted an extensive literature assessment and pain management, review, as well as a field review including safe opioid prescribing, ȖȖ EP 18: The medical staff is is identified as an organizational actively involved in pain • Convened a technical priority for the hospital. assessment, pain management, advisory panel—composed of and safe opioid prescribing members of leading health care ȖȖ Element of performance through the following activities: organizations—to talk about (EP) 3: The hospital provides high-quality and safe initiatives staff and licensed independent ƑƑ Participating in the regarding pain assessment and practitioners (LIPs) with establishment of protocols management educational resources and and quality metrics

NOV 2017 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

These pain assessment and management standards, which take effect January 1, 2018, are designed to improve the quality and safety of care provided by Joint Commission-accredited hospitals.

ƑƑ Reviewing the performance ȖȖ EP 6: The hospital monitors care, as well as strategies improvement data patients identified as being to address these issues high risk for adverse outcomes • Provision of Care, Treatment, and related to opioid treatment. ƑƑ Safe use, storage, and disposal Services 01.02.07—The hospital of opioids when prescribed assesses and manages the patient’s ȖȖ EP 7: The hospital reassesses pain and minimizes the risks and responds to the patient’s • Performance Improvement (PI) associated with treatment. pain through the following 01.01.01—The hospital collects activities: data to monitor its performance. ȖEȖ P 3: The hospital treats the patient’s pain or refers the ƑƑ Evaluation and • PI 02.01.01—The hospital compiles patient for treatment. documentation of response(s) and analyzes data. to pain intervention(s) ȖEȖ P 4: The hospital develops a To view the entire list of pain pain treatment plan based on ƑƑ Progress toward pain assessment and management evidence-based practices and management goals standards, which are available the patient’s clinical condition, including functional ability online through the end of past medical history, and pain (for example, ability to the calendar year, visit www. 60 | management goals. take a deep breath, turn jointcommission.org/prepublication_ in bed, and walk with standards_%E2%80%93_standards_ ȖEȖ P 5: The hospital involves improved pain control) revisions_related_to_pain_ patients in the pain assessment_and_management/. management treatment ƑƑ Side effects of treatment After January 1, 2018, these planning process through the standards may be accessed in the following efforts: ƑƑ Risk factors for adverse events main Joint Commission manual. caused by the treatment The R3 Report is a Joint ƑƑ Developing realistic Commission publication for expectations and ȖȖ EP 8: The hospital educates accredited organizations and measurable goals that are the patient and family on interested health care professionals understood by the patient discharge plans related to pain that details the resources used for for the degree, duration, management, including the development of new requirements. and reduction of pain following: The R3 Report goes into more depth than the main manual, ƑDƑ iscussing the objectives ƑƑ Pain management providing a rationale statement used to evaluate treatment plan of care for each element of performance. progress (for example, View the R3 Report at www. relief of pain and ƑƑ Side effects of pain jointcommission.org/r3_issue_11/. ♦ improved physical and management treatment psychosocial function) ƑƑ Activities of daily living, Disclaimer ƑPƑ roviding education on pain including the home The thoughts and opinions expressed management, treatment environment, that might in this column are solely those of options, and safe use of exacerbate pain or reduce Dr. Pellegrini and do not necessarily opioid and nonopioid effectiveness of the pain reflect those of The Joint Commission medications when prescribed management plan of or the American College of Surgeons.

V102 No 11 BULLETIN American College of Surgeons NTDB DATA POINTS

Distraction: Driving and cell phone use

by Richard J. Fantus, MD, FACS

his year marks the 10th fiddling with the entertainment/ Texting is the most alarming anniversary of the iconic navigation system, or reading TiPhone. Similar to what the paper—any action other than activity when the user is Apple’s visionary team did for driving while operating a motor behind the wheel, because the music industry with the vehicle impedes safety. The introduction of the iPod in smartphone, however, has taken reading or sending a text October 2001, Apple reinvented distracted driving to a new level. takes your eyes off the road the smartphone by introducing Texting is the most alarming for up to five seconds. If you a handheld device featuring activity when the user is behind a touchscreen and a virtual the wheel, because reading or were driving at 55 miles per keyboard with capabilities sending a text takes your eyes off hour, that driving distraction including the ability to play the road for up to five seconds. music, send and receive e-mail, If you were driving at 55 miles is the equivalent of driving | 61 browse the web, send and per hour, that driving distraction the entire length of a football receive text messages, and is the equivalent of driving follow GPS navigation. Almost the entire length of a football field with your eyes closed. two-thirds of Americans field with your eyes closed.† owned a smartphone (either an In 2015, according to the U.S. iPhone or other smartphone Department of Transportation, brands) in 2016, representing a National Highway Traffic, and threefold increase from 2010.* Safety Administration (NHTSA), 391,000 people were injured and 3,477 were killed in motor vehicle Driven to distraction crashes involving distracted Distracted driving has always drivers. Teenagers were the been around, whether an largest age group reported as individual was leaning over to driving distracted at the time of pick up an eight-track that had a fatal crash.† During daylight fallen under the car seat, eating a hours, upward of 660,000 drivers meal, shaving, applying makeup, are using smartphones while driving, which is a startling *Statista. Telecommunications. Smartphone penetration rate as share of the population in number of vehicles on the the United States from 2010 to 2022. Available road with distracted drivers. at: www.statista.com/statistics/201183/ The percentage of passenger- forecast-of-smartphone-penetration-in- the-us/. Accessed September 5, 2017. vehicle drivers visibly manipulating †United States Department of handheld devices or text Transportation. National Highway Traffic messaging remained constant Safety Administration. Distracted driving. Available at: www.nhtsa.gov/risky-driving/ in 2015 at 2.2 percent. These distracted-driving. Accessed September 5, 2017. findings are from the National

NOV 2017 BULLETIN American College of Surgeons NTDB DATA POINTS

FIGURE 1. DISCHARGE STATUS

Occupant Protection Use Survey, six records were found that school or in the workplace. which is conducted annually by contained a discharge status, Help all drivers, especially trained data collectors observing including five patients discharged teenagers, avoid the attraction 62 | at probabilistically sampled to home and one to a nursing to driving with distraction. intersections under the auspices home (see Figure 1, this page). Throughout the year, we of NHTSA’s National Center Of these patients, 83 percent will be highlighting these for Statistics and Analysis.‡ were male, on average 28 years data through brief reports that To examine the occurrence of age, had an average hospital will be found monthly in the of drivers injured while using a length of stay of 3.3 days, and an Bulletin. The NTDB Annual handheld interactive electronic average injury severity score of Report 2016 is available on the device in the National Trauma 8.6. Of those tested for alcohol, American College of Surgeons Data Bank® (NTDB®) research two out of five were positive website as a PDF file at facs.org/ admission year 2015, medical and over the legal limit. quality-programs/trauma/ntdb. In records were searched using the addition, information is available International Classification of on our website about how to Diseases (ICD), 10th Revision, Make sure teens get obtain NTDB data for more Clinical Modification codes. the message detailed study. To submit your Specifically searched were records In the transition to ICD-10, the trauma center’s data, contact that contained a code of V40- numbers of distracted drivers Melanie L. Neal, Manager, V49A (car occupant) that had a reported in the NTDB may be NTDB, at [email protected]. ♦ post-decimal place value of zero relatively low for this year, but (driver) and an activity code of the magnitude of the problem Y93.C2 (handheld interactive remains significant, especially Acknowledgement electronic device). A total of for teenage drivers. Parents Statistical support for this article was provided by Ryan Murphy, ‡ United States Department of should lead by example and have Transportation. National Highway Traffic conversations with younger- Data Analyst, NTDB. Safety Administration. Traffic Safety Facts. age drivers about the risks of Driver Electronic Device Use in 2015. Available at: www.nhtsa.gov/sites/nhtsa.dot.gov/ distracted driving. Educators files/documents/driver_electronic_device_use_ and employers can play a in_2015_0.pdf. Accessed September 5, 2017. role by spreading the word at

V102 No 11 BULLETIN American College of Surgeons NEWS

Barbara Lee Bass, MD, FACS, FRCS(Hon), installed as 98th ACS President

Dr. Bass

Barbara Lee Bass, MD, FACS, Before taking on her roles Committee on Education (2003– FRCS(Hon), the John F. and Carolyn at Houston Methodist Hospital 2006) and the Clinical Congress Bookout Presidential Endowed in 2005, Dr. Bass was professor Program Committee (2005–2011). Chair and chair, department of surgery (1994−2005), Prior to becoming a Regent, of surgery, Houston Methodist associate chair for research and Dr. Bass served on the ACS Hospital, TX, was installed academic affairs, and general Board of Governors (1995–2001), as the 98th President of the surgery residency program as a member of the Governors American College of Surgeons director, department of surgery, Executive Committee (1998–2001), (ACS) at the Convocation University of Maryland, and ultimately as Chair (1999– Ceremony at Clinical Congress Baltimore (1999−2005). While 2001). She chaired the Governors’ 2017 in San Diego, CA. at the University of Maryland, Committee on Surgical Practice | 63 Dr. Bass is highly regarded Dr. Bass also served as chief, (1997–1998) and was a member for her outstanding clinical gastrointestinal surgical research of the Governors’ Committees and academic contributions (1994−2005), Veterans Affairs on Socioeconomic Issues (1996– to general surgery and her (VA) Medical Center, Baltimore. 1998) and Physician Competence commitment to teaching the Earlier appointments included (1999–2001). In addition, she next generation of surgeons. She faculty positions at the George served on the ACS Health Policy is the executive director of the Washington University School of Advisory Committee (2008–2010) Houston Methodist Institute Medicine, the Uniformed Services and the Transition to Practice for Technology, Innovation University of Health Sciences workgroup (2012). She served and Education (MITIE), a (USUHS), and the Walter Reed on the ACS Women in Surgery state-of-the-art education and Army Institute of Research. Committee for many years as a research facility developed to A Fellow of the College since member and then as a consultant safely train practicing health 1988 and the 2013 recipient of the until 2014. She delivered the care professionals in new Distinguished Service Award— Olga M. Jonasson, MD, Lecture technologies and procedures. the College’s highest honor— at Clinical Congress 2014. She is professor of surgery Dr. Bass served as an ACS Regent Dr. Bass has been a champion at Weill Cornell Medical (2001–2010) and on the Executive of the National Surgical Quality College, New York, NY, and the Committee of the Board of Improvement Program (ACS Houston Methodist Institute Regents (2005–2009). As a Regent, NSQIP®) since its inception at for Academic Medicine, she was a member of the Finance the VA. While at the VA Medical and senior member of the Committee (2005–2010), Member Center in Baltimore, she helped Houston Methodist Hospital Services Liaison Committee to launch the program, and Research Institute. Dr. Bass (2004–2008), Central Judiciary served as a principal investigator was elected to honorary Committee (2002–2005), and at a participating institution fellowship in the Royal College the Scholarship Committee. She in the Agency for Healthcare of Surgeons earlier this year. is a Past-Chair of both the ACS Research and Quality’s testing

