Januar y 2014 | Vol ume 99 NUmber 1 | amer ic an col l ege of sur geon s Bulletin

14JAN cover 1.indd 1 12/2/2013 11:41:04 AM Contents

Feat ur es Cover st or ies: Annual R AS-ACS essay contest: Dealing with surgical complications 9 How surgeons deal with complications: Introductory remarks 10 R obert D. Winfield, MD

Accepting accountability and moving forward 11 Elisha G. Brownson, MD

R esponding to, reflecting on, and moving forward from a surgical complication 12 Tad Kim, MD

Talk it out, and slow it down 13 Pablo Serrano, MD, MPH | 1

Mea maxima culpa—Dealing with surgical complications 14 JaBaris D. Swain, MD, MPH

Consequences 15 G. Paul Wright, MD

Complications are shared experiences 16 William Yi, MD

Preoperative telemedicine evaluation of surgical mission patients: Should we use it routinely? 17 R ifat Latifi, MD, FACS; Francisco Mora, MD; Flamur Bekteshi; and R enato R ivera, MD, FACS

R eading the tea leaves for state legislatures in 2014 24 Jon H. Sutton

Highlights of the 2013 Clinical Congress 27

ACS Officers, R egents, and Board of Governors’ Executive Committee 38

JAN 2014 Bulle t in American College of Surgeons Contents continued

Stat emen t A look at T he Joint Commission: Dr. Mattox receives AMA award Action urged to prevent retained for citizenship and community Statement on advance directives surgical items 53 service 65 by patients: “Do Not R esuscitate” NT DB® data points: Members in the news 66 in the operating room 42 Annual R eport 2013: Where did Call for nominations for ACS Col umns they go? 55 Officers-Elect 67 R ichard J. Fantus, MD, FACS, and Call for nominations for ACS Board Looking forward 7 Michael L. Nance, MD, FACS of Governors 67 David B. Hoyt, MD, FACS R eport on ACSPA/ACS activities: What surgeons should know about... News October 2013 68 The benefits of attending a 2014 R onald M. Stewart, MD, FACS, to Lena M. Napolitano, MD, FACS, ACS Surgical Coding Workshop 44 head Committee on Trauma 57 FCCP, FCCM Dispatches from rural surgeons: Nominations for Jacobson Students need exposure to the Promising Investigator Award Schol ar ships joys of rural surgery 46 accepted through February 28 57 2014 International ACS NSQIP R obert A. Swendiman Building a global perspective at Scholarship applications due From residency to retirement: International Surgical Leaders February 14 76 Surgeons as employees: Is the forum 58 2 | 2013 Traveling Fellow reports lining always golden? 48 Chantay Moye on trip to Australia and Edward M. Copeland III, MD, FACS ACS, Arizona health care leaders New Zealand 78 ACS Clinical R esearch Program: share successes, discuss challenges Nancy Baxter, MD, FACS Patient-centered outcomes research: at IQ Forum 61 Is this really something new? 51 Nominations for 2014 Meet ings Cal endar volunteerism and humanitarian Caprice Greenberg, MD, MPH, Calendar of events 84 FACS; George J. Chang, MD, FACS; awards due February 28 63 and Heidi Nelson MD, FACS ACS and other specialty surgical organizations release Physicians as Assistants at Surgery report 64

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Social Media post-CC half-page ad.indd 1 10/16/2012 10:34:21 AM V99 No 1 Bulle t in American College of Surgeons T he American College of Surgeons is dedicated CliniCal COngress 2014 to improving the care of the surgical patient and to safeguarding standards of care in an CALL FOR SUBMISSIONS optimal and ethical practice environment. The American College of Surgeons Division of Education welcomes submissions to the following programs Edit or -in-CHIEF Letters to the Editor to be considered for presentation at Diane Schneidman should be sent the 2014 Annual Clinical Congress, with the writer’s Dir ect or , Division of name, address, October 26–30, 2014, San Francisco, CA Inte gr ate d Communicati ons e-mail address, and Lynn Kahn Oral presentatiOns daytime telephone ‹ Surgical Forum* Senior Edit or number via e-mail to 312-202-5336, [email protected] Tony Peregrin dschneidman@facs. org, or via mail to − (15 Excellence in research awards Cont r ibut ing Edit or s Diane S. Schneidman, were given in 2013) Jeannie Glickson Editor-in-Chief, − Accepted Surgical Forum abstracts Katie McCauley Bulletin, American will be published in the September College of Surgeons, Supplement of the Journal of the Gr aphic Designer 633 N. Saint Clair St., american college of Surgeons (JacS) T ina Woelke Chicago, IL 60611. ‹ SciEntiFic PaPErS* Edit or ial Advisor s Letters may be edited 312-202-5385, [email protected] Charles D. Mabry, MD, FACS for length or clarity. Leigh A. Neumayer, MD, FACS Permission to publish pOster presentatiOns Marshall Z. Schwartz, MD, FACS letters is assumed ‹ SciEntiFic PoStEr PrESEntationS Mark C. Weissler, MD, FACS unless the author 312-202-5325, [email protected] Fro nt cover design indicates otherwise. − Ten posters are selected annually for the T ina Woelke Posters of Exceptional Merit program VideO presentatiOns ‹ VidEo-BaSEd Education Bulletin of the American College of Surgeons (ISSN 0002-8045) 312-202-5262, [email protected] is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical submissiOn infOrmatiOn Student Members, Affiliate Members, and to medical libraries ‹ abstracts are to be submitted online only. and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: ‹ Submission period begins after december 1, 2013. Send address changes to Bulletin of the American College of ‹ deadline: 5:00 pm (cSt), march 1, 2014. Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada ‹ late submissions are not permitted. there are no returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. considerations made for “late-breaking abstracts.” The American College of Surgeons’ headquarters is located at ‹ abstract specifications and requirements for 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; each individual program will be posted on the toll-free: 800-621-4111; e-mail:[email protected]; website: www.facs.org. Washington, DC, Office is located at 20 F acS website at www.facs.org/education/. review Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. the information carefully prior to submission. 202‑337-2701; website: www.tmiva.net/20fstreetcc/home. ‹ duplicate submissions (submitting the same Unless specifically stated otherwise, the opinions expressed abstract to more than one program) are not allowed. and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by *Accepted authors are encouraged to submit full manuscripts to JacS. nor official policy of the American College of Surgeons. ©2014 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.

2014 CC Call for Abstracts AD BULLETIN 10_14_13.indd 1 10/22/2013 3:43:24 PM Officers and Staff of the American College of Surgeons

James W. Gigantelli, MD, FACS Alliance/American Omaha, NE College of Surgeons Officers Advisory Council Clinical Research B.J. Hancock, MD, FACS, FRCSC Program Carlos A. Pellegrini, MD, FACS Winnipeg, MB to the Board Seattle, WA Heidi Nelson, MD, FACS President Enrique Hernandez, MD, FACS of R egents Chair Layton F. Rikkers, MD, FACS Philadelphia, PA (Past-Presidents) Convention and Meetings Madison, WI Lenworth M. Jacobs, Jr., MD, FACS Felix Niespodziewanski First Vice-President Hartford, CT Kathryn D. Anderson, MD, FACS Director Corona, CA John T. Preskitt, MD, FACS L. Scott Levin, MD, FACS Division of Education Dallas, TX Philadelphia, PA W. Gerald Austen, MD, FACS Ajit K. Sachdeva, MD, Second Vice-President Boston, MA *Mark A. Malangoni, MD, FACS FACS, FRCSC Edward E. Cornwell III, Philadelphia, PA L. D. Britt, MD, MPH, Director MD, FACS, FCCM FACS, FCCM Executive Services Raymond F. Morgan, MD, FACS Norfolk, VA Washington, DC Charlottesville, VA Barbara L. Dean Secretary John L. Cameron, MD, FACS Director William G. Cioffi, Jr., MD, FACS *Leigh A. Neumayer, MD, FACS Baltimore, MD Salt Lake City, UT Finance and Facilities Providence, RI Gay L. Vincent, CPA Treasurer Edward M. Copeland III, MD, FACS *Carlos A. Pellegrini, MD, FACS Gainesville, FL Director Seattle, WA David B. Hoyt, MD, FACS Human Resources and Chicago, IL A. Brent Eastman, MD, FACS Valerie W. Rusch, MD, FACS San Diego, CA Talent management Executive Director New York, NY Michelle McGovern Gay L. Vincent, CPA Gerald B. Healy, MD, FACS Director Marshall Z. Schwartz, MD, FACS Wellesley, MA Chicago, IL Philadelphia, PA Chief Financial Officer Information Technology R. Scott Jones, MD, FACS Howard Tanzman Howard M. Snyder III, MD, FACS Charlottesville, VA Philadelphia, PA Director Edward R. Laws, MD, FACS 4 | Beth H. Sutton, MD, FACS Boston, MA Division of Integrated Officers-Elect Wichita Falls, TX Communications LaSalle D. Leffall, Jr., MD, FACS Lynn Kahn (take office October 2014) Steven D. Wexner, MD, FACS Washington, DC Director Weston, FL Andrew L. Warshaw, MD, FACS Lloyd D. MacLean, MD, FACS Michael J. Zinner, MD, FACS Journal of the American Boston, MA Montreal, QC College of Surgeons President-Elect Boston, MA LaMar S. McGinnis, Jr., MD, FACS Timothy J. Eberlein, MD, FACS Jay L. Grosfeld, MD, FACS Atlanta, GA Editor-in-Chief *Executive Committee Indianapolis, IN Division of Member Services First Vice-President-Elect David G. Murray, MD, FACS Syracuse, NY Patricia L. Turner, MD, FACS Kenneth L. Mattox, MD, FACS Director Houston, TX Board of Patricia J. Numann, MD, FACS Second Vice- Syracuse, NY PERFORMANCE IMPROVEMENT President-Elect Governors/ Will Chapleau, RN, EMT-P Richard R. Sabo, MD, FACS Director Executive Bozeman, MT Division of Research and Committee Seymour I. Schwartz, MD, FACS Optimal Patient Care Board of R egents Gary L. Timmerman, MD, FACS Rochester, NY CliffordY . Ko, MD, MS, FACS *Julie A. Freischlag, MD, FACS Sioux Falls, SD Frank C. Spencer, MD, FACS Director Baltimore, MD Chair New York, NY Chair Fabrizio Michelassi, MD, FACS Cancer: *Mark C. Weissler, MD, FACS New York, NY David P. Winchester, MD, FACS Chapel Hill, NC VICE-Chair Medical Director Vice-Chair Executive Staff Lorrie A. Langdale, MD, FACS Trauma: *John L. D. Atkinson, MD, FACS Seattle, WA Executive Director David B. Hoyt, MD, FACS John Fildes, MD, FACS Rochester, MN Secretary Medical Director Margaret M. Dunn, MD, FACS Karen Brasel, MD, FACS Division of Advocacy Dayton, OH Milwaukee, WI and Health Policy Frank G. Opelka, MD, FACS James K. Elsey, MD, FACS James C. Denneny III, MD, FACS Associate Medical Director Atlanta, GA Columbia, MO Christian Shalgian Henri R. Ford, MD, FACS Joseph J. Tepas III, MD, FACS Director Los Angeles, CA Jacksonville, FL American College of Gerald M. Fried, MD, Sherry M. Wren, MD, FACS Surgeons Foundation FACS, FRCSC Palo Alto, CA Martin H. Wojcik Montreal, QC Executive Director

V99 No 1 Bulle t in American College of Surgeons Author bios

a b c d

e f g | 5

h i j k

Dr . Baxt er (a) is a colorectal surgeon Dr . Copel and (e) is emeritus Dr . Kim (h) is a PGY-9 cardiothoracic in practice at Saint Michael’s Hospital, distinguished professor, University of surgery resident, University of Toronto, ON, and an assistant professor, Florida College of Medicine, Gainesville, Mississippi Medical Center, Jackson. faculty of medicine, University of Toronto. and a Past-President of the ACS. Dr . L at ifi (i) is a professor of surgery, MR . Bekt eshi (b) is a technical Dr . Fant us (f) is director, trauma University of Arizona, Tucson, director of director, International Virtual services, and chief, section of surgical critical trauma, Hamad Medical Corporation, Doha, e-Hospital Foundation, Austin, TX. care, Advocate Illinois Masonic Medical Qatar; and president and founder, International Center, and clinical professor of surgery, Virtual e-Hospital Foundation, Austin, TX. Dr . Br owns on (c) is a fourth- University of Illinois College of Medicine, year general surgery resident, Boston Chicago. He is Past-Chair of the ad hoc Dr . Mor a (j) is a physician with the University Medical Center, MA. Trauma Registry Advisory Committee mobile surgery program, The Cinterandes of the ACS Committee on Trauma. Foundation, Cuenca, Ecuador; a member of Dr. Chan g (d) is associate professor, the International Trauma System Development department of surgical oncology, division Dr . Gr eenber g (g) is associate professor Program at Virginia Commonwealth of surgery; associate medical director, and the WARF Professor of Surgical Research, University, Richmond, VA; and Advisor to colorectal center; and director of clinical department of surgery; and director, the Ministry of Health of Ecuador in trauma operations, minimally invasive and new Wisconsin Surgical Outcomes Research system development, Quito, Ecuador. technologies in oncologic surgery program, Program, University of Wisconsin, Madison. University of Texas MD Anderson Cancer She is Co-Chair of the Cancer Care Delivery Ms. Moye (k) is Communications Center, Houston. He is Co-Chair of the Research Committee, Alliance/ACS CRP. Manager, ACS Division of Integrated Cancer Care Delivery Research Committee, Communications, Washington, DC. Alliance/American College of Surgeons (ACS) Clinical Research Program. continued on next page Titles and locations current at the time articles were submitted for publication. JAN 2014 Bulle t in American College of Surgeons Author bios continued

l m n

o p q r 6 |

s t u

Dr. Nance (l) is Templeton Dr . Ser r ano (p) completed his Mr. Swendiman (s) is a fourth-year Professor of Surgery and director, fellowship in hepatobiliary and pancreatic medical student at the University of North pediatric trauma program, Children’s surgical oncology at the University of Carolina School of Medicine, Chapel Hill, Hospital of Philadelphia, PA. Toronto, ON, and is now an assistant and is currently working toward a master’s professor, division of general surgery, of public policy at the Harvard Kennedy Dr. Napol itan o (m) is professor of McMaster University, Hamilton, ON. School of Government, Cambridge, MA, surgery, University of Michigan Medical as a Dubin Fellow for Emerging Leaders. School, Ann Arbor, and division chief, Mr . Sut t on (q) is Manager, State acute care surgery, University of Michigan Affairs, ACS Division of Advocacy and Dr . Win fiel d (t) is an assistant Hospital. She is Immediate Past-Chair Health Policy, Washington, DC. professor, trauma, acute, and critical of the ACS Board of Governors. care surgery, Washington University, Dr . Swain (r) is an Arthur Tracy Cabot St. Louis, MO, and Chair of the Resident Dr . Nel son (n) is Fred C. Andersen Research Fellow and global health equity and Associate Society of the ACS. Professor of Surgery and chair, department resident in surgery at the Center for Surgery of surgery, Mayo Clinic, Rochester, MN, and and Public Health, Brigham and Women’s Dr . Wr ight (u) is a fourth-year general Program Director of the Alliance/ACS CRP. Hospital, Harvard Medical School, Boston. surgery resident, Grand Rapids Medical Education Partners/Michigan State Dr . R iver a (o) is a general surgeon, St. University Program, and the RAS Liaison to Joseph’s Hospital, Breese, IL, and mission the ACS Health Policy Advisory Council. leader of Bohol Operation Giving Back. Dr . Yi (not pictured) is a fourth-year general surgery resident at Medstar Washington Hospital Center, Washington, DC.

V99 No 1 Bulle t in American College of Surgeons Executive Director’s report

Looking forward

by David B. Hoyt, MD, FACS

t press time, the nation was both reflecting on the 50-year anniversary of the assassination Aof U.S. President John F. Kennedy and prepar- ing for the holiday season. These two contrasting events reminded me that over the last 50 years, all Americans, particularly surgeons, have borne wit- ness to many profound changes in our society and our profession—some more positive than others.

A fateful day I was a 14-year-old high school freshman the day President Kennedy was assassinated. Like most young people of the time, I felt a connection to the youthful president and his wife, and his steadfast efforts to deal with the difficult issues of the day Even during those tumultuous were inspiring. The early 1960s were a precarious time in U.S. his- days in the nation’s history, tory. The climate of confrontation with communism, however, much progress occurred, | 7 the vulnerability of the world to nuclear destruction particularly in medicine. as evidenced in the proliferation of bomb shelters both in people’s homes and at schools, and the rising aware- ness of racial inequities created a strong sense of fear among many Americans. During his short time in office, however, Presi- dent Kennedy generated a feeling of optimism and confidence about the future. He took on the Cold War with strength and resolve, established the Peace Corps, and shared his vision of excellence and innovation in science, space exploration, medicine, human rights, and racial and gender equality. And, with his beautiful and intelligent wife and children, the Kennedy White House emanated a touch of class and vigor. His assassination in November 1963 seemingly put an end to much of the national enthusiasm, and the country’s mood took a rather dark turn. The war in Vietnam escalated over the coming years, and, in response, the size, number, and volatility of anti- war protests grew. Although Kennedy’s successor, Lyndon B. Johnson, signed the Civil Rights Act, frus- trations over ongoing racial disparities erupted into inner-city riots. In the 1970s, the revelations in the Pentagon Papers followed by Watergate during the Nixon Administration left many Americans feeling betrayed and distrustful of politicians.

JAN 2014 Bulle t in American College of Surgeons Executive Director’s report

To overcome these challenges, we must call upon not only our ingenuity, but also our past experience and collective wisdom.

viding quality care and how they will be paid? What Progress continues new regulatory burdens will they face in their efforts Even during those tumultuous days in the nation’s his- to provide accountable, reliable, transparent, patient- tory, however, much progress occurred, particularly centered care? Will their efforts to maintain certifica- in medicine. Technological and scientific advances in tion and licensure detract from their time in the oper- angiography, ultrasound, magnetic resonance imag- ating room and consulting with patients? ing, computed tomography, and so on have led to more Unquestionably, our profession faces many chal- accurate and speedier diagnoses. Innovative surgical lenges, and, yes, we live in a time of great uncertainty. techniques, including endovascular, laparoscopic, and But as I look back on the last 50 years and recall walking robot-assisted procedures, have led to safer operations home from school on a cold, rainy November afternoon with shorter recovery times. in Hudson, OH, I am reminded that these difficulties Furthermore, in the last 50 years, we have wit- are relatively small, albeit significant, in comparison nessed the development of acute care and trauma sys- with what the nation was experiencing at that moment. tems, multidisciplinary teams for cancer care, the rise of transplant surgery, and advances in every surgical L ooking forward 8 | specialty. As a result, many more critically injured and ill patients have a far greater chance of leading long The American College of Surgeons (ACS) is working and productive lives. hard to help its members meet these evolving demands Outside of surgery, the nation and the rest of the and to ensure that surgeons are involved in setting the world have benefitted from other technological inno- standards for the profession. In the process, we would vations—many of which have evolved directly or indi- be wise to draw on the values, inspiration, and leader- rectly through the fulfillment of President Kennedy’s ship that President Kennedy demonstrated during his vision of landing on the moon and exploring the rest brief time in office. We must look to the future not with of the galaxy. Examples include computerization and fear and cynicism, but with a commitment to continu- electronic and digital communication. Indeed, 50 years ing to make progress in the delivery of quality care ago, few among us would have imagined the swift and and to building on the legacy of those innovators who wide-ranging effects of modern technology on nearly came before us. And as we begin 2014, to paraphrase every aspect of our day-to-day existence. President Kennedy, I would ask each of you to ask not what your profession can do for you, but what you can do for your profession. Continued uncertainty I look forward to working with all of you and am Nonetheless, numerous issues continue to confront the committed to ensuring that the ACS will continue to world, many of which cannot be resolved with technol- meet your expectations and the needs of your patients. ogy alone. To overcome these challenges, we must call Thank you for the privilege of serving as one of the upon not only our ingenuity, but also our past experi- leaders of this organization, and happy New Year.  ence and collective wisdom. Examples of high-priority issues in surgery include access to and ongoing disparities in health care, outside interference with the surgical practice environment, and economic concerns. Many surgeons also have con- cerns regarding how they will be evaluated profession- ally as the nation moves toward a value-based health If you have comments or suggestions about this or other issues, please care system. Who will decide whether they are pro- send them to Dr. Hoyt at [email protected].

V99 No 1 Bulle t in American College of Surgeons RAS-ACS essay contest

Annual RAS-ACS essay contest:

| 9

JAN 2014 Bulle t in American College of Surgeons RAS-ACS Essay Contest

How surgeons deal with complications: Introductory remarks

10 |

by Robert D. Winfield, MD

urgeons, both in training and in practice, face po- members on the subject. Essays are judged by a pan- tential complications with nearly every decision el of Communications Committee members, and in Smade or action taken. We each cope with these addition to publication in the Bulletin, the author of events in slightly different ways but share common the winning essay receives a $500 prize. experiences: the feeling of guilt or shame when fac- This year’s topic, How Surgeons Deal with Com- ing a patient or family member after an adverse plications, generated a robust response from the RAS- event; analyzing our actions in an effort to improve; ACS membership, and we were pleased to select the seeking the advice of a colleague or mentor; and ul- essay written by Elisha Brownson, MD, from the Bos- timately coming to peace with ourselves so that we ton University Medical Center, MA, as our winner. may provide quality care to the next patient who Although Dr. Brownson’s essay stood out from the needs us to be at our best. In this issue of the Bul- rest, all of the thought pieces that follow are excellent letin, members of the Resident and Associate Soci- and worthy discourses and share universal themes ety of the American College of Surgeons (RAS-ACS) on this emotional topic. I anticipate that most readers share their experiences with and perceptions on the will empathize with the authors and will learn from subject of complications. these selections from the next generation of surgeons.  Each year, the Communications Committee of the RAS-ACS selects a topic of broad interest to young surgeons and solicits brief essays from interested

V99 No 1 Bulle t in American College of Surgeons RAS-ACS essay contest

Accepting accountability and moving forward

by Elisha G. Brownson, MD

nap. not advance recklessly to the operating room. It is In an instant, the whole procedure changed. this awareness that our colleagues and attendings SI had been called to assist another co-resident in attempt to reproduce at the podium of our morbid- removing a port-a-cath at the bedside. It had been dif- ity and mortality conferences, but often we are our ficult, and despite retrieving the port, the tunneled own greatest critic in this process. line was proving to be more of a struggle to remove. The sterile field was taken down. My gown, gloves, It was my hands that came to assist, that applied stron- and mask were removed. Are you all done now? We ger tension, and that snapped the catheter. It was my invited the patient’s wife back to the room so the | 11 complication. attending surgeon and I could explain our findings My thoughts flashed back to the consent form that and the plan going forward. It is a challenge, in a the patient had signed. The risks of the procedure include: field wrought with pride and confidence, to expose bleeding (not expected to be more than a tablespoon), infec- our failures to patients and their families. But this tion (we are removing the port due to suspected infection), humility carries forward with us and shapes us. Every damage to nearby structures… surgeon has those poignant faces or names engraved Did we even mention retained foreign body? in their memory, and they stay with us for the dura- In a calm voice, I asked my co-resident to get our tion of our career. chief resident to the bedside and get the nurse to put The patient was wheeled off to interventional the patient on telemetry. There we were, with an radiology. Thankfully, retrieval of his catheter was awake patient and a catheter that I could not retrieve. resolved promptly and without further complications. Surgeons must often face complications in a The next day, I apprehensively walked into the patient’s much more overt way than our medical colleagues. room to round. Deep breath. Move forward. Another day And, unlike a hospital-acquired pneumonia, which in residency. These were the thoughts that were run- often can be attributed to several factors with shared ning through my head that morning. responsibility among numerous providers, surgical I am a surgeon in training and as my responsibili- complications can often fall into the operator’s hands. ties grow, I understand more intimately the unique Our hands, which we have trained to heal, are also challenges of our field.I have learned from this patient held accountable for their actions. and have found that our complications spur us on to I returned to our workroom feeling a mixture of strive for better care in the future.  embarrassment, regret, and disappointment in myself. My chief’s response surprised me. She said that this problem was a sign that I was operating because, in the end, we cannot operate without encountering complications. We must reconcile this fact within ourselves to move forward, while at the same time proceeding with great care and detail so that we do

JAN 2014 Bulle t in American College of Surgeons RAS-ACS essay contest

Responding to, reflecting on, and moving forward from a surgical complication

by Tad Kim, MD

am nearing the end of preparing the gastric conduit ever remember stapling the right gastroepiploic pedicle for an esophageal replacement during a long and to the gastric conduit, and from that incident forward, Icomplicated esophagectomy. I staple the left gastric both my assistant and I have checked, double-checked, pedicle along the lesser curvature. The orientation of and triple-checked the orientation of the stomach and the stomach does not look right. It dawns on me that, the anatomy before dividing what we believe is the left yes, I did the unthinkable. I stapled the right gastro- gastric pedicle. This simple tactic, “the pause”, serves as epiploic pedicle—the blood supply for the gastric con- an effective checkpoint to prevent errors. 12 | duit. Her stomach is now unusable. As much as I wanted to mentally kick myself and • Reflect on the error.O ne of my mentors likes to keep retreat from the world and the gravity of my error, I a “little black book” in which he writes down lessons still had a patient with an open abdomen who needed and thoughts for improvement after every case. He calls an esophagectomy and an alternative replacement. In these entries his “black book thoughts”. As surgeons, we such situations, there is no time to retreat, rationalize, all need to have a means of reflecting on and, impor- and ponder; there is only time to humbly admit the mis- tantly, documenting our black book thoughts for pos- take and find a solution. In the face of a serious error, terity. This process allows us to accept what we have the surgeon needs to respond by accepting that he or done, be transparent with ourselves, reflect on errors, she has made a mistake—without excuse, defense, or develop error-prevention strategies, and ultimately for- rationalization—and quickly return to caring for the give ourselves. patient. In this particular situation, the solution was to create a pedicled segment of jejunum to serve as an • Forgive yourself. It is impossible to be an effective clini- interposition between the proximal esophagus and cian and surgeon working with the weight of regret and remnant distal stomach. the fear of repeating mistakes. Our prior errors should Once the error has been physically resolved to the live with, but not hinder, us. We must be able to forgive best of the surgeon’s ability, he or she should proceed ourselves so that we can continue to do the right thing as follows: and take care of our future patients. It is a chance to heal not only the patient, but also ourselves.  • Be transparent with the patient, your colleagues, and yourself. Transparency is essential not only because the patient and family have the right to know the truth about Acknowledgement the complication, but also because discussing complica- The author would like to acknowledge Sara S. Kim, MD, a tions with your colleagues serves as a foundation for les- first-year general surgery resident at the University of North sons in how to prevent and compensate for such errors. Carolina-Chapel Hill, for her assistance with this essay.

