Bulletin August 2012

AUGUST 2012 Volume 97, Number 8

INSPIRING QUALITY: Highest Standards, Better Outcomes

FEATURES Diane S. Schneidman From the Chair of the RAS-ACS: Leadership skills continue Editor-in-Chief to serve past RAS-ACS Chairs in their current roles 9 Lynn Kahn Heena P. Santry, MD Director, Division of Integrated Communications Surgical leadership and political advocacy 14 Tony Peregrin Ross F. Goldberg, MD; Haytham M.A. Kaafarani, MD, MPH; Jillian Smith, MD; Senior Editor and Robert Winfield, MD Jeannie Glickson Advanced degrees for surgeons and their impact on leadership 19 Katie McCauley Feibi Zheng, MD, MBA; Nicolas J. Mouawad, MD, MPH, MBA, MRCS; Contributing Editors Nina E. Glass, MD; and Osama Hamed, MD Tina Woelke Women leaders in surgery: Past, present, and future 24 Graphic Designer Juliet A. Emamaullee, MD, Phd: Megan V. Lyons, MD; Elizabeth Berdan, MD; Charles D. Mabry, and Amy Bazzarelli, MD MD, FACS Leigh A. Neumayer, Surgical leadership across generations 30 MD, FACS Sangeetha Prabhakaran, MD; Konstantinos E. Economopoulos, MD; Marshall Z. Schwartz, LCDR Daniel J. Grabo, MD; and Joseph V. Sakran, MD, MPH MD, FACS Mark C. Weissler, Surgery at the end of life: For love or money? 36 MD, FACS Amy E. Liepert, MD; Stefan W. Leichtle, MD; and Brian J. Santin, MD Editorial Advisors Tina Woelke From battlefield to bedside—and back again 41 Front cover design Paula Rasich Training global surgery fellows 46 Stephen R. Sullivan, MD, MPH; Christopher D. Hughes, MD, MPH, FACS; Future meetings Maxi Raymonville, MD; Selwyn O. Rogers, MD, FACS; Michael L. Steer, MD, FACS; Clinical Congress and John G. Meara, MD, DMD, FACS 2012 Chicago, IL, September 30– October 4 DEPARTMENTS 2013 Washington, DC, October 6–10 Looking forward 4 2014 San Francisco, CA, Editorial by David B. Hoyt, MD, FACS, ACS Executive Director October 26–30

Participating in the Medicare eRx Incentive Program 6 Letters to the Editor should be Sana Gokak, MPH sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to [email protected], or via mail to Diane S. Schneidman, Editor-in- Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or clarity. Permis- sion to publish letters is assumed un- On the cover: In a series of articles beginning on page 9, members of the Resident and less the author indicates otherwise. Associate Society of the American College of Surgeons—a society that is a launching pad for future generations of surgical leaders—address the subject of leadership. NEWS Bulletin of the American College of Surgeons (ISSN Dr. W. Hardy Hendren III 0002-8045) is published monthly receives 2012 Jacobson Innovation Award by the American College of Sur- 51 geons, 633 N. Saint Clair St., New leadership at the helm of ACSPA-SurgeonsPAC 53 Chicago, IL 60611. It is distrib- Chantay Moye uted without charge to Fellows, Associate Fellows, Resident and Dr. Armstrong named Florida Surgeon General, Secretary of Health 54 Medical Student Members, Af- filiate Members, and to medical NQF endorses SQA’s Patient-Focused Care Survey 55 libraries and allied health personnel. Periodicals postage paid at Trauma meetings calendar 55 Chicago, IL, and additional mail- ing offices. POSTMASTER: Send Florida initiative uses ACS NSQIP processes address changes to Bulletin of the ® American College of Surgeons, to measure and improve care 57 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian From surgeon to grassroots advocate: Publications Mail Agreement No. Chapter leaders engage in advocacy development 58 40035010. Canada returns to: Alexis Macias and Oscar Guillamondegui, MD, FACS Station A, PO Box 54, Windsor, ON N9A 6J5. HPRI representatives visit Lord Ribeiro at U.K.’s House of Lords 60 The American College of Surgeons’ headquarters is lo- Surgical quality forum focuses cated at 633 N. Saint Clair St., on how QI can help curb health care costs 61 Chicago, IL 60611-3211; tel. 312-202-5000; toll-free: 800- Correction 62 621-4111; e-mail:postmaster@ facs.org; website: www.facs. A look at The ointJ Commission: org. Washington, DC, office is SafeCare offers quality framework in resource-restricted settings 63 located at 20 F Street N.W. Suite 1000, Washington, DC. 20001- ACS Clinical Research Program: What’s new in renal cell carcinoma 65 6701; tel. 202-337-2701; web- Maxwell V. Meng, MD, FACS, and Heidi Nelson, MD, FACS site: www.tmiva.net/20fstreetcc/ home. November 1 closing date for Faculty Research Fellowship applications 69 Unless specifically stated otherwise, the opinions expressed Apply by September 4 for ACS Resident Research Scholarships 70 and statements made in this publication reflect the authors’ 2012 Health Policy Scholars announced 72 personal observations and do not imply endorsement by nor official NTDB® data points: Surf’s up 74 policy of the American College of Surgeons. Richard J. Fantus, MD, FACS Chapter news 77 ©2012 by the American Rhonda Peebles College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382. The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment. Looking forward

n the past decade, Congress has approved 14 pieces of legislation that have postponed

reductions in Medicare physician payment,

which would have been incurred due to the government’sI continued use of the flawed sustainable growth rate (SGR) formula to calculate fees. ’’ Congress’ most recent action of this type occurred earlier this year, when legislators averted another steep cut in payment by passing a 10-month short- term patch. Although these patches have offered some short- term relief to surgical practices and ensured ongo- The ACS has developed a ing access to care for Medicare beneficiaries, they provide no long-term stability and add to both the proposal called the value- size of future payment reductions and the costs of permanently repealing the SGR. Indeed, the based update (VBU), which cumulative effect of Congress’ failure to repeal the SGR is a 27 percent cut in Medicare payment that we believe is a viable is scheduled to take effect on January 1, 2013. The American College of Surgeons (ACS), the alternative to the SGR. surgical specialty societies, other medical associations, patient groups, and most members of Con- gress agree that this course of action must end. ’’ Disagreements arise, however, when the discussion turns to the development of a replacement for the SGR and how to fund its repeal. The ACS has developed a proposal called the value-based update (VBU), which we believe is a viable alternative to the SGR. Need for repeal outcomes and reduce costs. The VBU proposal is The SGR was enacted as part of the Balanced premised on the belief that higher quality care, bet- Budget Act of 1997 and was intended to be used ter patient outcomes, and, therefore, reduced health as a prospective measure for controlling the growth care spending are achievable goals and that quality of Medicare payments for physician services. The improvement programs can be incorporated into a premise behind the SGR formula was that it would more financially sustainable and patient-centered set health care spending targets, which, if exceeded, payment system. would result in a proportionate cut in the physician payment the following year. However, this approach Five principles was ill-suited to account for both the volume and The VBU is based on the following five principles the complexity of physician services, let alone the that the College and its allies believe must apply to unique needs of individual patients. any viable alternative to the SGR: The College and other surgical and medical associations have maintained that a better way to • Complement the current quality-related payment reduce health care spending is through improved incentive programs, such as the Physician Quality patient outcomes. Over the last year, the College’s Report System, the Electronic Prescribing Incen- Inspiring Quality campaign has successfully illus- tive Program, and the Electronic Health Record trated how quality improvement programs, such as Incentive Program, while making necessary adjust- the ACS National Surgical Quality Improvement ments to those programs to facilitate participation 4 Program (ACS NSQIP®), can improve patient by specialists

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • Provide a model that would have been immune to meantime, rest assured that the American College of the outcome of the Supreme Court’s decision on Surgeons is working hard to repeal and replace the the constitutionality of the Affordable Care Act broken Medicare SGR formula with a model that is good for our patients, is appropriate for surgical • Incorporate mechanisms that lead to improved practices, and inspires quality throughout the entire quality of care and reduced waste health care system. • Account for the varying ability of different seg- ments of the health care system to improve care and reduce spending • Create incentives for the provision of primary care services that appropriately and adequately address the needs of an increasingly complex David B. Hoyt, MD, FACS patient population At press time, the College and the surgical societies had developed a four-step plan for repealing the SGR and replacing it with the VBU. This proposal had not yet been finalized, but plans were in mo- tion to roll out the VBU to Fellows over the course of the summer.

Time for change Without question, a Medicare physician payment system that relies on the use of the SGR is unsustainable. It is time for Congress to muster the political will to repeal the SGR and replace it with a truly sustainable, patient-centric reimbursement mechanism. The College’s leadership and the Division of Advocacy and Health Policy have worked very hard to develop what we believe is a viable and meaningful alternative to the SGR—a plan that makes the provision of high-quality, patient-focused care the key factor in determining how surgeons and other physicians are paid. We have introduced the concepts of the VBU and are continuing to schedule additional meetings to make improvements in the model with surgical specialty societies, other physician groups, and health care leaders and think tanks in Washington, DC. We are also working with members of Congress to test the political waters for the establishment of the VBU Medicare physician payment system. As we further develop the plan, we are planning to hold an all-Fellow webinar to walk through the proposal and solicit input and answer questions from the College’s membership. As always, I look forward If you have comments or suggestions about this or other issues, to hearing your feedback on this proposal. In the please send them to Dr. Hoyt at [email protected]. 5

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about...

Participating in the Medicare eRx Incentive Program by Sana Gokak, MPH

he deadline to file for a hardship exemption What are the incentives and penalties under the eRx from the 2013 Electronic Prescribing (eRx) program? Incentive Program has passed, and by now Tsurgeons should be thinking about the requirements Table 2 on page 7 shows both the incentives and for the next few years. The Centers for Medicare & penalties for each year starting from 2012. Medicaid Services’ (CMS) eRx Incentive Program was authorized by the Medicare Improvements for Do I still have time to qualify for the 2012 eRx bonus? Patients and Providers Act of 2008. CMS defines e-prescribing as “the ability to electronically send Yes, EPs can still qualify for the 2012 eRx pay- an accurate, error-free, and understandable pre- ment incentive of 1 percent. To qualify, EPs must scription directly to a pharmacy from the point-of- report electronically 25 times from January 1 to care.”* Eligible professionals (EPs) who successfully December 31, 2012, for denominator eligible visits e-prescribe in 2012 can qualify for an incentive (see Table 3 on page 7 for the eligible denominator payment of 1 percent. The program is currently set codes). Denominator eligible codes are composed to expire in 2015. This article addresses questions of evaluation and management codes. surgeons may have regarding remaining incentives and penalties for 2012–2014. (See Table 1 on this Is it too late now to avoid the 2013 eRx penalty for page for an overview of the eRx incentives and nonparticipation? penalties remaining for 2012–2014.) Yes, it is too late for health care professionals to *Centers for Medicare & Medicaid Services. Available at: https://www.cms. avoid the 2013 eRx payment penalty of 1.5 per- gov/Medicare/E-Health/Eprescribing/index.html. Accessed June 27, 2012. cent of the Medicare Part B physician fee schedule

Table 1. Overview of the eRx incentives and penalties for 2012 through 2014 2012 2013 2014 Receive incentive Report 25 denominator Report 25 denominator No incentive payment in place after 2013 eligible prescriptions from eligible prescriptions from January 1 to December 31, January 1, to December 31, 2012, to receive incentive 2013, to receive incentive payment of 1.0% on Medi- payment of 0.5% on Medi- care Part B payment care Part B payment

Avoid penalty Deadline to avoid the 2012 Deadline to avoid the 2013 1. Report electronically 25 times for payment penalty has passed payment penalty has passed denominator eligible visits from January 1 to December 31, 2012, or 2. Report on any 10 electronic prescriptions from January 1 to June 30, 2013, or 3. Apply for a significant hardship exemption by June 30, 2013, or 4. Be automatically exempt

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS amount for covered professional services if they did • Qualify for an automatic exemption from the eRx not do one of the following: Incentive Program. EPs will be automatically exempt from the 2013 eRx Incentive Program penalty • Report prescriptions electronically 25 times from if they meet any one of the following criteria: January 1 to December 31, 2011, for denominator eligible visits. —The EP was a successful electronic prescriber during the 2011 eRx 12-month reporting period • Report prescriptions electronically 10 times of January 1 to December 31, 2011 from January 1 to June 30, 2012, for any visit (which does not have to be associated with a —The EP is not a MD, doctor of osteopathic denominator eligible code but was submitted in medicine (DO), podiatrist, nurse practitioner, conjunction with a billable, covered procedure or physician assistant by June 30, 2012 not associated with a global period). —The EP does not have at least 100 Medicare • Apply for a significant hardship exemption to Part B physician fee schedule cases containing avoid the 2013 eRx penalty on the CMS website denominator eligible codes (listed in Table 3) for by June 30, 2012, and receive CMS approval (it dates of service from January 1 to June 30, 2012 may take close to 30 days after application for the exemption for CMS to notify EPs regarding —At least 10 percent or more of the EP’s Medi- approval). See Table 4, page 8, for a list of the care Part B physician fee schedule charges are 2013 and 2014 significant hardship exemptions. not from denominator eligible codes (listed in Table 3) for dates of service from January 1 to June 30, 2012 Table 2. —The EP does not have prescribing privileges and Incentives and penalties for eRx reported G8644 on a billable Medicare Part B Year Incentive Penalty service at least once on a claim between January 1 and June 30, 2012 2012 1.0% 1.0% 2013 0.5 1.5 What should I do to avoid the 2014 eRx payment 2014 N/A 2.0 penalty? To avoid the 2014 eRx payment penalty of 2 per- Table 3. cent of the Medicare Part B physician fee schedule eRx measure denominator codes (eligible cases) amount for covered professional services, health care professionals must do one of the following: 90801, 90802, 99205, 99211, 99334, 99335, 90804, 90805, 99212, 99213, 99336, 99337, • Report electronically 25 times for denominator eligible visits from January 1 to December 31, 2012. 90806, 90807, 99214, 99215, 99341, 99342, 90808, 90809, 99304, 99305, 99343, 99344, • Report electronically at least 10 times from January 90862, 92002, 99306, 99307, 99345, 99347, 1 to June 30, 2013, for any visit (does not have to be associated with a denominator eligible code but must 92004, 92012, 99308, 99309, 99348, 99349, be submitted in conjunction with a billable, covered 92014, 96150, 99310, 99315, 99350, G0101, procedure not associated with a global period). 96151, 96152, 99316, 99324, G0108, G0109 99201, 99202, 99325, 99326, • Apply for a significant hardship exemption by June 30, 2013, once the portal opens in early 99203, 99204, 99327, 99328, 2013. See Table 4, page 8, for a list of the 2014 significant hardship exemptions. 7