NOV 2017 BULLETIN American College of Surgeons NEWS

Dr. Bass is highly regarded for her outstanding clinical and academic contributions to general surgery and her commitment to teaching the next generation of surgeons.

of the program (1994−2002). She launch this effort, she hosted editor of many surgical journals, went on to serve on the NSQIP the “Retooling Reimagined” including the Journal of the Steering Committee (2004–2010). symposium at MITIE in 2016 American College of Surgeons, A contributor to a number and a national invitational Annals of Surgery, and Surgery. Her of ACS educational initiatives, meeting of stakeholders at continuing practice in endocrine Dr. Bass was an author for the the ACS this summer. and breast surgery affords her Surgical Education and Self- Dr. Bass has held leadership the opportunity to enjoy the Assessment Program (1996−2002). roles in other professional rewards of serving patients as During her term as an ACS organizations, including serving a surgeon and to contribute to Regent and Chair of the as chair, American Board of the education and training of American Board of Surgery, Surgery; president, Society for residents and medical students. she served on the American Surgery of the Alimentary Tract; Dr. Bass graduated summa Surgical Association’s Blue president, Society of Surgical cum laude with a bachelor Ribbon Committee, cosponsored Chairs; and treasurer, American of science degree from Tufts by the ACS, to evaluate and Surgical Association. She has University, Medford, MA (1975). recommend changes in surgical inspired other women in surgery She earned her medical degree training. As Chair of the Program and as a result has received the (1979) from the University 64 | Committee, she led the Clinical Nina Starr Braunwald Award and of Virginia, Charlottesville, Congress strategic planning the Olga Jonasson Distinguished where she was elected to the process in 2006. As a result, the Member Award from the Alpha Omega Alpha Honor annual meeting was restructured Association of Women Surgeons. Medical Society. She completed progressively between 2007 A mentor to more than 50 her surgical internship and and 2010 to facilitate access pre- and postdoctoral fellows, general surgery residency at to high-quality specialty and she has authored or co-authored George Washington University, program-specific content tracks. 155 peer-reviewed papers, and Washington, DC (1986), while Programmatic review, targeted has delivered more than 60 completing a gastrointestinal expansion, a review course for named lectureships and many surgical research fellowship and board examination preparation, other invited lectureships in serving as Captain, U.S. Army Meet-the-Expert Sessions, and the U.S. and around the globe. Medical Corps (1982−1984). Town Hall meetings were added Dr. Bass’ research programs in to the Clinical Congress during gastrointestinal cell biology, this process. Dr. Bass continued computational surgery, surgical Vice-Presidents to serve as a consultant to the outcomes sciences, and clinical During the Convocation, Charles Program Committee until 2014. research have been funded D. Mabry, MD, FACS, was installed She serves as Co-Chair by the National Institutes of as ACS First Vice-President, of the Committee on Skills Health (NIH), the VA Research and Basil Pruitt, Jr., MD, FACS, Training for Surgeons in Practice program, the National Science FCCM, MCCM, was installed as with Ajit K. Sachdeva, MD, Foundation, and other groups. ACS Second Vice-President. FACS, FRCSC, Director, ACS Her first grant was an ACS Dr. Mabry is a general Division of Education. This Faculty Research Award (1987). surgeon from Pine Bluff, AR, and committee is working to address She has served as a member of the associate professor of surgery and retooling needs and strategies NIH Surgery and Bioengineering practice management advisor for practicing surgeons who Section and has served on the to the chair, department of need to acquire new skills. To editorial boards or as associate surgery, University of Arkansas

V102 No 11 BULLETIN American College of Surgeons NEWS

Dr. Mabry’s command of analytical data and effective communication skills led to his appointment to represent the ACS on the American Medical Association Relative Value Update Committee. In a related activity, he serves on the ACS General Surgery Coding and Reimbursement Committee.

Dr. Mabry for Medical Sciences, Little and Reimbursement Committee Arkansas for Medical Sciences Rock. Dr. Mabry also is medical (1992−present). At present, (1975 and 1979, respectively). director of physician practice Dr. Mabry is a member of the Dr. Pruitt is Past-Governor management, Jefferson Regional ACS Health Policy Advisory of the ACS; the Dr. Ferdinand Medical Center, Pine Bluff. Group and Chair of the Health P. Herff Chair in Surgery, Dr. Mabry serves on the Policy Advisory Council. clinical professor of surgery, Governor’s Trauma Advisory He served three terms on the department of surgery, trauma Committee for the State of Board of Regents (2002−2011). division, University of Texas Arkansas and is Chair of As a Regent, he was a member Health Science Center, San the Committee’s Quality of the Finance Committee Antonio; and professor of Improvement Subcommittee. (2003−2011), the Executive surgery, USUHS. Dr. Pruitt is an He is Chairman of the Board for Committee (2010−2011), and the esteemed leader in four broad the Arkansas Preferred Provider Advisory Council for Pediatric areas: burn, trauma, injury, and | 65 Organization. He previously Surgery (2002−2003); he chaired critical care surgery; biomedical served on the Continuing Medical the Member Services Liaison research and scholarship; Education Committee and Committee (2008−2011) and organizational leadership and Vice-Chair of the Board for the the Health Policy Steering development; and mentorship. Arkansas Foundation for Medical Committee (2006−2009). In 1967−1968, Dr. Pruitt was Care. In addition, he has served Dr. Mabry also has served chief of surgery and chief of on the Governor’s Advisory on the Board of Governors professional services at the busiest Council for Emergency Medical Committee on Socioeconomic evacuation hospital in Vietnam Service−Training Committee. Issues (2007−2009, 2011−2013) (400−500 major operations per A Fellow of the College since and Health Policy and Advocacy month) and then chief of the 1988, Dr. Mabry has been a Workgroup (2013−2014), trauma research team, studying tireless and committed volunteer the Program Committee the cardiopulmonary responses since he joined the Young (2006−2009, 2011−2014), and the to injury in combat casualties. Surgeons Committee in 1989. He Communications Committee Dr. Pruitt served as Commander was a member of the committee (1991−1995, 2002−2003). He is a and Director of the U.S. Army until 1993 and then went on to Past-President of the Arkansas Institute of Surgical Research serve as Vice-Chair through 1995. Chapter, Past-Chair of the for 27 years and became a His command of analytical data Arkansas Committee on Trauma, trailblazer in the management and effective communication and member of the Arkansas of trauma, burns, and critical skills led to his appointment Committee on Applicants. care patients worldwide. to represent the ACS on the Dr. Mabry is a 1971 graduate Dr. Pruitt has been recognized American Medical Association of the University of Central with appointments to NIH Relative Value Update Arkansas, Conway. He earned study sections, the VA Merit Committee (1995−present). In a his medical degree and Review Board for Surgery, and related activity, he serves on the completed his general surgery the Shriners Hospitals Research ACS General Surgery Coding residency at the University of Advisory Board and Clinical

NOV 2017 BULLETIN American College of Surgeons NEWS

Dr. Pruitt served as Commander and Director of the U.S. Army Institute of Surgical Research for 27 years and became a trailblazer in the management of trauma, burns, and critical care patients worldwide.