• Create a moment of pause the next time you encounter a situation similar to the one that led to the error. I will for-

V99 No 1 Bulle t in American College of Surgeons RAS-ACS essay contest

Talk it out, and slow it down

by Pablo Serrano, MD, MPH

e don’t like to think about the fact that sur- matic mode.” Little did I know, but I was actually tak- geons make mistakes. Yet, a significant pro- ing down and resecting the normal duodenum of the Wportion of our patients suffer complications patient and not the Roux-en-Y. As a result, we had to either on the wards or in the operating room, and perform a much larger operation with an end-to-end some of these problems are direct consequences of anastomosis to the second portion of the duodenum, our mistakes. which led to several postoperative complications. The emotional reactions of surgeons to adverse Many thoughts were going through my mind. A events can be categorized into different phases: couple of these bothered me tremendously: one was | 13 that my patient had just suffered a major complica- 1. The kick, during which feelings of failure emerge tion that was avoidable, and the other was that my credibility and identity as a good surgeon-in-training 2. The fall, in which a sense of chaos prevails were in jeopardy. This error marked the beginning of my training as 3. The recovery, when we try to learn from our mistakes a fellow, and I was unsettled for a long time. Talking about and discussing this operative complication with 4. The long-term impact, which involves integrating what residents, fellows, and junior and senior staff helped me we have learned into our practice* to deal with these emotions—not only talking about the technical aspects of the operation, but also how But how do we integrate these lessons into our to prevent something like this from happening again. everyday lives? Through this experience, I learned the concept of I remember it as if it happened yesterday. It was the “slowing down when you should.” My mistake was first week of my fellowship, and I was assigned a non- definitely attributable to a failure to slow down and complex case with a resident. I was nervous because it be mindful at a crucial moment during the operation. was one of my first few independent cases, but, at the By talking about this surgical error, I was able to dig same time, I was excited to be able to prove to others into this problem—to look at it head-on and not shy that, “I can do it.” away from it. We planned to resect a pancreatic cyst that had pre- Talking about our reactions to cases involving sur- viously been internally drained to a Roux-en-Y. At some gical complications should not leave us feeling embar- point in the case, I felt the complex portion was over. rassed or denigrated. Rather, expressing our feelings We had identified the anatomy of the Roux limb, and regarding these situations should allow us to achieve we simply had to take it down. I thought this step was an understanding of two crucial and conflicting reali- the routine part of the operation and resorted to “auto- ties—our desire for perfection as we strive for our best and our imperfection on this real, lifelong journey.  *Luu S, Patel P, St-Martin L, Leung AS, Regehr G, Murnaghan ML, Gall- inger S, Moulton CA. Waking up the next morning: Surgeons’ emotion- al reactions to adverse events. Med Educ. 2012;46(12):1179-1188.

JAN 2014 Bulle t in American College of Surgeons RAS-ACS essay contest

Mea maxima culpa— Dealing with surgical complications

by JaBaris D. Swain, MD, MPH

is eyes became sunken and retreated back- craft can recall complications that have haunted their wards. His face grew pale. Within seconds, a clinical practice. To this point, there are few situations Hlifeless corpse replaced the spirit of a once viva- in which specific complications are essentially unavoid- cious, living being. My mind was paralyzed, but my able; they just happen. Yet, irrespective of the context, instincts remained engaged. Without delay, I initiat- we must recognize that in almost every situation— ed chest compressions, glaring intently at the moni- regardless of the setting—rests an opportunity for tor and hoping that the asynchronous beats would the surgeon to be inquisitive, to be transparent, to be 14 | somehow reorganize into a familiar rhythm again; introspective, and to learn from the moment at hand. but they did not. Instead, the tracing flattened. This In whatever way we choose to address our compli- man and his soul had drifted away, and there was no cations, either in our clinical practice or on the basis way I could call him back. He was gone forever, and of consultation, we must challenge ourselves to be in the recesses of my mind, I felt I was in some way responsive in identifying sentinel causality. We must responsible. demonstrate equipoise between self-assessment and In medicine, a “complication” refers to the unfavor- constructive peer censure. We must continue to rec- able evolution of a disease, condition, therapy, or pro- ognize the inherent frailties of the human experience cedure. By and large, complications are unintended, and work toward shifting from a culture of blame and, particularly in surgery, they frequently occur with and duplicity to one of accountability and trust. Final- little or no advance notice. Occasionally, complications ly, we must be dedicated to delivering responsible, arise without any true reason as to how or why they patient-centered care in a safe, collegial environment occurred. What is clear, however, is that the costs asso- that includes equitable treatment and full disclosure to ciated with most complications are high—sometimes all patients and families alike. These tenets may repre- conferring unnecessary morbidity and premature mor- sent the way forward in our specialty and inarguably tality, which is every surgeon’s nightmare. will define how well we are able to truly advance our Much interest is frequently placed on understanding profession beyond the veil of complications.  how to avoid the varying types of complications, but little is ever spoken regarding how to conduct oneself when, indeed, confronted with the reality of an unde- sirable surgery-related event. This notion has emerged as being critically important to us as surgeons, given that we are now judged not only by the scope and adeptness of our surgical skill, but also on the bases of the short- and long-term complication rates associ- ated with the care we provide. Invariably, we will all face complications. Even those whom we hail as masters and experts of our

V99 No 1 Bulle t in American College of Surgeons RAS-ACS essay contest

Consequences

by G. Paul Wright, MD

he family gathers in the waiting area, holding his soiled scrubs. His mind races. What if he had just hands, exchanging stories. The surgeon ap- improved the exposure? He rinses the blood splatter Tpears. He’s done this operation many times be- from his neck. What if he hadn’t pushed forward? fore, he assures them. The family offers reassurance The door opens, the surgeon removes his cap. He to the patient as well. Hugs are exchanged, along did all he could. The tumor was large. There was with a final kiss from his wife of 50 years. Off rolls a bleeding. His heart could not take the stress. He’s husband, a father, a grandfather—entrusting his life passed. Tears flow as everyone gathered huddles to a man he’s spoken with for less than 30 minutes. together in a consoling embrace. There are no dry | 15 In the operating room, lines are in place and eyes except for the surgeon. He weeps within—weeps checklists are completed. The team has done this for what he’s done. routine many times before. The belly is opened; His peers will offer solace—the tumor was large, everyone knows the process from here. The surgeon’s the tissue quality was poor. His heart was already hand reaches in, but something feels different than in suboptimal condition. Inside he knows this out- the images displayed on the monitor. What seemed come was avoidable. Knows his pride put this man small before has now grown and is near the major in danger. Knows the void now created in this fam- vascular structures. The surgeon ponders the next ily. Knows these feelings will trouble him for days, move, constantly assessing the risk of proceeding. To weeks, months, years. resect is to cure; to not resect is failure. Heal by steel But there isn’t time to ponder these consequences. it is, and they press on. The next case is on the table.  The dissection is tedious, the exposure difficult. Frustration mounts as the lighting just never seems quite right. Red flags are all around, but to not resect is failure. Then the bleeding starts. The open cavity fills torrentially. The patient’s blood pressure drops, while the heart rate rises. The head of the table is now a flurry of activity. Sponges are used in an attempt to quell the crimson surge but to no avail. The monitor alarms. The pulse is absent. Compressions begin, but this chapter is closed. No more morning strolls with his wife. No more weekends manning the grill with his son during football season. No more pushing his granddaughter on the backyard swing. The family gathers in the consultation room. Once jovial, they now sit in silence, waiting, hoping. On the other side of the restricted area, the surgeon changes

JAN 2014 Bulle t in American College of Surgeons RAS-ACS essay contest

Complications are shared experiences

by William Yi, MD

s a surgeon, when complications happen, I tend of his son that he would miss while in the hospital, and to take them very personally. I see these techni- about how the patient needed to quit smoking. A small Acal or clinical errors as damning evaluations of amount of time was devoted to explaining what the my own effort, work, and worth. I think all surgeons next steps in his care would be, the challenges ahead, have this mentality to some extent—the belief that and what each of us needed to do. Sitting there, huddled their value and ability as a physician is tied to their together, it felt like a discussion on a team bus headed patients’ outcomes. for a big game. Teammates talking about our personal 16 | This belief, of course, is foolish because clinical out- lives, but also focused on what needed to be done to comes are dependent on many factors outside of the achieve a positive outcome. surgeon’s control, such as patient follow-up, comor- When mistakes occur, retreating into seclusion and bidities, and so on. However, as “captains of the ship,” self-blame are common reactions. For surgeons, this surgeons inherently believe that the outcomes are in reaction is borne of the theory that they are ultimately our control. When the outcomes go wrong, the effects in control of the patient’s care and outcomes. However, on our self-worth can be devastating. we are not. After my first complication, I found myself in a semi- Surgeons have a complex relationship with their depressive state, wondering whether I was cut out to patients, one marked by the common goal of a posi- be a surgeon. As one of my patients showed me, how- tive outcome. When successes happen, we should cel- ever, this was borne out of an error in how I viewed ebrate together. And when failures occur, we should the surgeon-patient relationship. grieve and rebound together as well. This is a unique I received my education after inadvertently ligat- method of dealing with errors as surgeons that we all ing the common bile duct on a patient. The patient should embrace.  remained in the hospital for months, and for the first few days after the complication, I became a mute, walk- ing the halls in a zombie-like daze of regret and self- anger. My attending paged me a few days later and asked me to meet him in the patient’s room. As I entered with my head held low, not wanting to make eye con- tact with the patient whom I had injured, the patient put his hand on my shoulder and told me, “Doc, you’re my surgeon. We can’t take this on together if you’ve already given up.” We talked for about 15 minutes that day—the patient, my attending, and I. We talked about the patient’s kids, about the championship football game

V99 No 1 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

| 17

Preoperative telemedicine evaluation of surgical mission patients: Should we use it routinely?

by Rifat Latifi, MD, FACS; Francisco Mora, MD; Flamur Bekteshi; and Renato Rivera, MD, FACS

JAN 2014 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

Highlights s most surgeons know, medical care is insuf- ficient or nonexistent in many regions of the • R eports that on-site preoperative evaluation world.1 The lack of access to surgical care ac- of global surgery patients is a complex, A counts for a high number of disability-adjusted life time-consuming, and often chaotic process 2 and that telemedicine could be used to years (DALYs), defined as years of healthy life lost. expedite the delivery of lifesaving care DALYs have been launched by the World Bank and by the World Health Organization (WHO) as a mea- • Describes how the authors reviewed patient sure of the global burden of disease. WHO estimates information and radiologic studies using SAFT that 2 billion people have no access to basic surgical before embarking on a surgical mission in the care and that surgery could be used to cure 11 per- Philippines, followed by in-person follow-up cent of the global burden of disease.3 • Authors found a 98 percent correlation Surgical humanitarian missions, including those rate between SAFT and in-person outreach efforts arranged through the American Col- preoperative evaluations lege of Surgeons’ Operation Giving Back program, • Demonstrates that low-cost telemedicine have become a viable method of providing surgical 4 18 | is a viable and secure tool for preoperative care to patients in underserved areas. Many other evaluation of surgical mission patients, and organizations around the world facilitate such mis- its routine use should be encouraged sions as well, which typically involve a broad spec- trum of surgical disciplines. Preoperative evaluation of surgical mission patients is a complex, time-consuming, and often chaotic process. Typically, these evaluations require intense work by the operating team on the day of arrival at the mission site. On-site screening, unfortunately, precludes many patients from receiving surgical treat- ment due to the identification of last-minute medical issues, such as comorbidities or the lack of necessary test results. Many of these patients wait for years to obtain surgical care only to be told they are inap- propriate candidates for the surgical care that will be provided through the mission. It is unclear how many patients are disqualified from participation during on-site screening worldwide for any of the aforementioned reasons, but it is likely that the num- ber is considerable.

T he mission For the last seven years, the Association of Filipino Physicians of Southern Illinois has organized a team of surgeons, anesthesiologists, nurses, and other health care professionals to deliver surgical care in Tagbila- ran, the capital city of the island province of Bohol

V99 No 1 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

To assess the applicability of telemedicine in advance of short-term surgical missions, our team conducted a study comparing the use of store-and-forward telemedicine (SAFT) with in-person, on-site preoperative evaluations of surgical mission patients.

in the Philippines. Since 2012, this mission has been ovarian cyst resection, breast tumor resection, gall- called Bohol Operation Giving Back. From year to bladder removal, cleft lip/palate repair, and superficial year, with some exceptions, the all-volunteer surgical soft-tumor resection or parotid gland/mass resection. team comprises general surgeons with different sub- We excluded from the study all patients in need of specialty interests, otolaryngology surgeons, plastic obstetrics-gynecology or plastic surgery. surgeons, obstetrics-gynecology surgeons, anesthesi- One of the authors of this article, Francisco Mora, ologists, certified registered nurse anesthetists, and/or MD, a second-year general surgery resident, was other health care practitioners. During these annual deployed to Tagbilaran one week before the surgi- one-week surgical missions, the team has performed cal mission in February 2012. Using a laptop and an array of general surgery operations, including thy- basic Internet connection, Dr. Mora transferred the roidectomies for advanced goiters and thyroid cancer, upcoming surgical mission patients’ data and images hernia repairs, hysterectomies, oophorectomies, and to a secure server via SAFT software. The software other operations. featured specially designed screens (see Figure 1, Over the last five years of this mission, surgeon vol- page 20). unteers and their teams have performed 446 operations: The data and images transferred included: 168 thyroidectomies, 75 hysterectomies/oophorecto- | 19 mies, 69 cleft lip and palate repairs, 66 hernia repairs, • Patients’ demographic characteristics (age and gender) 19 superficial tumor removals, 17 breast operations • Preoperative diagnosis (from lumpectomies to mastectomies), 16 cholecys- • Biopsy results (when available) tectomies, and 16 other procedures. They operated on • Duration of disease 299 female and 147 male patients with the mean age • Results of radiologic imaging studies of 34. All year long, in advance of the one-week surgi- cal mission, the nongovernmental organization Gift For patients with goiter, hernia, and other condi- of Life Foundation for the Philippines and the local tions showing visible pathology, digital photos taken medical team see patients and identify those in need with a standard digital camera also were included. of surgery. On the day of our surgical team’s arrival, One of the mission surgeons, Rifat Latifi, MD, many surgical candidates are screened—sometimes FACS, a co-author of this article, reviewed all of the more than 200 in a single day. After evaluating patients, data and images from a remote location and made the each surgeon will schedule four to seven operations a decision whether to operate and what type of operation day for six operative days. was required. On the day the surgical team arrived at the site, the operating surgeon examined each patient in person preoperatively and made the final decision Exploring telemedicine for evaluation regarding whether to proceed with the operation. To assess the applicability of telemedicine in advance Any changes in the originally uploaded plans were of short-term surgical missions, our team conducted recorded. a study comparing the use of store-and-forward tele- medicine (SAFT) with in-person, on-site preoperative evaluations of surgical mission patients. The institu- R esults tional review board (IRB) at the University of Arizona, In all, 93 general surgery patients were evaluated using Tucson, approved this study. SAFT applications (see Table 1, page 21). Preoperative The local medical team identified patients in need SAFT diagnosis leading to a surgical opinion was pos- of various operations, including thyroid gland/mass sible in 88 (93 percent) patients. Figure 2, page 21, fea- resection, inguinal hernia repair, myoma resection, tures samples of three conditions evaluated via SAFT.

JAN 2014 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

Figure 1. Medweb ™ SAFT screens

In five patients (less than 5 percent), the remote surgeon required more information or better images (see Table 2, page 21) to render 1A. Home page an opinion. Of those five patients, during the on-site in-person evaluation, the surgical team found that two had a lipoma, two had an ingui- nal hernia, and one patient had a breast mass. Figure 3, page 22, is a photo of one of these con- ditions, a mass on the patient’s flank that turned out to be a lipoma. The remote surgeon, using SAFT, prelimi- narily decided against an operation in five (less than 5 percent) of the patients: two had severe hyperthyroidism and required medical therapy before surgery; one had been misdiagnosed by 20 | the local medical team as having an inguinal 1B. Consult screen hernia but, per SAFT, did not; one had a lipoma that did not require removal; and one patient had a breast tumor that appeared suspicious for can- cer that required further evaluation and staging (see Table 3, page 22). The correlation rate between SAFT and in- person preoperative evaluations was 98 percent. Only two operations preliminarily arranged based on the SAFT evaluations were canceled after an in-person on-site consult, both due to a lack of indication for surgery. Overall, preop- erative telemedicine evaluation decreased the on-site screening time significantly over what 1C. Ultrasound image it would have been, as compared with previ- ous missions.

Effective evaluation method Several studies have shown that telemedicine is a safe and reliable method for evaluating surgical patients preoperatively and postop- eratively.5-11 However, the infrastructure for using low-cost telemedicine technologies has yet to become ubiquitous worldwide.12 Most studies have used one of the two main tech- niques: SAFT or live teleconsultation. For 1D. Intraoperative and postoperative view of a patient that underwent the most part, live telemedicine consultation thyroidectomy.

V99 No 1 Bulle t in American College of Surgeons Preoperative telemedicine evaluation Figure 2.

2A. Phyllodes tumor 2B. Giant goiter 2C. Large lipoma requires advanced infrastructure and technology, but low bandwidth tele- medicine for intraoperative consul- Table 1. Patients evaluated via SAFT tations in the jungles of Ecuador has SA FT diagnosis Confi mation 9,12 been reported. Subsequently, Merrell Number of and opinion by in-person and colleagues in Richmond, VA, used Condition patients rendered evaluation (%) remote screening to evaluate 51 patients T hyroid mass 52 52 100% in Kenya using e-mails and attachments (mostly, giant containing patient data and images. In goiter) this study, 33 patients (65 percent) were Inguinal hernia 14 12 86 deemed poor candidates for operative Gallbladder 7 7 100 care for various reasons. The rest of the disease patients underwent successful surgical Superficial soft- 7 5 86 | 21 10 procedures. Although a large number tissue tumor of patients were considered non-can- Breast tumor 9 8 89 didates for surgical services, the real number of patients that typically are Parotid mass 4 4 100 disqualified from receiving care on sur- T otal 93 88 95 gical missions has never been reported. In our study, the number of patients who did not receive operative care was Table 2. much lower; however, this high accep- Conditions unable to render tance rate may reflect careful patient an opinion via SAFT selection by the Gift of Life Foundation for the Philippines and past experience. Condition N Other studies have reported good results Lipoma 2 in the use of preoperative screening Inguinal hernia 2 using telemedicine for patients treated Breast mass 1 in the Amazon basin.11 T otal 5 Like many other reports, this study demonstrated that the use of SAFT immediately before such missions is safe and reliable. We were unable to render an opinion in advance of our surgical mission via SAFT only for a small num- ber of patients. Additional information that was unobtainable remotely (for example, from maneuvers during in-per- son physical examinations) was required. The development of standardized SAFT

JAN 2014 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

Table 3. Patients deemed non-operative candidates via SAFT

SA FT diagnosis N R eason Goiter 2 Severe hyperthyroidism; medical therapy required Inguinal hernia 1 Misdiagnosis by local team; no indication for surgery Lipoma 1 No indication for excision Breast tumor 1 Further evaluation and staging required

Figure 3. techniques for surgical mission and additional Flank mass, undiagnosable via SAFT live telemedicine consultation protocols may be a solution to this problem. Some studies have established guidelines for capturing radio- logic images for telemedicine patients.13,14

Future applications Similar studies are needed to assess the qual- ity of other imaging methods for telemedicine patients with superficial soft-tissue tumors and hernias, to name just two conditions. Videos 22 | showing surgical mission patients’ pathology tests and physical examinations also are need- ed. The authors believe that videos obtained by smartphones or other video equipment would help to remotely identify such condi- tions as thyroid lobe goiter with greater pre- cision (differentiating, for example, between involvement by one lobe versus both lobes), especially in patients with a bilateral giant goi- ter, as depicted in Figure 4, this page. Some- times, massive goiters are difficult to evaluate Figure 4. even in an anesthetized patient on the oper- Bilateral giant goiter ating table. Although involvement of surgery residents and surgical fellows may be admirable in these missions, training a local nurse or physician— someone who lives year-round in the under- served area—to perform preoperative evalua- tions and forward the data and images to the mission’s surgical team is advisable. Having a local nurse or physician participate in this meaningful manner would strengthen the on-site surgical mission and aid in the devel- opment of sustainable health care teams. Per- haps most importantly, this local involvement would facilitate long-term postoperative fol- low-up care for all surgical mission patients.

V99 No 1 Bulle t in American College of Surgeons Preoperative telemedicine evaluation

Like many other reports, this study demonstrated that the use of SAFT immediately before such missions is safe and reliable.

Summary R efer ences Low-cost telemedicine is a viable and secure 1. Weiser TG, Regenbogen SE, Thompson DK, Haynes AL, Lipsitz tool for preoperative evaluation of surgi- S, Berry W, Gawande A. An estimation of the global volume of cal mission patients. It increases efficiency surgery: A modeling strategy based on available data. Lancet. 2008;372(9633):139-144. and optimizes the use of existing resourc- 2. Debas HT, Gosselin R, McCord C, Thind A. Chapter 67: Surgery. In: es. More specifically, it helps ensure an Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans accurate assessment of patients before the DB, Prabhat J, Mills A, Musgrove P, eds. Disease Control Priorities surgical team arrives, reduces on-site pre- in Developing Countries. Second ed. Washington, DC: World Bank; screening time, and decreases the number 2006. Available at: http://www.ncbi.nlm.nih.gov/books/NBK11719/. Accessed November 12, 2013. of surgical candidates on the waiting list. 3. World Health Organization. WHO global initiative for emergency Routine use of telemedicine in surgical mis- and essential surgical care. Available at: http://www.who.int/ sions most likely would reduce preopera- surgery/en/. Accessed May 1, 2013. tive times and the number of operations 4. American College of Surgeons. Operation Giving Back. Available at: canceled at the last minute. Moreover, it http://www.operationgivingback.facs.org/. Accessed May 25, 2013. 5. Rodas E, Mora F, Tamariz F, Cone SW, Merrell RC. Low-bandwidth may be effectively used for long-term fol- telemedicine for pre- and postoperative evaluation in mobile surgical low-up care, including the management of services. J Telemed Telecare. 2005;11(4):191-193. | 23 any postoperative complications. 6. Rosser JC Jr, Prosst RL, Rodas EB, Rosser LE, Murayama M, Brem H. Evaluation of the effectiveness of portable low-bandwidth telemedical applications for postoperative follow-up: Initial results. J Am Coll Surg. 2000;191(2):196-203. Acknowledgments 7. Rosser JC Jr, Bell RL, Harnett B, Rodas E, Murayama M, Merrell R. The authors thank all the members of Borja Use of mobile low-bandwidth telemedical techniques for extreme Family Hospital in Tagbilaran, Philippines, telemedicine applications. J Am Coll Surg. 1999;189(4):397-404. and all members of Bohol Operation Giving 8. Meade K, Lam DM. A deployable telemedicine capability in support Back 2013 for their support and assistance with of humanitarian operations. Telemed J E Health. 2007;13(3):331-340. 9. Rodas EB, LatifiR , Cone S, Broderick TJ, Doarn CR, Merrell RC. this project, as well as the Medweb team for Telesurgical presence and consultation for open surgery. Arch Surg. their generous technical support, and Ronald 2002;137(12):1360-1363. Merrell, MD, FACS, professor, Virginia Com- 10. Lee S, Broderick T, Haynes J, Bagwell C, Doarn CR, Merrell RC. The monwealth University, Richmond, VA, for his role of low-bandwidth telemedicine in surgical prescreening. J Pediatr valuable editorial comments and review of the Surg. 2003;38(9):1181-1183. 11. Otake LR, Thomson JG, Persing JA, Merrell RC. Telemedicine: Low- manuscript.  bandwidth applications for intermittent health services in remote areas. JAMA. 1998; 280(15):1305-1306. 12. LatifiR . Using telemedicine to strengthen medical systems in Editor’s note limited-resource countries. Bull Am Coll Surg. 2012;97(10):15-21. Dr. Mora’s participation was funded by the Inter- 13. Cone SW, Carucci LR, Yu J, Rafiq A, Doarn CR, Merrell RC. Acquisition and evaluation of radiography images by digital camera. national Virtual e-Hospital Foundation. Telemed J E Health. 2005;11(2):130-136. 14. Krupinski E, Gonzales M, Gonzales C, Weinstein RS. Evaluation of a digital camera for acquiring radiographic images for telemedicine applications. Telemed J E Health. 2000;6(3):297-230.