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 4. penalties, visit the following CMS Web page: http:// Hardship exemptions available for 2013 and 2014 www.cms.gov/ERxIncentive/20_Payment_Adjust- ment_Information.asp. Inability to electronically prescribe due to state or federal law or local law or regulation If you have any questions, contact Sana Gokak, ACS Division of Advocacy and Health Policy, at 202- The EP prescribes fewer than 100 prescriptions during 337-2701 or [email protected]. You may also contact a six-month payment adjustment reporting period the CMS eRx help desk at 866-288-8912.  The EP practices in a rural area without sufficient high- speed Internet access (G8642) The EP practices in an area without sufficient available pharmacies for electronic prescribing (G8643)

• Be automatically exempt from the eRx Incentive Program. EPs will be automatically exempt from the 2014 eRx Incentive Program penalty if they meet any one of the following: —The EP is a successful electronic prescriber during the 2012 eRx 12-month reporting period of January 1 to December 31, 2012 —The EP is not a MD, DO, podiatrist, nurse practitioner, or physician assistant by June 30, 2013 —The EP does not have at least 100 Medicare Part B physician fee schedule cases containing denominator eligible codes (listed in Table 3) for dates of service from January 1 to June 30, 2013 —At least 10 percent or more of the EP’s Medi- care Part B physician fee schedule charges are not from denominator eligible codes (listed in Ms. Gokak is Quality Associ- ate, Regulatory Affairs, Divi- Table 3) for dates of service from January 1 to sion of Advocacy and Health June 30, 2013 Policy, Washington, DC. —The EP does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between January 1 to June 30, 2013 For more information on the eRx Incentive Pro- gram, continue to check the American College of Surgeons website at http://www.facs.org/ahp/erx.html or the CMS eRx website at https://www.cms.gov/ 8 ERxIncentive/. For more information on payment

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From the Chair of the RAS-ACS: Leadership skills continue to serve past RAS-ACS Chairs in their current roles

by Heena P. Santry, MD

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS urgeons lead in many differ- the quality of bariatric surgery to the growing trend ent ways. Surgeons lead in of surgical health services research. the operating room (OR), At a later point in my career, Danielle Katz, MD, heading a team of practitio- FACS, encouraged me to become actively involved ners caring for a singleS patient who has put his or her in one of the four standing committees of the RAS, well-being in their hands. Surgeons lead on rounds, which quickly led to roles on the RAS Communica- heading a clinical team responsible for the day-to- tions Committee, the College’s Women in Surgery day progress of a patient’s surgical care. Surgeons Committee, the RAS Web portal, the Advisory lead by educating their colleagues, fellows, residents, Council on General Surgery, and now the RAS Ex- medical students, and affiliated practitioners about ecutive Board. These experiences have provided me the clinical and technical aspects of the art and with opportunities for professional development, science of surgery. Surgeons lead by conducting networking, and leadership training far beyond the research with widespread implications for surgical resources available in any of my training programs. I diseases and quality of care in surgery. Surgeons firmly believe that these experiences in the RAS have lead by serving in key roles for their institutional, improved my ability to lead as a clinician, an educa- loco-regional, and national organizations and com- tor, a researcher, and as a member of society who is mittees. Surgeons lead by being the voice for the interested in improving access to quality surgical care. house of surgery to state and federal legislators. The greatest and most challenging of these experiences And notably, surgeons lead by mentoring the future has been serving as Chair of the RAS this year. generation of surgical leaders. The Resident and As- sociate Society of the American College of Surgeons Past Chairs’ experiences (RAS-ACS) is the home of that future generation of Rather than focus on my own experiences as RAS surgical leaders. Chair, however, I have taken this opportunity to As a junior surgical resident, I was aware of the ACS explore how those who have preceded me as leaders and knew that the faculty at my residency who were of this organization over the last decade were shaped my leaders on rounds, in the OR, and in the research as leaders as a result of their early engagement in the laboratories proudly acknowledged their Fellowship College through the RAS. The nine previous Chairs in the College, along with their other professional of the RAS from 2002 to 2011 were contacted via credentials. The latter represented years of hard work e-mail and asked to describe how their experiences and ambition toward a degree, and the former repre- as RAS Chairs have shaped them as professionals. sented the dedication to quality patient care, technical Responses were analyzed using standard qualitative innovation, and continuous professional development methods with NVivo software. in the field of surgery—a process that starts when one All nine past RAS Chairs responded to the query. becomes a surgical intern and lasts throughout one’s Qualitative analysis of their responses revealed seven surgical career. However, I was unaware of how to consistent themes, which are italicized in the follow- embrace that process and how to become a surgical ing text. Their comments, some of which are high- leader until I became active in the RAS. lighted below, and their current roles richly describe the many ways in which surgeons also serve as leaders. Mentorship and future leaders Respondents found that they gained both specific I was fortunate early in my career to have a mentor leadership skills (5/9) as well as insight into the workings who introduced me to several key leaders within the of complex organizations (7/9) and the issues facing the College, including Thomas R. Russell, MD, FACS, surgical profession (3/9) as a result of their experiences former Executive Director; Ajit K. Sachdeva, MD, as RAS Chair. Dr. Katz noted, “Understanding an FACS, FRCSC, Director of the Division of Educa- organization, its position in a greater context, and tion; and R. Scott Jones, MD, FACS, former Presi- having some element of ‘institutional memory’ are dent and the first Director of the Division of Research critical for providing successful leadership.” Joshua and Optimal Patient Care. Through the professional M.V. Mammen, MD, FACS, responded that he relationships that I developed with these leaders, I was “gain[ed] a perspective into the complex decisions able to provide the perspective of young surgeons on that have to be made in leadership positions…[and 10 a number of important surgical issues ranging from learned to] anticipate barriers to change and to

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The last decade of RAS Chairs Chair Name Current responsibilities* 2002–2003 Willie Underwood III, MD, MPH Dr. Underwood is associate professor of surgical oncology, department of urology, Roswell Park Cancer Institute, Buffalo, NY. His career consists of delivering clinical care in urologic oncology, performing health service research, and contributing to health policy. His research focuses on understanding health system-related and societal factors that affect health outcomes and examines racial and socioeconomic differences in cancer knowledge, early detection, treatment, and survival. Dr. Underwood has also evaluated the impact of health policy changes in residency training on health care quality. His research reflects a commitment to improving the health and health care of Americans in general, and of the poor and disenfranchised more specifically. 2003–2004 Jeffrey Upperman, MD, FACS Dr. Upperman is currently associate professor of surgery at the Uni- versity of Southern California, Los Angeles, and the director of trauma at Children’s Hospital Los Angeles. 2004–2005 Danielle A. Katz, MD, FACS Dr. Katz is associate professor of orthopaedic surgery at the State University of New York Upstate Medical University, Syracuse. She specializes in pediatric orthopaedic surgery and is the assistant program director for the residency program in orthopaedic surgery. She serves on a number of committees within her institution, including the clinical quality improvement committee and the institutional review board. Dr. Katz is currently the Secretary of the New York Chap- ter and a member of the Governing Council of the Young Fellows Association. 2005–2006 Michael Sutherland, MD, FACS Dr. Sutherland is assistant professor of surgery at the University of Arkansas for Medical Sciences and is in private practice in Pine Bluff, AR. He is a general, trauma, and vascular surgeon with an interest in surgical critical care. He is the chair of the Arkansas Trauma Edu- cation and Research Foundation and is actively involved in the development of the statewide Arkansas Trauma System. He currently serves on the General Surgery Coding and Reimbursement Commit- tee of the College and is on the Society for Vascular Surgery Health Policy Committee. He participates at the American Medical Associa- tion (AMA) Relative Value Scale Update Committee (RUC) and is a member of the ACSPA-SurgeonsPAC Board of Directors. 2006–2007 Gregory S. Cherr, MD, RVT, FACS Dr. Cherr is chief of vascular surgery, Buffalo General Hospital, NY, as well as associate professor of surgery with tenure and research associate professor of social and preventive medicine at the University at Buffalo, NY. He also serves as director, medical student programs, in the department of surgery.

*As described by the past Chairs with minor editing for tense and style. continued on next page maneuver through obstacles that may be present.” organizational framework to reach important goals Jeffrey Upperman, MD, FACS, said, “RAS prepared and objectives.” According to Michael Sutherland, me for working in a large organization with com- MD, FACS, he learned that leaders succeed, in part, peting demands and learning to work within an by delegating to “hard workers who will bring their 11

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The last decade of RAS Chairs (continued) Chair Name Current responsibilities* 2007–2008 Ted James, MD, FACS Dr. James is a surgical oncologist and associate professor of surgery at the University of Vermont College of Medicine where he serves as clerkship director for surgery. He is active in quality and outcomes research in cancer care delivery as well as translational research in oncology. 2008–2009 Jacob Moalem, MD, FACS Dr. Moalem is assistant professor of endocrine surgery and of en- docrinology at the University of Rochester, NY. He currently serves as Chair of the Young Physicians’ Surgical Caucus at the AMA, and is also on the Executive Board of the ACS Young Fellows Association and the Board of Directors of the ACSPA-SurgeonsPAC. He is a delegate for the ACS at the AMA. He runs a practice in endocrine surgery and he conducts ongoing research in endocrine surgery and surgical education. 2009–2010 Joshua Broghammer, MD, FACS Dr. Broghammer is assistant professor of urology at the University of Kansas Medical Center, Kansas City, where he focuses on trauma and male genitourinary reconstruction. He is passionate about resident education and studies the management of renal injuries, post-prostatectomy complications, and the treatment of urethral stricture disease. He is also a member of the ACS Legislative Com- mittee. 2010–2011 Joshua M. V. Mammen, MD, FACS Dr. Mammen is an assistant professor of surgery and molecular and integrative physiology at the University of Kansas, Kansas City. He also serves as the associate program director of the surgery residency program. He is a surgical oncologist with a focus on melanoma, sarcoma, breast cancer, colorectal cancer, and peritoneal surface malignancies. His basic science laboratory focuses on the use of nat- ural compound derivatives in the treatment of melanoma. 2011–2012 Heena P. Santry, MD, MS Dr. Santry is assistant professor of surgery and quantitative health sciences at the University of Massachusetts Medical School. She is an acute care surgeon and health services researcher whose work focuses on quality and outcomes for unexpected surgical emergen- cies. In addition to her work in the RAS-ACS, she is active in the Col- lege’s Women in Surgery Committee. *As described by the past Chairs with minor editing for tense and style.

energy and expertise to a project or a committee.” care initiatives, economics, and advocacy, as well as Dr. Katz echoed this sentiment, stating, “Personally, credentialing, and family leave policies. during that year as Chair I learned that I could hold Beyond skills and issues, however, the ability to a position of leadership, but also that, as a leader, represent and network with one’s peers in surgical train- I needed to rely on those around me. Surrounding ing (2/9 and 8/9 respectively) was a common theme oneself with talent seems to me to be a remarkably among respondents. Willie Underwood III, MD, helpful aspect of being an effective leader.” Among MPH, was one of the early chairs of the RAS when the difficult and complicated issues facing the College it was evolving from its prior iteration as the Can- and the profession of surgery that respondents were didates and Associates Society. He noted, “We were able to understand better and even address during excited—we wanted to make a difference, to have 12 their tenure were changes in surgical education, health our voices heard. At the time, surgical training was

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS under attack, and there was no venue for the surgical of the College, recruited me to Arkansas during my residents to express their opinions in an organized time as the Chair of RAS.” forum.” Dr. Mammen stated, “I had the privilege to Not surprisingly, respondents found that their ex- communicate the opinions of my colleagues to the periences as RAS Chair served as a foundation for their leadership of the American College of Surgeons.” future successes (4/9). Many of these successes are listed Networking with peers was, however, a more pow- in the table on pages 11–12. Dr. Upperman summed erful theme. For Joshua Broghammer, MD, FACS, it up well: “I also learned an incredible amount from this was “the most important aspect” of his experi- the ACS leadership on how surgeons are relevant to ence as RAS Chair. He commented that he made health in America.” numerous contacts “from around the country with various backgrounds and specialties, which creates What’s ahead an incredible network of resources which I can call As the current Chair of the RAS, it is my privilege on from time to time and will continue to do so in to introduce this special issue of the Bulletin and to the future.” Gregory S. Cherr, MD, RVT, FACS, reflect on what it means to be a leader as learned cited a “network of friends and colleagues who pro- through participation in the RAS. The following four vide me with support and advice in my professional articles, written by RAS members, will delve into the and personal life” as an important component of the many manifestations of surgical leadership. Readers Chair experience. will learn about the historical underpinnings of surgi- The ability to find role-models and mentors (8/9) cal leadership, the cardinal traits of effective leaders in among leaders of the College was also a resounding surgery, and the ways in which every member of the theme among respondents, and yielded the richest College can take the opportunity to lead both within commentary. “The inherent mentorship that is built the organization and in myriad other arenas that shape into the three-year progression from Secretary to Vice- the delivery of surgical care. I hope this informative Chair to Chair was crucial to my development,” Dr. and engaging issue will inspire you to encourage and Moalem said. “By the point that I became Chair, I promote the young surgeons around you to embrace had numerous mentors and friends among ex-officio a path to leadership within our profession.  Chairs of RAS, and among the Regents and Governors of the College.” “I also had the opportunity to see the leaders of the College at work in the Board of Regents and some of the ACS committees and tried to understand what qualities made these well-established leaders as successful as they were,” noted Dr. Katz. Echoing these observations, Dr. Mammon responded, “I was able to meet many of the thought leaders in surgery and thereby gain a perspective into the complex decisions that have to be made in leadership positions.” Dr. Santry is assistant professor of surgery and Some respondents cited specific benefits of mentor- quantitative health sciences, ship. For example, Dr. Broghammer noted, “Through University of Massachusetts my interactions with senior urologists on the Board Medical School, Worcester, of Regents I have developed relationships that have and Chair, RAS-ACS. helped promote me within my subspecialty organization, the American Urological Association.” Dr. Cherr was able to meet “many outstanding medical educators who helped me to understand that it is possible to have a successful academic career in surgical education.” Finally, Dr. Sutherland directly credits his exposure “to the leaders of the College” as the reason for his current position and stated, “Dr. [Charles] Mabry [MD, FACS], my partner and a former Regent 13