Dr. Pruitt

Outcomes Studies Advisory Medicine. This year, the ACS committees, as a Scudder Orator Board. He has served as a has distinguished Dr. Pruitt (1984), and as an Excelsior reviewer and referee for the Hong as an Icon in Surgery. Surgical Society/Edward D. Kong Research Grants Council, A Fellow of the College Churchill Lecturer (1988). the BC (British Columbia) Health since 1966, Dr. Pruitt was an He served on the Executive Research Foundation and Alberta ACS Governor (1973−1979), Committee (1974−1980) and as Heritage Foundation, the U.S. serving on the Board of a Councilor (1981−1984) of the VA, and the NIH. Perhaps Dr. Governors (B/G) Nominating South Texas Chapter of the ACS. Pruitt’s most enduring legacy Committee (1977−1979, Chair, In addition to his many is his mentorship of a cadre of 1978−1979). He has served on years of service to the College, leading physicians and scientists, what is now known as the Dr. Pruitt has served as president including 46 directors of burn Committee on Perioperative of 12 surgical societies, including 66 | centers, more than 20 department Care (1969−1975; Vice-Chair, the American Burn Association, chairs, and 11 past-presidents of 1973−1975; Senior Member, American Association for the the American Burn Association. 1975−1979). He remained on Surgery of Trauma, American Dr. Pruitt has received the Editorial Committee of that Surgical Association, Halsted national and international committee (1979−1984) and Society, International Society for commendations for his was a contributing author or Burn Injuries, Southern Surgical contributions to patient co-editor of Manual of Surgical Association, and the Western care. A few examples Nutrition (1974), Manual on Control Surgical Association. He is an include the National Safety of Surgical Infections, 1st edition Honorary Fellow of the Society Council’s Surgeons Award (1976), Manual of Surgical Critical of Black Academic Surgeons for Distinguished Service Care (1977), Manual of Preoperative and an honorary member of to Safety, the Danis Prize of and Postoperative Care, and the the Japanese Association for the Société Internationale de Manual on Control of Infection in Acute Medicine. He served for Chirurgie, the Medallion for Surgical Patients, 2nd edition (1984). 20 years as the associate editor Scientific Achievement of the He has played an active role and 17 years as the editor-in- American Surgical Association, on the Committee on Trauma chief of the Journal of Trauma. the Distinguished Investigator (1974−1980, Senior Member, Dr. Pruitt graduated from Award of the Society of Critical 1980−1984), the International Harvard College, Boston, Care Medicine, the G. Whitaker Relations Committee (1982−1989, MA (1952), and Tufts Medical International Burns Prize, the Chair 1987–1989), and the Surgical School (1957). He completed Tanner-Vandeput-Boswick History Group (2013−present; his initial surgical training at International Burn Prize, the Chair, Program Committee, Boston City Hospital (1962) and Lifetime Achievement Award 2014−present). He has served completed his surgical residency of the Society of University as an Advanced Trauma Life at Brooke General Hospital, Surgeons, the Roswell Support instructor (1981−present), San Antonio, TX (1964). ♦ Park Medal, and the King on Surgical Education and Self- Faisal International Prize in Assessment Program development

V102 No 11 BULLETIN American College of Surgeons NEWS

Dr. Mary Edwards Walker Award presented to Dr. Kuy

Dr. Kuy

At the Convocation Ceremony excellence, and commitment at Clinical Congress 2017 in San to public service. Diego, CA, the American College of Surgeons (ACS) presented the 2017 Dr. Mary Edwards Inspiration to practice Walker Inspiring Women in Dr. Kuy was born in a labor camp Surgery Award to SreyRam Kuy, in Cambodia in 1978 during the MD, MHS, FACS. This award was Cambodian genocide known as established by the ACS Women the Killing Fields. Following the in Surgery Committee (WiSC) overthrow of the Khmer Rouge, and is presented annually her family fled to a refugee camp | 67 at the Clinical Congress in in Thailand where Dr. Kuy, recognition of an individual’s her sister, and her mother were significant contributions to severely injured by a grenade. the advancement of women All three lives were saved by in the field of surgery. surgeons volunteering at the The award is named in honor refugee camp. These volunteer of Mary Edwards Walker, MD. surgeons helped inspire Dr. Kuy Dr. Walker volunteered to to pursue a career in medicine. Dr. Walker serve with the Union Army at Her family moved to the U.S. in (photo courtesy of the outbreak of the American 1981 and settled in Oregon. Dr. Kuy Library of Congress) Civil War and was the first attended Oregon State University, female surgeon ever employed Corvallis, and went on to complete by the U.S. Army. Dr. Walker medical school at Oregon Health is the only woman to have ever & Sciences University, Portland. received the Congressional She earned her master’s degree Medal of Honor, the highest U.S. in health policy, public health, Armed Forces decoration for and outcomes research at Yale bravery. Through Dr. Walker’s University School of Medicine, example of perseverance, New Haven, CT, as a Robert excellence, and pioneering Wood Johnson Clinical Scholar. behavior, she paved the way for today’s women surgeons. Dr. Kuy’s career embodies An accomplished early career the spirit of this award and As associate chief of staff, Michael demonstrates her personal E. DeBakey Veterans Affairs (VA) determination, professional Medical Center, Houston, TX,

NOV 2017 BULLETIN American College of Surgeons NEWS

Dr. Kuy’s career embodies the spirit of this award and demonstrates her personal determination, professional excellence, and commitment to public service.

Dr. Kuy oversees 5,000 staff in assistant chief, general surgery; quality in the Louisiana Medicaid a complex VA hospital with the and chair, Systems Redesign population, the Ford Foundation’s busiest emergency department Committee. She also was a Gerald E. Bruce Community and operating rooms in the member, Quality, Safety & Value Service Award for her work VA system. Dr. Kuy previously Board, Overton Brooks VA serving veterans, and Random served as chief medical officer Medical Center, Shreveport, LA. Acts’ Caught in the Act national for Medicaid in the Louisiana Dr. Kuy’s successful efforts public service award. Dr. Kuy Department of Health, Baton to reduce patient mortality and also was selected for the Early Rouge. Under her leadership, morbidity and decrease adverse Career Achievement Award in Louisiana was the first state events were profiled by the VA 2017 by Oregon Health & Sciences 68 | to develop a Zika prevention National Center for Patient Safety. University School of Medicine. strategy for pregnant Medicaid Her work in increasing veterans’ Dr. Kuy is grateful for the patients. Dr. Kuy also led access to care through clinic many incredible mentors and initiatives that enabled women efficiency was profiled by the teachers who have inspired with breast cancer to have access Association for VA Surgeons, and her on her journey, and she is to reconstructive surgery and the templates she developed were proud to be a part of the surgical testing, led efforts to coordinate disseminated for implementation family. She has dedicated her medical disaster relief efforts at VA medical centers across career to improving the quality during the historic Louisiana the country. Dr. Kuy has of medical care and increasing flooding of 2016, and led served on the National Quality the public’s access to quality Louisiana Medicaid’s initiative Forum, the National Board care. The College is proud to to tackle the opioid epidemic. of Medical Examiners, and have Dr. Kuy as a member and Dr. Kuy developed statewide the Accreditation Council for looks forward to what challenges health performance metrics, Continuing Medical Education. she will tackle next. ♦ pay-for-performance incentives, In 2017, Dr. Kuy was selected and novel Medicaid Expansion to be a Presidential Leadership Early Wins measures, which Scholar, a joint, bipartisan enabled the state of Louisiana leadership program taught by to assess how access to care Presidents George W. Bush, directly affects lives. Before William J. Clinton, and George serving as Chief Medical Officer H. W. Bush. She subsequently for Louisiana Medicaid, Dr. Kuy delivered the keynote served in numerous leadership commencement address at the roles in the VA system, including Bush Institute. Dr. Kuy received the following: director, Center the Greater Baton Rouge Business for Innovations in Quality, Report’s 40 Under 40 Award for Outcomes and Patient Safety; her work to improve health care

V102 No 11 BULLETIN American College of Surgeons NEWS

Honorary Fellowship in the ACS awarded to 10 prominent surgeons

Honorary Fellowship in along the lines of a residency Committee (2008–2014). He the American College of program. In his role as Group created Internet-based educational Surgeons (ACS) was awarded Clinical Director in the RCSI courses for the Surgical Infection to 10 outstanding surgeons Hospitals Group, he has a Society-Europe and the European from around the world at the continued medical leadership Society for Surgical Research October 22 Convocation that role with an emphasis on quality that many European surgical preceded the official start and safety and reconfiguration residencies use. He was head of Clinical Congress 2017 in of surgical services to ensure of the department of surgery, San Diego, CA. The granting adequate elective work within University of Santiago de of Honorary Fellowships the group. His prominence Compostela, La Coruña (1993– is one of the highlights of as a surgical educator was 2004), and has been president of Clinical Congress. This year’s recognized with the coveted the Surgical Infection Society- recipients were as follows. Association of Surgeons in Europe and the European Patrick J. Broe, MCh, FRCSI, Training’s 2015 Silver Scalpel Society for Surgical Research. | 69 FRCSEd(Hon), of Dublin, Ireland, Award for inspirational trainers. Francisco J. F. Castro Sousa, is a past-president (2012–2014) Miguel A. Cainzos, MD, PhD, MD, FACS, of Coimbra, Portugal, and emeritus clinical professor of FACS, of La Coruña, Spain, is has been a leader in Portuguese surgery of the Royal College of recognized internationally for surgery for nearly 40 years. He Surgeons in Ireland (RCSI). After his contributions as a surgical trained and has practiced at the graduating from the University investigator and educator. Coimbra University Hospital, College Dublin Medical School Dr. Cainzos has done important eventually becoming chair of in 1974 and completing his basic work to reduce surgical infections surgical services (1998–present) surgical training in Ireland, he in Spain. He was appointed and professor of surgery at was granted RCSI Fellowship Director of the National Plan University of Coimbra Medical in 1978. Dr. Broe completed to Reduce Surgical Infections School (1990–present). Dr. Sousa the Higher Surgical Training by Spain’s Ministry of Health has been dedicated to better Program in Ireland, eventually in 1996, and over the following patient care and trainee education becoming Consultant General four years established a network at those institutions and beyond, Surgeon to Beaumont Hospital, to enable multicenter studies serving as president of the medical Dublin, in 1987 until his recent on surgical infections across school’s scientific board (1998– retirement from that role. Elected specialties. His leadership resulted 2004) and dean (2004–2009). He as an RCSI council member in in reduced surgical infections was named honorary professor 1991, Dr. Broe has continuously and the establishment of national of surgery at the Complutense served in a leadership role in the guidelines for their prevention. University of Madrid, Spain, and organization. He has chaired Dr. Cainzos has been a Fellow has been a visiting professor in the several RCSI committees of the ACS since 1997, serving U.S. and globally. He has served centered on surgical education as Spain Chapter President as secretary and president of the and training. As RCSI president, (2000–2009), Chapter Governor Portuguese Society of Surgery, Dr. Broe revamped the duration (2009–2015), and member of among other roles, and has been and scope of surgical training the International Relations a leader and member of several