JAN 2014 Bulle t in American College of Surgeons State legislatures in 2014

Reading the tea leaves for state legislatures in 2014

by Jon H. Sutton

24 | recurring character on The Tonight Show with It is also at the state level where medical licensure Johnny Carson was Carnac the Magnificent. A and insurance markets are regulated, and where Med- A“mystic from the East,” Carnac would divine icaid payment is determined. Public health issues are the answers to unknown questions that were con- often addressed at the state level, as are banking and tained in a “hermetically sealed envelope.” State Af- health care systems overall (trauma center/system fairs staff in the American College of Surgeons (ACS) approval, hospital/ambulatory surgery center licen- Division of Advocacy and Health Policy would like sure, and so on). Medical liability reform, while often to have this mystical ability to predict what is likely discussed and attempted at the federal level, actually to happen in the state legislatures in 2014, but, unfor- gets enacted at the state level—with varying degrees tunately, there is no crystal ball or Carnac available of success. And certainly there can be a hodgepodge to help divine the future of state legislation. Howev- of health care-related issues relating to trauma, can- er, it is possible to make some educated guesses about cer, bariatric surgery, quality and patient safety, and 2014, especially after a look back at what happened medical education. in 2013. Legislative schedules are typically limited, with most state legislatures meeting for two to three months between January and July. Then legislators adjourn Where the action is and return home, providing plenty of opportunities Advocacy at the state level has become much more for in-district visits with their constituents. important in recent years because that is where all the action seems to be taking place. The 16-day fed- eral government shutdown in October 2013 reflects Brief look back the end result of hyper-partisanship, and impedes A detailed review of state legislatures in 2013 was pub- good governance. However, at the state level, leg- lished in the December 2013 issue of the Bulletin (pages islators get bills passed, with or without partisan- 31–35), but for the sake of more accurately assessing ship. States must, by law, have balanced budgets, so the issues likely to top the state legislatures’ agendas in spending plans that the majority party introduces 2014, it’s worthwhile to briefly look back at 2013. Fol- are acted upon, as are other initiatives near and dear lowing are some of the issues debated heavily in the to the majority’s heart. state legislatures last year.

V99 No 1 Bulle t in American College of Surgeons State legislatures in 2014

Advocacy at the state level has become much more important in recent years because that is where all the action seems to be taking place.

Medical liability reform. A number of states saw leg- Advanced practice nurses, optometrists, dentists, po- islative and judicial activity related to medical liabil- diatrists, and other practitioners regularly go to their ity reform.* Legislators in Arkansas looked at poten- legislators to see what they can achieve with varying tial constitutional amendments to implement caps on degrees of success. One point worth noting with re- noneconomic damages and other reforms similar to spect to scope issues is that they generally result in leg- those in the groundbreaking Medical Injury Compen- islators’ friends fighting over some aspect of the issue, sation Reform Act (MICRA). Meanwhile, efforts were and legislators typically prefer to avoid such conflicts. under way in California, the birthplace of MICRA, to attack the statute at the ballot box. The Supreme Cancer/trauma. Many states sought to require insur- Courts in New Jersey and in Oklahoma issued rul- ance companies to provide for additional imaging in ings, and other states passed disclosure, apology, and those cases where dense breast tissue is detected. In offer laws Oregon( ); clarified existing medical liability addition, after multiple attempts, Texas succeeded in reform laws (Michigan); and introduced and enacted enacting the Uniform Emergency Volunteer Health the concept of provider shields relating to public/private Practitioners Act.† payor guidelines used as evidence in medical liability | 25 lawsuits (Georgia). Provider shields create a barrier between physicians R inging in the new year and public or private payor guidelines that could be Some significant issues are likely to be considered in used as evidence in medical liability lawsuits. Evidence the states this year. A few examples of what to watch related to the public and private payor guidelines is for are as follows: inadmissible in court and may not be used to demon- strate negligence or failure to follow a standard of care. • As mentioned previously, MICRA is once again under attack in California. An initiative, should it receive the Injury prevention. Legislators at the state level saw required number of signatures, will be on the November the usual mix of youth concussion education, firearm 2014 ballot, which would not only increase the cap on safety, and distracted driving bills introduced and, in noneconomic damages from $250,000 to approximately some cases, enacted by their legislatures. For the past $1.1 million, but would impose mandatory random drug few years, it has been popular in the states to address testing and other dictates on physicians. A summary use of handheld communication devices and texting description of this initiative (13-001) is available at the while driving. California Secretary of State’s Web page.‡

Scope of practice. Many bills are introduced every year Campaign efforts to defeat or pass this ballot initiative at the state level, which would expand the scope of are going to be very expensive—in the hundreds of mil- practice for nonphysician health care practitioners. lions of dollars. Surgeons, ACS chapters, and the entire California medical community will be hearing from *American College of Surgeons. Advocacy and health policy medical li- those organizations that oppose the initiative and will ability reform. Available at: http://www.facs.org/ahp/proliability.html. want and need to be engaged. Accessed October 23, 2013. †American College of Surgeons. Uniform Emergency Volunteer Health Practitioners Act. Available at: http://www.facs.org/ahp/uevhpa.html. • With the implementation of the Affordable Care Act Accessed on October 24, 2013. (ACA), legislators in some states may be taking another ‡ California Secretary of State. Debrah Bowen. Initiatives and referenda cleared for circulation. Available at: http://www.sos.ca.gov/elections/ look at the essential benefits package to determine what ballot-measures/cleared-for-circulation.htm. Accessed October 24, 2013. procedures should be covered. Now would be a good

JAN 2014 Bulle t in American College of Surgeons State legislatures in 2014

With the implementation of the Affordable Care Act (ACA), legislators in some states may be taking another look at the essential benefits package to determine what procedures should be covered.

time for surgeons to advocate for coverage of proce- this issue has gotten a second wind and certainly gener- dures they believe should be included in the benefits ated considerable concern among the parents of children package. Other ACA-related issues may include trans- who want to play football or other sports where concus- parency of fee schedules for providers, Medicaid expan- sions are a possibility. sion and improving Medicaid payment, participation in networks included in insurance plans purchased through • Now that many state budgets are in slightly better shape, the exchanges, and so on. 2014 may be the year to start looking at not only trau- ma system development, but also funding for these sys- • As mentioned earlier, provider shield legislation was tems. Possible models would include raising the fee on passed in 2013 for the first time in Georgia. This legisla- the issuance of driver’s licenses or vehicle registrations tion was drafted in response to a joint effort by the medi- with those additional funds directed to the trauma sys- cal and the trial attorney communities. While Georgia is tem. Another possibility would be an increase in the the first state to do this, it is likely to catch fire in other tobacco tax. state legislatures, so surgeons and ACS chapters should 26 | pay close attention in their states and look for advocacy • With 2014 being an election year, state legislators will opportunities should provider shield or other liability be looking to introduce the kind of legislation they can reform legislation be introduced. get passed to bolster the likelihood of re-election. With this in mind, now might be a good time for surgeons • Many scope-of-practice bills are expected to be intro- to contact their state legislators and suggest that they duced this year. In particular, advanced practice nurses introduce and pass bills that would be good for the pro- (APNs) have been very active at the grassroots level for fession, for patients, and for the state. the last year or so, educating state legislators about their desire to practice independently and why they think they This summary lists just a few legislative and policy should be allowed to do so. A counterbalance to this trends to watch for at the state level. Certainly, many movement—not just for APNs, but really any non-phy- other issues will arise, and ACS State Affairs staff would sician provider group seeking independent practice—is a like to hear from surgeons and chapters when they do. law that Texas passed in 2013 that creates a team-based, Send correspondence to [email protected]. Like- physician-led collaborative model of practice. It would wise, when the College issues a grassroots advocacy not be surprising to see the Texas model bill popping request for action, surgeons and chapters need to par- up all over the country, especially in those states where ticipate. Typically a five-minute visit to the Surgery scope-of-practice battles rage on year after year. State Legislative Action Center to send a prewritten letter to a state legislator is all that is required. The • At least eight states passed breast imaging laws in 2013, ACS Surgery State Legislative Action Center is avail- and many more will be considered in the state legisla- able at http://www.facs.org/sslac/index.html. It’s easy to tures in 2014. These bills mandate that coverage be pro- do but can make a world of difference in the outcome vided for an additional imaging test when dense breast of a piece of legislation in the states.  tissue is found.

• The few remaining states that have yet to adopt youth concussion education and prevention laws will likely be considering such legislation. In light of recent national coverage of brain injury in professional football players,

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

Highlights of the 2013 Clinical Congress | 27

JAN 2014 Bulle t in American College of Surgeons Clinical Congress highlights

he 2013 Clinical Congress of the American Col- 28 | lege of Surgeons (ACS) provided surgeons, med- Tical students, surgical residents, and other mem- bers of the operating room team with the opportunity to immerse themselves in a variety of educational ex- periences and to interact with their peers. Total reg- istration for this year’s meeting was 13,367, including 8,857 physicians; the remaining registrants were ex- hibitors, guests, spouses, and convention personnel.

Centennial celebration concludes Over the course of the last year, ACS Fellows have been commemorating the 100th anniversary of the found- ing of the College. Adding to the excitement of the 2013 conference were activities marking the conclusion Scenes from the 2013 Clinical Congress. of the Centennial celebration. Once again, a special Photos on this page: T he College celebrated its 100th birthday with a confetti drop at the Opening Ceremony exhibit, 100 Years of Inspiring Quality—An Interactive and with a birthday card signed by meeting attendees. Timeline, was on display at the meeting with new fea- Overleaf: Top row, left to right: T he processional at Convocation; tures added to spotlight the lessons learned from the Drs. Pellegrini and Hoyt ceremonially marking the College’s 100th ACS Inspiring Quality Tour and other developments anniversary with the Centennial cake-cutting. Second row: in 2012–2013. Dr. Chen (left) delivering the Olga Jonasson Lecture; audience members applauding Dr. Chen. T hird row: T he exhibit floor; The ACS leadership also hosted an evening of cof- Mr. McCullough delivering the Martin Memoral Lecture. Fourth row: fee, cordials, and conversation. During this social Members of the Young Fellows Association Governing Council meet; event, College leaders conducted a Centennial cake- surgeons participate in a hands-on fl xible endoscopy workshop. cutting ceremony. The ACS International Relations (Photos throughout this article by Charles Giorno Photography and Oscar & Associates Photography.) Committee and Operation Giving Back also presented a Centenary International Reception in honor of the College’s milestone anniversary.

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

A. Brent Eastman, MD, FACS, outgoing President, presents the Presidential Medallion to Dr. Pellegrini during Convocation.

Dr. Eastman presents the Distinguished Service Award to Dr. Bass.

Dr. Pellegrini gives his Presidential Address.

In a related activity, a new Surgical History Group FACS, as First Vice-President, and John T. Preskitt, | 29 held an organizational breakfast under the leadership MD, FACS, as Second Vice-President. Dr. Rikkers is of former ACS President LaMar S. McGinnis, Jr., MD, professor emeritus at the University of Wisconsin-Mad- FACS. The primary focus of the new group will be ison and Editor-in-Chief of Surgery News. Dr. Preskitt the preservation of College’s historical resources. Fur- is a surgical oncologist at Baylor University Medical thermore, the ACS Foundation announced the offi- Center, Dallas, TX. cial launch of the 1913 Legacy Campaign fundraising In addition, Honorary Fellowship was conferred initiative. The campaign will secure gifts to advance on six international surgeons: Markus W. Büchler, programming that is critical to the College, while also MD, of Heidelberg, Germany; R.J. (Bill) Heald, recognizing the Centennial and looking forward to the CBE, MChir, FRCS(Ed)(Eng), Basingstoke, Hamp- next 100 years. shire, UK; J. Octavio Ruiz Speare, MD, MSc, FACS, Mexico City, Mexico; Prinya Sakiyalak, MD, FACS, FRCS(T), Bangkok, Thailand; Norman S. Williams, Convocation MS, FMedSci, PRCS(Eng), London, UK; and Cheng- Although considerable attention was directed toward Har Yip, MB, BS, FRCS(Glas)(Eng), Kuala, Lumpur, the ACS Centennial, the underlying focus was the Malaysia. future of the organization as exemplified by the theme of the 2013 Clinical Congress—“The Next 100 Years.” Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), The Named L ectures Henry N. Harkins Professor and Chair, department of As always, Clinical Congress featured several Named surgery, University of Washington Medicine, Seattle, Lectures, starting with the Martin Memorial Lecture, was installed as the 94th President of the ACS during presented immediately after the Opening Ceremony on the 2013 Convocation ceremonies on October 6. Dr. Pel- October 7. In honor of the conclusion of the College’s legrini presented his Presidential Address, The Surgeon Centennial celebration, historian David McCullough, of the Future: Anchoring Innovation and Science with recipient of two Pulitzer Prizes and two National Book Moral Values, to the College’s 1,622 Initiates. Awards, delivered the well-received lecture, Something Two Vice-Presidents assumed office during the New, Something Old with Renewed Force: The Role Convocation as well: Layton “Bing” Rikkers, MD, of History and Innovation in Medicine.

JAN 2014 Bulle t in American College of Surgeons Clinical Congress highlights

2013 NSC Surgeons’ Award for Service to Safety: Dr. Stewart (second from left) with (left to right): 2012 NSC Surgeons’ Award for Service to Safety: Dr. Templeton (middle) with, Dr. R otondo, Dr. Coimbra, and Dr. Teater. left to right: Michael F. R otondo, MD, FACS, Chair, COT; Michael L. Nance, MD, FACS, Chair, COT Quality Data R esources Committee; R aul Coimbra, MD, FACS, recorder, American Association for the Surgery of Trauma; and Don Teater, MD, medical advisor, NSC.

Other Named Lectures presented at the 2013 Clinical Congress were as follows:

• Pauline W. Chen, MD, FACS, a transplant surgeon and New York Times columnist presented the Olga M. Jonasson Lecture: Conduct Unbecoming

Robert H. Bartlett, MD, FACS, 30 | • professor emeri- tus of surgery at the University of Michigan, Ann Arbor, presented the John H. Gibbon, Jr., Lecture: Extracorporeal Life Support: Gibbon Fulfilled

• Peter W. Carmel, MD, D. Med Sci, FACS, chair emeritus, department of neurological surgery, and professor of neurological surgery, New Jersey Medi- ACS COT Meritorious Achievement Award: Dr. Sonneborn (center) cal School at Rutgers University, Newark, presented with Dr. Coimbra (left) and Dr. R otondo. the Charles G. Drake History of Surgery Lecture: Neurosurgical Contributions to Anesthesiology in the Early 20th Century

• Roy A. J. Spence, OBE, JP, MD, LLD(Hon), FRCS(Edin)(I), FRCS(Eng, Glas)(Hon), professor of surgery at Queen’s University of Belfast and the University of Ulster, Northern Ireland, gave the I.S. Ravdin Lecture in the Basic and Surgical Sciences: Reflections of a Surgeon in Troubled Times

• Ian C. Lavery, MD, FACS, staff surgeon, depart- ment of colon and rectal surgery, the Cleveland Clin- ical, OH, presented the Herand Abcarian Lecture: How Health Care Reform Will Impact the Practice of Surgery Surgical Forum dedicatee Dr. Bland (center) with O. Joe Hines, MD, FACS, Chair of the Committee for the Forum on Fundamental • Mark A. Talamini, MD, FACS, professor and chair- Surgical Problems, and Mary T. Hawn, MD, FACS, who made man, department of surgery, Stony Brook University introductory remarks at the presentation.

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

Surgical Forum Excellence in R esearch Award recipients. Front row, left to right: Drs. Maclellan, Tapia, Vrecenak, Linden, T hirunavukkarasu, R ivard, and Pandit. Back row: Drs. Hamarneh, Sherman, Pontarelli, Kleiman, Dedy, T hompson, and Kirby. Not pictured: Dr. Mella.

School of Medicine, Stony Brook, NY, presented the PA, gave the Commission on Cancer Oncology Lecture: | 31 Excelsior Surgical Society/Edward D. Churchill Lec- Re-engineering of Care: Surgical Leadership ture: Surgery and Technology: A Complicated Part- nership Awards and honors • Ronald V. Maier, MD, FACS, the Jane and Donald D. Several surgeons were honored for their contribu- Trunkey Endowed Chair in Trauma Surgery and pro- tions to the ACS. Barbara Lee Bass, MD, FACS, the fessor and vice-chair, department of surgery, University John F. and Carolyn Bookout Distinguished Endowed of Washington, Harborview Medical Center, Seattle, Chair and chair of the department of surgery at Hous- presented the Scudder Oration on Trauma: A Century ton Methodist Hospital, TX, received the ACS Distin- of Evolution in Trauma Resuscitation guished Service Award, the College’s highest honor, during the Convocation. The Board of Regents pre- • Norman S. Williams, MS, FMedSci, PRCS, President sented the award to Dr. Bass in appreciation of her of the Royal College of Surgeons, London, UK, gave the exceptional service to the organization for more than Distinguished Lecture of the International Society of “20 years in noteworthy leadership roles,” as well as Surgery: Attempts to Innovate in Coloproctology and “her outstanding clinical and academic contributions Beyond to the field of surgery.” The Fellows Leadership Society (FLS) of the ACS • Bruce L. Gewertz, MD, FACS, the H. and S. Nichols Foundation presented the 2013 Distinguished Philan- Distinguished Chair in Surgery; surgeon-in-chief; chair, thropist Award to Elias S. Hanna, MD, FACS. The department of surgery; vice-president of interventional award was announced during the 25th annual FLS services; and vice-dean of academic affairs, Cedars-Sinai, Benefactor Recognition Luncheon in recognition of Medical Center, Los Angeles, CA, presented the Eth- Dr. Hanna’s philanthropic contributions and service ics and Philosophy Lecture: Sustaining Fulfillment in to the international community. Work and Life Other awards were presented to surgeons for their commitment to trauma care. John M. Templeton, Jr., • Glenn D. Steele, Jr., MD, FACS, president and chief MD, FACS, a retired pediatric surgeon in Bryn Mawr, executive officer, Geisinger Health System, Danville, PA, received the National Safety Council (NSC) 2012

JAN 2014 Bulle t in American College of Surgeons Clinical Congress highlights

Joan and Julius H. Jacobson II Promising Investigator Awardee Dr. Haider (right) with David R . Flum, MD, FACS; and Saima Haider.

Surgeons’ Award for Service to Safety at the annual ACS national outreach for his commitment to improv- Committee on Trauma (COT) Dinner on October 7. ing medical and surgical care in Ethiopia. Jerone T. The award recognizes Dr. Templeton’s “zeal for the care Landström, MD, FACS, a general surgeon and Navy 32 | of injured children, his longstanding interest in injury reservist, Tamuning, Guam, received the Surgical prevention, and his generous philanthropic support of Volunteerism Award for military outreach in rec- young investigators in the field of injury prevention.” ognition of his contributions in the Federated States Ronald M. Stewart, MD, FACS, professor and chair, of Micronesia, Guam, the Philippines, and Afghani- department of surgery, University of Texas Health Sci- stan. Katrina B. Mitchell, MD, a general surgery ence Center, San Antonio, received the National Safe- resident at Weill Cornell Medical College, New York, ty Council 2013 Award for Service to Safety during NY, received the Surgical Volunteerism Award for the COT Dinner. Dr. Stewart was recognized “for his outreach during residency for her contributions to commitment to the advancement of the care of injured improving surgical care and education in Tanzania. patients in Texas through leadership in the organiza- Practicing surgeons, residents, and medical students tion of a regional trauma care system and outstanding were recognized for their contributions to advancing trauma research.” In addition, the COT presented its the art and science of surgery. The 2013 Owen Wan- Meritorious Achievement Award to Ricardo G. Son- gensteen Surgical Forum on Fundamental Surgical neborn, MD, FACS, a retired general surgeon in San- Problems was dedicated to Kirby I. Bland, MD, FACS, tiago, Chile. professor and chairman, department of surgery, Univer- Donald R. Laub, Sr., MD, FACS, a plastic and sity of Alabama, Birmingham, for his contributions to reconstructive surgeon, Redwood City, CA, received the science of surgical research, as well as for his years the 2013 ACS/Pfizer Surgical Humanitarian Award dedicated to mentoring surgical residents. for his lifetime of service to patients in developing Residents honored with the Surgical Forum Excel- countries and for his development of a much-emu- lence in Research Awards included: Elizabeth M. lated model for providing surgical outreach around Pontarelli, MD; David A. Kleiman, MD; Mahesh the world. Three surgeons received the ACS/Pfizer Thirunavukkarasu, PhD; Sulaiman R. Hamarneh, Surgical Volunteerism Award. Ingida Asfaw, MD, MD; Viraj Pandit, MD; Allison F. Linden, MD, FACS, a cardiothoracic surgeon and clinical associ- MPH; Colleen Rivard, MD; Jesse D. Vrecenak, ate professor of surgery at Wayne State University MD; Reid A. Maclellan, MD; Nicole M. Tapia, MD; School of Medicine, Detroit, MI, and chief of staff at Nicholas J. Dedy, MD; Scott K. Sherman, MD; Juan St. Joseph Mercy Oakland-Trinity Health, Pontiac, Rodolfo Mella, MD, MPH; E. Will Kirby, MD; and received the Surgical Volunteerism Award for inter- Jonathan R. Thompson, MD.

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

Dr. Quick, recipient of the R esident Award for Exemplary Teaching (third from right), pictured with (left to right): Glenn T. Ault, MD, MSEd, FACS, Chair, R esident Award Program, Committee on R esident Education; R ebecca M. Minter, MD, FACS, Chair, Committee on R esident Education; Dr. Pellegrini; David B. Hoyt, MD, FACS, Executive Director; and Ajit K. Sachdeva, MD, FACS, FR CSC, Director, Division of Education.

| 33

Dr. Fox, recipient of the Jameson L. Chassin, MD, FACS, Award for Professionalism in General Surgery (fourth from right), pictured with (left to right): R andy J. Woods, MD, FACS, residency program director, Wright State University School of Medicine; Dr. Minter; Dr. Pellegrini; Dr. Hoyt; Dr. Sachdeva; and Celia M. Divino, MD, FACS, Chair, Chassin Professionalism Award, Committee on R esident Education.