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical leadership and political advocacy by Ross F. Goldberg, MD; Haytham M.A. Kaafarani, MD, MPH; Jillian Smith, MD; and Robert Winfield, DM

ost surgeons seek to directly assist our pa- that some of these measures were unreliable.1 The tients through the course of their illnesses, surgical profession’s failure to make itself heard in this paying little attention to the political en- specific instance and in many similar situations is due vironment or health care policy. After all, in part to our unfamiliarity with how policy is shaped arguably,M among all specialties in medicine, surgery and with the political process. In other words, our can demonstrate the clearest relationship between traditional focus on academia rather than advocacy clinical action and patient outcomes. However, over has not served surgery well in recent years. the last decade, it has become increasingly apparent Over the last few years, the American College of that the independent patient-surgeon relationship is Surgeons (ACS) has increasingly recognized and slowly vanishing. improved upon its ability to advocate on behalf of all surgeons in the U.S. The ACS established Surgeons as political advocates the American College of Surgeons Professional When we’re sitting with our patients in the clinic, Association (ACSPA), which, because of its tax rounding by the bedside, or operating in the middle status, was able to form a political action commit- of the night, worries regarding insurance coverage, tee (PAC), the ACSPA-SurgeonsPAC, with the goal Medicare reimbursement, and litigation may find of relaying the perspective of surgeons to members their way into the physician’s conscious and/or sub- of Congress.2 In the current era of health care re- conscious thoughts. The fact of the matter is that the form, it is becoming more and more essential that provision of health care services has grown in the last we make every effort to be influential players in century from a two-person contract to a complex re- health care policymaking; otherwise, politicians lationship that involves multiple stakeholders. It was and bureaucrats with little or no understanding of only a matter of time until health care policy started patient care will decide for us. to be shaped mostly by non-clinicians. The rising health care costs and the variability of What is political advocacy? patient outcomes across different providers has led to Advocacy is part of the political process, and is the development of multiple performance indicators, defined as the actions of an individual or a group as an attempt to improve quality of care while de- engaged in an effort to influence public policy creasing costs. The Centers for Medicare & Medicaid through political, social, and economic systems and Services and private insurers immediately adopted institutions.3 Advocacy covers a broad range of ac- many of these indicators for pay-for-performance tivities, including public speaking, media campaigns, 3 14 purposes, despite multiple clinical studies suggesting research, and lobbying. In fact, lobbying is a key

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS part of modern politics. It is defined as the act of ap- ing meetings, and facilitating congressional visits proaching legislators directly on an issue in attempt between legislators and PAC members. to influence his or her decisions.3 Anyone can lobby, Political money in our system is divided into two including individuals, groups, constituents, private- categories, “hard dollars” and “soft dollars.” Hard sector interests, corporations, government officials, dollars are contributed by an individual and given and, of course, advocacy groups. directly to a candidate, political party, or PAC. These Quite often the act of lobbying has negative con- dollars are reported to the U.S. Federal Election notations associated with it, as some individuals Commission, which regulates campaign finance and may interpret this process as involving people with enforces strict rules on who can contribute to candi- significant socioeconomic standing who use their dates and to what extent. Contributions are capped power, money, and influence to corrupt the law and at $5,000 per PAC per year.5 for personal gain. However, lobbying can be a tool Soft dollars are contributions from either cor- that is used to protect others’ interests against cor- porate accounts or dollars spent by unions and are ruption, ensuring that minority interests are fairly used for administrative and educational purposes. defended. In general terms, the value of lobbying Recently, due to the U.S. Supreme Court’s decision and advocacy comes down to who is best able to in Citizens United v. Federal Election Commission, convince their legislators to see things and act upon soft dollars have been allowed to be used for election- them from their point of view. One key access point related independent expenditures. Regardless of the that lobbyists have to legislators is through campaign type of contribution one makes, be it in hard or soft contributions. dollars, it is important and vital for everyone to be In 2010, the Center for Responsive Politics estimat- an active member in their respective PACs, and ed that candidates in the 2010 midterm congressional contributing is a good way to start. election spent approximately $3.7 billion.4 To finance their campaigns, the candidates relied on assistance Getting involved from a variety of sources, including individuals, in- So, suffice it to say, advocacy is important for the terest groups, corporations, and unions. For federal future of your career. The next step in becoming a elections, the primary source of campaign funds is surgeon advocate is figuring out how to participate in individuals, followed by PACs. these efforts despite a busy and demanding schedule. PACs are organized for the purpose of raising In reality, meaningful advocacy work can take place and spending money to elect candidates who are fairly quickly in the form of a phone call, a letter, or likely to uphold the beliefs or interests of their an e-mail—and we all have time to make one more members. PACs raise money from their eligible phone call or send one more e-mail. membership, and then make contributions to The first step in getting involved is to understand political campaigns. These groups also encourage the issues. Although this is another task that may seem members to become more politically active by daunting or time-consuming, many resources are providing relevant educational materials, organiz- available to help surgeons get up to speed on relevant issues. Many different websites, blogs, and listservs are available to physicians seeking to stay current on How to find and contact Congress members legislative activities. Advocacy experts suggest the best Listservs/blogs/websites way to become a more influential advocate is to focus http://www.politico.com/politicopulse/ your attention on topics about which you are most http://cookpolitical.com/ passionate, and then seek out information regarding http://drudgereport.com/ legislation on that specific topic. Registries of active legislation organized by topic exist on the U.S. Senate Contact elected officials and House of Representatives’ websites (http://www. http://www.usa.gov/Contact/Elected.shtml senate.gov/pagelayout/legislative/b_three_sections_with_ http://www.senate.gov/ teasers/active_leg_page.htm and http://thomas.loc.gov/ http://www.house.gov/ home/LegislativeData.php?n=BSS, respectively). Al- https://www.votizen.com/ ternatively, to narrow a search to health care-related topics, the ACS Division of Advocacy and Health 15

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Policy has a very detailed website that summarizes or when writing letters and e-mails to policymakers. state and federal legislation on which the ACS has However, these talking points are only examples or issued statements.6 templates of items that may be covered during these exchanges. The important thing to remember is to The five-minute phone call speak up about what is important to you, including Five minutes may not seem like enough time to topics outside the realm of health care. The key purpose make a substantial impact, but every phone call or of these communications is to build a relationship with e-mail represents one more of that representative’s a representative. The more times you call, the more you constituents. It is not always possible to speak directly move from “just another caller” to “a concerned and to a representative, which is fine as long as you are engaged constituent,” which will only strengthen your talking to someone from the representative’s staff. ability to discuss pertinent issues with your representa- The staff members collect these opinions, tally the tives, and influence their perspectives on issues that are counts, and summarize the findings to the legislator. important to you and your profession. And there is power in numbers, which means it is important to encourage colleagues to participate in Advocacy days grassroots efforts as well. Website references in the Many state and professional medical societies host box on page 15 provide guidelines for locating and advocacy days at the local or national level, such as contacting representatives by phone, letter, e-mail, the College’s Advocacy Summit (http://www.facs.org/ or even via social networking tools, such as Twitter. ahp/summit). These organized events usually start with With regard to key topics, such as sustainable a morning overview of the issues and talking points, growth rate (SGR) repeal or health care reform, followed by meetings with lawmakers. Visits with specialty groups, including the ACS, draft talking elected officials or their staff members can occur at points to which users may refer during phone calls any time throughout the year.

Select federal and state issues relevant to surgeons SGR Each legislative cycle, the SGR, which is a flawed formula used to calculate Medicare reimbursement, is perpetuated by the U.S. Congress, creating billions to trillions of dollars in potential debt that ultimately may result in sharp Medicare payment cuts to physicians, particularly surgeons. Tort reform Medical liability insurance rates continue to rise and make provision of care in certain locales unattractive or financially impossible. Tort reform offers the promise of limiting liability and may help preserve the viability of surgical practices. Workforce issues Recent threats have included proposed cuts in graduate medical education funding, which would limit the number of residency slots and worsen the surgical workforce shortage. Trauma systems funding The trauma system provides care to millions of Americans each year, and additionally provides provisional support in the event of mass casualty scenarios. Funding continues the support of the maintenance and improvement of this critical national safety program. Scope of practice Each year, nonphysicians push for titles and privileges previously restricted to physicians and surgeons. This threatens both practice viability as well as public trust in the health care system as non-qualified individuals are permitted to prescribe medications or perform procedures without adequate training. Biomedical research Research is the foundation of discoveries that change the way we practice. As budget cuts threaten research funding, the surgical perspective on critical biomedical issues and the importance of funding research efforts is vital.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Another way to get involved is to join a PAC. The sider the issue of the SGR. The SGR was developed strength and ability of a PAC to communicate mes- and implemented to allow for increases in Medicare sages to legislators comes from members’ donations physician reimbursement based on the volume and and participation. There is an old quote, “You either intensity of services delivered, but was also designed to are at the table or on the menu,” and supporting limit increases in the Medicare budget by implement- PACs ensures that they stay relevant and important ing fee reductions for services that exceed spending and continue to be key components in successful targets.11 Unfortunately, flaws in the SGR have led to political lobbying and advocacy. discrepancies between budgeted funds and payments, and with each passing fiscal year, the cuts in physician The price of apathy reimbursement are added to those of the previous Fortunately, a nation governed by democratic year. This policy has not yet led to a significant de- rule affords its citizens the opportunity to engage crease in physician reimbursement because Congress in political activities to whatever extent they wish. has consistently provided temporizing “fixes” to main- However, U.S. physicians and surgeons have often tain reimbursement rates. These temporary patches been reluctant or relatively unwilling to participate have had a cumulative effect, and physicians now in the political process. Physicians, on the whole, face a potential Medicare payment cut of nearly 30 voted in federal elections at lower rates than the gen- percent in 2013. The consequences of this situation eral population, and traditionally have had limited are potentially devastating to surgeons, as cuts of this involvement in political activities.7,8 The reasons for magnitude threaten the ability of practices with large this apparent apathy are many and are as individual as each physician’s personal beliefs and professional Dr. Goldberg is director practices. Nonetheless, the simple truth is that a of minimally invasive and collective lack of participation by physicians and hepatic surgery, Maricopa surgeons will ultimately place decision-making power Medical Center, Phoenix, into the hands of others whose understanding of the AZ. He is the RAS-ACS day-to-day practice of medicine is limited, and whose Liaison to the ACSPA- comprehension of the health care delivery system SurgeonsPAC Board of lacks appropriate perspective. As a consequence, Directors and an active policies may emerge that are often irresponsive to the member of the RAS-ACS needs of physicians or patients. Issues Committee. The cost of indifference has the potential to be very high for surgeons. With the passage of the Affordable Care Act (ACA) in 2010, we have been launched into one of the most pivotal times in the history of U.S. medicine.9,10 The ACA will have far-reaching implications on nationwide health care delivery and finance and will affect the practice of surgery and the Dr. Kaafarani is an acute care surgery fellow, Mas- lives of surgeons in ways that are likely not entirely sachusetts General Hospital known at this stage of planning and implementation. and Harvard Medical Continuing to evaluate the feasibility and impact of School, Boston, MA. He the ACA as it transitions from paper to practice will is the RAS-ACS Liaison, require a concerted effort and strong leadership from Committee on Trauma, and the surgical community. Aside from the monumental member of RAS-ACS Com- shifts resulting from the ACA, several issues relevant munications and Interna- to surgeons are currently being addressed in Washing- tional Medical Graduates ton, DC, and in state capitals nationwide, and those Committees. merit attention as well (see table, page 16). Apathy toward these issues may or may not ultimately lead to unwanted consequences for surgeons and their patients. To use a pertinent example, con- 17

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS proportions of Medicare patients to remain financially campaign finance law. Available at: http://www.fec.gov/ pages/brochures/fecfeca.shtml#Contribution_Limits. Ac- viable. It further has the potential to lead to declin- cessed June 13, 2012. ing surgeon participation in the Medicare program, 6. American College of Surgeons. Division of Advocacy and leaving a significant segment of society without ac- Health Policy. Take action: Protect your patients and your cess to appropriate care. The impact may be more profession. Available at: http://www.facs.org/ahp/index. far-reaching than this, though, because many private html. Accessed May 24, 2012. 7. Grande D, Asch DA, Armstrong K. Do doctors vote? J Gen insurance companies base their reimbursement rates Intern Med. 2007;22(5):585-589. on what Medicare pays, leading to a second hit to 8. Huddle TS. Perspective: Medical professionalism and medi- surgeons, regardless of Medicare participation. This cal education should not involve commitments to political would be a doomsday situation for the U.S. surgical advocacy. Acad Med. 2011;86(3):378-383. 9. The Patient rotectionP and Affordable Care Act 2010. community. Available at: http://democrats.senate.gov/pdfs/reform/ Surgeon involvement in advocacy offers no guaran- patient-protection-affordable-care-act-as-passed.pdf. Ac- tee that scenarios such as the one previously described cessed February 28, 2012. can be avoided. However, without large-scale partici- 10. U.S. Federal Election Commission. Quick answers to general pation by the surgical community, the opportunity questions. How much can I contribute? Available at: http:// fec.gov/ans/answers_general.shtml#How_much_can_I_ to help shape reasonable solutions to these types of contibute. Accessed May 24, 2012. challenges will be lost. 11. Dorman T. Unsustainable growth rate: Physician perspective. Crit Care Med. 2006;34(3 Suppl):S78-81. Conclusion The world of health care is changing rapidly. Sur- geons can no longer sit in their offices or focus solely on work in the operating room when it comes to Dr. Smith is a general surgery resident at the Univer- taking care of and watching out for their patients. sity of Massachusetts Medical The political world has continued to merge with the School, Worcester. She is the health care world, and it is the surgeons’ responsibil- RAS-ACS Liaison to the ity to ensure that their patients have access to the Women in Surgery Commit- best care possible. Being politically aware and politi- tee and an active member of cally active has now become a core part of being a the Issues Committee. practicing surgeon. The more surgeons are involved, the better things will be for our patients and for the world of health care. We are already leaders in the operating room and in the hospital; now we need to take the next step and lead outside the hospital walls as well. Our patients do not deserve anything less than that.  References Dr. Winfield is assistant professor of surgery, section 1. Kaafarani HM, Borzecki AM, Itani KM, Loveland S, Mull of trauma, acute care, and HJ, Hickson K, Macdonald S, Shin M, Rosen AK. Valid- critical care surgery, Wash- ity of selected patient safety indicators: Opportunities and ington University, St. Louis, concerns. J Am Coll Surg. 2011;212(6):924-934. MO. He is also Secretary of 2. American College of Surgeons Professional Assocation- the RAS-ACS. SurgeonsPAC. Available at: http://www.surgeonspac.org. 3. NP Action. Lobbying versus advocacy: Legal definitions. Available at: http://www.npaction.org/article/articlev- iew/76/1/248. Accessed May 24, 2012. 4. The Center for Responsive Politics. Midterm elections will cost at least $3.7 billion, Center for Responsive Politics estimates. Available at: http://www.opensecrets. org/news/2010/02/midterm-elections-will-cost-at.html. Accessed June 13, 2012. 18 5. The Federal lectionE Commission. The FEC and the federal

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Advanced degrees for surgeons and their impact on leadership by Feibi Zheng, MD, MBA; Nicolas J. Mouawad, MD, MPH, MBA, MRCS; Nina E. Glass, MD; and Osama Hamed, MD