NOV 2017 BULLETIN American College of Surgeons NEWS

other domestic and international of the new medical school in Clinica Alemana de Santiago, medical societies. A Fellow of the 1990. In the early 1990s, he was a 440-bed, private, not-for- ACS since 1996, Dr. Sousa served instrumental in founding the profit academic institution. as an International Governor University of Insubria, which now He was appointed director of (2009–2015) and President of the has more than 12,000 students. surgery in 1999 and medical Portugal Chapter (2010–present). A Fellow of the ACS since 1980, director in 2012. Dr. Hepp In addition, he has published Dr. Dionigi has written more than launched Clinica Alemana more than 800 scientific articles 700 scientific publications and de Santiago’s liver transplant and five books on improving seven books, including the sixth program in 1993, which provides research in general surgery, edition of the renowned Chirurgia, special financial support to laparoscopy, and robotics. and has received many awards, make liver transplantation Dr. Sousa founded the Coimbra accolades, and distinguished available to all. In 2001, he was Liver and Transplantation appointments, including the involved in creating the Clinica 70 | Programme in 1992. Invernizzi Award, Italy’s highest Alemana School of Medicine, Renzo Dionigi, MD, FACS, medical teaching honor. Universidad del Desarrollo, FRCSEd(Hon), ASA(Hon), of Milan, Juan Hepp, MD, FACS, where he has served as professor Italy, has had a prolific surgical of Santiago, Chile, will be since 2007. Dr. Hepp is a past- career that has spanned both recognized for his contributions president of the Chilean U.S. and international surgery. to liver and transplantation Society of Surgery (2008). Early in his career, Dr. Dionigi surgery in Chile. He was Valerie J. Lund, CBE, MB, BS, conducted research at the awarded a German Academic FRCS, FRCSEd, of Wraybury, U.K., University of Cincinnati College Exchange Fellowship in 1981 to has led a distinguished career for of Medicine, OH, in the areas of study abdominal surgery and nearly 40 years, during which she surgical infection, immunology, transplantation in Hanover. contributed to surgery and her and transplantation. In the 1970s, Dr. Hepp returned to Chile specialty, otolaryngology-head he worked closely with Stanley and performed the first liver and neck surgery. Dr. Lund is Dudrick, MD, FACS, to introduce transplantation in the country professor of rhinology, University the concept and practice of total in 1985. He cofounded the College London, and an honorary parenteral nutrition to Europe, “Corporacion pro trasplante consultant at several hospitals. and he studied the effects of hepático” (1988) and the She has been honored for her artificial nutrition on some “Corporacion de trasplantes” groundbreaking contributions to aspects of the immune response. (1989), the latter of which the treatment of paranasal sinus Dr. Dionigi became a professor was in charge of transplant cancer and has been involved of surgery at the University of procurement and, now, supports in endoscopic sinus surgery Pavia, Italy, in 1984, and in 1986 transplantation in Chile. He and its extended applications was assigned by the medical also was involved in drafting an since the 1980s. Dr. Lund is a faculty there to open a branch amendment to the transplant prolific medical writer, having of the Pavia Medical School in law in 1994 and in many other contributed 36 books and Varese. He became chief of the pro-transplantation activities in monographs, 86 book chapters, department of surgery and dean the country. In 1992, he joined and more than 320 peer-reviewed

V102 No 11 BULLETIN American College of Surgeons NEWS

papers to the scientific corpus. guest lectures and written more trauma and orthopaedic surgeon In addition to lecturing widely, than 1,000 journal articles. In at Ipswitch Hospital, U.K., from Dr. Lund has been awarded the early 1980s, Dr. Makuuchi 1993 to 2014, where she chaired numerous honors from around developed various surgical several hospital committees. the world for her work in techniques and new procedures Dr. Marx joined the RCS in 1981, otolaryngology and rhinology; involving ultrasonography, and was elected president in 2014. these distinctions include the including ultrasonically guided In that role, Dr. Marx established George Davey Howell Memorial parcutaneous transhepatic the Emerging Leaders program Prize from the University cholangiography and bile to encourage women to enter of London in 1990, the W. J. drainage, intraoperative the surgical profession. She Harrison Prize from the Royal ultrasonography, ultrasonically chairs the RCS Invited Review Society of Medicine in 2012, and guided subsegmentectomy, Mechanism Committee, as well several honorary degrees and and four new techniques for as the Trauma and Orthopaedic society fellowships from around hepatectomies preserving Specialist Advisory Committee, | 71 the world. She was awarded the inferior right hepatic which developed a new training a Commander of the British vein. Dr. Makuuchi’s curriculum for the specialty. Empire (CBE) in 2008 for her continuing success in using In 2007, she received a CBE service to medicine in the U.K. ultrasonography for a variety of for her service to medicine. Masatoshi Makuuchi, MD, hepatic and gastroenterologic Dr. Marx was appointed Deputy PhD, of Tokyo, Japan, will be procedures has made him Lieutenant of Suffolk County and recognized for years of clinical one of the world’s foremost elected president of the British and academic service, as well experts in the applied surgical Orthopaedic Association in 2008. as his contributions to the use use of the technology. Orgoi Sergelen, MD, PhD, of ultrasonography in surgery. Clare L. Marx, CBE, DL, MB, FACS, of Ulaanbaatar, Mongolia, Dr. Makuuchi has worked in BS, FRCS, of Woodbridge, U.K., is being honored for her several leadership positions at is immediate past-president of commitment to treating the prestigious medical institutions, the Royal College of Surgeons people of Mongolia, which has including professor and of England. She was the first the world’s lowest population chairman, the first department woman in the history of the density. To address the of surgery, Shinshu University organization to hold the office, absence of basic surgical care, School of Medicine (1990–1994); as well as the first woman to Dr. Sergelen led the Mongolian and professor and chairman, serve as president of the British World Health Organization’s hepato-biliary-pancreatic Orthopaedic Association. An Global Initiative for Emergency surgery division, artificial orthopaedic surgeon, Dr. Marx and Essential Surgical Care. organ and transplantation trained in the London, U.K., This coordinated effort to division department of surgery, area and was appointed as a address the absence of adequate University of Tokyo (1997–2007). consultant orthopaedic surgeon capacity for emergency and He also has served as president at St. Mary’s Hospital and St. essential surgical care services of surgical organizations and Charles Hospital, London, in in low- and middle-income has delivered more than 1,000 1990. She served as consultant countries resulted in dramatic

NOV 2017 BULLETIN American College of Surgeons NEWS

improvements in surgical and present); dean of the Medical Honorary Fellowship to each anesthetic care capabilities in College (2003–2011); and of the renowned surgeons. more than 300 isolated rural chair, department of plastic Sir Rickman Godlee, communities. Dr. Sergelen surgery (1994–2000). Dr. Wei president of the Royal College orchestrated the nationwide and his team reconstructed of Surgeons of England, was expansion of laparoscopy and optimized functional awarded the first Honorary over a 10-year period. In 2005, aesthetic outcomes for more Fellowship in the ACS during when nearly 50 percent of the than 22,000 patients who the College’s first Convocation population was still nomadic, suffered from traumatic injury in 1913. Since then, 468 only 4 percent of gallbladders or tumor resection, and his internationally prominent were removed laparoscopically; work to develop autologous surgeons, including the 10 now, laparoscopic tissue transplantation has chosen this year, have been cholecystectomy is available revolutionized reconstruction named Honorary Fellows 72 | in 17 of 21 provinces. She also for those patients. He also of the ACS. Following are introduced the Advanced is the innovator of the the full citations provided Trauma Life Support® program osteoseptocutaneous fibula by colleagues and friends of to Mongolia, where traumatic flap, which dramatically the Honorary Fellows. ♦ injury is the third leading cause improved the reconstruction of death. Dr. Sergelen led the of composite bone and soft development of lower-cost liver tissue defects in the jaw and transplant and orchestrated extremities. In addition to inclusion for all transplantation his clinical accomplishments, into the government health Dr. Wei has welcomed more plan. This initiative improved than 1,300 visiting surgeons intensive care unit capability, from 75 countries to observe pathology, gastrointestinal him and his team. He has support, and pharmacy, personally trained and mentored strengthening the entire health more than 100 fellows in his care system in Mongolia. specialty and has been a visiting Fu-Chan Wei, MD, of Taipei, professor around the world; Taiwan, is a world-renowned contributed more than 500 pioneer in reconstructive scientific articles, 18 books, microsurgery. He has been a 100 books chapters, and 600 professor of surgery at Chang invited lectures; and has been Gung Memorial Hospital awarded nearly every major and Chang Gung University, honor in the fields of plastic Taipei, since 1990 and in that surgery and microsurgery. time has served as chairman Courtney M. Townsend, of vascularized composite Jr., MD, FACS, ACS Immediate allotransplantation, (2011– Past-President, conferred the

V102 No 11 BULLETIN American College of Surgeons NEWS

Citation for Prof. Patrick J. Broe, MCh, FRCSI, FRCSEd(Hon)

by A. Brent Eastman, MD, FACS, FRCSI(Hon), FRCSEd(Hon)

Prof. Patrick J. Broe is a His prominence as a surgical general surgeon from Dublin, educator was recognized when Ireland. He is emeritus clinical he was awarded the coveted professor of surgery and was Association of Surgeons in president of the Royal College Training’s 2015 Silver Scalpel of Surgeons in Ireland (RCSI) Award for inspirational trainers from 2012 to 2014. Recently who have scored highly across retired from surgical practice, five categories: leadership, he is group clinical director for resourcefulness, training and the RCSI Hospitals Group. development, professionalism, Graduating in 1974 from and communication. the University College Dublin Professor Broe has a continued Medical School, Professor Broe medical leadership role with did his basic surgical training important emphasis on quality | 73 in Ireland and was granted and patient safety, as well as RCSI Fellowship in 1978. He reconfiguration of surgical spent two years stateside doing services in his current role as laboratory-based research into the group clinical director. He is a Professor Broe pathogenesis of acute pancreatitis remarkable individual who has and its complications at the Johns dedicated his professional life to Hopkins Hospital, Baltimore, the development of surgery in MD, which formed the basis of Ireland and who is well deserving his master’s degree in surgery. of this honor. I am privileged He spent a year at Guy’s Hospital to present him for Honorary London, U.K., followed in 1985 Fellowship in our American by the higher surgical training College of Surgeons, as he once programme in Ireland, eventually welcomed me into honorary becoming consultant general fellowship with the RCSI. ♦ surgeon to both Richmond and later Beaumont Hospitals. Elected as an RCSI council member in 1991, Professor Broe has continuously served in a leadership role. He chaired many committees and, under his presidency, the Training Committee totally revamped the duration and scope of Irish surgical training along the lines of a residency programme.