Adil H. Haider, MB, BS, MPH, FACS, assistant ACS Division of Education to recognize excellence professor, department of surgery, Johns Hopkins in teaching by a resident and to highlight the impor- Medical School, Baltimore, MD, received the ninth tance of teaching in residents’ daily lives. Dr. Quick Joan L. and Julius H. Jacobson II Promising Investiga- was selected by an independent review panel of the tor Award. The award honors outstanding surgeons Committee on Resident Education. engaged in research, advancing the art and science The inaugural Jameson L. Chassin, MD, FACS, of surgery, and demonstrating early promise of sig- Award for Professionalism in General Surgery was nificant contributions to the practice of surgery and presented to Justin P. Fox, MD, MHS, a chief resi- patient safety. dent in general surgery at the Wright State Univer- The eleventh annual ACS Resident Award for Exem- sity School of Medicine in Dayton, OH. The award plary Teaching was presented to Jacob A. Quick, MD, recognizes a chief resident in general surgery who chief resident in general surgery at the University of exemplifies the values of compassion, technical skill, Missouri, Columbia. The award is sponsored by the and devotion to science and learning. The award is

JAN 2014 Bulle t in American College of Surgeons Clinical Congress highlights

Exceptional Scientific Posters of Merit awards, from left to right: Drs. Duh, R usch, Phillips, Ferguson, and Hawn.

| 34 Basic Science R esearch poster awards, left to right: Dr. Sachdeva; Andre R . Campbell, MD, FACS; Mr. Onwugbufor; Ms. Anderson; Mr. Ellis; Mr. R obinson; and Dr. Freischlag.

administered by the ACS Division of Education and of Intraoperative Imaging on Risk-Adjusted Quality will now be granted on an annual basis. The ACS Outcomes. established the new award with gifts from the Chas- Furthermore, the following medical students were sin family, colleagues, and friends of the late Jameson honored for their Basic Science Research posters: L. Chassin, MD, FACS, who was a skilled surgeon, teacher, and scholar in New York City. Dr. Fox was • First place: Alison A. Smith, Tulane University, New selected by an independent review panel of the Com- Orleans, LA, for The Use of Paracrine Factors from mittee on Resident Education. Reprogrammed Mesenchymal Stem Cells to Treat Bio- Valerie W. Rusch, MD, FACS, Chair of the ACS film-Infected Wounds in Vivo Program Committee; Quan-Yang Duh, MD, FACS, Vice-Chair of the Program Committee; and Mary T. • Second place: Ryan J. Ellis, National Institutes of Health, Hawn, MD, FACS, presented Best Scientific Poster Bethesda, MD, for Genome-Wide Methylation Patterns Presentation Awards to Junior Investigator Winner in Papillary Thyroid Cancer Are Distinct Based on His- Elizabeth A. Phillips, MD, Boston, MA, for the post- tologic Subtype and Tumor Genotype er Does a Surgical Career Affect a Woman’s Child- bearing? A Report on Pregnancy and Fertility Trends • Third place: Scott T. Robinson, Emory University School Amongst Female Surgeons, and to Senior Investigator of Medicine, Atlanta, GA, for A Novel Platelet Lysate Winner T. Bruce Ferguson, Jr., MD, FACS, Green- Scaffold Promotes Human Mesenchymal Stem Cell ville, NC, for Image-Guided Surgery: The Impact Growth and Invasion

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

International Scholars and Travelers 2013. Front row, left to right: Drs. Poon, Smith, Faraj, Tsoulfas, Wong, and Pastor. Middle row: Drs. Mshelbwala, Wakeman, Nigri, Del Chiaro, Chokotho, Ulloa, Satoi, and Schroen. Back row: Drs. Itoh, Heuer, Ademuyiwa, Howle, Norese, Adeleye, and Agarwal.

The following medical students were recognized Wong, MB, ChB, FACS, Elias Hanna Scholar; Car- | 35 for their Clinical and Educational Research posters: los Pastor, MD; Philip M. Mshelbwala, MB, BS, FWACS; Christopher John Wakeman, MB, ChB, • First place: Barbara J. Williams, University of California- MMed(Sci); Giuseppe R. Nigri, MD, PhD, FACS; Irvine School of Medicine, for Intravenous Infusion of Marco Del Chiaro, MD, PhD, Dr. Abdol and Mrs. Bendavia during Renal Revascularization Attenuates Joan Islami Scholar I; Linda Carolyn Chokotho, Cardiac Injury and Dysfunction in Swine Renovascu- MB, BS; Jorge H. Ulloa, MD, FACS; Sohei Satoi, lar Hypertension MD, PhD, FACS, Dr. Abdol and Mrs. Joan Islami Scholar II; Anneke T. Schroen, MD, MPH, FACS, • Second place: Michael T. Onwugbufor, Children’s Nation- ACS Traveling Fellow to Germany; Shinji Itoh, MD, al Medical Center, Washington, DC, for Myocardial PhD, Japan Exchange Fellow; Matthias Heuer, MD, Cytochrome Oxidase Activity Increases with Age and PhD, German Exchange Fellow; Adesoji Oludotun Hypoxemia in Patients with Congenital Heart Disease Ademuyiwa, MB, BS, Baxiram S. and Kankuben B. Gelot Scholar; Julie Rina Howle, MB, BS, FRACS, • Third place: Jamie E. Anderson, University of Califor- Murray F. Brennan Scholar; Mariano Norese, MD; nia-San Diego, for Cockcroft-Gault Equation Estimates Amos Olufemi Adeleye, MB, BS, FWACS; and Rajiv of Nephron Mass and Need Can Predict Improved Agarwal, MB, BS, MS, Louis C. Argenta Scholar. Outcomes in Expanded Criteria Donor Kidney Trans- The Commission on Cancer presented the State plantation Chair Outstanding Performance Award to the follow- ing surgeons: Allen Silbergleit, MD, FACS, Michigan; The International Relations Committee welcomed Patrick Jackson, MD, FACS, District of Columbia; and the International Guest Scholars for 2013 and other William Dooley, MD, FACS, Oklahoma. guests at a luncheon October 8, including: Jensen Amy E. Tan, MD, FACS, a general surgeon in Blue T-C Poon, MB, BS, FRCS(Ed), FACS, Carlos Pel- Hill, ME, attended the Clinical Congress as the recipi- legrini Traveling Fellow; Stephen Ridley Smith, ent of the 2013 Nizar N. Oweida Scholarship. Addi- FRACS, ANZ Exchange Fellow; Walid Faraj, MB, tionally, Anees B. Chagpar, MD, MPH, FACS, direc- BS, FACS; Georgios Tsoulfas, MD, FACS, Stavros tor of the Breast Center-Smilow Cancer Hospital at Niarchos Foundation Scholar; George Kwok Chu Yale University, New Haven, CT, recipient of the 2013

JAN 2014 Bulle t in American College of Surgeons Clinical Congress highlights

Oweida Scholarship recipient, Dr. Tan.

Dr. R oland (far left) and Dr. Milroy (far right) presented the Committee on Cancer Liaison’s Outstanding Performance awards to three State Chairs: Drs. Silbergleit, Jackson, and Dooley.

Claude Organ Traveling Fellowship, spoke before the Elect. Jay L. Grosfeld, MD, FACS, Lafayette F. Page ACS Scholarships Committee. Professor Emeritus of Pediatric Surgery, Indiana Uni- 36 | Lastly, the Resident and Associate Society (RAS) versity School of Medicine, Indianapolis, was elected of the ACS presented a $500 award to the winner of First Vice-President-Elect; Kenneth L. Mattox, MD, the 2013 RAS essay contest—Elisha G. Brownson, FACS, Distinguished Service Professor, Michael E. MD, a surgical resident at Boston Medical Center, DeBakey Department of Surgery, Baylor College of MA. The theme of this year’s essay contest was How Medicine; and chief of staff and chief of surgery, Ben Surgeons Deal with Complications. This year’s essays Taub General Hospital, Houston, TX, was elected are published in this issue of the Bulletin beginning Second Vice-President-Elect. on page 11. The Board of Governors of the ACS elected one new member of the Board of Regents: James Gig- antelli, MD, FACS, professor of ophthalmology and Annual Business Meeting assistant dean of government relations at the Univer- The ACS Annual Business Meeting of Members con- sity of Nebraska Medical Center, Omaha. Reelect- vened October 9 with Dr. Pellegrini presiding and the ed to additional three-year terms on the Board of following officials presenting reports: Julie A. Freis- Regents were: Margaret M. Dunn, MD, FACS, a chlag, MD, FACS, Chair of the Board of Regents; general surgeon, Dayton, OH; Howard M. Snyder Robert R. Bahnson, MD, FACS, Chair of the Amer- III, MD, FACS, a urological surgeon, Philadelphia, ican College of Surgeons Professional Association PA; and Michael J. Zinner, MD, FACS, a general political action committee (ACSPA-SurgeonsPAC) surgeon, Boston. Dr. Freischlag, the William Stew- Board of Directors; Lena M. Napolitano, MD, FACS, art Halsted Professor, chair of the department of sur- Chair of the Board of Governors; and David B. Hoyt, gery, and surgeon-in-chief at Johns Hopkins Hospital MD, FACS, ACS Executive Director. in Baltimore, MD, will continue to serve as Chair of The election of the ACS President-Elect, Vice-Pres- the Board of Regents. Mark C. Weissler, MD, FACS, idents-Elect, Regents, and Governors also took place Joseph P. Riddle Distinguished Professor at the Uni- during the Annual Business Meeting. versity of North Carolina, Chapel Hill, will continue Andrew L. Warshaw, MD, FACS, surgeon-in- to serve as Vice-Chair. chief emeritus, Massachusetts General Hospital, and The Board of Governors elected Gary L. Timmer- the W. Gerald Austen Professor of Surgery at Harvard man, MD, FACS, a general surgeon, Sioux Falls, Medical School, Boston, MA, was elected President- SD, to serve as Chair of its Executive Committee;

V99 No 1 Bulle t in American College of Surgeons Clinical Congress highlights

An ice sculpture commemorating the College’s 100-year anniversary. Playing in the background is the television episode of M*A*S*H that mentions the ACS.

Dr. Warshaw (left) and Dr. Pellegrini at the Annual Business Meeting of Members.

Fabrizio Michelassi, MD, FACS, a general surgeon, For mor e infor mat ion | 37 New York, NY, as Vice-Chair; and Lorrie Langdale, MD, FACS, a general surgeon, Seattle, WA, as Secre- T his article contains information that is tary. Newly elected to serve on the Executive Commit- discussed in greater depth in previous tee of the Board of Governors are Karen Brasel, MD, issues of the Bulletin. T he following is a list FACS, a general surgeon, Milwaukee, WI, and Joseph of where these articles can be found. H. Tepas III, MD, FACS, a pediatric surgeon, Jack- September 2013 sonville, FL. In addition, James C. Denneny III, MD, FACS, a otolaryngology surgeon, Columbia, MO, and • Barbara Lee Bass, MD, FACS, selected to receive 2013 Distinguished Sherry M. Wren, MD, FACS, a general surgeon, Palo Service Award, page 58 Alto, CA, have been reelected to the Board of Gover- nors’ Executive Committee. Governors-at-Large from • Fellows honored for volunteerism, page 68 throughout the world and Specialty Society Governors November 2013 also were installed. • Carlos A. Pellegrini, MD, FACS, installed as 94th ACS President, page 46 Clinical Congress 2014 • Six prominent surgeons accorded Honorary Be sure to attend the 2014 Clinical Congress October 26-30 Fellowship in the ACS, page 48 in San Francisco, CA. Details regarding the educational December 2013 program, registration, housing, and transportation will • Presidential Address: T he surgeon of be posted at www.facs.org.  the future: Anchoring innovation and science with moral values, page 8 • Andrew L. Warshaw, MD, FACS, is President-Elect of the College, page 54 • New ACS R egents and Governors elected, page 57

JAN 2014 Bulle t in American College of Surgeons ACS Officers, Regents, and Board of Governors’ Executive Committee

Officers/Officers-Elect

Carlos A. Pellegrini L ayton F. R ikkers President First Vice-President General surgery General surgery T he Henry N. Harkins Professor Professor emeritus, University of and Chair, department of surgery, Wisconsin-Madison; and University of Washington, Seattle Editor-in-Chief, Surgery News Seattle, WA Madison, WI

John T. Preskitt Edward E. Cornwell III Second Vice-President Secretary General surgery General surgery Clinical professor of surgery, T he LaSalle D. Leffall, Jr. Professor Texas A&M Health Science Center and Chairman of Surgery, Howard Baylor campus; director of surgical University College of Medicine; oncology, Baylor Sammons Cancer and surgeon-in-chief, Howard Center University Hospital Dallas, TX Washington, DC 38 |

William G. Cioffi, Jr. Andrew L . Warshaw Treasurer President-Elect General surgery General surgery J. Murray Beardsley Professor and W. Gerald Austen Professor of chairman, Alpert Medical School of Surgery, Harvard Medical School; Brown University; and surgeon-in- and senior consultant, international chief, R hode Island Hospital and T he and regional clinical relations, Miriam Hospital Massachusetts General Hospital and Providence, RI Partners HealthCare Boston, MA

Jay L . Grosfeld Kenneth L . Mattox First Vice-President-Elect Second Vice-President-Elect Pediatric surgery General surgery Lafayette F. Page Professor Emeritus Distinguished Service Professor, of Pediatric Surgery, Indiana Michael E. DeBakey Department of University School of Medicine, Surgery, Baylor College of Medicine; Indianapolis and chief of staff and chief of Indianapolis, IN surgery, Ben Taub General Hospital, Houston, TX

V99 No 1 Bulle t in American College of Surgeons ACS Officers, Regents, and Board of Governors’ Executive Committee

Board of Regents

Julie A. Freischlag Mark C. Weissler Chair Vice-Chair Vascular surgery Otolaryngology William Stewart Halsted Professor Joseph P. R iddle Distinguished and surgeon-in-chief, T he Johns Professor of Otolaryngology, Hopkins Hospital professor of otolaryngology–head Baltimore, MD and neck surgery, and professor and chief of head and neck oncology, University of North Carolina Neurosciences Hospital Chapel Hill, NC

John L .D. Atkinson Margaret M. Dunn Neurological surgery General Surgery Professor of neurosurgery, Professor of surgery and executive department of neurological surgery, associate dean, Wright State Mayo Clinic University Boonshoft School of Rochester, MN Medicine; and chief executive officer, Wright State Physicians Dayton, OH | 39

Henri R . Ford James K. Elsey Pediatric surgery General and vascular surgery Vice-president and surgeon-in-chief, Private practice, visiting professor Children’s Hospital of Los Angeles; of surgery, Emory University School vice-chairman and vice-dean for of Medicine medical education, Keck School of Atlanta, GA Medicine, University of Southern California Los Angeles, CA

Gerald M. Fried James W. Gigantelli General surgery Ophthalmology Adair Family Professor and chairman, Professor of ophthalmology and department of surgery, McGill assistant dean of government University; and surgeon-in-chief, relations at the University of McGill University Health Centre Nebraska Medical Center, Omaha Hospitals Omaha, NE Montreal, QC

JAN 2014 Bulle t in American College of Surgeons ACS Officers, Regents, and Board of Governors’ Executive Committee

Board of Regents

B.J. Hancock Enrique Hernandez Pediatric surgery Gynecology (oncology) Associate professor, departments T he Abraham R oth Professor and of surgery and pediatrics and child Chair of the department of obstetrics, health, University of Manitoba; and gynecology, and reproductive pediatric surgeon and pediatric science; director, division of interventionist, Children’s Hospital of gynecologic oncology; and professor Winnipeg of pathology, Temple University Winnipeg, MB Philadelphia, PA

L enworth M. Jacobs, Jr. L . Scott L evin General surgery Plastic and reconstructive surgery Professor of surgery and chairman, Paul B. Magnuson Chair of department of traumatology and Orthopaedic Surgery, chair of emergency medicine, University of the department of orthopaedics, Connecticut; and director, trauma and professor of surgery at program, Hartford Hospital the University of Pennsylvania Hartford, CT School of Medicine; plastic and reconstructive surgeon, University | 40 of Pennsylvania Health System Philadelphia, PA

Mark A. Malangoni R aymond F. Morgan General surgery Plastic surgery Associate executive director, Milton T. Edgerton Professor and American Board of Surgery chair, department of plastic surgery, Philadelphia, PA University of Virginia Health Sciences Center Charlottesville, VA

L eigh A. Neumayer Valerie W. R usch General surgery Thoracic surgery Professor of surgery, University of Chief, thoracic service, Memorial Utah; Jon and Karen Huntsman Sloan-Kettering Cancer Center; Presidential Professor of Cancer and professor of surgery, Cornell R esearch, Huntsman Cancer Institute; University Medical College and co-director, Integrated Breast New York, NY Program, Huntsman Cancer Hospital Salt Lake City, UT

V99 No 1 Bulle t in American College of Surgeons ACS Officers, Regents, and Board of Governors’ Executive Committee

Board of Regents/ Board of Governors’ Executive Committee

Marshall Z. Schwartz Howard M. Snyder III Pediatric surgery Urology Professor of surgery and pediatrics, Associate director of pediatric Drexel University College of urology, T he Children's Hospital Medicine, Temple University School of Philadelphia; and professor of of Medicine; and surgeon-in-chief, St. urology, University of Pennsylvania Christopher’s Hospital for Children School of Medicine Philadelphia, PA Philadelphia, PA

Beth H. Sutton Steven D. Wexner General Surgery Colorectal surgery Private practice, Wichita Falls; Chair, department of colorectal and clinical professor of surgery, surgery, Cleveland Clinic-Florida; University of Texas Southwestern clinical professor of surgery and Medical School, Dallas affiliate dean for clinical education, Wichita Falls, TX Florida International University; and affiliate professor and associate dean for academic affairs, Florida Atlantic | University in Boca R aton 41 Ft. Lauderdale, FL

Michael J. Zinner Gary L . T immerman General surgery Chair, Board of Governors Moseley Professor of Surgery, General surgery Harvard Medical School; clinical Sanford Surgical Associates director, Dana-Farber/BWH Cancer Sioux Falls, SD Center; and surgeon-in-chief, Brigham and Women’s Hospital Boston, MA

Fabrizio Michelassi L orrie L angdale Vice-Chair, Board of Governors Secretary, Board of Governors General surgery General surgery Lewis Atterbury Stimson Professor, Professor of surgery, University of Chairman, department of surgery, Washington; chief, general surgery Weill Cornell Medical College; and director SICU, VA-Puget Sound and surgeon-in-chief, New York- Health Care System Presbyterian/Weill Cornell Medical Seattle, WA Center New York, NY

JAN 2014 Bulle t in American College of Surgeons Statement

Statement on advance directives by patients: “Do Not Resuscitate” in the operating room

T he Board of R egents of the t is generally expected that the surgeon will assume primary re- American College of Surgeons Isponsibility for advising patients regarding risks, benefits, and 1 approved a revised [ST-19] Statement alternatives when discussing a potential operation. This policy focuses on patients who accept a surgeon’s recommendation to on Advance Directives by Patients: have surgery and who already have in place an advance direc- “Do Not R esuscitate” in the Operating tive, specifically, a “DoN ot Resuscitate” (DNR) order. The best R oom, at the Board’s meeting in approach for these patients is a policy of “required reconsider- October 2013. T he revised statement ation” of the existing DNR orders.2 Required reconsideration was developed and submitted means that the patient or designated surrogate and the physi- by the Committee on Ethics. T he cians who will be responsible for the patient’s care should, when possible, discuss the new intraoperative and perioperative risks original statement was published associated with the surgical procedure, the patient’s treatment in the September 1994 Bulletin. goals, and an approach for potentially life-threatening problems consistent with the patient’s values and preferences. Some patients with DNR status become candidates for surgi- cal procedures that may provide them with significant benefit, 42 | even though the procedure may not change the natural history of the underlying disease. Examples include procedures to treat intestinal obstruction in individuals with advanced malignancy and surgical procedures such as amputation to alleviate pain or prevent progression of underlying illness. When such patients who have DNR orders in place undergo surgical procedures and the accompanying sedation or anesthe- sia, they are subjected to new and potentially correctable risks of cardiopulmonary arrest. Furthermore, many of the therapeu- tic actions employed in resuscitation (for example, intubation, mechanical ventilation, and administration of vasoactive drugs) are also an integral part of routine anesthesia management, and it is appropriate that the patient be so informed. Policies that lead either to the automatic enforcement of all DNR orders or to disregarding or automatically cancelling such orders do not sufficiently support a patient’s right to self-deter- mination.3-5 An institutional policy of automatic cancellation of DNR status in cases where a surgical procedure is to be carried out removes the patient or the patient’s duly authorized represen- tative from appropriate participation in decision making. Auto- matic enforcement of DNR orders without discussion and clari- fication may not adequately inform patients or their authorized representatives about the new risks associated with surgery and anesthesia and may lead to inappropriate perioperative and anes- thetic management. The required reconsideration discussion should occur as early as practical after a decision is made to have surgery. This discus- sion may result in the patient agreeing to suspend the DNR order

V99 No 1 Bulle t in American College of Surgeons Statement

The required reconsideration discussion should occur as early as practical after a decision is made to have surgery.

during surgery and the perioperative period, retaining the original R efer ences DNR order, or modifying the DNR order. Required reconsidera- 1. Joint Commission on Accreditation of tion works best when the patient has decision-making capacity Healthcare Organizations. Manual of the and when time is available for a conversation. However, even in Joint Commission on Accreditation of Health urgent situations or when the patient lacks decision-making capac- Care Organizations. Patient Rights Chapter. ity, the surgeon can usually discuss the situation with the patient’s Chicago, IL: JCAHO; 1994. 2. Cohen CB, Cohen PJ. Required designated surrogate. In emergency situations, it may be impos- reconsideration of “Do-Not-Resuscitate” sible or impractical for the surgeon to speak with the patient or orders in the operating room and certain the patient’s duly authorized representative prior to the patient’s other treatment settings. Law Med Health approaching demise, when irreversible damage occurs, or similar Care. 1992;20(4):354-363. circumstances. In such situations, the surgeon must use his or her 3. AORN position statement: Perioperative care of patients with Do-Not-Resuscitate best judgment as to what the patient would wish. or Allow-Natural-Death Orders. 2009. Once a decision is reached on the patient’s DNR status as a Available at: www.aorn.org/WorkArea/ result of the required reconsideration conversation, the surgeon DownloadAsset.aspx?id=21917. Accessed must continue his or her leadership role in the following areas: September 11, 2013. (1) documenting and conveying the patient’s advance directive 4. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care and DNR status to the members of the operating room team; (2) of patients with Do-Not-Resuscitate orders | 43 helping the operating room team members understand and inter- or other directives that limit treatment. pret the patient’s advance directive; and (3) if necessary, finding 2008. Available at: http://www.asahq. an alternate team member to replace an individual who has an org/For-Healthcare-Professionals/~/ ethical or professional conflict with the patient’s advance direc- media/For%20Members/documents/ 6 Standards%20Guidelines%20Stmts/ tive instructions. Ethical%20Guidelines%20for%20the%20 State law and institutional policies may also impact DNR orders Anesthesia%20Care%20of%20Patients. and must be taken into account in determining the appropriate ashx. Accessed November 18, 2013. course of action.  5. American College of Surgeons. Statement of the American College of Surgeons on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. Bull Am Coll of Surg. 1994;79(9):29. 6. Demme RA, Singer EA, Greenlaw J, Quill TE. Ethical issues in palliative care. Anesthesiol Clin. 2006;24(1):129-144.

JAN 2014 Bulle t in American College of Surgeons What surgeons14JA shNoulBULLd know about...

The benefits of attending a 2014 ACS Surgical Coding Workshop

Editor’s note: T his column is an is an ACS member, team experiences, and backgrounds updated version of an article that members or practice employees with the group. Attendees also was published in the March 2013 may attend the workshop learn how their colleagues are Bulletin. T his revised column was prepared by the R egulatory and at the ACS member rate. handling coding, billing, and Quality staff in the ACS Division practice management issues. of Advocacy and Health Policy. How often does coding change? ach year the American Should I plan to attend a What will I learn? College of Surgeons (ACS) workshop each year? The topics discussed at an Ehosts a series of two-day Codes change frequently. In ACS coding workshop change workshops on the application fact, the AMA updates the CPT annually due to the addition, of changes to the Current code set annually. Moreover, deletion, and revision of the CPT Procedural Terminology (CPT)* improvements in coding code set. However, the focus of code set with an emphasis on constructs, additions of new the first day of the workshop is codes that general surgeons technology, and changes to on how to code correctly. Topics commonly use. Instructors coding and reimbursement may include coding accurately 44 | from the practice management rules and payment policies for evaluation and management consulting firm KarenZupko make it necessary to attend (E/M) services, reducing the risk & Associates deliver practical a workshop annually. of an audit, and new Medicare explanations for each change, rules, regulations, and policies. using real case examples These topics are addressed with and educational materials What are the advantages of an emphasis on their effects on developed by the American attending an ACS Surgical surgical practices. Additionally, Medical Association (AMA). Coding Workshop? the instructors discuss how When accurate coding is aligned to appropriately apply coding with a clear understanding of and modifier guidelines to Who should attend an ACS payment policy rules, practices accurately report multiple Surgical Coding Workshop? will begin to improve profit procedure combinations. Surgeons, administrators, margins. Attending an ACS The Centers for Medicare & managers, coders, and coding workshop increases Medicaid Services’ Physician reimbursement staff all report participants’ knowledge of Quality Reporting Initiative, benefitting from the workshops. coding principles and helps Electronic Health Record, Team attendance is strongly them develop the skills needed Electronic Prescribing Incentive encouraged to ensure accurate, to decrease coding errors and Programs, and the Physician complete, and consistent coding. reduce the risk of an audit. Value-Based Payment Modifier, Registration discounts are The workshop also comprises all of which are updated offered when three or more team information regarding the new annually, also are addressed. members are enrolled at the same codes for the year and audit The second day of the time. Moreover, if the physician trends and allows participants workshop is dedicated to to practice accurate coding. surgical case coding. The *All specific references to CPT codes and Additionally, attendees have instructor discusses the descriptions are © 2013 American Medical the opportunity to share their information that should be Association. All rights reserved. CPT and CodeManager are registered trademarks different coding and practice included in an operative of the American Medical Association. management ideas, knowledge, note if a surgeon is seeking

V99 No 1 Bulle t in American College of Surgeons What surgeons14JA shNoulBULLd know about...