Good leaders are made not born. If you have the desire is reflected in the increasing number of dual-degree and willpower, you can become an effective leader. Good programs (MD/MBA, MD/PhD, and MD/MPH) leaders develop through a never ending process of self- available throughout the U.S. study, education, training, and experience.1 In surgery, a growing number of surgeons in leader- —A.G. Jago ship positions have dual degrees. This article explores the motivations behind pursuing dual degrees, as eadership is defined as “the process of social well as the impact they may have on preparation influence in which one person can enlist the for leadership roles. What is the unique perspective aid and support of others in the accomplish- of the traditional physician-scientist, MD/PhD, in ment of a common task.”2 In 1935, physicians helping to guide academic surgery? How does new Lwere in charge of 35 percent of the hospitals in emphasis and interest in international surgery benefit the U.S.3 In contrast, in 2009, physicians headed from more surgeons with MD/MPH dual degrees? fewer than 4 percent (235) of nearly 6,500 hospitals.4 How does an improved business perspective achieved Inadequate leadership education and preparation in through an MD/MBA help inform surgeons who the curricula of most U.S. medical schools and resi- interact as much with hospital administrators and in- dency programs has contributed to this shift. Success vestors as they do with patients? This article addresses in academic medicine requires scientific and clinical these and other pertinent questions for surgeons in aptitude. However, a hallmark of accomplishment this evolving profession. that receives little attention in medical school curricula is aptitude for leadership and organizational Physicians pursuing an MBA skill. In particular, physicians must learn and apply The increasing complexity of health care delivery advanced skills in recruitment, retention, commu- and declining reimbursement have prompted physi- nication, conflict resolution, and strategic planning. cians and physicians-in-training to evaluate whether In the past, physicians acquired most of these excellent clinical education alone is enough to sustain skills through passive observation of peers and a successful career. Some senior physicians are taking mentors, who were sometimes inconsistent in management and business courses, while others are their behavior as role models. With more special- taking on more extensive training to obtain an MBA. ized leadership skills required, pursuit of a second Physicians-in-training are following suit. The number degree might facilitate preparation for leadership of MD/MBA programs has increased dramatically positions. Medical schools have taken note of this over the past 30 years, and there are now more than 5 new interest among students and physicians, which 65 such programs in the U.S. 19

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS “When you get an MBA, you learn a new lan- ing the professional networks necessary to launch guage,” said Robert Udelsman, MD, MBA, William a new device or commercialize a new technology.7 H. Carmalt Professor and chairman of surgery, Yale Senior physicians with increasing administrative re- University, New Haven, CT. “It’s been helpful to sponsibilities often pursue an MBA to communicate me in understanding how funds get channeled more clearly and negotiate more effectively with other through departments and hospitals and how differ- hospital administrators and executives. ent institutions work. Before getting the MBA, my Two traditional paths currently exist for MD/ only financial knowledge came from buying a house, MBAs. College graduates may apply to one of the 65 paying a mortgage, managing a section, and funding MD/MBA joint degree programs currently available, grants.” (Personal communication with Dr. Zheng, and senior physicians may decide to take evening February 3, 2012.) and/or weekend classes in pursuit of an executive The MBA curriculum generally consists of a founda- MBA. Though less common, a third pathway exists tion of core classes divided along the traditional business for residents wishing to pursue an MBA during their verticals of strategy, operations, finance, marketing, “research years,” if their chair and program director see leadership, and human resource management. Elective value in formalized leadership and business training. courses delve into industry or country/region-specific Lastly, new leadership tracks such as those at Duke topics—such as health care operations, provider strategy, University, Durham NC, and the Methodist Hospital and medical device commercialization—and develop in Houston, TX, now enable MD/MBA graduates to both analytical and soft skills, such as model and simula- leverage their MBA skills in administrative rotations tion building and negotiation, respectively. while in surgical residency. A 2007 survey of MD/MBA degree holders indi- Pursuing an MBA requires a significant investment cates that the most pertinent skills these individuals of time and money. A traditional full-time MBA had acquired were those related to “evaluating sys- program takes 22 months to complete, and tuition tems, operations, and implementing improvements, for a top program is approximately $80,000 per learning how to be an effective leader, comprehending year. MD/MBA joint programs condense the dual- financial principles, working within a team, and nego- training pathway into five years (usually saving one tiating effectively.”6 Though there is high variability, year of tuition). An executive MBA is geared toward most surgical training programs do not provide formal physicians with some management experience (usu- training on negotiation, health care process improve- ally more than 10 years of work experience) and costs ment, or financial principles. considerably more, averaging approximately $150,000 “We shouldn’t think of academic surgery only as for a 22-month part-time program. In the 2007 survey teaching, basic science research and clinical work of MD/MBA degree holders mentioned earlier in this anymore,” noted Lynt Johnson, MD, MBA, FACS, article, 81 percent of the 87 survey responders believed Robert J. Coffey Professor and chairman of surgery, that their business degree had been “very useful or es- Georgetown University, Washington DC. “Leader- sential in the advancement of their careers.”6 The cost ship comes in many flavors. In the next 10 to 20 years, of the degree can be significantly subsidized through I think there [will be] tremendous opportunities, in scholarships and grants or sponsorship arrangements both departmental leadership and hospital leadership, with employers (hospitals or departments). for surgeons with a background in business.” (Personal Determining whether an MBA is worth pursuing communication with Dr. Zheng, March 20, 2012.) depends on an individual’s goals. What is clear is that The decision to pursue an MBA is dependent on knowledge of business practices and how to navigate individual career aspirations. Those who embark on the complex health care environment is essential for joint-degree programs often look to broaden their a successful surgical career today. To that end, the careers outside of clinical work. MD/MBAs are often surgical societies have created several resources and recruited into management positions at bio-pharma opportunities for surgeons and surgeons-in-training and medical device firms, as strategy consultants for to develop these skills. For residents, the Surgical management consulting firms, and as associates for Council on Resident Education portal offers a series investment banks, sometimes without completing a of online lectures on systems-based practices, which residency. Physicians with entrepreneurial inclina- covers basic principles of negotiation, cost account- 20 tions also find that an MBA may be helpful in building, and so on. For residents looking to sharpen their

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS leadership skills, the American College of Surgeons ity of programs. Most MD/MPH programs take five (ACS) Division of Education, in partnership with the years to complete. However, some institutions allow Resident and Associate Society (RAS) of the ACS, has enrollees to take all the required coursework within created an annual Resident as Teachers and Leaders the four years of medical training. Alternatively, phy- course that helps residents master critical nonclinical sicians may complete the stand-alone MPH program skills related to leading a team and teaching. These over a single year full-time or, for certain programs, tools provide an introduction into the business of over a longer period part-time. medicine and formalized leadership instruction, and Opinions vary as to the optimal course for pursuing they may also help physicians determine whether an MPH. Proponents of combining the programs in an additional degree in management is appropriate. medical school claim that physicians gain a greater perception of the complementary disciplines of medicine Global surgery and the MPH degree and public health and that they appreciate the seamless The MPH degree has become one of the most popu- integration of the fields. On the other hand, however, lar supplementary advanced degrees for physicians to some academicians maintain that the MPH should be obtain. Although traditional medical education for obtained on its own so that it is not abbreviated in any physicians has focused on identifying and treating way to accommodate the work involved in earning a illnesses on behalf of an individual patient, public medical degree or fulfilling residency responsibilities. health education is directed at populations, and In fact, the rigors of surgical clinical training may disal- includes the assessment of risk factors, the develop- low a combined approach, but some physicians may ment of health education programs, and implemen- consider pursuing it separately during research years. tation of appropriate strategies with the goal of not Increasingly, programs are offering the MPH pro- only increasing overall health, but also of reducing gram to medically trained personnel. Driving this shift infirmary and preventing disease. As such, it would is greater awareness of global health concerns as well as seem a viable transition for health care professionals the formalization of public health curricula. In some with medical training to expand individual-based institutions, more than 20 percent of medical students methodologies to population-based programs—to enter an MPH program at some point between entering effectively transition from empowering patients to medical school and leaving for residency.9 empowering communities. The addition of international experience to as- The MPH degree is a freestanding professional similate population-based strategies into practice has credential that may lead to a career in a variety of also proved valuable.10 Individuals with an MPH can areas, including health education and promotion, expect to effectively and efficiently participate in the health policy and management, epidemiology, bio- provision and administration of preventative health statistics, environmental health, and toxicology, as services, either domestically or abroad, as well as be well as international medicine. In fact, the current involved in health care policy, continuous quality political milieu has propelled the topic of health care improvement efforts, the delivery of culturally com- and health policy into the foreground, essentially petent care, and international collaboration. compounding the interest in and necessity for na- Many health leaders have obtained their MPH. In tional strategies for public health. A dedicated MPH fact, every director of the U.S. Centers for Disease curriculum can motivate and equip surgeons to tackle Control and Prevention since 1956 has had a dual the salient contemporary considerations of disease MD/MPH degree, except for one who had an MD/ prevention, health care provisions, and administrative PhD.11 These directors’ contributions to national and cost curtailment. global health are indisputable. As with other advanced degrees for physicians, Within the surgical leadership, the adoption of dual acquisition of an MPH can be achieved in two ways: degrees is somewhat different. Of the 303 surgeons integrating the curriculum along with medical educa- appointed to either the ACS Board of Regents or tion, culminating in combined MD/MPH programs, Board of Governors, 18 have combined MD/PhDs, or pursuing a supplementary degree at a separate 11 have MD/MBAs, and 25 have other advanced dual time.8 The choice of a particular pathway is dependent degrees (for example, MD/MSc, MD/JD, and even on personal career goals and motivation, associated MD/MA); the MD/MPH contingent only accounts current responsibilities, and the institutional availabil- for four individuals. 21

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Colleagues with MPH degrees emphasize that cost-effective depends on the individual’s career goals. their coursework prepared them to conduct needs What is clear, however, is that surgeons are steadfast assessments and involve priority populations and in their aim to inspire and achieve quality as well as stakeholders in specific planning processes, design embrace the opportunity to equip themselves with strategies, and interventions. It also helped them to the necessary skills to face future challenges. With design instruments to collect data, manage fiscal and the MPH advanced degree, a surgeon can transform human resources, and implement action plans and into the veritable global physician. obtain acceptance and support for programs. These skills have enabled residents to set up make- The physician-scientist track shift surgical clinics in underserved nations, determine The MD/PhD is the most traditionally pursued where and how to set up latrines and provide sanitary dual degree among physicians. Graduates of these conditions, and even how to find and preserve neces- programs are typically innovative, comprehensively sary fresh water. In addition to formal coursework, trained physician-scientists prepared to play a key relief missions to Haiti, India, Honduras, and Kenya role in the translation of scientific findings to clini- have demonstrated the importance of understanding cal practice and vice-versa. MD/PhD programs typi- how to allocate and optimize scarce resources. The cally attract students with a strong aptitude for the increasing burden of global disease and the economics basic sciences and a passion for understanding how of health care policy is a contemporary international things work. More recently, physicians are pursuing concern. Whether the MD/MPH is worthwhile and less conventional degrees in fields ranging from an- thropology to zoology. Currently, the Association of American Medical Colleges recognizes more than 100 Dr. Zheng is in PGY-3 12. at The Methodist Hospi- MD/PhD programs available nationwide. tal, Houston, TX. She is a Most MD/PhD programs include two years de- member of the RAS-ACS voted to the basic science courses of the traditional Education Committee. MD curriculum, and to one major graduate course, followed by three to four years of graduate study, including the pursuit of a doctoral thesis in the chosen field, supplemented with an ongoing clinical tutorial during those years. The final 13 to 14 months of clinical rotations are, again, part of the medical school course. It is expected that students will complete both degrees in seven or eight years with some variability inherent in pursuing research. The discipline of study may comprise a wide variety of biomedical sciences, such as biochemistry, cell bi- ology, immunology, microbiology, neuroscience, and Dr. Mouawad is a fellow, so on. If a physician’s passion for scientific research division of vascular diseases and surgery, Ohio State becomes evident during residency, this interest can University Wexner Medical be translated into a PhD degree, which typically takes Center, Columbus. He is three years to complete, during or after residency, in Vice-Chair of the RAS-ACS addition to the clinical years of residency. Membership Committee, Most MD/PhD graduates follow career paths a member of RAS-ACS consistent with their training as physician-scientists Communications Commit- and enter academic medicine with a focus on tee, and the appointed RAS running research laboratories. Devoting time to a representative to the ACS research career is essential for physician-scientists International Relations to succeed in obtaining the necessary funding for Committee. their research endeavors. “The PhD degree was very helpful and gave me a 22 strong background that allowed me to address scientific

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS issues critically,” said Kevin Staveley-O’Carroll, MD, at: http://www.nytimes.com/2011/09/06/business/doctors- discover-the-benefits-of-business-school.html?pagewanted=all. PhD, program director and head of the liver, pancreas, Accessed March 23, 2012. and foregut tumor program at Penn State Hershey 8. American Medical Student Association’s MD/MPH joint Cancer Institute, and holder of an R01 grant, “It is degree programs. Available at: http://www.amsa.org/AMSA/ becoming very competitive to obtain R01 funding Homepage/About/Committees/CEH/MDMPHPrograms. and having the PhD degree definitely set me apart and aspx. Accessed March 23, 2012. 9. Harris R, Kinsinger LS, Tolleson-Rinehart S, Viera AJ, Dent G. gave me an edge in obtaining the appropriate funding The MD-MPH program at the University of North Carolina for my research.” (Personal communication with Dr. at Chapel Hill. Acad Med. 2008;83(4):371-377. Hamed, February 10, 2012.) 10. Eckhert NL, Bennett NM, Grande D, Dandoy S. Teaching pre- Many surgeons with MD/PhD degrees maintain vention through electives. Acad Med. 2000;75(7 Suppl):S85-89. 11. Centers for Disease Control and Prevention. Past CDC direc- busy and productive research labs, and at the same tors/administrators. Available at: http://www.cdc.gov/about/ time have active clinical practices. The MD/PhD history/pastdirectors.htm. Accessed March 23, 2012. degree is the most common dual degree among the 12. Association of American Medical Colleges: Summary of MD- department of surgery chairs of the top 50 medical PhD Programs and Policies. Available at: https://www.aamc. schools named by U.S. News & World Report, and org/students/download/62760/data/faqtable.pdf. Accessed March 23, 2012. the most common dual degree in the 303 surgeons 13. Hill L. Becoming a Manager: How New Managers Master the appointed to either the ACS Board of Regents or Challenges of Leadership. 2nd ed. Boston, MA: Harvard Busi- Board of Governors.13 These data suggest that despite ness Press; 2003. the added time required to succeed in research, these surgeons succeed in managing their time to also incorporate administrative work and leadership positions Dr. Glass is a PGY-4 gen- in national surgical societies. eral surgery resident at New York University Langone Conclusion Medical Center, New York, Research in organizational behavior and business NY. She is Vice-Chair of administration indicates that people making the RAS-ACS Education Com- transition from individual contributors to leaders mittee. find that the experience of leading differs significantly from what was anticipated and is substantially more challenging.13 Surgeons interested in leadership positions have multiple options for development. “Good leaders develop through a never-ending process of self-study, education, training, and experience.”1 Obtaining a dual degree is one way to accelerate and focus these processes.  Dr. Hamed is a hepatopan- References creatobiliary and minimally invasive surgeon at Trihealth 1. Jago AG. Leadership: Perspectives in theory and research. Man- Oncology Institute, Cincin- agement Science. 1982;28(3):315-336. nati, OH. He is Chair of An Integrative Theory of Leadership 2. Chemers M. . Mahwah, NJ: RAS-ACS Education Com- Lawrence Erlbaum Associates; 1997. 3. MacEachern, MT. Hospital Organization and Management. mittee. Chicago, IL: Physicians Record Co; 1935. 4. Gunderman R, Kanter SL. Perspective: Educating physicians to lead hospitals. Acad Med. 2009;84(10):1348-1351. 5. Association of MD/MBA Programs. Available at: http://md- mbaprograms.com. Accessed March 23, 2012. 6. Parekh SG, Singh B. An MBA: The utility and effect on physicians’ careers. J Bone Joint Surg Am. 2007;89(2):442-447. 7. Freudenheim M. Doctors discover the benefits of business school. The New York Times. September 6, 2011. Available 23