NOV 2017 BULLETIN American College of Surgeons NEWS

Citation for Prof. Miguel A. Cainzos, MD, PhD, FACS

by Mark Malangoni, MD, FACS

Prof. Miguel A. Cainzos is a organizations. He has served as general surgeon from Santiago President of and Governor for de Compostela, Spain. He is the Spain Chapter of the ACS. recognized internationally for his In 1996, the Spanish contributions to education and Ministry of Health appointed surgical infections. He has been a Professor Cainzos director of Fellow of the American College of the national plan to reduce Surgeons (ACS) since 1997 and has surgical infections. Over the helped advance the international next four years, he established presence of the College. a network enabling multicenter Professor Cainzos earned his studies on surgical infections medical and doctoral degrees across specialties, resulting in a in surgery, both summa cum reduction in surgical infections 74 | laude, at the University of and establishment of national Santiago de Compostela. After guidelines for their prevention. completing a general surgery Professor Cainzos is a residency at the Hospital consummate clinician and General de Galicia in 1980, he educator. He has published Professor Cainzos pursued additional training more than 110 peer-reviewed in the U.S., the U.K., and articles and seven books, as Germany and was appointed well as created Internet-based assistant professor of surgery educational courses for the SIS- at the University of Santiago Europe and European Society de Compostela in 1983. He for Surgical Research that are was promoted to professor used in many European surgical with tenure in 1995 and is residency programs. ♦ now chief of the division of general surgery at both the Hospital General de Galicia and the Hospital Clinico Uinversitario. He was head of the department of surgery at the University of Santiago de Compostela from 1993 to 2004. Professor Cainzos has been president of the Surgical Infection Society (SIS)-Europe and the European Society for Surgical Research and is a member of numerous professional

V102 No 11 BULLETIN American College of Surgeons NEWS

Citation for Prof. Francisco J. F. Castro Sousa, MD, FACS

by Enrique Moreno González, MD, FACS(Hon)

Prof. Francisco J. F. Castro honorary member of the French Sousa is a general surgeon Association of Surgery, the from Coimbra, Portugal. He Surgical Rumanian Academy, and was born in Coimbra and the Brazilian College of Digestive attended medical school at Surgery, and was a member the University of Coimbra. of the Portuguese Medical He began his general surgery Association. Professor Castro training there before accepting Sousa held many leadership roles a visiting fellowship at Mount with the Portuguese Society Sinai Hospital, New York, NY, of Surgery, such as secretary, followed by additional training vice-president, president of the at the University of Paris, directory board, and president; France, with Henri Bismuth, he also served as president of MD, FACS(Hon), receiving his both the Laparoscopic Chapter | 75 specialty certification in 1980. and the Hepato-Pancreato-Biliary Since 1988, Professor Chapter. He has been extremely Castro Sousa has been chief of active in the American College of service at Coimbra University Surgeons (ACS) since becoming Professor Castro Sousa Hospital and shortly thereafter a Fellow in 1995 and is President was promoted to professor of of the ACS Portuguese Chapter surgery. From the start, he and the Governor for Portugal. has been dedicated to better With more than 800 scientific patient care and began serving articles and five surgical books as a member of the commission published, he is dedicated to faculty and the council of the improving surgical research medical school. He has been and finding new approaches in vice-president and president of general surgery, laparoscopy, and the Scientific Board, president robotics. He is equally dedicated of the Directive Board, and to hepatobiliary and pancreatic dean of the University of surgery and founded the Coimbra Medical School. Coimbra Liver Transplantation Professor Castro Sousa was Programme. He is known named an honorary professor worldwide as a surgical leader of surgery at the Complutense who is dedicated to improving University of Madrid, Spain, education and patient care and and has been a visiting professor promotes the highest standards in New York; Boston, MA; related to ethical behavior. For all Rochester, MN; Copenhagen, these reasons, Professor Castro Denmark; and other cities Sousa is deserving of Honorary around the world. He is an Fellowship in College. ♦

NOV 2017 BULLETIN American College of Surgeons NEWS

Citation for Prof. Renzo Dionigi, MD, FACS, FRCSEd(Hon), ASA(Hon) by L. D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon)

Prof. Renzo Dionigi is a general In 1986, he was charged with surgeon from Varese, Italy. opening a new branch of the Pavia Professor Dionigi has had Medical School in Varese. He a remarkable career and is became both surgery department highly deserving of this honor chair and dean of the new medical by measure of his academic school. Additionally, he was qualifications and contributions instrumental in the founding to U.S. and international surgery. of another new university, the He received his medical degree University of Insubria, which now and surgical training at the famed has more than 12,000 students, University of Pavia, Italy. Early and was the school’s first rector. in his career, he studied under He has authored more than the supervision of William A. 700 scientific publications and 76 | Altemeier, MD, FACS, and James seven books, including the sixth Wesley Alexander, MD, FACS, at edition of the renowned Chirurgia, the University Cincinnati School and has received many awards, of Medicine, OH. During those accolades, and distinguished three years, he conducted research appointments, including the Professor Dionigi in the areas of surgical infections, Invernizzi Award, Italy’s highest immunology, and transplantation medical teaching honor. and was fortunate enough to Renzo is an Honorary Fellow meet his lovely wife, Janet. of the Royal College of Surgeons A close and collegial of Edinburgh and the American collaboration with Stanley Surgical Association. He has been Dudrick, MD, FACS, resulted in an active American College of Professor Dionigi being the first Surgeons Fellow for many years, to introduce the concept and and I can think of no one more practice of artificial nutrition deserving of this coveted honor. ♦ to our European colleagues. Even with his extensive expertise in surgery, since his 1984 appointment as professor of surgery at the University of Pavia, his major clinical interest has been focused on advanced oncologic surgery, particularly hepato-pancreato- biliary surgery. He also is the architect of novel techniques for immuno-guided surgery.

V102 No 11 BULLETIN American College of Surgeons NEWS

Citation for Prof. Juan Hepp, MD, FACS

by Patricia J. Numann, MD, FACS

Prof. Juan Hepp is a general in Chile in 1990. He wrote surgeon from Santiago, Chile. the first book on laparoscopic Professor Hepp was born in cholecystectomy in Spanish and Southern Chile, where while three others on laparoscopic accompanying his physician and hepatobiliary surgery. father on rounds, he decided to In 2001, he was involved in become a surgeon. After finishing creating the Clinica Alemana surgical training, he was awarded School of Medicine, Universidad a German Academic Exchange del Desarrollo, where he Fellowship to study abdominal has served as professor since surgery and transplantation 2007. He supported the Joint in Hanover, Germany. Commission International Returning to Chile, he accreditation in 1993 at his performed the country’s first institution and in 2010 joined | 77 liver transplant in 1985. He co- the Presidential Commission founded the “Corporacion pro for Health Reform in Chile. trasplante hepático” in 1988 and Professor Hepp is the the “Corporacion de trasplantes” Governor for the Chile Chapter of Professor Hepp in 1989, which was in charge the American College of Surgeons of transplant procurement. and was Chapter President from He also was instrumental in 2001 to 2002; he also is past- drafting Chile’s amendment to president of the Chilean Society the transplant law in 1994. of Surgery (2008). He was made In 1992, he joined Clinica an honorary member of the Alemana de Santiago, a 440- European Surgical Association bed private, not-for-profit in 2010 and the American academic institution. He was Surgical Association in 2016. appointed director of surgery Juan, his wife Carmen, and in 1999 and medical director in their five children enjoy spending 2012. Professor Hepp, in 1993, time at their farm in Patagonia. ♦ launched the hospital’s liver transplant program, which provides special financial support that makes liver transplant available to all who need this procedure. Focusing his clinical work mainly on abdominal and hepatobiliary surgery, he was one of the leaders to implement laparoscopic cholecystectomy

NOV 2017 BULLETIN American College of Surgeons NEWS

Citation for Prof. Valerie J. Lund, CBE, MB, BS, FRCS, FRCSEd

by Gerald B. Healy, MD, FACS, FRCS(Hon), FRCSI(Hon)