Addit ional ACS coding r esour ces To assist surgeons in their efforts to address coding questions, the ACS also offers the following resources:

• T he Coding Hotline (1-800-227-7911), hours of • Coding and Practice Management Corner (previously operation 7:00 am–4:00 pm Mountain T ime. T he Socioeconomic T ips), a column in the Bulletin, provides tips on Coding Hotline staff will answer five free coding a range of reimbursement-related issues. T he topics change questions a year for each Fellow of the ACS. For monthly and in past years have included coding for hernia and additional information on the ACS Coding Hotline, other complex abdominal repairs, debridement, and sentinel visit www.facs.org/ahp/coding/secoding.html. lymph node mapping and its relation to biopsy. T hese and other articles are available at www.facs.org/ahp/pubs/tips/index.html. reimbursement for an for 6.5 CME credits for each operation performed with an day of attendance. In addition, How do I register? assistant or co-surgeon. Other nonphysician attendees who The ACS offers a special price for topics discussed include: are members of the American members and their coding staffs. Academy of Professional ACS Fellows and their staff should • Coding for excisional breast biopsy Coders are eligible for 6.5 be sure to have their ACS member or partial mastectomy continuing education units number available and enter it for each day of attendance. for each person registering. ACS • Coding for component separation membership is not a requirement release for attendance. Register for the When and where will the two-day workshop online at • When and how to report E/M 2014 ACS Surgical Coding www.karenzupko.com/workshops/ services for major and minor Workshops take place? americancollegeofsurgeons/index. procedures, especially trauma html or call 312-642-8310. • February 6–7, Las Vegas, NV For hotel reservations, | 45 • The use of modifier 58 in wound • April 10–11, Chicago, IL contact the hotel that is hosting care, lesion excision, and breast • May 15–16, Washington, DC the workshop using the and colon surgery • August 21–22, Nashville, TN number provided during the registration process, and then • Services included in the global The dates and location indicate that you are attending surgical package change each year; visit the the ACS Surgical Coding ACS practice management Workshop for special pricing. • The difference between returning Web page at www.facs.org/ahp/ The ACS also offers a patient to the operating room to workshops/index.html for the most special airfare discounts on treat a surgical complication and a current dates and locations. United. Contact an ACS Travel staged procedure New in 2014, the ACS Counselor at 800-456-4147 is offering a one-day or [email protected], or • Procedures correctly documented Comprehensive Breast Coding contact United Airlines by phone and reported that are unrelated Workshop, which will be at 800-521-4041 or online at to surgeries done previously in presented February 21 in www.united.com. When the global period Orlando, FL. The workshop will booking individual travel, be provide instruction on how to sure to indicate the name of • How to initiate a successful appeal incorporate the 2014 CPT breast the meeting and refer to the when paid incorrectly biopsy and imaging coding ACS file numbers provided for changes, identify required any applicable discounts.  documentation to accurately Can I earn CME for incorporate ICD-10 verbiage attending a workshop? into office notes and pre- and Editor’s note Physician attendees are eligible postoperative diagnosis in Accurate coding is the responsibility to receive continuing medical operative notes, use appropriate of the provider. This article is education (CME) credits through modifiers to ensure accurate intended only as a resource to the ACS. Physicians are eligible claim submission, and more. assist in the billing process.

JAN 2014 Bulle t in American College of Surgeons Dispatches from rural surgeons

Students need exposure to

the joys of rural surgery by R obert A. Swendiman

want you to know that Dr. “You remember that Bill I have taken a 180-degree turn. Tate is a good man. He did Tate is a good man, you hear?” I completed my third year of “Imy gallbladder 15 years She grinned at Dr. Tate as medical school in a program that ago, his daddy did my C-section, she shook her finger at me. emphasizes rural care in western and his daddy birthed me. You My four weeks as a sub-intern North Carolina. I am currently understand? He’s a good man.” in rural surgery were inspiring. finishing my master’s thesis on The patient, who I will Dr. Tate’s grandfather came to the effects of federal and state call “Rose,” a spunky North Linville in 1910 as the town’s first policies on a rural hospital Carolinian in her mid-70s, was general surgeon. Later, his son system in the region. As a referring to William C. Tate III, took over the practice, and now general surgery applicant, I have MD, FACS, a general surgeon his grandson runs the clinic with sought out residency programs 46 | in the town of Linville, NC. his partner, Thomas Matthews that have an academic and It was in my first week as a Haizlip, Jr., MD, FACS. As general clinical focus on rural disparities. fourth-year medical student surgeons in the truest sense, I would not have followed on a sub-internship in rural they have served the citizens of this trajectory had it not been surgery. Rose’s eyes twinkled western North Carolina expertly. for the opportunity to learn through her bifocals as she I had the opportunity to first-assist in a rural environment with reminded me again how lucky on a range of cases, including engaging mentors. During my I was to be working at the Tate amputations, hemi-colectomies, first two years at the University Clinic. Today, her daughter had skin grafts, cholecystectomies, of North Carolina (UNC) driven her to this small practice and endoscopies. More School of Medicine, I was for a biopsy of a suspicious importantly, for those four assigned to five “community lesion on her left arm. weeks, I felt like part of the weeks” in a pediatrics office Dr. Tate knocked and then town. I saw how their kindness, in the northwest corner of unceremoniously walked into humanity, and investment in the state. This experience was the exam room. He greeted the community have positively my first foray into medicine Rose with a kiss on her cheek affected patients’ lives. outside the academic and urban and a warm hug. The visit began environments. I immediately with an update on his mother’s appreciated how invested health, followed by discussion Opportunity leads the physicians were in the of the renovations going on to inspiration community. They knew their at the local church. It was a But what spurred my interest in patients on a personal level. good few minutes before the rural surgery? It certainly was Thus, I chose to complete my conversation turned to medicine. not my upbringing. I was born entire third year in Asheville, I reported a quick history and and raised in the Washington, NC, where I trained under a physical exam to Dr. Tate, and DC, metropolitan area and have group of superb mentors. a biopsy was done. Rose left spent most of my adult life in Almost everyone reading this with another hug from Dr. Tate the suburbs of Chapel Hill, NC. column likely has had at least one and some more advice for me. However, in the last two years, mentor in surgery. Somewhere

V99 No 1 Bulle t in American College of Surgeons Dispatches from rural surgeons

More than 80 percent of general surgery residents are now pursuing fellowship training, which is negatively correlated with a career in rural practice.

in our careers, we met a clinician As someone who is still R efer ences who was a leader and pushed us to in training, I do not have a 1. Jarman BT, Cogbill TH, Mathiason be better. We seek to emulate such silver bullet to fix these issues. MA, O’Heron CT, Foley EF, Martin RF, mentors, and they often influence However, I do believe, rural Weigelt JA, Brasel KJ, Webb TP. Factors us far more than we realize. surgeons and medical schools correlated with surgery resident choice Dr. Tate is one of those people can take a few actions right to practice general surgery in a rural for me, as is Dr. Haizlip. These away. These suggestions stem area. J Surg Educ. 2009;66(6):319-324. 2. Cofer JB, Petros TJ, Burkolder HC, clinicians have shown me how to from my own experience and Clarke PC. General surgery at rural be a surgeon committed to both current evidence on rural care. Tennessee hospitals: A survey of rural the patient and the community. Tennessee hospital administrators. They are the ones who made the • Become a mentor. Rural surgeons Am Surg. 2011;77(7):820-825. case for my decision to embark should become closely involved 3. Milligan JL, Nelson HS Jr, Mancini ML, Goldman MH. Rural surgery on a career in rural surgery. with local and state medical rotation during surgical residency. schools, taking students under Am Surg. 2009;75(9):743-745. their wings. Without caring 4. Adra SW, Trickey AW, Crosby ME, Pointing the way clinicians like Dr. Tate, I would Kurtzman SH, Friedell ML, Reines HD. Approximately one-quarter of never have heard Rose’s story General surgery vs fellowship: The role of the independent academic medical the U.S. population lives in rural regarding how important his center. J Surg Educ. 2012;69(6):740-745. areas, yet only 15 percent of the practice was to her and her family. 5. Chipp C, Dewane S, Brems C, | 47 American physician workforce Johnson ME, Warner TD, Roberts provides services in these regions. • Expose students earlier to rural LW. “If only someone had told The shortage of rural surgeons care. It is nearly impossible to me…”: Lessons from rural providers. J Rural Health. 2011;27(1):122-130. is even more worrisome: only recruit general surgeons to one of every 10 U.S. surgeons rural areas if they have not had practices in a rural community.1 exposure to the field. For this are from similar backgrounds.1,3 Unfortunately, this workforce reason, undergraduate medical Medical schools must emphasize shortage is expected to worsen education students should have recruitment of students from over the next decade, as nearly the opportunity to serve in rural these communities to increase the half of all rural general surgeons communities. They should have number of physicians who will are more than 50 years old.2,3 clerkships in the third and fourth choose to return to underserved More than 80 percent of general years that require them to move rural areas. At UNC, efforts surgery residents are now beyond academic wards and into already are under way to attract pursuing fellowship training, new environments. Schools should students from rural areas. which is negatively correlated offer sub-internships at rural with a career in rural practice.1,4 clinics and encourage students to These recommendations Lack of exposure to rural participate. If medical students can be implemented easily, and surgery in medical school and never experience the joy of being they would make a significant residency and worries regarding part of a close-knit community, difference in the career choices of heavy caseloads, isolation, and how can we expect them to join medical students and residents. diminished resources also are one after residency? However, all stakeholders must barriers to recruitment.1,5 The make a concerted effort, starting American College of Surgeons • Recruit more students from from the ground up. Caring for Advisory Council for Rural rural backgrounds. The statistics patients in a small community Surgery has been charged with suggest that my story would be an is an honor and a life-changing finding ways to overcome some exception. Most physicians who experience, but no one will know of these recruiting obstacles. work in underserved rural areas it without living it first. 

JAN 2014 Bulle t in American College of Surgeons From residency to retirement

Surgeons as employees: Is the lining always golden?

by Edward M. Copeland III, MD, FACS

T he idea of proceeding into hen I recently queried hours are more predictable, one of the many private third-year medical and the employed physician Wstudents at the is protected from the practice models of the University of Florida College perils of private practice, past is not part of [third- of Medicine, Gainesville, FL, primarily the cost of medical about their plans for practice liability insurance and year medical students’] after finishing their residencies, oppressive night call. mindset. In other words, 75 percent of them indicated Even employed trauma that they plan to work for some surgeons have a satisfactory 48 | they plan to be employees form of a health conglomerate. lifestyle. They are usually on of the “system.” The idea of proceeding into call no more than once every one of the many private four days, and their inpatient practice models of the past is demands are limited because not part of their mindset. In typically one of the members of other words, they plan to be the trauma group is designated employees of the “system.” as having responsibility for inpatients, usually a week at a time. When on the inpatient T he allure of hospital service, night call is not a employment responsibility. So at worst, In a 2008 article titled night call is once every three “Medicine in a vortex,” days and patients are admitted published in the Bulletin of the to the team member who is American College of Surgeons, responsible for inpatients that I outlined the likely reasons week. Because the service for these students’ decisions.* usually includes acute care Basically, physicians entering surgery, surgical specialists, the workforce today enjoy such as surgical oncologists the lifestyle employee status and laparoscopic surgeons, affords and, for the time being, have no acute care or trauma have an income initially better responsibilities. than that of a junior partner Much has been written in a private practice. Work about the pros and cons of this system. I will limit my *Copeland EM, Trunkey DD. Medicine in a vortex: Quantity versus quality. comments to the potential Bull Am Coll Surg. 2008;93(6):10-13. pitfalls for employed physicians.

V99 No 1 Bulle t in American College of Surgeons AFro loomk r aetsi Thedency Joint to rCeotirmmemeissiontn

Even employed trauma surgeons have a satisfactory lifestyle. They are usually on call no more than once every four days, and their inpatient demands are limited because typically one of the members of the trauma group is designated as having responsibility for inpatients, usually a week at a time.

this sudden interest in trauma purposes along with the ability Financial incentives center development? The to provide better care to the for hospitals obvious and true answer is trauma patient. Fortunately, In an editorial published in to provide better care to the there has been a proliferation General Surgery News, “Health injured patient. The other of trauma fellowships to staff care delivery: Its origin and reason, however, is income to some these new centers. its dilemma. Who is in charge the hospital. Trauma patients What would happen if in the USA?,” I concluded that often have multiple medical reimbursement changed? For the answer is hospitals.† The problems, each of which is example, what if my legal reason is quite simple: our attached to a billable Current unbundling were to disappear reimbursement for medical Procedural Terminology and patient reimbursement | 49 care collects primarily on (CPT) code. Medicare, as an was based on the entire the hospital side of the example, uses a computer hospital event rather than on profession from both private program that groups these CPT multiple CPT codes? Would and government insurers. codes into diagnostic-related the financial incentive for Many hospitals are flush with groups (DRGs) from which having a trauma center take money, and salaries of hospital reimbursement is determined. precedence over providing care administrators can reach well The CPT codes associated with for the trauma patient? Would above the $1 million mark. All trauma care fall into multiple the trauma center disappear of this money comes from the DRGs, thereby generating a along with the elimination delivery of health care services potential surplus of income. of its associated expense? or from the investment of This phenomenon I have Hospital systems are in prior money obtained from termed “legal unbundling” a rush to form meaningful the provision of patient care. of reimbursement. financial relationships So, for now, hospital systems In the early days of trauma with freestanding facilities. have the financial resources to centers, the criteria to be a This event is occurring in recruit physicians as employees Level I center were strict and metropolitan and rural areas and with what may turn out the term “trauma center” of the country. For rural to be inflated salaries. was applied only to Level I hospitals, the advantage is Trauma centers are centers. Level II centers now telemedicine, especially for proliferating, at least throughout are advertised as trauma the evaluation of radiographs Florida, and especially in for- centers or trauma hospitals by subspecialty radiologists in profit hospital systems. Why and are accepted as such by the “mother” institution. The the public, by various triage attachment of the name of the †Copeland EM. Health care delivery: Its origin services, and by payors. mother institution to the small and its dilemma. Gen Surg News. 2008;35(12). Therefore, in my opinion, the hospitals is seen as a way to Available at: http://www.generalsurgerynews. com/ViewArticle.aspx?d_id=77&a_ rush to become a “trauma stimulate retired patients who id=12155. Accessed November 21, 2013. center” is for reimbursement have a second home in desirable

JAN 2014 Bulle t in American College of Surgeons From residency to retirement

The simple result of this process is that there are often two employees for only a single job— and somebody, unfortunately, has to go. If this somebody is a surgeon, radiologist, or any other specialist, where will he or she go?

remote areas to seek follow- the year 2020.‡ Consequently, and their salaries are safe up care in a facility associated states are rushing to increase from dramatic reductions. with the mother hospital rather the physician pipeline by Most young physicians live than returning to their primary establishing new medical at the end of their income residence. It also allows for schools and/or increasing the stream and carry a large establishment of large specialty student body size of existing personal debt service. I advise groups so that a specialist has ones. New osteopathic schools them to do their best to avoid time to travel to the rural are opening, and the number becoming a victim of the area on a scheduled basis. of American students studying system. Do not totally rely on abroad continues to increase. quality measures to ensure 50 | When a void is recognized in your continued employment. A surplus of surgeons? a free society, there typically Many of these quality measures For metropolitan and is a rush to fill the void, which are not yet “drilled down” to surrounding areas economy of often results in a plethora of identify the best surgeon who scale makes financial sense and individuals seeking to seal cares for the patients with the has led to the amalgamation of the gap. So what was once highest severity index scores. several hospitals into a single recognized as a need has now Do not totally rely on disease functional unit. Eventually, as become a surplus. We are protocols to protect your in many businesses, one system several years from realizing quality of clinical practice. is incorporated (bought out) such an event, but I believe Many protocols are devised to by a larger system. The simple one is on the horizon. take the best surgeons and the result of this process is that The bottom line is that worst surgeons and create a there are often two employees employee status is almost median of clinical care among for only a single job—and always at the discretion of the them. Such a system could somebody, unfortunately, has employer. On the expense side result in your being a victim of to go. If this somebody is a of the ledger, often the most “downsizing” for reasons other surgeon, radiologist, or any costly items are employee than quality of care. Political other specialist, where will salaries and benefits. These connections and personality are he or she go? I suppose that if costs are not fixed and may just a couple of other reasons.  the U.S. population continues be subject to reduction at to rise and if the Affordable the employer’s discretion. As Care Act creates many more employees, surgeons will need “paying” patients, such a to do their best to ensure that dilemma is unlikely to occur. they are largely indispensable The thought process driving medical education today is ‡Cooper, RA. Weighing the evidence the possibility of having a for expanding physician supply. Ann deficit of 20,000 physicians in Intern Med. 2004;141(9):705-714.

V99 No 1 Bulle t in American College of Surgeons A CSloo Clinick at aThel Re Jointsearc Cho mmProissiogramn

Patient-centered outcomes research: Is this really something new?

by Caprice Greenberg, MD, MPH, FACS; George J. Chang, MD, FACS; and Heidi Nelson MD, FACS

e all are familiar with the on best evidence that will help Dr. Greenberg’s study seeks traditional government patients and their providers to develop a new approach to Wfunding agencies that make better informed decisions surveillance following breast sponsor research, including the about their care, including cancer treatment that will be National Institutes of Health, cancer care. The CER priorities more patient-centered and the U.S. Department of Defense, of PCORI are distinguished effective than the existing one- and the many and varied private from prior initiatives such as size-fits-all approach and will foundations, such as the Susan G. the American Recovery and consider individual risk factors. Komen Breast Cancer Foundation, Reinvestment Act of 2009 by The project has three primary but few of us are familiar with an emphasis on stakeholder goals: (1) use existing data from | 51 the new Patient-Centered engagement to help researchers clinical trials sponsored by one Outcomes Research Institute design research questions and of the leading cancer cooperative (PCORI). Two authors of this measure outcomes that are groups to evaluate how risk of column—Dr. Chang and Dr. most relevant to them. More recurrence and side effects of Greenberg of the Cancer Care information regarding PCORI treatment vary based on patient Delivery Research Committee of is available at www.pcori.org. and cancer characteristics; (2) the Alliance/American College use existing data to evaluate the of Surgeons Clinical Research effectiveness of the latest imaging Program (ACS CRP)—were Alliance/ACS Cr p technology for improving recently awarded PCORI grants. awards approved survival in patients previously This column is intended to PCORI approved two awards treated for breast cancer; and inform Bulletin readers of this sponsored by the Alliance/ (3) engage cancer survivors, new institute, the research it ACS CRP to fund CER aimed providers, and health outcomes will support, and the projects at answering questions most researchers in the development that are getting under way. important to patients and their of an improved patient-centered PCORI is an independent, caregivers. The newly approved approach to guide posttreatment not-for-profit research funding awards will fund studies on care, as well as identify the institution authorized by posttreatment surveillance: highest-priority strategies for Congress as part of the Affordable prospective randomized trials. Care Act of 2010. It is funded • Posttreatment Surveillance in Dr. Chang’s study will address through a trust that receives Breast Cancer: Bringing CER to a critical question that patients monies from the U.S. Treasury the Alliance (Dr. Greenberg) often raise: “Based on my and fees assessed on private and individual tumor characteristics, public health plans. PCORI is • Patient-Centered, Risk-Stratified conditions, and preferences, charged with funding clinical Surveillance after Curative what is the best way to monitor comparative effectiveness research Resection of Colorectal Cancer me?” By tailoring the strategy (CER) to provide information (Dr. Chang) for monitoring to the individual

JAN 2014 Bulle t in American College of Surgeons ACS Clinical Research Program

PCORI approved two awards sponsored by the Alliance/ACS CRP to fund CER aimed at answering questions most important to patients and their caregivers.

colorectal cancer survivors— research into clinical practice. were selected through a highly taking into account their risk By addressing the cancer care competitive review process for recurrence, eligibility for delivery research question that is in which scientists, patients, salvage treatment, and personal the most relevant to patients and caregivers, and other stakeholders preferences—the study seeks their providers and refining the helped to evaluate more than 570 to improve the cancer care study design based on stakeholder proposals that responded to five experience for patients and input we hope to improve the PCORI funding announcements. identify strategies to improve the relevance of both the research Proposals were evaluated effectiveness of cancer monitoring question and the study outcomes on the basis of scientific merit, and reduce the burden on patients to maximize the potential for how well they engage patients and the health care system. incorporation into daily practice. and other stakeholders, their The major goal of these projects methodological rigor, and how is to improve the effectiveness well they fit within PCORI’s New approach of posttreatment surveillance national research priorities. All These studies represent an in real-world practice, and the awards were approved pending 52 | important new approach Alliance/ACS CRP provides the completion of a business and to research—one in which ideal setting to conduct this work. programmatic review by patients and providers together Both observational studies PCORI staff and issuance of identify the most pressing will use data from the National a formal award contract. research questions. As part of Cancer Data Base as well as Over the next few years, previous work with the Agency legacy data from Alliance clinical we can anticipate a continued for Healthcare Research and trials and other databases and increase in the support and Quality’s Developing Evidence will engage cancer survivors, focus on health services to Inform Decisions about health care providers, and research, including patient- Effectiveness Cancer Consortium, researchers to guide the centered outcomes, comparative stakeholders were engaged to development of an improved effectiveness, and cancer care identify the highest priority approach to surveillance that delivery research. The Cancer topic for CER in cancer care. recognizes individual patient Care Delivery Research Posttreatment surveillance risk factors and allows for design Committee of the ACS CRP aims was identified for a variety of of future prospective studies. to develop a program to support reasons, including the number The knowledge gained through investigators in their pursuit of of patients and practitioners these studies will provide studies in this important area. facing this decision every day, the important new tools to guide These two initial PCORI projects uncertainty about the optimal patients and their clinicians in will play an important role in approach, and the applicability making individualized decisions launching this initiative.  across cancer sites. By designing regarding cancer surveillance. parallel studies in colon and breast cancer, we hope to take a more efficient approach to research by Additional studies sharing resources and experience. The studies are two of 71 projects Furthermore, a major totaling more than $114 million challenge exists in translating approved for funding in PCORI’s knowledge generated by latest round of awards. All

V99 No 1 Bulle t in American College of Surgeons A look at The14JA JointNBULL Commission

Action urged to prevent retained surgical items

he Joint Commission has or from a patient’s report of organization-wide, standardized issued a Sentinel Event pain or discomfort. Beyond policy and procedures for the TAlert urging hospitals and the human toll, studies have prevention of URFOs through a ambulatory surgery centers to shown that objects left behind collaborative process promoting take a fresh look at how to avoid after surgery may cost as much consistency in practice to achieve leaving items such as sponges, as $200,000 per case in medical zero defects | 53 towels, and instruments in a and liability payments. patient’s body after surgery. “Leaving a foreign object • Establishing procedures for The unintended retention of behind after surgery is a well- counting of items, wound foreign objects (URFOs)— known problem, but one that can opening and closure, and when also called retained surgical be prevented,” said Ana Pujols intraoperative radiographs should items (RSIs)—after invasive McKee, MD, executive vice- be performed procedures can cause death, president and chief medical officer and surviving patients may of The Joint Commission. “It’s • Researching the potential of sustain both physical and critical to establish and comply using assistive technologies emotional harm, depending with policies and procedures (such as barcoding and radio on the type of object and the to make sure all surgical items frequency identification systems) length of time it is retained. are identified and accounted to supplement manual counting The Joint Commission for, as well to ensure that there procedures and methodical wound has received more than 770 is open communication by exploration voluntary reports of URFOs all members of the surgical in the past seven years. These team about any concerns.” • Encouraging effective cases resulted in 16 deaths, and Some actions communication during each appoximately 95 percent of these recommended in The Joint surgical procedure, including incidents resulted in additional Commission Alert include: team briefings and debriefings, care and/or an extended hospital to allow the opportunity for any stay. There may be an extended • Creating a highly reliable and team member to express concerns time frame between occurrence standardized counting system regarding the safety of the patient, and detection of an URFO, to ensure all surgical items are including the potential for an although these objects are most identified and accounted for URFO commonly detected immediately after the procedure, by X ray, • Developing and implementing • Completing appropriate during routine follow-up visits, effective evidence-based, documentation, which should

JAN 2014 Bulle t in American College of Surgeons A look at The Joint Commission

“Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented,” said Ana Pujols McKee, MD, executive vice-president and chief medical officer of The Joint Commission. “It’s critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns.”