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Women leaders in surgery: Past, present, and future by Juliet A. Emamaullee, MD, PhD; Megan V. Lyons, MD; Elizabeth Berdan, MD; and Amy Bazzarelli, MD

ver the past 25 years the proportion of moting the advancement of women into the upper women entering medical school has in- echelons of surgical leadership will be discussed. creased dramatically, such that nearly half of today’s graduating medical students are Prominent women leaders in surgery Owomen.1 However, the number of women entering the surgical specialties remains relatively small.  Dr. Jonasson has long been hailed as a pioneer The reason for this discrepancy is multifactorial for women surgeons around the world. Born in and has been attributed to unconscious bias, a lack 1934 in Illinois, Dr. Jonasson attended medical of female role models, and perceptions regarding school and completed her surgical residency at the inability to achieve work-life balance. Although University of Illinois, Chicago, after being inspired women have made great strides in medicine and by her mother’s nursing career. She then went on to more recently in surgery, a “glass ceiling” still complete research fellowships in immunochemistry exists for women surgeons when it comes to lead- at the Walter Reed Army Medical Center, Wash- ership roles at the departmental, institutional, ington, DC, transplantation immunobiology at and national level. Indeed, in the U.S., only 12 Massachusetts General Hospital, Boston, and car- percent of department chairs in all specialties of diovascular and thoracic surgery at the University medicine are women.2 of Illinois.3 Several notable women surgeons have, despite From 1967 to 1987, Dr. Jonasson was a surgi- many barriers, achieved the highest levels of lead- cal faculty member at the University of Illinois ership in surgery. In this article, three remarkable Hospital. As the first woman transplant surgeon, women—Olga Jonasson, MD, FACS; Kathryn An- she developed one of Illinois’ first transplantation derson, MD, FACS; and Patricia Numann, MD, programs, and she performed the state’s inaugural FACS—will be highlighted for their achievements kidney transplant. Dr. Jonasson also was a leader in in surgical leadership (see photos, page 25). histocompatibility testing. In 1987, Dr. Jonasson This article goes on to examine current initia- left Illinois for Ohio State University, Columbus, tives in surgical training aimed at increasing the where she became the first woman in the U.S. to leadership potential of the next generation of head an academic surgery department at a coedu- women surgeons. In addition, the complexity of cational school of medicine.4 the glass ceiling, as it relates to women surgeons Dr. Jonasson received many awards and ac- who are seeking promotions and leadership roles, colades over her illustrious career. She was the 24 will be explored. Finally, initiatives aimed at pro- first female initiate of many surgical societies,

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Jonasson Dr. Anderson Dr. Numann

including the Association for Academic Surgery, gender. After being denied a surgical internship at the American Surgical Association, and the Society her own medical school, she pursued a nonsurgi- of University Surgeons. She was the first woman to cal internship at Boston Children’s Hospital. In serve as director of the American Board of Surgery her general surgery residency, Dr. Anderson was and the first woman appointed to an ACS execu- assigned only seven cases in her first two years. tive committee.5 Dr. Jonasson held both editorial Fortunately, she was able to advance her surgical and reviewer roles at many prestigious surgical training in community hospitals, where she as- journals, including the Annals of Surgery, Journal sisted in more than 700 cases in the subsequent of the American College of Surgeons, Journal of the year. Even though she was an accomplished resi- American Medical Association, and the New England dent, she struggled to find a position in a pediatric Journal of Medicine.5 surgery fellowship. She was offered a position Dr. Jonasson passed away after a brief illness only after the selected fellow was called away for in August 2006 at the age of 72. She will always military duty.7,8 be remembered for her contributions to clinical Despite the obstacles she faced early in her career, medicine, and she will be celebrated as an innova- Dr. Anderson has gone on to have a distinguished tive and inspiring teacher. Her mentorship efforts career as a pediatric surgeon, practicing at Chil- helped to advance and develop the careers of many dren’s National Medical Center in Washington, young surgeons, both male and female. DC, and Children’s Hospital in Los Angeles, CA. She has held prominent positions in many pediatric  Likewise, Dr. Anderson paved the way for women and surgical societies, as well as on numerous medi- leaders in surgery by becoming both the first woman cal and surgical journal editorial boards.6 Officer of the ACS in 1992 and subsequently advanc- Mentorship is a principle that Dr. Anderson ing through the ranks to be elected as the first woman believes in strongly, after being mentored by President of the ACS in 2005. Born in England in Dorothy Heard, MD, at the University of Cam- 1939, she moved to the U.S. in 1962 after marrying bridge, and W. Hardy Hendren III, MD, FACS, her husband, an American. After earning her medical at Boston Children’s Hospital. She has continued degree at Harvard University, Boston, MA, Dr. An- to embrace the principles of mentorship in sur- derson completed her residency in general surgery at gery during her professional career. Throughout Georgetown University Hospital, Washington, DC.6 her career she has helped many medical students, Throughout her training, Dr. Anderson encoun- residents, and attending surgeons navigate their tered significant discrimination because of her career paths. 25

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS  Currently serving as the 92nd President of percent of medical graduates in Switzerland the ACS, Dr. Numann has been inspiring women identifying as women.11 surgeons for the past 40 years. After completing While a rapid progression in the proportion of medical school and general surgery residency at total female medical school graduates has been the State University of New York (SUNY) Upstate observed, this trend has not extended into surgical Medical University in Syracuse, she decided to residency. Although the number of women in gen- stay loyal to her alma mater by completing the eral surgery training has increased markedly from rest of her professional career at the center where 21.2 percent in 1999 to 35.2 percent in 2009, the she trained.9 number of women residents has failed to achieve As an attending surgeon at SUNY, Dr. Numann parity with their male counterparts. Women’s rep- held many leadership positions, including associ- resentation is and has been even more discrepant ate dean of the college of medicine, associate dean in other specialties including orthopaedic surgery of the college of medicine clinical affairs, profes- and neurosurgery.1 In addition, enrollment in sor of surgery, medical director of the University general surgery residencies has declined overall, Hospital, and the Lloyd S. Rogers Professor of which some individuals in the field attribute to Surgery. After retiring from clinical practice in the progressive increase in female medical school 2007, SUNY awarded her emeritus status and in matriculates—who may be reluctant to pursue 2009 created the Patricia J. Numann, MD, Chair this rigorous career path.12 As we face a projected of Surgery, the first endowed chair for a woman shortage of general surgeons over the next decade, surgeon in the U.S.9 it is worrisome that some of the brightest and most Since becoming a Fellow of the College in 1974, talented medical school graduates are not entering Dr. Numann has worked tirelessly on numerous surgical training programs. ACS committees and boards. She has also received Many studies have looked at various factors that countless awards over the years at local, national, may influence a female student’s thoughts regarding and international levels. She is renowned for her whether to pursue a career in the surgical special- approachable spirit and inspires all who have the ties. Considerations such as lifestyle implications honor of meeting her. of career choice, the surgical culture, the lack of Dr. Numann is perhaps most recognized for female mentors in academic surgery, and equity her singular role in establishing the Association issues have been shown to play roles in female stu- of Women Surgeons (AWS). In an effort to meet dents’ career choices. In one recent study of more other women surgeons at the annual ACS Clini- than 1,300 students, 24 percent of male and only cal Congress she organized a breakfast for women 15 percent of female medical students expressed surgeons at the meeting in 1981.9 Growing inter- interest in a surgical career.13 Women, in particular, est in this annual event led to the establishment have indicated their reluctance to pursue a surgical of the AWS, the mission of which is to “inspire, career due to lifestyle implications, and were more encourage, and enable women surgeons to realize prone than men to be dissuaded from a surgical their professional and personal goals.” The AWS career due to a decision to have children.12 has expanded tremendously since that first break- However, women students who had strong female fast meeting, and now has a membership of more role models or faculty members in general were more than 1,600 members in more than 15 countries.10 likely to pursue a career in surgery.12 These findings highlight the importance of female surgeons Training the next generation in academic practice and surgical leadership roles. It is well known that presently the majority of Not surprisingly, gender discrimination encoun- medical students, both in the U.S. and abroad, tered during surgical clerkship had a negative in- are female. Women have become an increasingly fluence on whether to choose a surgical career. In greater proportion of American medical school another study, male academic surgeons were more graduates throughout the last 50 years, with a likely than their female colleagues to state that growth from 6.9 percent in 1966 to 48.3 per- surgery was “not a good choice for women.”12 Un- cent in 2010.1 Even higher numbers have been conscious bias regarding traditional roles for males 26 reported in other areas of the world, with 62.1 and females likely played a role in this finding. In

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the same study, women actually found increased a women president or recorder of the American career satisfaction in positions with predictable Surgical Association. work schedules and that offer opportunities to Although the number of women surgeons in posi- achieve work-life balance. tions of power continues to be low, the rise in the Research suggests that attitudes are changing and number of women choosing a career in surgery is that female medical students are, indeed, interested encouraging. To build upon this trend, efforts must in surgical careers. The proportion of females be made to retain women in surgery and to accurately entering surgical residency is growing, albeit at a identify challenges unique to women. Programs aimed slower rate than what has been observed in medical at building leadership skills and identifying and schools. It is clear that increasing the number of supporting prospects for promotion will improve women surgeons available to act as mentors and women’s representation in positions of seniority. role models will serve to increase female medical In order for positive change to occur, it is im- students’ enthusiasm for careers in surgery. In ad- portant to acknowledge that even in 2012 gender dition, a dynamic residency program with a less disparities for women in surgery exist. The glass traditional surgical culture and more emphasis on ceiling metaphor implies that women and men have collegiality, diversity, and flexibility is necessary to equal access to entry- and mid-level positions but attract more female students.14 not more senior positions. In reality, this metaphor is not entirely accurate. A more appropriate The leaky pipeline analogy is the “leaky pipeline,” which reflects the It continues to be uncommon to find women in fact that the percentages of women found at the leadership positions across all specialties at most end of the pipeline do not match the percentages medical schools. In fact, the demographic has been of women found at the input. In 2009, across the so significantly skewed historically that various board in medicine, 17 percent of full professors organizations have taken corrective actions. For were women, even though women constituted example, in 1998 the Association of American 24 percent of medical school students in 1975.15 Medical College’s (AAMC) Increasing Women’s Furthermore, it has been well-established that the Leadership Committee formalized a data collection proportion of women who have advanced to senior process to quantify the advancement of women in ranks continually has been lower than that of their academic medicine. Information was collected on male counterparts.16,17 This finding suggests that a variety of data points that confirmed the lack of the scarcity of women in leadership positions is not women in leadership positions at many medical the result of insufficient numbers; rather, it repre- schools. This information was used to make recom- sents attrition of women along that pipeline. This mendations for the professional improvements for loss of proportional representation at advancing women in medicine. stages of a woman’s career holds true in all fields In 2003, the Women in Medicine Coordinating of medicine—and is not limited to surgery.16,17 Committee was established to develop new strate- The challenges women surgeons face are complex gies for advancing women in academic medicine, and difficult to measure and, as a consequence, and in 2009, this group was approved by the problematic to resolve. Women in surgery face AAMC board of directors as an AAMC profes- salary discrimination, slower promotion rates, sional development group, now called the Group on conflicting cues regarding when to start a fam- Women in Medicine and Science. Of note, AAMC ily, greater home-life conflict and depression, less board recognition, which is a critical component research support, and restricted access to posi- for the advancement of women in academia, was tions that lead to promotions and other forms of formalized just three years ago. recognition. Within the field of surgery, the paucity of women What is behind this discrimination and the un- in positions of seniority is sobering, with women conscious bias against women? Well-intentioned holding only four chairs in surgery departments in chairs and program directors may not consider a the U.S., while the number of female full professors woman for positions due to concern about over- in surgery rose to a meager 8 percent in 2010.1 It burdening women faculty and residents. Although is also interesting to note that there has yet to be more women residents and fellows are having chil- 27