Prof. Valerie J. Lund is an Commander of the British Empire otolaryngologist from Wraysbury, (CBE) in 2008 for her services U.K. Her career has spanned to medicine in the Empire. almost 40 years and has been A tireless educator, Professor distinguished by many seminal Lund has worked to enhance contributions to surgery and surgical education and training at her specialty, otolaryngology– the Royal College of Surgeons of head and neck surgery. England, where she served on the A daughter of the U.K., governing council from 1995 to Professor Lund is professor of 2006. She has mentored numerous rhinology at University College, young surgeons and investigators London, and consultant to and has seen them go on to numerous British hospitals. She make significant contributions 78 | has been honored around the to surgery worldwide. world for her groundbreaking Valerie enjoys archaeology, contributions to the endoscopic cooking, and, best of all, eating. treatment of paranasal sinus She is a wonderful colleague cancer. This approach has saved and friend. The words that Professor Lund many patients from radical and best describe her character and disfiguring surgery. Her many career are integrity, intellect, and honors include giving numerous innovation, and I am delighted named lectureships and achieving that she will be bestowed honorary society memberships Honorary Fellowship in the in the U.S., Belgium, Denmark, American College of Surgeons for the Netherlands, Germany, Spain, her tireless dedication to patients, Romania, Russia, and South students, and colleagues alike. ♦ Africa. She was also named the prestigious Sims Commonwealth Professor in 2002; this is a joint appointment by the Royal Colleges of Australia, New Zealand, Canada, England, and South Africa. Professor Lund was also one of the first women inducted into the Collegium Amicitae Sacrum, her specialty’s most distinguished international honor society, with only 200 members worldwide. Her majesty, Queen Elizabeth II, awarded her a

V102 No 11 BULLETIN American College of Surgeons NEWS

Citation for Prof. Masatoshi Makuuchi, MD, PhD

by Junji Machi, MD, PhD, FACS

Prof. Masatoshi Makuuchi as a future potential surgical is a general surgeon from tool, even in the early 1980s. Tokyo, Japan. He was born Professor Makuuchi created and raised in Tokyo. many innovative surgical Professor Makuuchi received procedures, ultrasound- his medical degree in 1973 from guided hepatic resections, and the University of Tokyo, the top transplantations. Over many medical school in Japan. Since years, he continued academic then, he has remained at the surgical works, including basic University of Tokyo and related and clinical research. He was institutions. He moved up the an excellent educator and many academic ladder, chairing the active hepatic surgeons in Japan surgical department, and has been are his former students and the president of many surgical residents. His contributions to | 79 societies and has held honorary hepatic surgery are evident not professorships and fellowships only in Japan, but around the both in Japan and internationally. world. He visited many developed Professor Makuuchi’s and developing countries and Professor Makuuchi remarkable contributions invited foreign surgeons to in surgery are too many to his institute to teach them list here; therefore, allow his innovative techniques. me to summarize his most Professor Makuuchi is a significant clinical and academic distinguished surgeon, educator, achievements. Professor and researcher, as well as a Makuuchi was the number world-renowned leader, which one pioneer of intraoperative is evidenced in his service as ultrasound. In late 1970s, he professor emeritus at Tokyo developed ultrasound probes University and his recent specifically for use during appointment to president hepatic resection for hepatoma. of the Towa Hospital. ♦ My former mentor, the late Bernard Sigel, MD, FACS, was the pioneer of intraoperative ultrasound in the U.S., and both Drs. Makuuchi and Sigel, together with the late Lloyd Nyhus, MD, FACS, were the key persons to advocate, encourage, and support the general use of ultrasound by surgeons

NOV 2017 BULLETIN American College of Surgeons NEWS

Citation for Prof. Clare L. Marx, CBE, DL, MB, BS, FRCS

by Hilary A. Sanfey, MB, BCh, MHPE, FACS, FRCSI

Prof. Clare L. Marx is an committee, which developed a orthopaedic surgeon from new curriculum for the specialty. Woodbridge, U.K. She is She participates in numerous immediate Past-President of educational committees, the Royal College of Surgeons including chairing the Specialty of England (RCS) and was Appointment Committee for the first woman to hold this Orthopaedic Surgery, and served office. Additionally, she is as orthopaedic advisor for the the first woman to serve National Confidential Enquiry as president of the British into Perioperative Deaths. In Orthopaedic Association. 2007, she received a Commander Professor Marx studied and of the British Empire for completed her training at the services to medicine and was 80 | University College London appointed deputy lieutenant Medical School before accepting of Suffolk county in 2008. a fellowship in arthroplasty at Troubled by low percentages Brigham and Women’s Hospital, of women entering surgery, Boston, MA. Subsequently, she has changed the status Professor Marx she was appointed consultant quo by successfully breaking orthopaedic surgeon at St. Mary’s down barriers and creating and St. Charles Hospitals, London, pathways for others to follow. before moving to Ipswich Through her mentorship, many Hospital as the clinical director women surgeons have achieved of the accident and emergency societal leadership positions. department and chairing the Equally concerned with medical staff committee. challenges in delivering quality An advocate for elevating training with reduced work professionalism, the RCS under hours, Professor Marx believes her leadership published Good professionals need to continuously Surgical Practice, examining strive for improvements in outcomes of underperforming the quality and care of their surgeons. She has emphasized the patients. During her presidency, importance of aspects of surgical the RCS issued an apology performance by building patients’ regarding junior physicians’ trust through compassionate contract negotiations and communication. Professor Marx perceptions that the RCS was chairs the RCS Invited Review unsupportive of trainees. ♦ Mechanism, underscoring patient safety, as well as the trauma and orthopaedic specialist advisory

V102 No 11 BULLETIN American College of Surgeons NEWS

Citation for Prof. Orgoi Sergelen, MD, PhD, FACS

by Raymond R. Price, MD, FACS

Prof. Orgoi Sergelen is a general Mongolian success regionally surgeon specializing in liver in Central and Southeast Asia. transplantation and laparoscopic In 2005, when nearly half surgery from Ulaanbaatar, of the population was still Mongolia. Mongolia is the most nomadic and only 4 percent sparsely populated country in the of gallbladders were removed world, and Professor Sergelen has laparoscopically, Professor been a true pioneer in modern Sergelen orchestrated the surgical care. Challenges of expansion of laparoscopy. Now a rugged geography, serious laparoscopic cholecystectomy is political and financial constraints, available in 17 of 21 provinces. and the large nomadic population With trauma as the third have never prevented her leading cause of death in from improving health care in Mongolia, she oversaw the | 81 Mongolia. Despite her naysayers, introduction of the Advanced she has led several projects Trauma Life Support® program. that are presenting impressive Professor Sergelen led the examples of possibilities development of lower-cost liver Professor Sergelen for other low- and middle- transplants and orchestrated income countries (LMICs). inclusion for all transplantation Addressing this absence of into the government health plan basic surgical care, Professor in Mongolia, where liver cancer Sergelen led the Mongolian is the most prevalent cancer. This World Health Organization’s initiative improved intensive (WHO) Global Initiative for care unit capability, pathology, Emergency and Essential gastrointestinal support, and Surgical Care (GIEESC). This pharmacy, strengthening their coordinated effort addressing overall health care system. absence of adequate capacity Professor Sergelen, truly for emergency and essential one of modern surgery’s most surgical care services in impactful leaders for LMICs, has LMICs resulted in dramatic challenged the popular dogma improvements in surgical and that surgery was too expensive anesthetic care capabilities in and instead broadened the world’s more than 300 isolated rural view of the impact surgery can communities. The World have for all communities. ♦ Health Organization designated Mongolia as the first WHO GIEESC Collaborating Center, with goals to expand the

NOV 2017 BULLETIN American College of Surgeons NEWS

Citation for Prof. Fu-Chan Wei, MD

by Kant Y. Lin, MD, FACS

Prof. Fu-Chan Wei is a plastic and he has personally trained surgeon from Taipei, Taiwan. He and mentored more than 100 is a world-renowned pioneer in fellows. Over the years, he has reconstructive microsurgery. been recognized with virtually Professor Wei was born in every major honor awarded in Tainan, Taiwan, and received plastic surgery and microsurgery. his medical degree from the The American Society of Plastic Kaohsiung Medical College. He Surgery named him one of the 20 completed plastic surgery training most important innovators in the at the Chang Gung Memorial last 40 years of plastic surgery. Hospital in Taipei, with additional Through his career of fellowship training in hand and hard work, innovation, and microsurgery at the University of achievement, he remains a kind 82 | Toronto, ON, and at the Kleinert and humble physician dedicated Institute in Louisville, KY. He to restoring the health and dignity has served on the faculties of the of his fellow human beings. He is Chinese Medical University; the the ideal role model for all plastic Taipei Medical University; and surgeons to emulate, and he is Professor Wei the Chang Gung Medical College, greatly deserving of this honor. ♦ where he was dean of the college from 2003 to 2011. He is now the chief of the Center of Vascularized Composite Allo-Transplantation at Chang Gung Memorial Hospital. Professor Wei’s contributions to plastic surgery, especially to microsurgery, are legendary. His work to develop autologous tissue transplantation revolutionized cancer and trauma patient reconstruction. In addition to being a master clinician, Professor Wei is a prolific author, researcher, and educator. His scholarship has profoundly influenced his surgical peers; 1,335 visiting surgeons from 75 countries have gone to Taiwan to observe him and his team. His influence extends to the next generation, as well,