include the results of counts of after a procedure are soft goods, Database—one of the nation’s surgical items, instruments, and such as sponges and towels; most comprehensive voluntary URFOs (such as needle or device small miscellaneous items, such reporting systems for serious fragments deemed safer to remain as broken parts of instruments adverse events in health care. than remove) and actions taken and stapler components; and The database includes detailed if count discrepancies occur. needles or other sharps. The cases information about both adverse Tracking discrepant counts is studied by The Joint Commission events and their underlying important to understanding showed the most common causes. Previous Alerts have practical problems root causes of URFOs are: addressed medical device alarms, 54 | risks associated with the use Although URFOs may occur • Absence of policies and of opioids, health care worker in previously healthy patients procedures fatigue, diagnostic imaging risks, during elective operations, one violence in health care facilities, study shows common risk factors • Failure to comply with existing maternal deaths, health care that can lead to foreign objects policies and procedures technology, anticoagulants, left behind include obesity, urgent wrong-site surgery, medication procedures, patients requiring • Problems with hierarchy and mix-ups, health care-associated more than one surgical procedure, intimidation in the surgical team infections, and patient multiple surgical teams, and suicides, among others. multiple staff turnovers during • Failure in communication with For a complete list and the procedure.* Occurrence of an physicians text of past issues of Sentinel URFO was nine times more likely Event Alert, visit The Joint when an operation was performed • Failure of staff to communicate Commission website at h t t p :// on an emergency basis and four relevant patient information www.jointcommission.org/ times more likely when the sentinel_event.aspx.  procedure changed unexpectedly.† • Inadequate or incomplete staff The Alert states that objects education most commonly left behind

*Gawande AA, Studdert DM, Orav Series of reports EJ, Brennan TA, Zinner MJ. Risk factors The warning about objects left for retained instruments and sponges after behind after surgery is part of a surgery. N Engl J Med. 2003;348(3):229-235. †The Patient Safety Authority. Beyond the series of Joint Commission count: Preventing retention of foreign objects. Alerts. Much of the information Pennsylvania Patient Safety Advisory. 2009. and guidance provided in Available at: http://patientsafetyauthority. org/ADVISORIES/AdvisoryLibrary/2009/ these Alerts is drawn from The Jun6(2)/Pages/39.aspx. Accessed May 16, 2013. Joint Commission’s Sentinel Event

V99 No 1 Bulle t in American College of Surgeons NTDB14JA® DANTBAULL POINTS

Annual Report 2013: Where did they go?

by R ichard J. Fantus, MD, FACS, and Michael L. Nance, MD, FACS

he 2013 Annual Report Annual Report, the first using of the National Trauma the NTDS, 506,452 records TData Bank® (NTDB®) were submitted. This year’s is an updated analysis of the report includes 833,311 records. largest aggregation of U.S. This year, to capture a better T he NT DB Annual Report and Canadian trauma registry picture of deaths listed in the 2013 is available on the ACS data ever assembled. The NTDB, any patients who have website as a PDF file and as NTDB now contains more been recorded as “discharged to a PowerPoint presentation than 5 million records. The hospice” have been counted as at www.ntdb.org. 2013 Annual Report is based deaths, which brings the total In addition, information on 833,311 records with valid to 34,622 deaths. When taking regarding how to obtain trauma diagnoses from the a closer look at the emergency NT DB data for more | 55 single admission year of 2012. department disposition for all The data were submitted by comers, the overwhelming detailed study is available 805 facilities, including 235 majority are admitted to the on the website. Level I trauma centers, 267 general surgical floor (see Level II trauma centers, and the figure on page 56). 240 Level III or IV trauma The mission of the American centers; 33 are Level I or Level College of Surgeons (ACS) II pediatric-only centers. Committee on Trauma (COT) is to develop and implement meaningful programs for Continuous quality trauma care. In keeping improvements with this mission, the NTDB Each year the requirements for is committed to being the data submission quality have principal national repository increased. This data quality for trauma center registry improvement effort started in data. The purpose of this earnest with the introduction report is to inform the medical of the National Trauma Data community, the public, and Standard (NTDS) in 2007, which decision makers about a was the basis of the first single wide variety of issues that admission year Annual Report of characterize the current state 2008. Along with this increase of care for injured persons in in data quality, over the past our country. It has implications six years the number of records in many areas, including submitted by the nation’s epidemiology, injury control, hospitals has escalated more research, education, acute than 165 percent. In the 2008 care, and resource allocation.

JAN 2014 Bulle t in American College of Surgeons NTDB14JA® DANTBAULL POINTS

56 |

Bulletin. The National Trauma Dedicated contributors Data Bank Annual Report 2013 Many dedicated individuals Many dedicated individuals is available on the ACS website who serve on the ACS COT who serve on the ACS COT as a PDF file and a PowerPoint and at trauma centers and at trauma centers around presentation at www.ntdb.org. the country have contributed In addition, information about around the country to the early development of the how to obtain NTDB data for have contributed to the NTDB and its rapid growth more detailed study is available in recent years. Building on on the website. To learn early development of these achievements, the goals more about submitting your the NT DB and its rapid in the coming years include trauma center’s data, contact improving data quality, Melanie L. Neal, Manager, growth in recent years. updating analytic methods, NTDB, at [email protected].  and enabling more useful inter-hospital comparisons. These efforts will be reflected in future NTDB reports to participating hospitals as well as in the Annual Reports. Throughout the year, we will be highlighting these data through brief reports in the

V99 No 1 Bulle t in American College of Surgeons News

Ronald M. Stewart, MD, FACS, to head Committee on Trauma

Dr. Stewart

The Board of Regents of the and direction as the COT enters and Trauma Advisory Council. American College of Surgeons its 92nd year of work to improve He was the recipient of the (ACS) recently appointed Ronald the care of injured patients,” Dr. 2013 National Safety Council M. Stewart, MD, FACS, to serve Rotondo said of the appointment. Surgeons’ Award for Service to as the next Chair of the ACS Dr. Stewart received his Safety (see p. 32) and the ACS Committee on Trauma (COT). medical degree and completed Arthur Ellenberger Award for Dr. Stewart is professor and chair his surgical residency at the Excellence in State Advocacy. of the department of surgery at the UT Health Science Center. He Dr. Stewart also served as University of Texas (UT) Health completed a two-year trauma and Chair of the South Texas Chapter Science Center, San Antonio. surgical critical care fellowship of the ACS COT and later as Dr. Stewart will take office at the University of Tennessee the ACS COT Region 6 Chief in March after the COT’s 2014 Health Science Center in (Texas, New Mexico, Louisiana, | 57 Annual Meeting, when he Memphis and then served as the and Arkansas). In addition, will become the 19th Chair director of trauma at University he is the Southern Surgical of the committee, succeeding Hospital in San Antonio. Association’s representative to Michael F. Rotondo, MD, In May 2000, then Texas the ACS Board of Governors.  FACS, of Rochester, NY. Gov. George W. Bush appointed “We congratulate Dr. Stewart Dr. Stewart to the Governor’s and look forward to his leadership Emergency Medical Services

Nominations for Jacobson Promising Investigator Award accepted through February 28

The American College of Surgeons (ACS) Surgical Research Committee is accepting nominations until February 28 for the 10th Joan L. and Julius H. Jacobson II Promising Investigator Award, to be conferred in 2014. This award recognizes outstanding surgeons who engage in research, advance the art and science of surgery, and demonstrate early promise of significant contribution to surgical practice and the safety of surgical patients. Surgeons who are at the “tipping point” of their research careers with a track record indicative of early promise and potential will receive special consideration for the award. Well-established surgeon- scientists are ineligible. To be considered for the award in 2014, submissions must be received by the February 28 deadline. For details on award criteria and nomination procedures, visit the Jacobson Promising Investigator Award website at http://www.facs.org/cqi/src/jacobson.html. For additional information, contact Carla Manosalvas at [email protected] or 312-202-5319. 

JAN 2014 Bulle t in American College of Surgeons News

Drs. Deane, Pellegrini, Eastman, Hoyt, and Turner Building a global perspective at International Surgical Leaders forum

| 58 by Chantay Moye

The American College of meeting was to begin a dialogue work toward fulfilling that Surgeons (ACS) recently on how each organization vision by developing a set hosted an International Surgical is affected by the critical of actionable items that will Leaders forum. Representatives challenges surrounding issues serve the best interests of from Australia, Canada, France, such as access to health care, patients around the world. Hong Kong, Ireland, Japan, rural surgery, education and David B. Hoyt, MD, FACS, Latin America, Lebanon, training, and internationalism. ACS Executive Director and Malaysia, Mexico, the Philippines, The idea, said Dr. Eastman, Co-Moderator of the program, the U.K., and the U.S. gathered is to collaboratively establish said the College welcomes at the ACS Washington Office to best practices that will directly opportunities to work with discuss possible ways to improve increase quality of care—a goal international organizations. surgical care throughout the that he said has been at the top of “We are all [nationally and world and to share novel ideas, his agenda throughout his career internationally] feeling the approaches, and resources on and tenure as ACS President. evolution of health care today. best practices in global surgery. Quoting Dr. Martin Luther There are financial pressures, Following an evening of King, Jr., Dr. Eastman said, quality, and accountability networking and connecting “Every nation must now pressures,” said Dr. Hoyt. with colleagues over dinner, develop an overriding loyalty He noted that in 2011, the Program Moderator A. Brent to mankind as a whole in College launched the ACS Eastman, MD, FACS, then- order to preserve the best in Inspiring Quality Tour to ACS President, began the day- their individual societies.” help inform policymakers long meeting by providing an He said the forum was an and the public about the overview and expectations of opportunity for the international benefits of various ACS quality the forum. The objective of the surgical community to improvement programs,

V99 No 1 Bulle t in American College of Surgeons News

Networking with colleagues over dinner on the Presidential medallions from the international rooftop terrace of the ACS Washington Office. surgical societies represented at the meeting Dr. Hoyt at the podium. such as the ACS National course, Dr. Turner said. ATLS practice that exist in different Surgical Quality Improvement courses have been presented countries to move forward with Program (ACS NSQIP®), in approximately 50 countries a renewed vision for the IRC the Commission on Cancer, to more than 1 million health and international interactions. the National Accreditation care professionals. Other As part of the effort Program for Breast Centers, examples of the College’s to revitalize the IRC, the the ACS Committee on Trauma international activities include committee has developed a (COT), and the ACS Bariatric the educational programs revised mission statement, | 59 Surgery Center Network. developed in collaboration which the Board of Regents Dr. Hoyt said that because with numerous international has approved: “To develop quality is of concern to surgeons institutions and the several relationships and partnerships throughout the world and health scholarships that allow for an between the College, care systems share many of the exchange between U.S. and international surgeons, and same challenges, this forum international surgical scholars. international surgical and may serve as a defining moment other health care organizations in improving the patient to address issues of surgical experience, quality of care across R evitalized IR C practice, education, research, all populations, and ultimately To help bolster the College’s advocacy, and leadership with reduce costs worldwide. global reach, the International the aim of achieving and Relations Committee (IRC) met safeguarding appropriately high several times with ACS leaders standards of clinical care, access, ACS efforts internationally who examined how the many safety, and quality improvement Patricia L. Turner, MD, FACS, ACS programs are interwoven to for surgery worldwide.” Director of the ACS Division form an international blanket. The IRC now comprises of Member Services, described Stephen A. Deane, MD, MB, approximately 30 members— the College’s organizational BS, FACS, FRACS, FRCSC, one-third domestic, one-third structure and said the divisions, Chair of the IRC, offered an international, and one-third committees, and governance international perspective on the naturalized members—as bodies work together to process of growing the surgical well as members of the ACS advance the practice of surgery profession from the viewpoint Young Fellows Association nationally and internationally. of someone who trained both in and Residents and Associates One ACS program that Australia and in North America. Society. The IRC construct is has had a profound impact He noted that it is important designed to break down silos internationally is the Advanced to understand the differences and bridge the gap between Trauma Life Support® (ATLS®) in training, certification, and it and other ACS programs.

JAN 2014 Bulle t in American College of Surgeons News

Front row (left to right): Peter Wong Toh Lee, MD; Michael Hollands, MB, BS, FACS, FR ACS; H.T. Luk, MB, BS, FACS; Herve Yangni-Angate, MD; Dr. Eastman; Patrick Broe, MCh, FR CSI; Ian. K. R itchie, MD, FR CS(Ed); and Samuel Shuchleib, MD, FACS. Back row (left to right): R aul Coimbra, MD, FACS; Dr. Hoyt; Michael Horrocks, MD, FR CS(Eng); Dr. Deane; Andrew Padmos, MD, FR CPC, FACP; Cecil R orabeck, OC, MD, FR CSC; Patricia Numann, MD, FACS, ACS Past-President; Alfred H. Belmonte, MD, FACS; Jamal Hoballah, MD, FACS; Katsuhiko Yanaga, MD, PhD, FACS; Dr. Pellegrini; Dr. Turner; R obert Lane, MB, BS, FACS, FR CS(Eng); Charles Mock, MD, FACS; and Fabrizio Michelassi, MD, FACS.

60 | “We have redefined our plan, and we can work toward meeting Or ganizat ions wit h For um r epr esentat ives our promises. The difference T he following international surgical societies were between the way we do things represented at the meeting: now and the way we did them in • Academy of Medicine of Malaysia–College of Surgeons the past is that we have realistic, deliverable goals,” said Carlos • ACS International R elations Committee A. Pellegrini, MD, FACS, then • College of Surgeons of Hong Kong President-Elect of the ACS. • Federation of Latin American Surgeons The international attendees and the ACS leaders at the • Japan Surgical Society meeting agreed to compare • Philippine College of Surgeons interests and concerns through • R oyal Australasian College of Surgeons a survey, which the Division of Member Services has • R oyal College of Surgeons of Canada completed. A broader group • R oyal College of Surgeon of Edinburgh of international surgeons • R oyal College of Surgeons of England met during the 2013 Clinical • R oyal College of Surgeons of Glasgow Congress. Another survey will be undertaken with the goal of • R oyal College of Surgeons in Ireland creating a matrix or database • West African College of Surgeons of activities and opportunities in which the surgical societies might become involved. 

V99 No 1 Bulle t in American College of Surgeons News

ACS, Arizona health care leaders share successes, discuss challenges at IQ Forum

At the IQ Forum (from left) Dr. Patel, Dr. Hoyt, Ms. Barraza, Dr. Hensing, R epresentative Carter, Dr. Johnson, and Dr. Flynn. | 61

The American College of Surgical Residency Program, care dollars,” said David B. Surgeons (ACS) hosted the ACS Banner Good Samaritan Medical Hoyt, MD, FACS, ACS Executive Surgical Health Care Quality Center; and President of the Director. “As the Centers for Forum, Arizona, the 14th stop Arizona Chapter of the ACS. Medicare & Medicaid Services on the Inspiring Quality (IQ) Forum speakers underscored and others start tying clinical Tour, on November 8. A panel of the critical role that quality data data and outcome measures to health care leaders from several measurement and reporting may value-based purchasing, hospitals Arizona institutions discussed the have on the future of health care have a reputational and financial promise of quality improvement delivery. They pointed to the incentive to participate in these programs in increasing the ACS National Surgical Quality tried-and-true programs.” value of health care. Improvement Program (ACS Arizona State Rep. Heather “Amidst the national dialogue NSQIP®) as a model that provides Carter (R), PhD, RN-BC, Chair surrounding patient access to surgeons with reliable data to help of the Arizona House Health health insurance, surgeons pinpoint areas for improvement. Committee, and clinical associate and health care providers must ACS NSQIP is unique in that it professor, Mary Lou Fulton continue to focus their efforts uses risk- and procedure mix- Teachers College, Arizona State on ensuring the delivery of adjusted data that are taken from University (ASU), Phoenix, patient care is the highest quality the patient’s medical chart, not delivered the keynote address. possible,” said Forum host Steven insurance claims, and are based “The recent Medicaid B. Johnson, MD, FACS, FCCM. on 30-day patient outcomes. Restoration Program Dr. Johnson is professor and “We know through published implemented in Arizona is an chairman, department of surgery, data and countless anecdotes that important example of how University of Arizona-Phoenix quality improvement programs, we have upheld the will of the College of Medicine; program like ACS NSQIP, improve patient Arizona voters who have twice director, Phoenix Integrated care and save valuable health voted to ensure our residents

JAN 2014 Bulle t in American College of Surgeons News “Clinical excellence and quality improvement programs not only result in improved patient outcomes but are essential for health systems and hospitals today.” –Dr. Hensing

have access to high-quality health at improving health care quality of quality assurance and health care,” Representative Carter said. and lowering costs. It is helpful care economics into students “Implementing this program to understand and recognize the so that they can understand the was the most fiscally responsible specific aspects of the law that crucial role these issues will decision for our great state and will impact the quality of health have in their future careers.” helps stop the out-of-control rising care, such as the creation of “In order for organizations to costs of uncompensated care.” accountable care organizations improve care, they need access “Clinical excellence and and certain changes to Medicare,” to the right data. Clinical, risk- quality improvement programs said Leila F. Barraza, JD, MPH, adjusted outcomes data give not only result in improved deputy director, Network for physicians critical insights into patient outcomes but are essential Public Health Law—Western their performance, allowing for health systems and hospitals Region, fellow, Public Health Law them to improve their work today. These efforts result in a and Policy Program, and adjunct and ultimately the care they reduction in waste, patient care professor of law, Sandra Day provide,” said Nirav Y. Patel, complications, liability exposure, O’Connor College of Law, ASU. MD, FACS, vice-chairman and unsatisfied patients, all Stuart D. Flynn, MD, dean, for quality and patient safety, positively impacting a hospital’s University of Arizona College of department of surgery, Banner economic survival,” added Medicine-Phoenix, noted that, Good Samaritan Medical Center. John A. Hensing, MD, FACP, “For many years, medical schools Video of the Arizona forum 62 | executive vice-president and chief did not emphasize the importance is available at InspiringQuality. medical officer, Banner Health. of quality improvement to facs.org and on the College’s “The Affordable Care Act residents. We now realize how YouTube channel.  includes many provisions aimed important it is to engrain concepts

A publiCATioN of AmE riCAN CollE g E of SurgE o NS p rofESSioNAl ASSo C i ATioN (ACSp A)

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

Downloadable from most digital communications devices. Also available online at www.facs.org/ahp/news/index.html.

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

ADVOCATE ad half page Bulletin shorter.indd 1 1/14/2013 11:24:28 AM V99 No 1 Bulle t in American College of Surgeons News

Nominations for 2014 volunteerism and humanitarian awards due February 28

The American College of donated for charitable clinical, and, in fact, may be expected Surgeons (ACS), in association educational, or other worthwhile based on the extent of the with Pfizer, Inc., is accepting activities related to surgery. professional obligation. nominations for the 2014 Volunteerism in this case does Nominations will be Surgical Volunteerism Award(s) not refer to uncompensated evaluated by the ACS Board and Surgical Humanitarian care provided as a matter of Governors Surgical Award. All nominations must be of necessity in most clinical Volunteerism and Humanitarian received by Friday, February 28. practices. Instead, volunteerism Awards Workgroup, with final The ACS/Pfizer Surgical should be characterized by approval of award winners Volunteerism Award—offered prospective, planned surgical by the Executive Committee in four potential categories each care to underserved patients of the Board of Governors. year—is given in recognition of with no anticipation of Potential nominees | 63 surgeons who are committed to reimbursement or economic gain. should make note of the giving back to society by making The ACS/Pfizer Surgical following conditions: significant contributions to Humanitarian Award is given surgical care through organized in recognition of an ACS Fellow • Self-nominations are permissible volunteer activities. The awards whose career has been dedicated but require at least one for Domestic, International, and to ensuring the provision of outside letter of support Military Outreach are intended surgical care to underserved for ACS Fellows in active surgical populations without expectation • Renomination of previous practice whose volunteer activities of commensurate reimbursement. nominees is acceptable but go above and beyond the usual This award is intended for requires an updated application professional commitments surgeons who have dedicated or retired Fellows who have a significant portion of their • Supplemental materials been involved in volunteerism surgical careers to full-time or should be kept to a minimum during their active practice near full-time humanitarian and will not be returned and into retirement. Resident efforts rather than routine Members and Associate Fellows surgical practice. Examples The nomination website (ACS Members) who have been include a career dedicated will open January 6, 2014, for involved in significant surgical to missionary surgery, the electronic submissions and volunteer activities during their founding and ongoing operations may be accessed through the postgraduate surgical training are of a charitable organization “Announcements” section of eligible for the Resident award. dedicated to providing surgical the Operation Giving Back Surgeons of all specialties are care to the underserved, or a (OGB) website at http://www. eligible for each of these awards. retirement characterized by operationgivingback.facs.org/. For the purposes of these surgical volunteer outreach. Contact OGB at [email protected] awards, “volunteerism” is Having received compensation with any questions.  defined as professional work in for this work does not preclude which one’s time or talents are a nominee from consideration

JAN 2014 Bulle t in American College of Surgeons News

ACS and other specialty surgical organizations release Physicians as Assistants at Surgery report

The American College of accurately reflect new and t he following Surgeons (ACS) and 15 other updated CPT codes and to help or ganizat ions specialty surgical organizations improve the quality of care for par t icipat ed in have jointly compiled and released the surgical patient, updates t he re port : the seventh edition of Physicians to the Physicians as Assistants • American Academy of as Assistants at Surgery, a report at Surgery report now will be Ophthalmology that provides guidance on how conducted annually, and a full often an operation might require review of all surgical CPT codes • American Academy of the use of a physician as an will be released every five years. Orthopaedic Surgeons assistant. This report reflects the “The frequency of updating the • American Academy of most recent clinical practices, and report is becoming increasingly Otolaryngology – Head often serves as a resource for the important,” said Mark Savarise, and Neck Surgery Centers for Medicare & Medicaid MD, FACS, ACS alternate advisor • American Association of Services and other payors. for the AMA CPT editorial panel. Neurological Surgeons Using the American Medical “Medicare and third-party payors • American College of Surgeons Association’s (AMA) Current are attracted to the report because 64 | • American Pediatric Procedural Terminology it provides a comprehensive Surgical Association (CPT) codes from the 2012 and clinical review of surgical 2013 coding manuals, each procedures to bring an informed • American Society of Colon participating organization opinion from surgeons in the and R ectal Surgeons reviewed codes applicable to field about the frequency with • American Society of their specialty that are classified which a physician’s services as an Plastic Surgeons as “Surgery” in CPT. CPT assistant at surgery are needed.” • American Society of is the most frequently used The College maintains Transplant Surgeons physician medical nomenclature that a physician who serves as • American Urological for reporting medical services an assistant in an operation Association and procedures to private should be a trained individual • Congress of Neurological and public health insurance who can participate in and Surgeons payors. Participants indicated actively assist the surgeon the frequency of an operation in completing the operation • Society for Surgical Oncology requiring the use of a physician safely. When a surgeon is • Society for Vascular Surgery as an assistant at surgery: (1) unavailable to serve as an • Society of American almost always; (2) almost never; assistant, a qualified surgical Gastrointestinal or (3) some of the time. resident or other qualified health Endoscopic Surgeons The newly released report care professional, such as a • T he American Congress adds 107 CPT codes that were registered nurse or a physician’s of Obstetricians and introduced since the last report assistant with experience in Gynecologists was issued in 2011. In addition, assisting during a procedure, the report revises 74 codes that may be used, according to the • T he Society of T horacic Surgeons had been previously included. ACS Statements on Principles. Historically, the report is Download the entire conducted approximately every report at http://www.facs.org/ other year. However, to more ahp/pubs/pas-2013.pdf. 

V99V99 No 1 Bulle t in AmericanAmerican College of SurgeonsSurgeons News i k s n i Dr. Mattox receives AMA award dz Cr u d e for citizenship and community T service The American Medical Association (AMA) awarded Kenneth L. Mattox, MD, FACS, the 2013 Benjamin Rush Award for Citizenship and Community Service November 16, during the opening session of the 2013 Interim Meeting of the AMA House of Delegates in National Harbor, MD. Dr. Mattox, Second Vice-President-Elect of the American College of Surgeons, is Distinguished Service Professor, Michael E. DeBakey Department of Surgery, Baylor Dr. Mattox College of Medicine; and chief of staff and chief of surgery, Ben Taub General Hospital, Houston, TX. The Benjamin Rush Award annually recognizes a physician who has exceeded professional responsibilities and contributed significantly to public service. Dr. Mattox provided exemplary service in the medical response to several natural disasters, including the 2001 tropical storm Allison and Hurricanes Katrina and Rita in 2005. As part of the Katrina Joint Unified Command, Dr. Mattox helped form an “evacuation city” to house, treat, clothe, and feed more than 27,000 evacuees from New Orleans, LA, in only 18 hours. Dr. Mattox is a past-president of the American Association for the Surgery of Trauma, past-president of the Harris County Medical Society in Texas, and was the Texas representative to the AMA House of Delegates from 2004 to 2006. He developed the internationally known Ben Taub Hospital Emergency Center and its trauma center and currently serves as board chair of the John P. McGovern Museum of Health & Medical Science, Houston. View an AMA press release announcing the award at http://www. | 65 ama-assn.org/ama/pub/news/news/2013/2013-11-18-houston-surgeon-receives-award-for-citizenship.page. 