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS dren, starting a family is still perceived negatively portunities to develop their leadership skills and by both faculty and residents alike.18 Study after pursue positions that will lead to advancement study in sociology, psychology, and business has and further job recognition. Over the past decade, pointed to the widely shared conscious and uncon- various surgical societies have developed a num- scious associations regarding the traits of women, ber of programs to promote mentorship, develop men, and leaders. People tend to associate the traits leadership skills, and facilitate the advancement of of a good leader with the traits of men rather than women surgeons through the various stages of an with the personality traits of women. More research academic career. The AWS has made this agenda is needed to further define the challenges unique a priority from its inception, and to this end, to women surgeons, so that a greater understand- AWS offers networking breakfasts at the annual ing of the impact of proposed interventions will meeting, mentorship programs, and a variety of achieve the goal of retaining and promoting this grants and awards targeted specifically toward the rich talent pool. female surgeon. The AWS leadership has also made a concerted Advancing into leadership roles effort to promote women surgeons through the In addition to teaching residents about surgery leadership ranks of every major surgical society— and patient care, chief residents, fellows, and such that many now have an AWS delegate or chair, established surgeons alike should seek out op- including the ACS Board of Governors. In the past few years, the ACS Women in Surgery Commit- tee has implemented an early-career mentorship program, which pairs prominent women surgeons Dr. Emamaullee is a PGY- 3 general surgery resident, with rising junior faculty in an effort to help these Emory University, Atlanta, physicians navigate the somewhat challenging road GA. She is the editor of the to promotion and advancement in academic sur- Resident and Associate gery. This program, and others like it, have brought Society Newsletter and also together female surgical trainees and practicing serves on the ACS Women in surgeons alike from around the country to discuss Surgery Committee. many of the issues addressed in this article. Conclusion While women have achieved parity with men in terms of medical school enrollment over the past decade, the gender gap in surgical specialty training programs has only recently started to slowly close. The increased proportion of women entering surgical training programs may be attributed Dr. Lyons is a PGY-4 plastic to a number of factors, including a steady rise in surgery resident, University of Manitoba, Winnipeg. the number of female surgeon mentors and role models, along with the cultural changes in surgical training programs with respect to duty hours and work-life balance. In order for the advancement of women surgeons to continue, additional resources should be developed to ensure that more women rise through the ranks in their departments, institutions, and surgical societies, as exemplified by the notable women surgeons highlighted in this article. More programs than ever before are available to help women surgeons locate suitable mentors and build leadership skills among female  28 surgical trainees and faculty alike.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS References Flynn J, Komalavilas P, Campbell KE, Dattilo JB, Bro- phy CM. Women in academic surgery: The pipeline is 1. Leadley J, Sloane R. Women in U.S. academic medi- busted. J Surg Educ. 2012;69(1):84-90. cine: Statistics and benchmarking report, 2009-2010. 17. Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X, Ter- Association of American Medical Colleges. 2011. Avail- rin M. Pregnancy among women surgeons: Trends over able at: http://www.cardiosource.org/acc/acc-mem- time. Arch Surg. 2012;Feb 20.[Epub ahead of print]. bership/~/media/Files/ACC/Membership/AAMC%20 20092010%20women%20in%20us%20academic%20 medicine%20statistics%20and%20benchmarking%20 report.ashx. Accessed June 1, 2012. 2. Zhuge Y, Kaufman J, Simeone DM, Chen H, Velazquez OC. Is there still a glass ceiling for women in academic surgery? Ann Surg. 2011;253(4):637-643. 3. Bartholomew A, Ascher N, Starzl T. Tribute: Dr. Olga Jonasson. Born in Peoria, Illinois, August 12, 1934. Died in Chicago, Illinois, August 30, 2006. Am J Transplant. 2007;7(8):1882-1883. Available at: http://onlinelibrary. wiley.com/doi/10.1111/j.1600-6143.2007.01872.x/ full. Accessed July 10, 2012. 4. National Library of Medicine. Olga Jonasson: Chang- ing the face of medicine. Available at: http://www. nlm.nih.gov/changingthefaceofmedicine/physicians/ biography_174.html. Accessed June 1, 2012. 5. Kemeny MM. Jonasson, Braunwald, and Morani. Three firsts in American surgery. Arch Surg. 1993;128(6):643- 646. Dr. Berdan is a PGY-3 6. National Library of Medicine. Kathryn Dorothy general surgery resident, Duncan Anderson: Changing the face of medicine. University of Minnesota, Available at: http://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_174.html. June 1, Minneapolis. 2012. 7. Childrens Hospital Los Angeles. Chief of surgery at Childrens Hospital Los Angeles is featured in NIH exhibit on women physicians. Press Release. 2003. Available at: http://www.chla.org/site/apps/nl/newslet- ter2.asp?c=ipINKTOAJsG&b=6089699. Accessed June 1, 2012. 8. Totenberg N. Olga M. Jonasson Lecture: Women in the professions. Bull Am Coll Surg. 2011;96(2):12-23. 9. Patricia J. Numann, MD, FACS, installed as 92nd Pres- ident of the ACS. Bull Am Coll Surg. 2011;96(11):40- 41. 10. Association of Women Surgeons. AWS history. Avail- able at: https://www.womensurgeons.org/About_AWS/ History.asp. Accessed June 19, 2012. Dr. Bazzarelli is a PGY-3 11. Kaderli R, Guller U, Muff B, Stefenelli U, Businger A. general surgery resident, Women in surgery: A survey in Switzerland. Arch Surg. University of Ottawa, ON. 2010;145(11):1119-1121. 12. Ahmadiyeh N, Cho NL, Kellogg KC, Lipsitz SR, Moore FD, Jr., Ashley SW, Zinner MJ, Breen EM. Career satisfaction of women in surgery: Perceptions, factors, and strategies. J Am Coll Surg. 210(1):23-28. 13. Baumgartner WA, Tseng EE, DeAngelis CD. Training women surgeons and their academic advancement. Ann Thorac Surg. 2001;71(2 Suppl):S22-24. 14. Schafer A. The Vanishing Physician-Scientist? Ithaca and London: Cornell University Press; 2009. 15. Nonnemaker L. Women physicians in academic medicine: New insights from cohort studies. N Engl J Med. 2000; Feb 10;342(6):399-405. 16. Sexton KW, Hocking KM, Wise E, Osgood MJ, Cheung- 29

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical leadership across generations by Sangeetha Prabhakaran, MD; Konstantinos P. Economopoulos, MD; LCDR Daniel J. Grabo, MD; and Joseph V. Sakran, MD, MPH

ver the last decade, a transformation has oc- increase and growing ethnic diversity of the U.S. curred in surgery. With rapid technological population, as well as the 78 million baby boomers advances, changes in reimbursement, and becoming Medicare-eligible over the next 18 years, are modifications to resident training programs, creating an ever more compelling need to transition Ostrong leadership is needed to ensure future success. from an acute to a chronic care model.6-9 As scientific knowledge accumulates, we realize that Changes in health care the etiology of disease is multifactorial. The interplay The future of the U.S. health care system is powered occurs between genes, infectious agents, environment, by the vision of those leaders who thoroughly under- nutrition, behavior, and society. To solve the mystery stand its past and have explored the dominant factors of complex medical conditions, multi- and interdis- that have played an important role in the transforma- ciplinary research teams consisting of physicians, tion of medicine throughout the twenty-first century. biologists, scientists, engineers, financial analysts, and While twentieth century medicine revolved around other professionals are essential.10 A major barrier has the treatment of disease, today’s focus is largely on pre- been the lack of a common language among these ventive care. The emerging application of the sciences, multidisciplinary groups, the development of which such as genomics, proteomics, medical technologies, would facilitate an effective and constructive dialogue. and informatics, has facilitated our understanding of Surgeon leaders with the capability to effectively build the molecular and cellular events leading to disease. and maintain multidisciplinary teams can set specific This new understanding should improve physicians’ goals, find solutions, and translate such collaboration ability to detect patients at risk and to potentially into effective health care delivery.11 implement necessary preventive strategies.1 With One major difference between the practice of the advancement of treatment options, medicine has medicine today and that of the twentieth century is shifted from the management of acute disease to the that patients have greater and easier access to medical management of chronic illnesses.2,3 One out of every information and tend to evaluate health care provid- two adults—almost 133 million Americans—suffers ers in various ways.12 The rise of social media, such as from at least one chronic illness, and in 2020 this blogs and online social networks, has further fueled number is expected to grow to 157 million.4 A grow- interest in the new “science of sentiment analysis,” a ing body of evidence shows that the rising rates of means of determining the attitude of an individual chronic disease are placing an unsustainable burden with respect to a specific topic or source.13 Access to on the national economy, with health care spending care is considered a social right, and the patient plays 5 30 expected to reach $4.2 trillion in 2016. The steady an indirect, though crucial, role in any future renova-

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS tions of medicine. Surgeons must safeguard patients’ considered work-hour restrictions to be an educational ability to access appropriate care. barrier and expressed a desire to work longer hours.16 Physicians, hospitals, and university researchers Training surgeons outside of the traditional Halsted may not generally be viewed as political entities, but model is not a novel concept. Since the early 1990s, when it comes to topics such as the highly debated with the advent of endovascular surgical techniques Affordable Care Act, all three parties have certain and continued progress in minimally invasive surgery, advantages over government leaders. A 2009 poll surgeons have spent time outside of the operating of 1,009 national adults ages 18 and older found room (OR) and in simulation labs learning new and that nearly three-quarters (73 percent) of Americans innovative techniques. The acceptance of surgical trust physicians to take the lead in reforming the skills education outside of the OR has been widely U.S. health care system.14 Whereas with great trust accepted, and this is no more apparent than in the comes great responsibility, surgeons, residents, and ACGME’s Residency Review Committee’s (RRC) researchers cannot further neglect our unsustainable requirements for surgical training programs, which health care system. To ensure that surgeons are able recommend access to simulation centers. In fact, the to influence the health policy development process, Fundamentals of Laparoscopic Surgery is a Web-based future medical education should incorporate formal educational module endorsed by the American Col- training that allows for the development of competent lege of Surgeons (ACS) and required for applicants physician leaders. to the American Board of Surgery (ABS). As technology advances among the surgical sub- Advances in surgical training specialties, components of specialty training may Surgical training has undergone rapid changes in be excluded from the current curriculum of general recent years. Beginning in 2003, the Accreditation surgery residency. Over the past two decades, the Council for Graduate Medical Education (ACGME) number of open, major vascular operations performed mandated that residency training programs restrict has significantly decreased and been replaced with duty hours and, thus, the 80-hour workweek was minimally invasive techniques, such as endovascular implemented. More recently, interns’ duty hours aneurysm repair.17 As a consequence, fewer open vas- were further limited to a maximum of 16 consecutive cular cases are trickling down from the fellow to the hours. The goal of these work-hour restrictions is to resident level, which ultimately takes away from the improve patient safety by reducing resident fatigue. experience in basic surgical principles, such as gaining Since the implementation of these new restrictions, proximal and distal vascular control. Simulation and concerns have arisen regarding resident education and skills training (using cadaveric, animal, inanimate, or competency, especially in the setting of technological computer models) are ways to teach surgical residents advancements in the treatment of surgical disease. not only the lifesaving skill of vascular control, but Traditional surgical resident education has occurred also to introduce vascular access and basic endovas- according to the model formalized by William S. cular techniques. Halsted, MD, FACS. The “see one, do one, teach The surgery training paradigm has certainly been one” paradigm guided surgical educators, and helped altered to accommodate work-hour restrictions while aspiring surgeons develop their technical skills. Al- still providing residents with the proper amount of though this model was successful in creating a highly exposure to surgical patients both in the clinic, emer- skilled surgical workforce, it relied on a high volume gency department, ward, intensive care unit, and OR. of operative cases with progressive levels of responsi- With the tendency toward specialization throughout bility that took years to amass. In the eyes of many all of medicine, a transition is already taking place, experienced surgical educators, work-hour restrictions with integrated surgical training programs or early can essentially deprive the resident of such educational specialization programs. This movement has allowed opportunities. This concern has been validated in a for rapid progression via a shorter course of basic/ review of the ACGME Resident Statistic Summary early general surgery training with a more dedicated that reported a decrease in total operative case volume period of development in the desired specialty train- and senior-level cases, with the number of junior-level ing program. cases remaining the same.15 Furthermore, in a survey Academic surgical units play a fundamental role of surgical trainees, a large subset of senior residents in the future of surgery and require effective leaders 31

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to maximize their impact. At the same time as the The importance demand for surgical procedures is growing, financial of mentorship in resources are becoming more limited. The current the development of changes make it imperative that modern surgical a surgical leader has leaders acquire not only surgical skills, but also the been widely acknowl- ability to develop critical thinking, problem solving, edged. In a discussion and team-building skills. Leadership development of mentorship in the must be incorporated early on into the resident cur- twenty-first century, riculum, which will facilitate the creation of leaders Eva Singletary, MD, who understand these changes and are effective FACS, said a good surgical educators. mentor should listen, facilitate and provide Leadership qualities networking experi- Various definitions of leadership exist, most of ences, share knowl- Dr. Turner which emphasize the importance of influence. edge of the system, of- For example, John C. Maxwell, who has written fer assistance as need- extensively on the topic, has stated, “Leadership is ed, teach by example, influence—nothing more, nothing less.”18 motivate, promote independence and balance, and Traditionally, leadership was judged largely on the rejoice in the success of their mentees.22 Even the basis of individual achievements. However, Wiley traditional method of mentoring, in which the men- Souba, MD, FACS, and colleagues have asserted tor served as technical expert, political strategist, that great leaders have integrated their strengths in role model, coach, and confidant, has given way to three fundamental areas: What they know, what they the mosaic model of mentoring, in which residents do, and who they are.19 This includes performance have multiple mentors, one for each sphere of their measures, such as knowledge, expertise, competence, life and work, including clinical practice, research, action, results, accomplishments, and personal quali- personal life, communication, management skills, ties and attributes. and so on. In an interview with 10 female surgical leaders, The ACS was founded with the primary goal of 60 percent said the greatest challenges for leaders improving the quality of care for the surgical patient are obtaining buy-in, building consensus, and lead- by setting high standards for surgical education and ing people through change.20 Other challenges iden- practice. As an organization that has fostered and tified during the interview include the following: developed surgical leadership over the past century, its maintaining clinical skills, creating positive cultures, impact on surgery in America and around the globe keeping communication open, avoiding burnout, has been tremendous. One of our young leaders, recognizing and implementing ideas, dealing with Patricia L. Turner, MD, FACS, Director of the ACS difficult personalities, being a role model, managing Division of Member Services, exemplifies the type of funds, and making tough decisions. leader who has cultivated mentors on multiple levels Traditionally, the emphasis in surgical leadership in order to excel at both the professional and personal was almost solely on technical and clinical expertise level (see photo, this page). with minimal consideration given to management Born and raised in Washington, DC, Dr. Turner skills. A total of 258 leadership behaviors were ob- said she “always wanted to be a surgeon, even as a served over the course of 63 hours in a recent study.21 young girl,” a sentiment not every physician may Surgeons most frequently showed the following relate to. So, where does her passion and drive come behaviors: guiding and supporting (33 percent), from? Who was mentoring her at such a young age? communicating and coordinating (20 percent), As Dr. Turner’s career developed, many individuals and task management (15 percent). Most of these provided guidance and contributed to her success. behaviors were directed to the room rather than at She cites L.D. Britt, MD, MPH, FACS, FCCM, a specific team member. Surgeons demonstrated FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), leadership qualities significantly more often during immediate Past-President of the ACS, as the indi- 32 highly complex cases. vidual who has had the greatest effect on her career.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Interestingly, she never attended Eastern Virginia traits of leadership are inherited, with successful Medical School, Norfolk, where Dr. Britt is the leaders being endowed with the right combination Edward Brickhouse Professor and Chair of surgery. of qualities.24 In contrast, the “behavioral theory” is She did not train there as a resident, and she has grounded in the notion that leaders can be groomed not directly worked for Dr. Britt. Their relationship through proper teaching and observation. actually began at a meeting for medical students, Various types of leadership styles are often exhib- where she showed that same interest and zeal that ited by leaders. Autocratic leaders exert high levels many of us have seen in her. Over time, their rela- of power over their team members. Under this tionship developed, and Dr. Turner was able to use leadership style, there is a clear division between his wisdom, experience, and guidance to make the the leader and the followers. Few opportunities are necessary decisions to eventually become the surgical available for making suggestions, even if applying leader she is today. these recommendations would be in the team’s or Having the right mentors is only part of the the organization’s best interest. The autocratic style leadership equation. Without the commitment, of leadership often breeds resentment, which leads dedication, and a strong work ethic, Dr. Turner to high levels of absenteeism and staff turnover. would not be where she is today. In fact, as a junior On the opposite end of the spectrum are transac- faculty member at the University of Maryland, tional leaders, who tend to adapt to and thrive in chal- Baltimore, Dr. Turner admitted that her academic lenging environments. They promote networking and productivity could have been better. In conversa- encourage problem-solving and innovation. This form tions with Dr. Britt, she began to provide him with of leadership depends on some form of exchange—for various reasons why she had been less successful in example, productivity in return for rewards. her initial few years. Dr. Britt’s advice to her: “You Similar to the transactional leadership style, can complain about your situation, but if you want transformational leaders focus on collaboration and to get promoted, the coin of the realm is delivering working toward and promoting an ideal. Leaders results.” Dr. Turner stated that this was probably the work toward a common goal with followers and best single piece of advice she has been given with invest in their development. respect to her professional career. The current emphasis in surgical leadership has Dr. Turner is as dedicated to her family as she is shifted from the traditional autocratic and trans- to the ACS. Her husband and two young daughters, actional styles to a more transformational model.24 Morgan Elizabeth (age 6), and Jessica Carmen (age Thomas Lee, MD, recently published an article 12), plan to join her in Chicago this year. Balancing addressing the traditional approaches to leadership our personal and professional lives is vital to long- in medicine.25 According to Dr. Lee, physicians term success. see themselves as heroic lone healers, and working Dr. Turner provides an excellent example of why it in teams can be challenging. However, under the is important to find the right mentorship opportuni- transformational model, building effective teams is ties. Mentors will not do the work for their mentees, a key part of being a successful leader. In contrast but they will provide them guidance in their chosen to traditional leaders who try to maximize revenue field. This relationship has been viewed with much under existing revenue systems, new generation gratitude among the mentees, who desire to “carry leaders focus on measures, such as outcomes and on the torch” of mentorship in their lives. As Ruth performance improvement processes. Development Whitman once said, “In every art, beginners must of health care systems that are patient-centered is start with models of those who have practiced the now considered a touchstone toward improving same art before them.”23 quality of care. Traditionally, hospital departments were organized Theories of leadership around the physician. The culture of health care There are a wide range of theories regarding the de- organizations has been moving away from these velopment of skilled leaders. The “great man theory” silos to the development of units where a variety postulated by Thomas Carlyle says that leaders are of specialty physicians care for a particular patient born and not made, and great leaders emerge when population (such as heart patients) under one roof— they are needed. The “trait theory” describes how called “collocation.” Due to the fact that the practice 33