V102 No 11 BULLETIN American College of Surgeons NEWS

Call for nominations for the ACS Board of Regents and ACS Officers-Elect

The American College underrepresented minorities of Surgeons (ACS) 2018 for all leadership positions. Call for Nominations Nominating Committee of for Board of Regents the Fellows (NCF) and the All nominations must The 2018 Nominating Committee Nominating Committee of the include the following: of the Board of Governors Board of Governors (NCBG) (NCBG) will select nominees will be selecting nominees • A letter/letters of nomination for pending vacancies on the for leadership positions in Board of Regents to be filled the College as follows. • A personal statement from at Clinical Congress 2018. the candidate detailing their The deadline for submitting ACS service and interest in nominations is February 23, 2018. Call for nominations the position (for President- for Officers-Elect Elect position only) Criteria The 2018 NCF will select The NCBG will use the following nominees for the three • A current curriculum vitae (CV) guidelines when considering Officer-Elect positions of potential candidates: the ACS: President-Elect, • The name of one individual First Vice-President-Elect, who can serve as a reference • Nominees must be loyal | 83 and Second Vice-President- members of the College Elect. The deadline for Further details who have demonstrated submitting nominations Entities such as surgical outstanding integrity along is February 23, 2018. specialty societies, ACS with an unquestioned devotion Advisory Councils, ACS to the highest principles Criteria for consideration Committees, and ACS Chapters of surgical practice. The NCF will use the following that would like to provide guidelines when considering a letter of nomination must • Nominees must have potential candidates: provide a description of their demonstrated leadership selection process and the total qualities, such as service • Nominees must be loyal list of applicants reviewed. and active participation on members of the College who Any attempt to contact ACS committees or in other have demonstrated outstanding members of the NCF by a components of the College. integrity and an unquestioned candidate or on behalf of devotion to the highest a candidate will be viewed • The ACS encourages principles of surgical practice. negatively, and may result in consideration of women and disqualification. Applications underrepresented minorities • Nominees must have submitted without the for all leadership positions. demonstrated leadership requested information qualities, such as service will not be considered. • The NCBG recognizes the and active participation on Nominations importance of the Board of ACS committees or in other must be submitted to Regents representing all who components of the College. officerandbrnominations@facs. practice surgery in both org. If you have any questions, academic and community • The ACS encourages contact Emily Kalata at 312- practice, regardless of practice consideration of women and 202-5360 or [email protected]. location or configuration.

NOV 2017 BULLETIN American College of Surgeons NEWS

• Nominations are open to surgeons • A personal statement from the the requested information of all specialties, but particular candidate detailing their ACS will not be considered. consideration will be given service and interest in the position Nominations this nomination cycle to those may be submitted to in the following specialties: • A current curriculum vitae officerandbrnominations@facs. org. If you have any questions, ȖȖ Burn and critical care surgery • The name of one individual contact Emily Kalata at 312- ȖȖ Gastrointestinal surgery who can serve as a reference 202-5360 or [email protected]. ȖȖ General surgery For information only, the ȖȖ Pediatric surgery Further details current members of the Board of ȖȖ Surgical oncology Entities such as surgical Regents who will be considered ȖȖ Transplantation specialty societies, ACS Advisory for re-election are (all MD, ȖȖ Trauma Councils, ACS Committees, FACS): John L. D. Atkinson, ȖȖ Vascular surgery and ACS Chapters that would James C. Denneny III, Timothy like to provide a letter of J. Eberlein, Henri R. Ford, • Only individuals who are nomination must provide Enrique Hernandez, L. Scott currently and expected to at least two nominees and a Levin, Linda Phillips, Anton 84 | remain in active surgical description of their selection A. Sidawy, Beth H. Sutton, practice for their entire process along with the total and Steven D. Wexner. ♦ term may be nominated list of applicants reviewed. for election or reelection Any attempt to contact to the Board of Regents members of the NCBG by a candidate or on behalf of All nominations must a candidate will be viewed include the following: negatively, and may possibly result in disqualification. • A letter of nomination Applications submitted without

ACS accepting 2018 Jacobson Promising Investigator Award applications The American College of Surgeons Surgical Research Committee is accepting applications until February 23, 2018, for the 2018 Joan L. and Julius H. Jacobson II Promising Investigator Award. This award recognizes outstanding surgeons engaged in research, advancing the art and science of surgery, and demonstrating early promise of significant contributions to the practice of surgery and the safety of surgical patients. This award is intended for surgeons who are at the “tipping point” of their research careers with a track record indicative of early promise and potential. Well-established surgeon-scientists are ineligible for the award. For details on award criteria and nomination procedures, visit the Jacobson Promising Investigator Award web page at facs.org/quality-programs/about/cqi/Jacobson. ♦

V102 No 11 BULLETIN American College of Surgeons GRASSGRASSROOTSROOTS MAKE YOUR VOICE HEARD ROOTSBecome a surgeon advocate Grow your involvementGRASSROOT Rally your colleagues and peers Advance the College’s health policyGRASSROOT agenda Support local events

Serve as a trusted resource to your Member of Congress and their staff

Relay feedback to the College’s Division of Advocacy and Health Policy

Optimize communications between you and your legislators

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Making quality stick: Optimal Resources for Surgical Quality and Safety The SQO and review processes: Keys to staying on track Editor’s note: In July, the American College of Among those Surgeons (ACS) released Optimal Resources for committees are the panels Surgical Quality and Safety—a new manual that that are responsible for is intended to serve as a trusted resource for case review and peer review. At surgical leaders seeking to improve patient care the most basic level, case review and peer review in their institutions and make quality stick. Each refer to the formal processes that health care month, the Bulletin will highlight some of the professionals use to evaluate their clinical work and salient points made throughout “the red book.” ensure that prevailing standards of care are being met. The manual describes five types of review— Every hospital dedicated to quality single-discipline case review, multidisciplinary case improvement and patient safety should review, peer review of individual surgeons, data/ have a Surgical Quality Officer (SQO) on registry review, and educational review conferences. staff, as well as established processes for Surgeon leadership by the SQO or the chief of conducting case review and peer review. surgery is of the utmost importance in ensuring The role of the SQO is a relatively new adherence to established protocols and the fair one at many institutions, but it is a position of conduct of all reviews. Case review and peer increasing relevance. The SQO leads efforts to review are defining characteristics of surgery as establish and maintain the infrastructure and a profession that is committed to self-regulation, standards necessary to ensure that the surgical identification of outliers, and research and 86 | care provided within an institution is optimal and innovation aimed at improving quality and safety. that all team members have the resources, tools, Be sure to read next month’s overview training, and competencies needed to provide of Optimal Resources for Surgical Quality and safe, high-quality, cost-effective, and reliable care. Safety, which will focus on the role of the Optimal Resources for Surgical Quality Surgical Quality and Safety Committee and Safety outlines the key responsibilities and credentialing and privileging. of the SQO; describes the skills, training, Optimal Resources for Surgical Quality and and personal attributes that will ensure Safety is available for $44.95 per copy for orders the SQO’s success; identifies resources of nine copies or fewer and $39.95 for orders of that the SQO can use; and describes the 10 or more copies at web4.facs.org/eBusiness/ committees with which the SQO interacts. ProductCatalog/product.aspx?ID=853. ♦

Coming next month in JACS and online now

Responding to crisis: Surgeons as leaders in disaster response

Susan Briggs, MD, FACS, discusses how the demands of disaster relief have changed significantly over the last decades, and highlights some of the notable contributions of surgical teams responding to past and present humanitarian crises. This article and all other JACS content is available at www.journalacs.org. ♦

V102 No 11 BULLETIN American College of Surgeons NEWS

Associate Fellows: Apply now for ACS Fellowship

Associate Fellows who are Associate Fellowship is limited The application requests basic interested in pursuing the next to surgeons who have been in information regarding licensure, level of membership and who practice less than six years. certification, education, and meet the criteria for Fellowship hospital affiliations. Applicants are encouraged to start the also are asked to provide the application process now. Requirements names of five Fellows of the Applications for American The basic requirements for College, preferably from their College of Surgeons (ACS) Domestic (U.S. and Canada) practice location, to serve Fellowship for induction at the Fellowship are as follows: as references. Applicants do 2018 Clinical Congress in Boston, not need to request letters of MA, are due December 1, 2017. • Certification by an appropriate recommendation; simply list ACS Fellowship is granted American Board of Medical the names in your application, to physicians who devote their Specialties surgical specialty and the College staff will practice entirely to surgical board, an American Osteopathic contact your references. services and who agree to practice Association surgical specialty If you need assistance finding in accordance with the College’s board, or the Royal College ACS Fellows in your area, go professional and ethical standards. of Surgeons in Canada to facs.org and click on the The College’s Fellowship “Find a Surgeon” button. Pledge and Statements on • One year of surgical practice When your application is | 87 Principles, found on the ACS after the completion of all formal processed, you will receive an website at facs.org, outline the training (including fellowships) e-mail notification providing ACS standards of practice. All details about the application ACS Fellows and applicants • Appointment at a primary hospital timeline along with a request for Fellowship are expected to with no reportable action pending for your surgical case list. adhere to these standards. All Fellowship applicants Surgeons voluntarily submit A full list of the domestic are required to participate in applications for Fellowship, requirements can be accessed a personal interview by an thereby inviting an evaluation at facs.org/member-services/ ACS committee in their local of their practice by their peers. join/fellows. The list of area. Exceptions are made for In evaluating the eligibility of requirements for International military applicants. Following Fellowship applicants, the College Fellowship is online at facs.org/ the interview, you will receive investigates each applicant’s entire member-services/join/international. notification by July 15 of the surgical practice. Applicants Associate Fellows who are up- action taken on your application. for Fellowship are required to-date with their membership Approved applicants are to provide to the appointed dues may apply online for free by designated as Initiates to be committees of the College all visiting facs.org/member-services/ inducted as Fellows during information deemed necessary for join and clicking on the link for the Convocation Ceremony the investigation and evaluation either Fellow or International at the Clinical Congress. of their surgical practice. Fellow. You will need your log- Contact Member Services It is our intention that all in information to access the with questions at any time Associate Fellows consider application. If you do not have throughout the application applying for Fellowship your log-in information, contact process. We look forward to within the first six years of the College’s Member Services you becoming a Fellow of the their surgical practice. To staff at 800-293-9623 or via e-mail American College of Surgeons. ♦ encourage that transition, at [email protected].