Now AvAilABlE from the American College of Surgeons

! ACS Members who are recertifying Transfer your ACS CME credit can now enjoy the ease of submitting their ACS CME credits directly to the to the American Board of Surgery (ABS). American Board of Surgery From members’ MyCME page, click on the “Send CME to ABS” option electronically! at the top of the page. Submission is quick and easy: → Review your transcript for accuracy and authorize transfer of credits → Have your ABS 13-digit authorization number ready

log into the member web portal MyCME at www.eFACS.org to get started Y o u r C M E @ Your ConvE niE n CE A MERi CAN CollE g E o F SuR g E o NS • DiviS ioN o F E D u CAtioN

CME to ABS ad - June 2010 BULLETIN (4 in deep) REVISED LOGO.indd 1 9/16/2011 1:59:32 PM JAN 2014 Bulle t in American College of Surgeons News

Members in the news

Dr. Cofer Dr. Evans Dr. R othenberger Dr. Vayer

at Georgetown University, Physician Leaders Program, Joseph B. Cofer, MD, FACS, Washington, DC. He is a former which fosters collaboration 66 | a general surgeon and program President of the ACS Metropolitan and develops skills among director, department of surgery, Washington, DC, Chapter faculty from all departments. and professor of surgery, and, in 2009, was elected as an University of Tennessee College ABS director representing the Arthur J. Vayer, Jr., MD, FACS, of Medicine, Chattanooga, American Medical Association. recently was installed as vice- President of the American speaker of the Medical Society College of Surgeons (ACS) David Rothenberger, MD, FACS, of Virginia (MSV) during the Tennessee Chapter, and chair on October 1, 2013, has organization’s annual meeting of the American Board of been appointed head of the at The Homestead Resort in Surgery, was named a 2014 department of surgery at the Hot Springs, VA. Dr. Vayer, a recipient of the Accreditation University of Minnesota (UMN), MSV member since 2006 and Council for Graduate Medical Minneapolis. He previously a general surgeon at Stafford Education’s J. Palmer Courage held the John P. Delaney Chair Surgical, Sentara Medical Group, to Teach Award. The award of Clinical Surgical Oncology also worked at Robert Cohen, honors program directors who and was deputy chairman of the MD, PC, Riverside Gloucester find innovative ways to teach department of surgery (2006– Surgery Associates and in private residents and remain committed 2013) at UMN. Dr. Rothenberger, practice. Dr. Vayer serves as to providing quality patient care. an internationally known an MSV delegate and associate surgical leader, is past-president director, an officer with the Prince Stephen R. T. Evans, MD, FACS, of the American Society of William County Medical Society, has been elected 2014–2015 Colon and Rectal Surgeons, the a committee member at Potomac vice-chair of the American American Board of Colon and Hospital, Woodridge, and chairs Board of Surgery (ABS) and Rectal Surgery, and the Research the performance evaluation will serve as chair in 2015–2016. Foundation of the American committee of Sentara Northern Dr. Evans is executive vice- Society of Colon and Rectal Virginia Medical Center.  president for medical affairs and Surgeons. Dr. Rothenberger is chief medical officer at MedStar founder and co-director of the Health and professor of surgery UMN Medical School Emerging

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Call for nominations for ACS Officers-Elect The 2014 Nominating Committee of the Fellows All nominations must include: (NCF) will select nominees for the three Officer-Elect • A letter of recommendation positions of the American College of Surgeons (ACS): • A personal statement from the candidate detailing President-Elect, First Vice-President-Elect, ACS service (for President-Elect position only) and Second Vice-President-Elect. The NCF will • A current curriculum vitae use the following guidelines when considering • The name of one individual who can serve as a potential candidates: reference • Nominees must be loyal members of the College In addition, nominating entities, such as surgical who have demonstrated outstanding integrity and specialty societies, ACS Advisory Councils, and ACS medical statesmanship, along with an unquestioned chapters, must provide a description of their selection devotion to the highest principles of surgical process and the total list of applicants reviewed. Any practice. attempt to contact members of the NCF by a candidate • Nominees must have demonstrated leadership or on behalf of a candidate will be viewed negatively qualities that might be reflected by service and and may result in disqualification. Applications active participation on ACS committees or in other submitted without the requested information will not components of the College. be considered. • Members of the Nominating Committee recognize The deadline for submitting nominations is the importance of achieving representation of all Friday, February 28, 2014. Please submit nominations who practice surgery. to [email protected]. If you have • The College encourages consideration of women questions, call Betty Sanders, ACS Senior Administrator, and other under-represented minorities. Board of Governors, at 312-202-5360. 

| 67 Call for nominations for ACS Board of Governors Help the American College of Surgeons (ACS) keep • Actively participate in a minimum of one Board of pace in a changing health care environment and Governors Workgroup meet the goals of its Inspiring Quality: Highest • Attend the spring Leadership Summit (spring meeting Standards, Better Outcomes Initiative by nominating attendance is not required for international governors) your chapter’s brightest, most engaged, responsible, • Participate in Board of Governors’ meetings, and forthright members to serve a three-year term Convocation, and the Annual Meeting of Members at on the ACS Board of Governors. Nominations for the Clinical Congress 2014 appointments must be submitted to your local • Complete an Annual Survey ACS chapter or surgical specialty society by Friday, • Attend chapter or specialty society meetings February 28, 2014. • Assist in establishing an ACS chapter and serve on the The Board of Governors is the representative Chapter governing board body of the ACS. The membership at-large nominates • Participate in local Committee on Applicants meetings two-thirds of the Governors, who are elected during and interviews the Annual Meeting of Members at the ACS Clinical • Provide reports to the ACS chapter or specialty society Congress. Certain surgical specialty societies, ACS and the Board of Governors Communications Pillar chapters, and federal medical services nominate one- • Promote ACS Fellowship in state and specialty society third of the Board of Governors. • Welcome new Fellows into the ACS The Governors shall act as a liaison between the An inclusive, transparent Board of Governors Board of Regents and the Fellows, and serve as a depends upon members who can actively serve as a clearinghouse for the Regents on general assigned link to their local community and as a resource for the subjects and local problems. ACS. For more information, go to http://www.facs.org/ A Governor’s duties include: about/governors/candidates.html. If you have questions, • Provide bi-directional communication between the call Betty Sanders, ACS Senior Administrator, Board of Board of Governors and the Fellows Governors, at 312-202-5360. 

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Report on ACSPA/ACS activities: October 2013

by Lena M. Napolitano, MD, FACS, FCCP, FCCM

• 114 of 228 Committee on Amer ican Colle ge of Trauma members (50 percent) Sur geon s Pr ofession al contributed $47,351 Associat ion (ACSPA) • 19 of 65 Commission on T he ACS currently has As of October 1, 2013, the Cancer members (29 percent) American College of Surgeons contributed $9,920 36,135 active, dues-paying Professional Association’s Fellows. At the 2013 Clinical political action committee This June, ACSPA-SurgeonsPAC (ACSPA-SurgeonsPAC) had raised Board Members Patrick Bailey, Congress, 1,622 Initiates $475,000 from 1,607 members MD, FACS; Clarence Watridge, were inducted into the of the College and staff ($295 MD, FACS; and Michael College, representing average contribution). Sutherland, MD, FACS, attended 68 | Contributions for 2013 the 2013 Physician PAC Forum one of the largest classes among ACSPA’s leaders are: in Louisville, KY. This year’s of Initiates in the last forum focused on engaging • 25 of 25 Officers dan Regents residents in the SurgeonsPAC, decade. T hese new Fellows in the U.S. (100 percent) hosting in-district fundraisers for represent the U.S, and contributed $17,300 members of Congress, integrating its territories, Canada, SurgeonsPAC and grassroots • 121 of 213 Governors in the strategies, disbursing the funds in and 55 other nations. U.S. (57 percent) contributed a strategic way, and other topics. $63,574 So far in the 2014 election cycle, the ACSPA-SurgeonsPAC • 15 of 15 members of the has contributed $218,000 to College’s Health Policy and 83 candidates, leadership Advocacy Group (100 percent) PACs, and party committees. contributed $16,699 Of this amount, 61 percent went to Republicans and 39 • 17 of 17 PAC Board members percent to Democrats. (100 percent) contributed $33,200 Amer ican Colle ge of • Eight of nine ACS Legislative Sur geons (ACS) Committee members (89 percent) contributed $5,250 Division of Member Services The Division of Member • 10 of 14 General Surgery Services continues to evaluate, Coding and Reimbursement refine, and create programs in Committee members (71 support of College leaders and percent) contributed $10,300 members. This year the Division

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is embarking on initiatives to surgeon employment practices. Also discussed were the Centers that the ACS anticipates will Governors were asked to provide for Medicare & Medicaid Services’ result in an enhanced member information regarding their (CMS) plans to change how experience. These efforts include: constituents’ views on issues Medicare pays physicians with pertinent to their practices. More a focus on recent proposed rules • Develop an overarching strategy than 195 Governors responded and the College’s response, as to expand international efforts to the survey, and their responses well as what Congress and multi- were presented to the Board of stakeholder groups are doing • Redesign the Advisory Councils Regents for consideration. to address the development of a The top five issues of concern to value-based health care system. • Fully implement the Board the Fellows of the College in 2013 of Governors’ redesign as reported by the Governors are: Advisory Councils • Conduct a needs assessment • Health care reform and The role and function of the its impact on practice Advisory Councils are being • Develop strategic plan for evaluated, and a workgroup ACS chapters • Professional liability/tort reform, of volunteer leaders from the | 69 risk management/patient safety Advisory Council Chairs has • Coordinate and centralize been formed to restructure the scholarships and fellowships • Medical education/graduate councils using a process similar medical education to that employed by the Board of • Implement a young Governors. The goal of this effort surgeon marketing and • Physician reimbursement/ is to improve communication recruitment campaign Medicare/Medicaid among the Advisory Councils, Governors, and Regents, • Conduct a member and • Competency measurement members, and specialty societies. non-member survey for the practicing surgeon/ The Advisory Council for newly trained surgeons Rural Surgery, chaired by Tyler The ACS currently has 36,135 Hughes, MD, FACS, continues active, dues-paying Fellows. The Joint Session of the to develop its primary initiatives, At the 2013 Clinical Congress, Board of Regents and Board has established a rural surgery 1,622 Initiates were inducted of Governors focused on presence at the Clinical Congress, into the College, representing Medicare physician payment. and is conducting preliminary one of the largest classes of Speakers described the College’s work on a set of rural surgery Initiates in the last decade. leadership role in Medicare standards and guidelines. This These new Fellows represent physician payment reform, year, the Clinical Congress the U.S. and its territories, and a series of presentations Program Planner included Canada, and 55 other nations. addressed alternatives the a wrapper with program College has developed to the information targeted to the rural broken reimbursement system. surgeon. Plans for 2014 include Board of Governors In addition, tools for quality a Rural Surgery Symposium The annual Board of Governors improvement that fit into in May and creation of an ACS survey was distributed in August transforming health care and Rural Surgery Ambassador and included questions pertaining payment systems were reviewed. Program. The Sixth Rural

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Surgery Symposium will take ACS, which brings the total be designed and developed to place at the College’s headquarters to 36 domestic chapters. assist chapters more broadly. in May 2014. The one-and-one- In January, a chapter listserv half-day program will include was created to promote sharing presentations on advocacy, of ideas and to encourage r as-ACS practice issues, and clinical discussion between the chapters. RAS-ACS continues to practice. Clinical practice topics A chapter mentor program, with move forward with several that will be addressed include stronger chapter administrators key initiatives, including critical care, pancreatitis, cancer assisting and offering guidance development of a Surgical care, management of large skin to those that may need help Jeopardy toolkit for domestic lesions, and palliative care. The in specific areas, is planned and international surgical Rural Surgeon Ambassador for 2014. An expanded Winter societies and chapters. Program will consist of council Learning Event for chapter Maintaining a strong social members speaking to chapters, leaders took place at the College media presence is a vital part medical students, and residents in December 2012, which of RAS outreach. The RAS-ACS on issues in rural surgery. included discussion of best Facebook page now has more 70 | Council members have already practices, social networking for than 1,200 followers, spanning been guests of chapters in chapters, implemention of Young 20 countries and 19 languages. Georgia, Ohio, and Maine. Fellows Association (YFA) and The RAS-ACS introduced Resident and Associate Society new programs at the (RAS) initiatives at the chapter 2013 Clinical Congress, Chapters level, and other topics regarding including Focus on RAS: The ACS is working to provide how chapters can be of greater A RAS Leadership Session. support to its domestic value to their members. A networking lunch for and international chapters A new chapter survey is all Resident and Associate to facilitate incremental being disseminated to assess Members of the ACS was improvement and performance and identify followed by the Governing re-energize each of them. the attributes of a high- Board meeting. Immediate Currently, Chapter Services functioning chapter, along Past-President of the ACS, A. staff assists with tasks related to with another study to uncover Brent Eastman, MD, FACS, bylaws, governance, strategies the perspectives of the chapter delivered the keynote address, for growth of membership, and membership. This latter survey focusing on the importance best practices in general, to is intended to cull crucial of RAS membership and revitalize and move chapters information from multiple involvement of residents within forward. Several international sources to more accurately the greater College structure. chapters are at various stages assess chapter “health.” The The RAS-ACS sponsored of being admitted to the resultant dashboard will offer two essay competitions in 2013, College, with surgeons in the performance indicators rating providing winners with awards Middle East, Eastern Europe, chapter performance in various and presentation opportunities and South America showing areas, and will allow chapters to and continues to coordinate particular interest. Three more identify areas for improvement. and publish content relative chapters have been approved for These data will be shared to members in the Bulletin. providing continuing medical with individual chapters and Because the ACS actively education (CME) credit via the best practice resources will incorporates Resident Members

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into the committee structure, T. Landström, MD, FACS, RAS has been able to support a Military Volunteer Outreach; Div isio n of Advocacy well-integrated liaison program. and Katrina B. Mitchell, MD, and Healt h Pol icy The selection committee Resident Volunteer Outreach. identified and filled more than To date, more than $39,000 Medicare physician payment 20 positions on ACS committees, in humanitarian donations Under current law, Medicare Advisory Councils, and Board of of Advanced Trauma Life physician payments will be Governor work groups this year. Support® (ATLS®) materials cut by approximately 24.4 have been facilitated through percent on January 1, 2014. For the OGB to health care the last two years, the ACS has YFA professionals in 20 countries, lobbied for physician payment The YFA serves as a including Afghanistan, the reform, urging Congress to clearinghouse and point of entry Dominican Republic, Ecuador, address the long-term implications for young Fellows who want Ethiopia, Gabon, Haiti, Liberia, of a broken physician payment to actively participate in the Kenya, Malawi, Mexico, Nepal, system and its incompatibility College but may be uncertain Nicaragua, Pakistan, Peru, with the provision of care. where or how to get started. the Philippines, Sierra Leone, Before adjourning for the | 71 The YFA also seeks to increase Thailand, Uganda, Vietnam, August congressional recess, the awareness of ACS programs/ and Zimbabwe. House Committee on Energy educational products that are In the past 12 months, and Commerce unanimously available to this demographic 38,162 visitors from 185 approved the Medicare Patient and to connect young Fellows countries completed 111,530 Access and Quality Improvement with their local/state chapters page views of the OGB website. Act. The bipartisan legislation and leaders with special A total of 207 volunteer would permanently repeal the emphasis on those chapters opportunities currently are Medicare sustainable growth without an identified YFA published on OGB; 62 were rate (SGR) formula and create a liaison. Another goal this year newly created or updated in new physician payment system. was to improve outreach the last year. Additionally, The Committee’s approval of to international young Fellows. more than 2,000 surgeons this legislation represents several have completed demographic months of collaboration with profiles in “My Giving Back.” the House Committee on Ways Operation Giving Back (OGB) OGB has been collaborating and Means, as well as input A new Board of Governors on global surgery advocacy from key stakeholders, including Workgroup has been created efforts internally with the the College and the broader to oversee selection of the International Relations physician community. Several ACS Surgical Humanitarian Committee and externally beneficial provisions are included and Volunteerism Awards. with the Royal Australasian in the Energy and Commerce The 2013 Humanitarian College of Surgeons, the legislation, including full repeal and Volunteerism award Royal College of Surgeons of of the SGR, and the ACS stresses recipients included Donald England-affiliated group the the importance of moving R. Laub, Sr., MD, FACS, International Collaboration legislation forward in 2014. Humanitarian Award; Ingida on Essential Surgery, and Although the ACS supports the Asfaw, MD, FACS, International the Alliance for Surgery overall effort to move payment Volunteer Outreach; Jerone and Anesthesia Presence. reform through the House and

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Senate, the College will continue the ACS in sending a letter of and increasing specialization to lobby for improvements to support for the legislation. while primary care remains all payment reform plans. The EHR Incentive Programs under-resourced. According to In written correspondence provide a financial incentive COGME this misdistribution and congressional testimony, the for the meaningful use of can be attributed partly to College encouraged Congress to certified EHR technology to the fact that many teaching implement its Value-Based Update achieve health and efficiency hospitals have not recognized (VBU) proposal. The College goals. There are three stages of the need for greater emphasis on also expressed strong support of meaningful use, with increased primary care training and that efforts to find more innovative requirements each year. The curriculum is often inadequate models of physician payment and last year eligible providers (EPs) in the areas of population health, asserted that any new payment qualified for the full incentive care coordination, team-based system should be based on the amount of $44,000 was 2012. practice, and other aspects of new complementary objectives of The maximum for 2013 was systems of care. To address these improving outcomes, quality, $39,000. Details on the EHR and other challenges, COGME safety, and efficiency while Incentive Program are posted at recommends that the GME 72 | simultaneously reducing the http://www.cms.gov/Regulations- system be reformed to improve growth in health care spending. and-Guidance/Legislation/ the value the public receives EHRIncentivePrograms/ for its investment by increasing index.html?redirect=/ partnerships among training EHR EHRIncentivePrograms/, programs, teaching hospitals, Rep. Diane Black, RN (R-TN), along with educational accreditation organizations, reintroduced legislation that materials and resources. state and federal governments, addresses several concerns with and other stakeholders. This respect to the current Electronic recommendation is based on the Health Record (EHR) Incentive Workforce assumption that greater value Program. Specifically, H.R. 1331, In August, the Council on in GME means better targeting the Electronic Health Record Graduate Medical Education of public GME money and more Improvement Act, would create (COGME) released its 21st report, effective training models. a hardship exemption from “Improving Value in Graduate The Affordable Care Act penalties for noncompliance for Medical Education.” In the authorized funding for loan small practices and physicians report, COGME recommends repayments for pediatric in and near retirement, an increase in Graduate Medical subspecialists, including shorten the gap between Education (GME) funding for pediatric surgeons, who agree the performance period and high-priority specialties, such as to practice in shortage areas for application of the penalty, general surgery, family medicine, at least two years. The College expand options for participation geriatrics, general internal signed a letter to the Deputy in the Incentive Program, medicine, certain pediatric Director for Management with improve quality measures by subspecialties, and psychiatry. the Office of Management and using specialty-led registries, COGME acknowledges the Budget (OMB) thanking the and establish an appeals many challenges facing GME, Obama Administration for process before application of such as poor geographic their previous support of the penalties. Twenty-one other distribution of physicians in Pediatric Subspecialty Loan medical organizations joined relation to population needs Repayment Program and asking

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that $5 million in funding once requirements and compliance. While ACS NSQIP is again be included within the The PQRS section of the website recognized for its high-quality Health Resources and Services is continually updated with data, this information must be Administration (HRSA) budget. new information, including actionable and used to improve The $5 million in funding was updated 2013 PQRS flow the quality of surgical care. In included in the President’s sheets for various surgical the coming months, ACS NSQIP budget plan; however, the money procedures and details on how will have an increased focus has yet to be appropriated by to report measures via claims, on assisting hospitals in their Congress. The ACS and other registries, and EHR. The ACS quality improvement efforts. stakeholders sent a letter to House staff continues to represent the An illustration of this emphasis and Senate appropriators urging surgical community at meetings on improving quality was them to include the $5 million regarding the future of PQRS and demonstrated at the national for the program in the fiscal possible changes to the program. conference with the release of year (FY) 2014 appropriations the new ACS NSQIP Surgical bill. The Senate for the first Risk Calculator. Based on data time included $5 million for this Division of R esear ch and from more than 1.4 million Opt imal Pat ient Car e (dr opC) program in its Labor, Health and operations, the Surgical Risk | 73 Human Services, and Education Calculator is designed to help appropriations bill. The ACS ACS NSQIP physicians provide patients will continue to push for the Approximately 497 sites with accurate estimations of funds to be appropriated. The participate in ACS National postoperative complications. authorization of this program Surgical Quality Improvement Covering more than 1,500 is set to expire after next year, Program (NSQIP®); 60 additional unique surgical procedures and Rep. Joe Courtney (D- sites are in the enrollment across multiple specialties, this CT) has recently introduced process, and another 53 hospitals instrument is a revolutionary legislation that would extend are pursuing the Pediatric new decision support tool. The this authorization through option. The Essentials option calculator has been publically FY 2018. The ACS sent a letter is the most popular adult released in an effort to improve of support for this legislation participation option with ACS the processes of informed in July and signed a coalition NSQIP Procedure Targeted the consent and shared decision letter of support in August. second most common option. making with patients. The The Eighth Annual ACS release of the calculator has led NSQIP National Conference to moderate press coverage for PQr s took place in July 2013 in San the ACS and its role in quality The ACS continues to provide Diego, CA. With more than of care. Additionally, CMS, Physician Quality Reporting 1,000 attendees, it was the through the PQRS, may soon System (PQRS) educational largest annual ACS NSQIP provide a financial incentive materials and resources conference to date. The focus for surgeons to calculate to Fellows and office staff of the conference was on the risk of operations using through the website, meetings, promoting quality improvement the Surgical Risk Calculator and publications. Columns through data analysis and and to discuss these patient- in the April and September collaboration. Next year’s specific risks with patients 2013 issues of the Bulletin conference will take place before a surgical procedure. provide information on PQRS July 26–29 in New York, NY. The risk calculator can be

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accessed on the ACS website Khalifa Medical City, Abu and outcomes. Additionally, at www.riskcalculator.facs.org. Dhabi. The international entry ACS NSQIP is evaluating the Collaboration continues to to the Best Practices Case Studies incorporation of financial play a critical role in the success is noteworthy, as there continues aspects of care into the program of ACS NSQIP and the quality to be significant growth to provide information not only improvement initiatives at and interest in ACS NSQIP on the quality of care, but also participating hospitals. Two among international hospitals. costs. Such “value” reporting ACS NSQIP collaboratives were Currently, 36 international sites will likely be commensurate recently honored with national are enrolled in ACS NSQIP with the priorities of the awards based on their leadership and another 12 sites are in overall health care movement in quality improvement, and the application process. at the broad policy level and each cited ACS NSQIP results This was the second year the individual hospital level. as key quality achievements. that the International ACS The Tennessee Surgical Quality NSQIP Scholarship Award was Collaborative and the Florida presented. The scholarship is MBSAQIP Surgical Care Initiative both presented to two surgeons from A total of 725 U.S. bariatric 74 | noted significant reductions countries other than the U.S. surgery centers participate in in complications and their or Canada who demonstrate the Metabolic and Bariatric resulting cost savings in their a strong interest in surgical Surgery Accreditation and award nomination entries. quality improvement. Recipients Quality Improvement Program The spirit of collaboration in 2013 were Ping Lan, PhD, (MBSAQIP), 634 of which are is also responsible for the MD, FACS, of the Sixth fully accredited; the remaining development of another ACS Affiliated Hospital of Sun Yat- 91 are provisionally approved. NSQIP quality improvement Sen University in Guangzhou, An additional 28 initial resource. Presented to all China, and Manuel Francisco applications are under review. attendees at the last ACS Roxas, MD, FPCS, FACS, of The Committee for Metabolic NSQIP conference, the fourth the Medical City in Pasig City, and Bariatric Surgery, the edition of ACS NSQIP’s Best Philippines. As part of their overarching advisory committee Practices Case Studies provides scholarship, Drs. Lan and for the MBSAQIP, works closely information on the experiences Roxas attended the ACS NSQIP with the American Society and expertise of hospitals that National Conference and visited for Metabolic and Bariatric have successfully implemented participating hospitals to learn Surgery (ASMBS) leadership quality improvement programs how to implement surgical via its Executive Council to at their institutions. The guide quality improvement methods ensure multi-membership also provides insight into the at their home institutions. representation from both the methods and tools used for Both surgeons submitted ACS and the ASMBS. Due to implementing initiatives in formal reports recounting their the collective work of both quality improvement. The latest scholarship experience and the ACS and the ASMBS edition of the Best Practices Case effusively praised the conference leadership, work is under Studies included entries from and the knowledge gained way to develop a critically the Cleveland (OH) Clinic, from their hospital visits. important quality improvement Tampa (FL) General Hospital, ACS NSQIP continues to initiative aimed at reducing Mayo Clinic Rochester (MN) develop tools to help hospitals acute hospital readmissions Methodist Hospital, and Sheikh achieve improved surgical care related to bariatric surgery.