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of medicine is highly evidence-based, performance Leadership development measures or outcome assessment plays a key role in The transformational change necessary for physicians referrals and potentially physician reimbursement. to develop business and leadership skills can be sup- The surgeon-leader must be well-versed in these ported and encouraged in a leadership development developments and possess not only basic leadership program that includes a specific curriculum design, qualities, but also sound financial management program monitoring, and opportunities to apply skills and the ability to collaborate with multidis- new skills in practice.26 Peter Büchler and colleagues ciplinary team members. demonstrated how implementation of business man- The contrast between clinical care and organiza- agement concepts changes workflow management and tional leadership has been described as a difference surgical training, and they emphasize the importance in cultures.26 Medical culture is largely character- of introducing a business skills curriculum into medi- ized by autonomous decision making, a reactive cal education and postgraduate surgical career devel- approach to problem solving, and a focus on opment.27 Leadership courses in surgery also assist individuals within the context of their biological, in the development of these skills, and examples of psychosocial, and sociological environments. The these courses include the College’s Residents as Teach- administrative focus is typically proactive, systems- ers and Leaders course and the Surgeons as Leaders oriented, and collective, and it is in sharp contrast course, as well as the career development programs to physicians’ focus on helping individual patients that the Association of Women Surgeons sponsors. one at a time. Conclusion With rapid changes occurring in the nation’s Dr. Prabhakaran is a health care system, the need for strong surgeon fellow in surgical oncology, Moffitt Cancer Center, leaders has never been greater. The essential qualities Tampa, FL. She is Chair, and requirements for such leadership have changed. RAS-ACS Communications Although excellent clinical knowledge, technical Committee, and member, skills, and strength of character are still the hallmarks International Medical of surgical leadership, current leaders also require Graduates Subcommittee. administrative and management skills. Incorpora- tion of early formal leadership training during both medical school and the residency period is necessary to produce capable leaders who can guide surgery through these changing times. 

Disclaimers The views expressed in this article are those of the authors and Dr. Economopoulos is a do not necessarily reflect the official policy or position of the U.S. research fellow in surgery, Department of the Navy, U.S. Department of Defense, or the Massachusetts General U.S. government. Hospital, Harvard Medical Dr. Grabo states: “I am a military service member. This work School, Boston, MA. was prepared as part of my official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.”

References 1. Snyderman R, Langheier J. Prospective health care: The second transformation of medicine. Genome Biol. 2006;7(2):104. 34 2. Partnership for Solutions. Chronic conditions: Making the

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS case for ongoing care. A Project of Johns Hopkins University people on board and engaged. J Surg Res. 2001;96:144–151. and The Robert Wood Johnson Foundation. September 2004. 20. Kass RB, Souba WW, Thorndyke LE. Challenges confronting Available at: http://www.partnershipforsolutions.org/DMS/ female surgical leaders: Overcoming the barriers. J Surg Res. files/chronicbook2004.pdf. Accessed March 11, 2012. 2006;132:179–187. 3. Snyderman R, Williams RS. Prospective medicine: The next 21. Parker SH, Yule S, Flin R, McKinley A. Surgeons’ leadership in health care transformation. Acad Med. 2003;78(11):1079- the operating room: An observational study. Am J Surg. 2011; 1084. Dec 16 [Epub ahead of print]. 4. Bodenheimer T, Chen E, Bennett HD. Confronting the 22. Singletary SE. Mentoring surgeons for the 21st century. Ann growing burden of chronic disease: Can the U.S. health care Surg Oncol. 2005;12:848–860. workforce do the job? Health Aff (Millwood). 2009;28(1):64- 23. Whitman R. Becoming a Poet. Boston, MA: The Writer, Inc; 74. 1982. 5. Trunkey DD. Health care reform: What went wrong. Ann Surg. 24. Patel VM, Warren O, Humphris P, Ahmed K, Ashrafian H, 2010;252(3):417-425. Rao C, Athanasiou T, Darzi A. What does leadership in surgery 6. U.S. Census Bureau. Available at: http://www.google. entail? ANZ J Surg. 2010;80(12):876-883. com/publicdata/explore?ds=kf7tgg1uo9ude_&met_ 25. Lee T. Turning doctors into leaders. Harvard Business Review y=population&tdim=true&fdim_y=country:US&dl=en& 2010;4:50-58. hl=en&q=us+population - !ctype=l&strail=false&bcs=d&n 26. McAlearney AS, McAlearney AS, Fisher D, Heiser K, Rob- selm=h&met_y=population&fdim_y=country:US&scale_ bins D, Kelleher K. Developing effective physician leaders: y=lin&ind_y=false&rdim=country&idim=country:US&ifdim Changing cultures and transforming organizations. Hosp Top. =country&tdim=true&hl=en&dl=en. Accessed Mar. 11, 2012 2005;83:11-18. 7. Wilensky GR. Directions for bipartisan medicare reform. N 27. Büchler P, Martin D, Knaebel HP, Büchler MW. Leadership Engl J Med. 2012;366:1071-1073. characteristics and business management in modern academic 8. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, surgery. Langenbecks Arch Surg. 2006;391(2):149-156. Bonomi A. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78. 9. American College of Physicians. The mpendingI Collapse of Dr. Grabo is trauma and Primary Care Medicine and Its Implications for the State of the surgical critical care attend- Nation’s Health Care. A report from the American College of ing surgeon, Navy Trauma Physicians. January 30, 2006. Available at http://www.acpon- Training Center, Division line.org/advocacy/events/state_of_healthcare/statehc06_1.pdf. Accessed Mar. 11, 2012. of Acute Care Surgery, 10. Center for Integration of Medicine and Innovative Technology. LAC+USC Medical Center, Available at: http://www.cimit.org/. Accessed: March 11, 2012. Los Angeles, CA. 11. Surgeons as leaders: From operating room to boardroom. Avail- able at: http://www.facs.org/education/surgeonsasleaders.html. Accessed March 11, 2012. 12. Siegrist RB Jr. The drive toward measuring the quality of performance of physicians. MedGenMed. 2006;8(2):86. 13. Siegrist RB Jr. The Relationship between Patient Satisfaction and Quality and Insights from the New Science of Sentiment Analysis. Paper presented at the 59th Annual Meeting of the Massachusetts Chapter of the American College of Surgeons. 2011; Boston, MA. 14. Saad L. On healthcare, Americans trust physicians over politicians. Gallup, Inc. Available at: http://www.gallup. Dr. Sakran is assistant com/poll/120890/Healthcare-Americans-Trust-Physicians- professor of surgery and Politicians.aspx. Accessed March 11, 2012. director, Global Health 15. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative and Disaster Preparedness, operative experience is decreasing during general surgery Medical University of South residency: A worrisome trend for surgical trainees? J Am Coll Carolina, Charleston. He is Surg. 2008;206:804-811. Vice-Chair, RAS-ACS Com- 16. Moalem J, Salzman P, Ruan DT, Cherr GS, Freiburg CB, Farkas RL, Brewster L, James TA. Should all duty hours be the same? munications Committee, and Results of a national survey of surgical trainees. J Am Coll Surg. RAS-ACS Liaison, Advisory 2009;209(1):47-54. Council for General Surgery. 17. Grabo DJ, DiMuzio PD, Kairys JC, McIlhenny SE, Crawford AG, Yeo CJ. Have endovascular procedures negatively impacted general surgery training? Ann Surg. 2007;246(3):472-477. 18. Maxwell JC. Developing the Leader Within You, 2nd ed. Thomas Nelson; 2000. 19. Souba WW. Leadership and strategic alignment—getting 35

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgery at the end of life:

For love or money?

total of 18 percent of Medicare beneficiaries undergo a major operation in the last four weeks before their death.1 The discussion regarding risks and benefits of operative interven- by Amy E. Liepert, MD; tions in an end-of-life situation can be emotionally Stefan W. Leichtle, MD; charged and ethically complex. Perception, expec- and Brian J. Santin, MD tations, and care plans often differ among patients and families, surgeons, and other physicians involved in a patient’s care. In a time of health care Editor’s note: The preceding articles by members of the Resident reform, outcomes tracking, and cost awareness, and Associate Society (RAS) focus on this becomes an even larger challenge. the leadership skills young surgeons A recent survey of patients found “hope” to be will need in the coming years. This among the most important aspects of care. Accord- article serves a different function. It ing to the survey, “Patients are uncomfortable with introduces Bulletin readers to the uncertainty about diagnoses and prognoses and of- topic that will be discussed during the 2 RAS Symposium at this year’s Clinical ten request tests to help alleviate those anxieties.” Congress, titled “Surgery at the End of Guilt may play an important role in decision mak- Life: For Love or Money?” The panel ing if all care options are not pursued. However, discussion will take place 1:00–4:00 considering that as much as 30 percent of health pm on Sunday, September 30, in Mc- care costs are associated with unnecessary tests, Cormick Place West. The symposium procedures, and treatments, how do surgeons make will feature the winners of the RAS 3 Issues Committee Essay Competition. decisions regarding end-of-life surgery and care? Those winning entries will be pub- What factors are important to discuss with patients lished in a future issue of the Bulletin. and families faced with difficult surgical decisions? And how do the costs and outcomes of end-of-life

36 surgery affect the health care system?

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgeon’s stake in the game tion is less clear. In fact, after taking into account the Autonomy is one foundation upon which all the economic impact on the patient’s family, time off from health care decision making is built. With respect work, decreased work productivity, and so on, amputa- to patients, autonomy refers to their rights to make tion becomes an even more unattractive option. In fact, decisions related to the care of their bodies. The physi- the contrary argument holds more truth—interven- cian’s respective autonomy—their freedom to provide tions, which are more aggressive in salvaging critical the best care to their patients based upon their best limb ischemia, have been shown to be associated with judgment—is often overlooked or simply ignored. In lower complication rates and costs.6 a viewpoint written by Ezekiel J. Emanuel, MD, PhD, Surgeons, at some point, are patients, too. If and Steven D. Pearson, MD, MSc, and published in surgeons evaluate themselves, what type and level the Journal of the American Medical Association, the of care would they prefer, particularly at the end of author appropriately defined physician autonomy life? Many health care professionals and surgeons as “the freedom to determine both the conditions opt out of medical care in this situation. This de- of practice and the care delivered with the principal cision may be surprising to the public, but not to goal that care decisions are aimed at promoting the most physicians. Many surgeons can recall a con- patient’s well-being.”4 versation regarding a critically ill, elderly patient In fact, some health care professionals are concerned lying on a proverbial mattress grave in the surgical that the impending changes resulting from health care intensive care unit (ICU) during which a physician reform may restrict or enhance surgeons’ autonomy. It or colleague has stated, “Don’t let that happen to is surgeons’ commitment to a high standard, a drive me.” Retired physician Ken Murray, MD, captured for intellectual excellence, and the role of stewards of this reality in an essay titled “How Doctors Die,” society that place them in a unique position to use which describes the story of an orthopaedic surgeon evidence-based clinical judgment to balance and effec- who chooses not to undergo any treatment for a tively address a patient’s desire for optimal health care. newly diagnosed pancreatic cancer but rather to Optimization of health care resources has gained in- spend his final months with friends and family. creased popularity in recent years and is the founding After receiving his diagnosis, he never stepped back principal of accountable care organizations (ACOs), inside a hospital.7 the end goal of which is to reduce wasteful spending. This story sheds light on how physicians react Economists define waste as any expense from which to the life and death situations to which they are profitable gains are not recuperated, such as the per- exposed more than any other profession. The fu- formance of unnecessary interventions. It has been tility of cardiopulmonary resuscitation (less than estimated that a human life has a value of at least $3 85 percent survival rate even if witnessed cardiac million and that medical care that results in one year arrest in a hospital), emergency department tho- of good quality life should cost less than $100,000.5 racotomies, and various other heroic measures are If the costs of care delivered outweigh the medical best appreciated by the physician community, who and quality of life benefits, then it is wasteful from experience it every day. After all, medicine is just an economic perspective.5 Along those same lines, a a form of palliation, and every human being has a surgeon could potentially define waste as performing 100 percent mortality rate; surgeons have frequent an operation from which the patient will never recover and firsthand experience with this truism. However, to a reasonable and meaningful quality of life. the complexity of health care and its delivery makes How might optimization of health care resources this simple understanding become quickly complex. translate into patient care? For example, should a pa- Surgeons are not alone when faced with deci- tient who presents with critical limb ischemia undergo sions regarding surgery at the end of life. Patients primary amputation rather than a “costly” endovascular and their families are also caught in the midst of intervention? In this case, a primary amputation might these decisions. For them it is often a foreign and appear to be economically sound, but a closer look confusing experience, as they are forced to make provides cause for reconsideration. After accounting life-altering decisions about themselves or a loved for the cost of hiring home health aides, modifying one under extreme stress. This situation is made an amputee’s home, and providing long-term care, even more extreme in the U.S., which has a culture the cost-effectiveness of a cheaper medical interven- that is focused on rescue care. 37