NOV 2017 BULLETIN American College of Surgeons CLINICAL CONGRESS 2018 OCTOBER 21–25 | BOSTON CONVENTION & EXHIBITION CENTER | BOSTON, MA

CALL FOR ABSTRACT SUBMISSIONS

The American College of Surgeons Division of Education welcomes abstract submissions to the following programs:

Owen H. Wangensteen Video-Based Scientific Forum Education

• ORAL PRESENTATIONS* • VIDEO PRESENTATIONS • e-POSTER PRESENTATIONS Videos are peer reviewed and may be *Accepted authors are encouraged recommended for inclusion in the ACS to submit full manuscripts to JACS Video Library following presentation

Submission Information

• Online submissions only • The submission period begins after December 1, 2017 • Deadline: 5:00 pm (CST) Wednesday, March 1, 2018 • Abstract and video specifications and guidelines will be posted on facs.org SCHOLARSHIPS

Traveling Fellow to Japan reports on experience

by Elizabeth C. Wick, MD, FACS

Dr. Wick (second from right), Professor Yanaga (second from left), and two staff surgeons from Jikei University at the Andaz hotel

| 89 I was honored to be the 2017 with tourists and employees. I was pleased to learn that American College of Surgeons The rest of the day was spent many of Dr. Yanaga’s colleagues (ACS) Traveling Fellow to Japan. exploring the Imperial Palace had spent time at the University My husband and sons and I gardens, temples, and shrines. of California, San Francisco traveled to Japan in April. We (UCSF), both with Lawrence began our journey in Tokyo, W. Way, MD, FACS, professor where we were greeted at Jikei University emeritus of surgery, division the airport by Prof. Seiichiro Although I was unable to observe of general surgery, and in the Yamamoto, MD, a colorectal operations at Jikei University, pediatric surgery group. Professor surgeon and my husband’s Prof. Katsuhiko Yanaga, MD, Hata was keen to spend time cousin. My husband had not PhD, FACS, President of the ACS at UCSF in the future to learn seen Seiichiro since he was Japan Chapter, kindly arranged more about surgical oncology eight years old, but somehow to meet at Jikei with some of or hepatobiliary surgery. they were able to spot each the general surgeons, followed other in the sea of passengers by dinner with his colleagues, at Narita International Airport. including Taigo Hata, MD, at Kyoto University Hospital Professor Yamamoto helped us Andaz Tokyo Toranomon Hills Prof. Shigeo Hisamori, MD, settle into our lodgings in Tokyo hotel in downtown Tokyo. PhD, facilitated my visit to Kyoto and then returned to work. Though it was a rainy night, the and Kyoto University Hospital. Because of the time change and view of the city was expansive, We took the Shinkansen train long trip, we all slept well, but and the surgeons explained from Tokyo to Kyoto—one of we woke early and ready to that many buildings, especially the highlights of the trip for explore Tokyo. We walked the hotels, are being constructed my sons. We were lucky to be streets and watched the sunrise in anticipation of the 2020 in Kyoto at the height of the and headed to the Tsukiji fish Olympic Games scheduled cherry blossom season. The market, which was bustling to take place in Tokyo. rivers and canals lined with

NOV 2017 BULLETIN American College of Surgeons SCHOLARSHIPS

Dr. Wick in front of Kyoto University Hospital

cherry blossoms were beautiful Tim Pohlemann, MD, PhD, and challenges with figuring out how as were the temples and shrines. his traveling fellow and Japanese to advance both spouses’ careers, I spent the day with Dr. Shigeo hosts. It was interesting to learn and so on. The one difference was and the residents and medical of the longstanding exchanges the training structure and the students. I observed a laparoscopic between Japanese and German variability of years of training and low anterior resection in the surgeons. The presidential dinner the timing of the transition from operating room and was most was more intimate but equally training to practice. Dr. Yamauchi impressed to observe the beautiful, and it was a privilege mentioned that there is great precise and deliberate surgical to speak with world leaders in interest in formalizing the technique and speed with which colorectal surgery, including training process along the the operation was conducted. Antonio M. de Lacy Fortuny, lines of the American Board of 90 | The team performed multiple MD, PhD, Barcelona, Spain, and Surgery. It was inspiring to see the emergency procedures the Michael Solomon, MB, BCh, BAO, interest in surgery from young same day, including perforated MSC, FRACS, Sydney, Australia. Japanese women, including both diverticulitis and appendicitis. I attended a few of the university and medical students. I enjoyed hearing more about international sessions at the The future is bright for women the medical school, residency, meeting, including those led by surgeons around the world. and transition to practice Dr. Lacy and then-ACS President Finally, Dr. Yamamoto invited structure in Japan, and I shared Courtney M. Townsend, Jr., MD, me to his medical school (class how it contrasted with the U.S. FACS. The following day, at the of 1991) get-together at a pub. approach. The medical students suggestion of Katsuhiko Yanaga, The camaraderie and long-term and residents in particular MD, PhD, FACS, and by the friendships that were evident were keen to have a chance invitation of Kazumi Kawase, reminded me that no matter to either do research or some MD, FACS, I attended the Japan where you are in the world, the clinical training in the U.S. Association of Women Surgeons unique nature of surgery and meeting. Many of the women team-based care that we practice surgeons brought their young leads to intense and lasting Japan Surgical Society children to the meeting. Hideko friendships that always seem to It was an honor to be included Yamauchi, MD, FACS, a breast pick up right where they left off, in the welcome dinner and surgeon at St. Luke’s International no matter how long it has been the presidential dinner at the University, translated for me since you have seen a colleague. Japan Surgical Society Meeting as the women in the room In summary, it was a great in Yokohama. The pride and went around and introduced privilege to visit Japan as the history of Japanese surgery was themselves, describing their ACS Traveling Fellow to Japan. evident at the welcome dinner, surgical role/training, family Everyone was incredibly kind and during which I had the pleasure situation, and goals. The themes hospitable, and I hope that one of dining with the president of were familiar—the stresses day I will be able to reciprocate the German Surgical Society, of balancing work and family, the warm welcome. ♦

V102 No 11 BULLETIN American College of Surgeons Exclusively for American College of Surgeons Members PROFESSIONAL PROTECTION PORTFOLIO

“The ACS Insurance Program provided both me and my spouse a really good value for life insurance at very competitive rates. I wish I had utilized this program earlier in my career.” —Benjamin Poulose M.D., M.P.H., F.A.C.S.

Three Insurance Coverages That Can Benefit Every Surgeon. 1. Life: 10-, 15- or 20-Year Level Term and/or Traditional Term 25% 2. Disability: Long Term Disability Income and/or Professional PACKAGE DISCOUNT Overhead Expense Insurance On Top Of Other 3. Accidental Death & Dismemberment (AD&D) and/or Qualifying Premium Hospital Indemnity Insurance Discounts When You Have All Three Request a Quote Now: Call Toll-Free: 1-800-433-1672 Apply Online 24/7: (M–F 8:00 a.m.–5:00 p.m. CT) www.acs-insurance.com

Underwritten by New York Life Insurance Company, New York, NY 10010, under Group Policy Form GMR, Complete terms, conditions, definitions, exclusions, limitations and renewability are outlined in the Certificate of Insurance provided to each insured for each coverage. ACS-0217 Administered by AmWINS Group Benefits, Inc. CA Insurance License No. 0F76076 AR Insurance License No. 1322 MEETINGS CALENDAR

Calendar of events*

*Dates and locations subject to change. For more information on College events, visit www.facs.org/events or facs.org/member-services/chapters/meetings.

New Jersey Chapter NOVEMBER December 2 FEBRUARY Iselin, NJ 2017 ACS Coding and Contact: Andrea Donelan, Puerto Rico Chapter Reimbursement Workshop [email protected], February 22–24 November 2–3 www.nj-acs.org San Juan, PR Chicago, IL Contact: Aixa Velez-Silva, Contact: KarenZupko & Associates, Inc., Brooklyn-Long Island Chapter [email protected], [email protected], December 6 www.acspuertoricochapter.org www.karenzupko.com/workshops2/ Uniondale, NY gensurg-workshops/ Contact: Teresa Barzyz, South Texas Chapter [email protected], February 22–24 South Korea Chapter www.bliacs.org/ Houston, TX November 2–4 Contact: Janna Pecquet, Seoul, South Korea Trinidad and Tobago Chapter [email protected], Contact: Dr. Hyung-Ho Kim, December 10 www.southtexasacs.org/ [email protected], Port of Spain, Trinidad ackss.or.kr and Tobago 92 | Contact: Dilip Dan, Keystone Chapter [email protected] MARCH November 3 Allentown, PA Peru Chapter Contact: Lauren Newmaster, March 14–16 [email protected], JANUARY 2018 Lima, Peru www.keystonesurgeons.org Southern California Chapter Contact: Dr. Herrera-Matta, January 19–21 [email protected] Wisconsin Surgical Society Santa Barbara, CA November 3–4 Contact: Tracey Dowden, Kohler, WI [email protected], FUTURE CLINICAL Contact: Terry Estness, www.socalsurgeons.org [email protected], CONGRESSES www.wisurgicalsociety.com Montana-Wyoming and Idaho Chapters 2018 January 26–28 October 21–25 Big Sky, MT Boston, MA DECEMBER Contact: Cyan Sportsman, [email protected], 2019 Massachusetts Chapter Montana and Wyoming: acschapter. October 27–31 December 2 wixsite.com/mtwyacs San Francisco, CA Boston, MA Idaho: acschapter.wixsite.com/idacs Contact: Brittany Fiore, 2020 [email protected], October 4–8 www.mcacs.org Chicago, IL

V102 No 11 BULLETIN American College of Surgeons