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The Standards Subcommittee CoC leadership and external has collected feedback from constituents developed an NAP BC the second public comment initial framework for health National Accreditation period and has voted to approve care system standards that Program for Breast Centers the MBSAQIP standards. will form the basis for an (NAPBC) accreditation has At press time the Standards accreditation model. An now been awarded to more Subcommittee’s goal is to October 2013 meeting was held than 500 U.S. breast centers, release and implement these with staff from two leading with another 223 centers standards in January 2014 health care systems to complete currently working toward with associated training and the initial draft, and pilot site accreditation or reaccreditation. educational activities. visits are targeted for the first As part of the NAPBC quarter of 2014. Release of a International Committee system accreditation manual exploration toward developing COC is targeted for later in 2014. an international arm of the A total of 1,507 cancer centers A cross-functional pediatric NAPBC, a survey was sent to in the U.S. and Puerto workgroup will be established 918 physicians in 43 countries Rico are accredited by the to evaluate existing pediatric representing 184 breast centers | 75 Commission on Cancer standards and develop an to inquire whether they would (COC). These institutions enhanced set of standard and be interested in learning more treat 71 percent of all newly pediatric performance measures about breast center accreditation diagnosed cancer patients with an eye toward providing and participating in a quality- annually. In the last year, 27 more value to program based breast accreditation new cancer programs joined participants and adding new program. The same survey the accreditation program, participants in this category. was sent to all International and 79 cancer programs The Cancer Quality Fellows of the ACS. The results received the Outstanding Improvement Program overwhelmingly supported the Achievement Award. (CQIP) has a new annual development of a global breast CoC leadership and external cancer program report under accreditation. Therefore, the constituents developed an development. CQIP 2013 was NAPBC identified three pilot initial framework for Oncology released to more than 1,500 sites (Montreal, QC; London, Medical Home (OMH) CoC-accredited hospitals in UK; and Dubai, UAE) and standards that will apply November 2013. The CQIP developed a questionnaire to large group practices. A 2013 report is based on cases based on the current American- component of this accreditation diagnosed in 2011 and includes based standards and asked is focused on data to measure more than 100 data points how they would satisfy the the OMH performance for each cancer diagnosed standards.This questionnaire against 19 clinically-based in patients treated in CoC- will be sent to each international performance measures. More accredited facilities. The CoC program and a catalog of than $1 million in grant plans to update and expand responses will be built to funding has been requested this report annually for its capture geographic differences from the Center for Medicare programs to use to improve and help guide international and Medicaid Innovation compliance with quality surveyors in the future.  to support development of measures, outcomes, and the this accreditation model. overall care for cancer patients.

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2014 International ACS NSQIP Scholarship applications due February 14

The American College of • Applicants must submit their career goals, indicating how Surgeons National Surgical applications from their intended they plan to transfer their Quality Improvement permanent institution. newly acquired learning to Program (ACS NSQIP®) their current workplace. and the ACS International • Applications will be accepted Relations Committee co- for processing only when the • Applicants must submit letters sponsor International ACS applicants have been in surgical of recommendation from NSQIP Scholarships for two practice, education, or research three of their colleagues. One surgeons from countries other for a minimum of one year letter must be from the chair than the U.S. or Canada who at their intended permanent of the department of their demonstrate a strong interest in location following completion hospital or in the program 76 | surgical quality improvement. of all formal training (including in which they hold academic Completed applications for the fellowships and scholarships). appointment or from an ACS 2014 scholarships and all of Fellow residing in their country. the supporting documentation • Applicants must be younger The chair’s or the Fellow’s must be received by the than 55 years of age at the letter should include a specific International Liaison Section time of application. statement detailing the nature no later than February 14. and extent of the applicant’s The scholarships of $10,000 • Applicants must have quality improvement activities. each provide the recipients demonstrated a commitment to Letters of recommendation with an opportunity to attend surgical quality improvement. should be submitted separately the 2014 ACS NSQIP National by the references. Conference July 26–29 in • Applicants must submit a fully New York, NY, and meet with completed application form • Applicants must submit program leadership and surgeon provided by the College on its a curriculum vitae of no champions from ACS NSQIP website. The application and more than 10 pages. participating hospitals. Following accompanying materials must the ACS NSQIP conference, the be typewritten and in English. The International ACS candidate is encouraged to visit Submission of a curriculum NSQIP Scholarships must be one to two hospitals reflecting vitae only is unacceptable. used in the year for which the candidate’s specific clinical they are designated. They interests. These hospitals • Applicants must provide cannot be postponed. should also have strong quality information regarding their Applicants who are programs. work setting, including their awarded scholarships will The scholarship requirements hospital and the patients they submit a full written report are as follows: see, as well as their participation of the experiences provided in quality improvement through the scholarships • Applicants must be graduates activities in this setting. upon completion of their of schools of medicine. They must also indicate their scholarships.

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The scholarships of $10,000 each provide the recipients with an opportunity to attend the 2014 ACS NSQIP National Conference July 26–29 in New York, NY, and meet with program leadership and surgeon champions from ACS NSQIP participating hospitals.

An unsuccessful applicant More information regarding Supporting materials and may reapply only twice and only the ACS National Surgical questions should be sent to by completing and submitting a Quality Improvement the International Liaison, current application form provided Program can be found at Kate Early, via e-mail by the College, together with http://www.acsnsqip.org. at [email protected]. new supporting documentation. To qualify for consideration All submissions must be The scholarships provide by the selection committee, received by the February 14 successful applicants with applicants must fulfill all deadline for the selection the privilege of participating requirements. The formal committee to consider in the ACS NSQIP National International ACS NSQIP each application. All Conference. Assistance will Scholar application appears applicants will be notified be provided in arranging on the ACS Scholarships Web of the selection committee’s hotel accommodations page at http://www.facs.org/ decision by April 30.  during the conference. memberservices/research.html.

| 77 American College of Surgeons Official Jewelry & Accessories #S5 #S6 #S1 designed, crafted and produced exclusively by Jim Henry, Inc. #S2 Tie Tac/Lapel Pin Ring Rollerball Pen - Chrome #S1 Single Gold-Filled $60 #S14 Solid 14K Gold $2250 #S25 Cross Townsend #S2 Solid 14K Gold $350 #S14.1 Solid 10K Gold $1650 Medalist with 23/K (Indicate finger size) Gold Plated Emblem $135 Cuff Links #S3 Single Gold-Filled $190 Tie Bar Money Clip (Not Shown) #S15 #S4 Solid 14K Gold $1100 #S15 Gold-Filled Emblem $65 #S26 With Gold-Filled emblem $75 #S3 Key (shown actual size Necktie #S4 of 3/40) #S16A Dark Blue $35 Desk Set (Not Shown) #S5 Single Gold-Filled $85 #S16B Light Blue $35 #S27 Solid Walnut with Cross #S6 Solid 14K Gold $750 #S17 Maroon $35 Gold-Filled Pen & Pencil/Gold- Extra long add $5.00 Filled emblem; name and year Miniature Key elected a Fellow engraved on (Not Shown) Diploma Plaques gold polished plate $325 #S7 Single Gold-Filled $70 #S18 Satin Gold Finish $340 #S8 Solid 14K Gold $450 #S19 Satin Silver Finish $340 Wallet (Not Shown) 8-1/20 x 120 metal plaque on #S28 Black cowhide with #S11 110x14-1/20 walnut. Specify #S12 Charm (Not Shown) Gold-Filled emblem $100 #S17 #S13 #S9 Single Gold-Filled $75 name, day, month, year selected. #S16A #S16B #S25 #S10 Solid 14K Gold $525 Men’s Bow Tie (Untied) Blazer Buttons (Not Shown) #S30 (Not Shown) #S29 Gold Electroplated Miniature Charm (set of 9) $35 #S11 Single Gold-Filled $65 #S22 Dark Blue $35 #S12 Solid 14K Gold $350 #S23 Maroon $35 Blazer Patch #S13 Sterling Silver w/ 180 Women’s Scarf - Silk #S30 Hand embroidered $35 Sterling Silver Neckchain $65 (Not Shown) #S13-1 Sterling Silver Charm $50 Shipping/Handling/Insurance 0 0 #S24 36 x 36 cream $35 Domestic (48 contingent states) $15 w/ dark blue and Alaska, Hawaii, Puerto Rico $30 #S14 #S18 maroon border #S19 Foreign $40 Form No. 913759-09/13

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T he Sydney Opera House, a work of art in light.

2013 Traveling Fellow reports on trip to Australia and New Zealand by Nancy Baxter, MD, FACS

It was a great honor to have NZ, and president of the Royal Otago in Christchurch. I was 78 | been selected the 2013 American Australasian College of Surgeons. pleased to share Minnesota College of Surgeons (ACS) He put me in contact with Ian connections with Bruce and Traveling Fellow to Australia Bissit, MD, FRACS, associate Frank, and meeting them before and New Zealand (ANZ). professor of surgery at the my travels reassured me that The fellowship allowed me to University of Auckland and head I would have a terrific trip. travel across the world to visit of the department of surgery and spectacular places, learn from consultant colorectal surgeon colleagues, and reconnect with at Auckland City Hospital, Auckland old friends. This truly was a trip and Mattias Soop, MD, PhD, After traveling from Toronto of a lifetime. The opportunity to department of surgery, University via Vancouver to Auckland, I visit surgeons in their practices of Auckland, NZ, who helped arrived at the North Island at in two countries, to learn about coordinate my involvement in 5:00 am. Fortunately, I was able their training, their approach to the Royal Australasian College to check into my hotel and get patient care, and their health care of Surgeons (RACS) Annual some sleep. With lingering jetlag, system showed me that while we Meeting in Auckland. Dr. Civil I found myself falling asleep at can learn a great deal from these advised me on specifics of the the dinner table on a number differences, our worries, struggles, trip, including top places to visit. of occasions; thankfully, my and successes are similar. Just before my visit “Down hosts were understanding. Well before my visit, the Under” I was greeted at the In Auckland, I attended the Australasians went out of their American Society of Colorectal RACS Annual Scientific Congress, way to welcome me and help Surgeons annual meeting by May 6–10, at the Crowne with planning. My experience Bruce Waxman, MB, BS, FACS, Plaza Convention Centre. The started at the 2012 ACS Clinical head of colorectal surgery, convention center is attached to Congress where I received a Monash Health in Melbourne the Sky Tower, the tallest building warm greeting from Ian Civil, Australia, and Frank Frizelle, in New Zealand. The Scientific MB, ChB, FACS, PRACS, a MB, ChB, MMedSc, FACS, Congress is a well-organized and general and trauma surgeon academic head of the department well-attended meeting of surgeons at Auckland City Hospital, of surgery at the University of of all specialties in Australasia.

V99 No 1 Bulle t in American College of Surgeons Scholarships

Drs. Barnett (left) and Dimick preparing Sky Tower to jump off the Sky Tower.

The meeting is organized to network with Torbjörn Holm, I also attended the lunch according to specialty tracks. Dr. MD, a colorectal surgeon at the meeting of the ANZ Chapter of Soop organized a phenomenal Karolinska Institute, Stockholm, the ACS. I was fortunate to hear colorectal surgery program in Sweden, and Thomas Read, A. Brent Eastman, MD, FACS, which I was pleased to participate. MD, FACS, a colorectal surgeon then-President of the ACS, give On the first full day of the in Burlington, MA. I also had an inspirational talk highlighting conference, I was involved in a the opportunity to attend the the benefits of international master class—a group session Women in Surgery Symposium, networks and collaborations. | 79 of approximately 80 attendees. coordinated by Eva Juhasz, BHB, He emphasized the importance The topic was Research: How MB, ChB, FRACS, a colorectal of building links between to Publish Your Research in a surgeon in Brightside, NZ, who, Australasian surgeons and the Good Journal. My presentation unfortunately was unable to ACS and made me feel very was titled How to Design Good attend. The symposium focused proud to represent the College. Studies—a subject that is tough on Past and Present Inspirations I attended a number of to tackle in 20 minutes, but my in Surgery, with presentations wonderful social events where efforts were warmly received. by several international I met international colleagues. I Later in the week I presented visitors, including myself and attended the welcome reception the ACS Lecture as part of the the following: Lillian Kao, on May 6, the colorectal section colorectal program titled Quality MD, FACS, associate professor dinner on May 8, at the Auckland Control in Colonoscopy: How to of surgery and critical care, Art Gallery hosted by Dr. Soop, Avoid Missing Tumors. During University of Texas Medical and on the final evening of the the talk I highlighted other School, Houston, and a faculty meeting, I attended a lovely gala surgeons’ and my research into member for the university’s dinner held at the Langham Hotel. the effectiveness of and quality Center for Clinical Research In addition, a number of measures in colonoscopy. and Evidence-Based Medicine; high-spirited surgeons from In preparation for the talk, Monica Bertagniolli, MD, the Association of Academic I learned a great deal about the FACS, a general surgeon, at the Surgery attend the RACS meeting status of colorectal screening department of surgery, Brigham annually to help lead the course, in Australia and New Zealand & Women’s Hospital, Boston, Developing a Career in Academic and what each country is doing MA. It was great to network Surgery, with the Academic in terms of colonoscopy quality not only with women from Section of RACS. I shared an assurance. Matt had invited a Australasia, but also with leaders adventure with these surgeons, number of prominent colorectal of the ACS. My presentation was or, more precisely, watched an surgeons to the meeting, and I on International Perspectives adventure unfold. Carlton Barnett, was lucky to have the opportunity in Women in Surgery. MD, FACS, a general surgeon,

JAN 2014 Bulle t in American College of Surgeons Scholarships

Dr. Baxter with Drs. Hanney and Kao in Queenstown. Dr. Hanney bungee jumping.

Denver Health Medical Center/ of surgery, and the institution could blame him? His friends University of Colorado, and Justin provides organized, systematic Carlton and Justin had just Dimick, MD, FACS, a general help to these patients, which is jumped off a building. surgeon, University of Michigan, likely to result in increased rates I traveled to Christchurch Ann Arbor, took the plunge from of smoking cessation, improved where I received a warm welcome the top of Sky Tower mentioned surgical outcomes, and more from Frank Frizelle MB, ChB, previously and lived to tell the lives saved. Since I have returned MMedSc, FACS, a colorectal 80 | tale. Only in New Zealand. from my trip I have already taken surgeon and department head, On May 10, I visited Auckland steps to see if a similar program department of surgery, University City Hospital, where I toured the might be implemented on a of Otago, Christchurch, and his facility with Arend Merrie, MB, provincial level through Cancer wife Marguerite Crooks, DMD. ChB, PhD, FRACS, a general Care Ontario. The Auckland City They opened their home to surgeon and director of general Hospital staff was welcoming, me and provided me with surgical training, Auckland and Dr. Merrie provided further an opportunity to visit the Hospital, and Julian Hayes, MB, insights into the health care Christchurch Hospital, the major ChB, FRACS, a general and a system and practice of colorectal tertiary referral center in the colorectal surgeon at Auckland surgery in New Zealand. South Island and affiliated with City Hospital. I presented the University of Otago. During grand rounds to the colorectal my two-day visit I was able to surgery group. My talk, How Queenstown observe in the operating room, Effective Is Colonoscopy for the I then flew from Auckland attend multidisciplinary tumor Prevention of Colorectal Cancer to Queenstown on the South rounds and teaching rounds, Mortality?, was well-received, Island. The view of the amazing and meet the general surgical and the surgeons in attendance mountains and farming stations trainees. Chris Wakeman, BSc, offered thoughtful comments. is breathtaking. Queenstown MB, ChB, MMedSci, FRACS, a I was very impressed by the is the home of unparalleled colorectal surgeon at Christchurch health care system and the focus outdoor adventure touring. Colorectal, NZ, and Tim Eglinton, of the hospital on population I was fortunate to have two MB, ChB, MMedSc, FRACS, a health. Most notable were the travel companions, Richard consultant colorectal surgeon at perioperative smoking cessation Hanney, MB, BS, FRACS, the hospital, helped with my visit. programs implemented on site University of Sydney; and Dr. Christchurch suffered a and the quality metrics in place Kao. Queenstown is also the massive earthquake on February for smoking cessation at the home of bungee jumping. 22, 2011, which caused widespread institution. Patients are motivated Lillian and I watched Richard damage to this beautiful Victorian to stop smoking around the time jump off a bridge, and who city. The response of the team at

V99 No 1 Bulle t in American College of Surgeons Scholarships

St. Vincent’s Hospital in Melbourne.

Christchurch Hospital to this oncology whom I knew from met my host, Sandy Herriot, natural disaster and their their fellowship days at Princess MA, MB, BChir, MD, FRCS, a participation in the recovery was Margaret Hospital in Toronto. colorectal surgeon, department inspiring. I promised to return With their help I had two of surgical oncology, Peter in 10 years to see the city rebuilt. stops arranged. First I visited MacCallum Cancer Centre, I shared a wonderful meal with St. Vincent’s Hospital where I Melbourne; department of the faculty and was encouraged was hosted by Rodney Woods, colorectal surgery, St. Vincent’s; to enjoy the magnificent local MB, BS, FRACS, director of and honorary senior lecturer, | 81 oysters. We drank some terrific colorectal surgery; and Jamie University of Melbourne. I wine from the vineyards of Keck, MB, BS, FRACS, director presented at grand rounds and New Zealand native Murray of anorectal physiology. I toured the facilities, which Brennan, MD, FACS, the Benno attended two multidisciplinary include an extensive tumor C. Schmidt Chair in Clinical rounds, as well as tumor board bank and offer opportunities Oncology and director of the and inflammatory bowel for translational research. center for international programs disease rounds. St. Vincent’s at Memorial Sloan-Kettering Hospital is a major force in Cancer Center, New York, NY. Australia for the management Newcastle I then traveled up the east coast of inflammatory bowel disease I then flew to Newcastle, of the South Island to Kaikoura (IBD). I had heard about this Australia, where I had been and fulfilled a lifelong dream of program and the rounds invited by Stephen Deane, MB, swimming with wild dolphins. throughout New Zealand and BS, FACS, FRACS, FRCSC, a New Zealand is a magical place Australia. Based on the same general surgeon with the John with wonderful people in a principles as tumor boards, Hunter Hospital, to visit the spectacular setting. I will be back. they facilitate multidisciplinary hospital and the University of management of complex IBD Newcastle. He and Stephen patients, enabling real-time Smith, MB, BS, BSc, FRACS, a Melbourne communication between colorectal surgeon, John Hunter I then left New Zealand and gastroenterologists, surgeons, Hospital and the University of flew to Melbourne, Australia, radiologists, pathologists, and Newcastle, who were the visitors where my stay was brief but nurses. I hope to institute from Australasia to the 2013 ACS engaging. This wonderful these principles at my Clinical Congress, coordinated Victorian city has become a hospital where we see a large the arrangements for my visit. I foodie’s paradise, and I was able number of IBD patients. received a wonderful welcome to reconnect with several friends Next, I visited the Peter in Newcastle, and my hosts and colleagues in medical MacCallum Cancer Centre and ensured an enjoyable stay.

JAN 2014 Bulle t in American College of Surgeons Scholarships

In preparation for the talk, I learned a great deal about the status of colorectal screening in Australia and New Zealand and what each country is doing in terms of colonoscopy quality assurance.

We started with a dinner with the next morning, where I of the world leaders in pelvic the surgeons in the colorectal presented my research in cancer exenteration. He is a wonderful service at John Hunter, including survivorship to the general and inspiring individual. I would Dr. Smith, Brian Draganic, surgery faculty and residents encourage anyone interested in FRACS, conjoint senior lecturer, at the John Hunter Hospital. additional training in this area University of Newcastle, and Later that day, I took a to seek him out. My professional Peter Pockney, MB, BCh, scenic train ride to Sydney. It visits ended with a wonderful colorectal surgeon, division of is a wonderful place where the dinner off Sydney Harbour. I surgery, and senior lecturer, people are friendly, the sun is was able to stay an extra day John Hunter, and their spouses. almost always shining, and the and visit friends. I was fortunate These surgeons are committed most fabulous beach you have to catch the Sydney Light to excellence in patient care and ever seen is just a ferry ride away. Festival. The Opera House is research, but they also have built Michael Solomon, MB, BCh, an amazing building that, when a wonderful, collegial team. BAO, MSc, FRACS, a colorectal lit up, becomes a work of art. 82 | On May 22, I attended the surgeon at Concord Repatriation morning training meeting with General Hospital and Royal registrars (residents and fellows). Prince Alfred Hospital in Sydney, Inspiring experience Later that day, I rounded with met me at my hotel and drove My experience as the ANZ Dr. Smith at the John Hunter me to the Royal Prince Albert Traveling Fellow was an Hospital and was amazed at Hospital. Professor Solomon incredible adventure. I interacted the amount of clinical research and I have been friends since he with and learned from wonderful performed there. This colorectal completed his colorectal surgery surgeons who have a passion unit has achieved the goal fellowship and master of science for quality patient care. The trip of enrolling all patients in a degree in clinical epidemiology made me look at my practice in clinical study. This feat shows at the University of Toronto. We different ways and has inspired the dedication of the unit’s began the tour of the hospital me to try to achieve more and surgeons, nurses, and patients to with a visit to the clinical do better in the future. I made research and continuous quality research training unit that he new friendships, reconnected improvement. Having learned initiated, the Surgical Outcomes with dear friends from the of this inspiring achievement, Research Centre. Professor past, and developed potential I now am committed to getting Solomon developed and led a collaborations for future research. more patients enrolled in master’s of surgery program that I am truly grateful to all the clinical studies. provides training and expertise surgeons who made my trip At city-wide rounds for the in clinical epidemiology to such a wonderful experience Newcastle Gut Club, I delivered surgeons throughout Australia. and to the ACS for selecting two presentations during two- Next, we participated in ward me to serve as the 2013 well-attended meetings of rounds. Professor Solomon’s ANZ Traveling Fellow.  gastroenterologists and general clinical work is remarkable. He surgeons, one in the evening is pushing the field of radical on colonoscopy effectiveness surgery for locally aggressive for prevention of colorectal primary and recurrent pelvic cancer mortality, and one cancers forward and is one

V99 No 1 Bulle t in American College of Surgeons Are you taking advantage of all the American College of Surgeons has to o er?

ACS members are dedicated to promoting the highest standards of surgical care through education and advocacy for Fellows and their peers. The College serves as an international forum through which surgeons can reinforce the values, ideals, and ethics that characterize the surgical profession.

MEMBERSHIP HAS BENEFITS THERE IS STRENGTH IN NUMBERS  Access to a broad range of CME Our members represent every surgical programming, including resources to specialty, practice setting, and stage of support Maintenance of Certifi cation practice. Their views and concerns help shape the College’s agenda for the future.  Subscriptions to ACS publications that bring you cutting-edge research If you aren’t a member of the American and news from the College and College of Surgeons, apply for Fellowship surgical community today. If you are already a member, maintain  Access to College-sponsored your status and consider getting involved in insurance programs the College’s e orts to make a di erence.  Free access to the College coding Together, we can bring about positive change consultation hotline, career for our patients and partners—and for the opportunities, and resume posting surgeons of the future.  And much more

Information on becoming a member of the College and an application form are available online at www.facs.org/memberservices/documents.html or contact Cynthia Hicks, Credentials Section, Division of Member Services, at 800-293-9623 or [email protected]. Meetings calendar

Calendar of events*

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

South Texas Chapter Trauma, Critical Care, January February 20–22 and Acute Care Surgery Austin, T X March 31–April 2 Southern California Chapter Contact: Janna Pecquet, Las Vegas, NV January 17–19 [email protected], Contact: Mary Allen, Santa Barbara, CA http://www.southtexasacs.org/ [email protected] Contact: Jim Dowden, [email protected], Montana, Wyoming, http://www.socalsurgeons.org/ and Idaho Chapters February 21–23 April L ouisiana Chapter Jackson, WY January 17–19 Contact: Janis Black, Japan Chapter New Orleans, LA [email protected] April 3 Contact: Janna Pecquet, Kyoto, Japan [email protected], Contact: Kazuhiko Yoshida, MD, FACS, http://www.laacs.org/ [email protected] March South Florida Chapter Minnesota Chapter April 14 84 | January 27 Metropolitan Washington, Ft. Lauderdale, FL DC, Chapter Minneapolis, MN Contact: Bill Bouck, March 8 Contact: Nonie Lowry, [email protected], Washington, DC [email protected] http://www.sfc-acs.org/ Contact: Jennifer Starkey, www.mnsurgicalsociety.org [email protected], http://www.dcfacs.org/ North Dakota and South Dakota Chapter February 7th Annual Consortium Meeting April 25–April 26 of the ACS-accredited Education Sioux Falls, SD Puerto R ico Chapter Institutes Contact: Terry Marks, February 20–22 March 21–March 22 [email protected] San Juan, Puerto R ico Chicago, IL Contact: Aixa Velez, Contact: Catherine Wojcik, [email protected] [email protected] Future Clinical North Texas Chapter Medical Disaster R esponse Congresses February 21–22 March 30 Dallas, T X Las Vegas, NV 2014 Contact: Nonie Lowry, Contact: Mary Allen, October 26–30 [email protected], [email protected] San Francisco, CA http://www.ntexas.org/ 2015 October 4–8 Chicago, IL

V99 No 1 Bulle t in American College of Surgeons