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Family perspective What do families mean when they ask physicians to “do everything” they possibly can to save a loved Surgeons, at some point, one? Do they expect major operations to be performed with little chance of success? Do they envision the are patients, too. If surgeons harsh realities of tracheostomies, feeding tubes, central lines, dialysis catheters, and epinephrine infusions as evaluate themselves, what part of a last-ditch effort to treat the patient? Some may, but several studies among families of critically type and level of care would and terminally ill patients suggest otherwise. These studies show that what patient families truly want they prefer, particularly includes: a trusting relationship between physician, patient, and family; emotional support and mutual at the end of life? Many respect; avoidance of treatments lacking real benefit; relief of discomfort and pain; and good communication health care professionals and between all involved parties.8,9 Are there explanations for the difference between these needs and the real- surgeons opt out of medical life situation that is frequently encountered in ICUs throughout the country? care in this situation. In his essay “Letting go,” Atul Gawande, MD, FACS, concluded that modern medicine, with its ability to maintain organ function in critically and terminally ill patients for weeks and months, has fundamentally changed the meaning of death.10 The process of dying has become a concept that can be hard to understand tient’s current state.12 Even when faced with dismal and no longer follows traditional knowledge and numbers about a patient’s prognosis, relatives tend to customs. Terminally ill patients and their families overestimate the chances for recovery, and frequently have to make treatment decisions regarding a disease focus on individual reports about cases, in which process they may not understand, procedures they may prognosis and actual survival differed substantially.13 be unable to pronounce, and survival statistics that Depending on religion and spirituality, a significant may be disputed even among medical experts. Quite number of people retain hope for a miracle that may often, families must decipher terms and phrases, such alter their loved one’s clinical course. as “full code,” “do not resuscitate,” “do not intubate,” Distrust and disbelief are common initial reactions “chest compressions,” and “vasopressors only.” They when families are faced with a poor prognosis, and are expected to make decisions about tube feeds and patients tend to believe that physicians offering a futil- other end-of-life procedures, and the reality is that all ity prognosis simply find the case beyond their scope they want is what is “best” for the person they love. of knowledge.14 This lack of trust may be exacerbated Even physicians—guided by years of medical train- by today’s health care environment, where life-long ing and personal experience—are often wrong when physician-patient relationships and the presence of a estimating the prognosis of critical patients. Christakis single, trusted family physician are rare. More often, and colleagues found that a mere 20 percent of physi- families face multiple, rotating ICU physicians who cians were correct in their prognosis for terminally ill may give divergent explanations and opinions about patients, with physicians commonly overestimating a patient’s prognosis. survival by 530 percent.10 The closer physicians were The consequences of treatments rendered in end- to their patients, the more optimistic and incorrect of-life care go beyond individual physicians, patients, they were in their prognosis.10 How, then, can families and families. Health care resources are increasingly and relatives be expected to make rational and correct scarce, and interventions with little or no benefit estimations in these situations? impose a financial strain on an already heavily bur- Families tend to rely less on medical facts and more dened heath care system and, eventually, on our 38 on their feelings and subjective impressions of a pa- entire society.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Outcomes and cost Are there identifiable factors that the surgeon can Surgery is a costly treatment option. When use to predict whether the patient with an emergent employed in dire situations with little hope for surgical problem is likely to survive the procedure longer-term success, such as in end-of-life-care, it and, equally important, to determine the postop- often results in prolonged critical care, additional erative hospital care and possibly the long-term invasive interventions, and extensive rehabilitation. rehabilitation associated with survival? Lissauer and In younger patients, “heroic interventions” may be colleagues found a surprising answer to this question: justified given the potential gain in remaining years severity of illness was not linked to care decisions of life, but are they justified for patients in their made by family members in a surgical ICU.17 The eighth, ninth, or tenth decade of life? patients that were either the sickest or the most likely The remarkable advances of medicine in the last to survive did not necessarily have corresponding century have substantially increased life expectancy. decisions made by family members. These findings This increase has produced new and challenging suggest that physicians and families have different medical and surgical situations. At the same time, criteria regarding care decisions at the end of life. the population is aging, and there are fewer young Physicians assess clinical factors to determine likeli- people to contribute to the increasing cost of care hood of survival, while family members rely on other for the elderly. criteria not necessarily linked to the clinical condition Nearly a third of Medicare beneficiaries undergo a of the patient. These factors are important, because major surgical procedure in the last year of life, and nearly one-third of patients admitted to a surgical 18 percent undergo an operation in the last month of ICU will face an end-of-life decision.17 life.1 The provision of this level of care places a huge To better gauge the risks and benefits of surgery at burden on the health care system and the national the end of life, more data are necessary regarding pat- economy. Furthermore, these cases often require terns of care, cost of care, outcomes related to patient large resource use, which adds to the expense while factors, and expectations of patients and their families. offering potentially little benefit in terms of quality In the meantime, an honest and realistic conversation of life gained. An important factor to consider in about the appropriateness of costly care to patients these situations is the patient’s quality of life prior to near to the end of life is crucial, and will, in turn, surgical intervention. Although the term “elderly” encourage additional data on this topic. typically applies to people 65 years or older, there The armamentarium of modern medicine has can be a very big difference between a 65-year-old provided physicians with the ability to treat even and an 85-year-old patient in terms of quality of life. the most severe diseases and conditions. However, it Outcomes are going to vary based upon this age dif- has also created difficult ethical situations in which ference as evidenced in a study of colorectal cancer there is a discrepancy between what could be done surgery in elderly patients. The patients classified as and what should be done for patients with critical “oldest old,” age 85 or greater, had worse outcomes surgical conditions. Physicians, patients, and families (specifically, 10-day mortality and length of stay) than may have differing perceptions of disease severity, elderly (age 65–85) and non-elderly patients, less than prognosis, and plan of care. These situations represent 65 years.15 (These results were for patients undergoing a tremendously stressful and frustrating experience both elective and emergent surgery.) for patients, families, and health care providers. De- Like all other patients, the elderly undergo op- cisions about end-of-life care touch the core values erations in elective, urgent, and emergent situations. of medical care. Physicians involved in the care of Each setting poses different clinical challenges for the severely ill patients need to find a balance between surgeon, patient, and family. In emergent and life- the principles of autonomy, requiring a physician to threatening situations, the patient may be unable to follow patients’ and families’ wishes, and beneficence, participate in the decision-making process, and the requiring a physician to explain why a treatment is family or surrogate decision maker may be unprepared unlikely to benefit a patient. to make life-or-death decisions on the patient’s behalf. Advance care planning, an open dialogue about A “do everything” mentality and plan often emerges the goals of care, and early introduction of palliative in these situations, and subsequently 20 percent of care are key issues in the discussion about surgery at 16 18  Americans die in an ICU. the end of life. 39

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS References 18. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl 1. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato WF, Billings JA, Lynch TJ. Early palliative care for patients AE, Gawande AA, Jha AK. The intensity and variation of with metastatic non-small-cell lung cancer. N Engl J Med. surgical care at the end of life: A retrospective cohort study. 2010;363(8):733-742. Lancet. 2011;378(9800):1408-1413. 2. Detsky AS. What patients really want from health care. JAMA. 2011;306(22):2500-2501. Dr. Liepert is a surgical 3. Wennberg JE, Fisher ES, Skinner JS. Geography and the critical care fellow, Univer- debate over Medicare reform. Health Aff (Millwood). 2002; sity of Pittsburgh (PA) Medi- July-Dec. Suppl Web Exclusives:W96-114. cal Center, and Chair of the 4. Emanuel EJ, Pearson SD. Physician autonomy and health RAS-ACS Issues Committee. care reform. JAMA. 2012;307(4):367-368. 5. Brook RH. The role of physicians in controlling medical care costs and reducing waste. JAMA. 2011;306(6):650-651. 6. Alonso A, Garcia LA. The costs of critical limb ischemia. Endovascular Today. 2011;2011(8):32-36. 7. Brownlee S. What doctors know and we can learn about dying. Time. Available at: http://ideas.time.com/2012/01/16/ what-doctors-know-and-we-can-learn-about-dying/. Ac- cessed June 19, 2012. 8. Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pi- chora D, Shortt S, Tranmer J, Lazar N, Kutsogiannis J, Lam M; Canadian Researchers End-of-Life Network (CARENET).What matters most in end-of-life care: Per- ceptions of seriously ill patients and their family members. Dr. Leichtle is a general CMAJ. 2006;174(5)627-633. surgery resident, Saint Joseph 9. Teno JM, Clarridge BR, Casey V, Welch LC, Wetle T, Shield Mercy Health System, Ann R, Mor V. Family perspectives on end-of-life care at the last Arbor, MI, and a member place of care. JAMA. 2004;291(1):88-93. of the RAS-ACS Issues and 10. Gawande A. Letting go. The New Yorker; August 2, 2010. Available at: http://www.newyorker.com/ Membership committees. reporting/2010/08/02/100802fa_fact_gawande. Accessed May 30, 2012. 11. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: Pro- spective cohort study. BMJ. 2000;320:469-472. 12. Boyd EA, Lo B, Evans LR, Malvar G, Apatira L, Luce JM, White DB. “It’s not just what the doctor tells me”: Factors that influence surrogate decision-makers’ perceptions of prognosis. Crit Care Med. 2010;38(5):1270-1275. 13. Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Dr. Santin is a vascular Care Med. 2010;182(7):905-909. 14. Zier LS, Burack JH, Micco G, Chipman AK, Frank surgery fellow, Good Samari- JA, White DB. Surrogate decision makers’ responses tan Hospital, Cincinnati to physicians’ predictions of medical futility. Chest. OH, and a member of the 2009;136(1):110-117. Society for Vascular Surgery 15. Al-Refaie WB, Parsons HM, Habermann EB, Kwaan Governing Council on Train- M, Spencer MP, Henderson WG, Rothenberger DA. Opera- ees. He is Vice-Chair of the tive outcomes beyond 30-day mortality: Colorectal cancer RAS-ACS. surgery in oldest old. Ann Surg. 2011;253(5):947-952. 16. Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD. Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med. 2004;32(3):638-643. 17. Meissner A, Genga KR, Studart FS, Settmacher U, Hofmann G, Reinhart K, Sakr Y. Epidemiology of and factors associated with end-of-life decisions in a surgical intensive care 40 unit. Crit Care Med. 2010;38(4):1060-1068.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From battlefield to bedside— and back again

by Paula Rasich

n April 4, James Cole, DO, FACS, boarded a commercial plane in Chicago, IL, for the 36-hour journey to the Far Western Desert, Morocco, an expanse of the Sahara in the southeastern part of the country. As a U.S. Navy OCommander and the senior member of a mobile forward resuscita- tive surgical suite (FRSS) attached to 4th Medical Battalion, 4th Marine Logistics Group, Dr. Cole and his 15-person surgical team were called upon to provide support to a bilateral live-fire training exercise between the U.S. Marine Corps and the Royal Armed Forces of Morocco. Over the last two decades, the 47-year-old father of four has been deployed to 10 countries as a military physician, often living in conditions that are spartan and, at times, hostile. Dr. Cole, who was recently promoted to the rank of Navy Captain, says his abid- ing interests in trauma care stretch far beyond the hospital walls he inhabits as a civilian surgeon. “I love trauma surgery, and I like the military, so that is sort of the perfect mix for me, being a trauma surgeon in a very austere environment,” he said. “It’s like pushing the trauma operative experience to a new level.”

Top: Members of Dr. Cole's FRSS on sand dunes in Morocco. Left: Dr. Cole in the OR. 41

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In his book, Dr. Cole talks about this and so many other memories that he couldn’t shake off. He recalls his residency at William Beaumont Army Medical Center, El Paso, TX, averaging 120-hour work weeks honing his surgical skills to perfection, and one rotation so grueling he felt for certain the relentless stress of being put on endless call would lead to his own demise. Looking back, he feels fortunate for his training in the military, especially under the direction of Col. Stephen Hetz, MD, FACS. “He was just a great leader, an awesome surgeon, and a great human being,” he said. “He was also a field surgeon, so he specifically prepared us for war, and I’m grateful for that.” Even with that preparation, however, there were difficult, trying moments over the years. Seeing children die, operating for lengthy sessions, and break- ing the news of lost loved ones to devastated family members were some of the pressures that had often left Dr. Cole physically and emotionally drained. In the 15 years since he became a surgeon, some of the memories that have haunted the surgeon the most were the trauma injuries afflicted on children—the Dr. Cole in the trauma bay at Advocate Good Samaritan Hospital. attempted murders of innocents. One such memory that didn’t fade with time was that of a little boy who was delivered to his trauma table with a screwdriver lodged into his chest, dying before his eyes. The trouble with trauma Spurred on by family and friends to share his sto- In his memoir, Trauma: My Life as an Emer- ries, he began writing about these and other events. gency Surgeon (published in 2011), Dr. Cole tells “I wrote about experiences that had weighed on me the story about a particular U.S. civilian trauma over the years, especially from when I was in training so horrific that the patient did not survive.* In and when I was in Iraq and Afghanistan,” he said. one passage, the author describes how he and his “I wrote about things that I had thought about over trauma team desperately tried to save the life of a and over and over for a long time. I was sad for some young woman who had been gunned down by her of these patients who were so traumatized.” estranged husband with a semi-automatic machine For Dr. Cole, completing the book proved to be gun. cathartic. After transcribing the details of every He writes, “Unfortunately, adversity is the very disturbing memory that continued to live on in his nature of trauma. Members of a trauma team get mind, he was finally able to release these powerful what’s handed to them. In our situation, it was a emotions and find peace. “It was as if my mind young woman who tried her best to avoid trouble, would not allow me to let go of the memories, but trouble sought her out. And now she was dead.” but writing this stuff down cleansed a lot of my This, he said, was the first time he was faced with thoughts,” he said. “It was strangely therapeutic.” a patient who had so many injuries that he didn’t Another benefit was that he gained new insight know where to get started. “I had plenty of expe- into his ever-evolving role as a physician. “Many rience dealing with people shot by someone, but trauma patients are substance abusers, mentally ill, that was the first time I was trying to treat someone or criminals. Many of my patients’ family members shot 30 times by an automatic weapon,” he said. don’t even want them to return home. At times, I *Cole J. Trauma: My Life as an Emergency Surgeon. New York City, NY: feel like a social worker,” he said. “But I realized that 42 St. Martin’s Press; 2011. I had been given a great gift over the years, and this

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS has allowed me to spend extra time without losing my patience to offer solutions, support, and alternatives to my patients’ difficult social lifestyle problems.” Labor of love Another reason the self-described “working stiff” put pen to paper was to provide a real-world view of the day-to-day life of surgeons and other health care professionals. “Not only did I want to just tell the story, but I also really wanted to set the record straight, or at least let people know what we have to go through to get our board certification in surgery and the responsibilities of the job we have chosen,” he said. “I think, unfortunately, a lot of people have the wrong impression of what being a doctor is all about based on TV shows that make it look a lot more fun and relaxing than it is.” In truth, learning every aspect of Dr. Cole’s surgical trade during residency often meant subsisting on a diet of sugar-laden snacks and caffeine-rich bever- Lt. Cdr. Johnny Sacco, CRNA (left) and Dr. Cole in southern ages, living in a sleep-deprived, semi-comatose state Morocco, April 2012. and being separated from his loved ones for long periods. “What we need more of in health care—and I’m talking doctors, nurses, technicians, providers medical team. An expert rifleman, paratrooper, and of every variety—are people who really want to care Navy diver, he had been attached to this elite group for patients and have the intestinal fortitude and several years prior to this assignment. For the next five commitment to drive on,” he said. “We need people months, Dr. Cole wore two hats: first, as the task force who are willing to put their hands in blood and are surgeon, supervising all health care matters related to willing to handle the stress of people dying. I want the Special Operations Task Force, and second, as a the right people to get into health care, and hopefully member of a forward surgical team providing support this book might inspire a few people to do that.” to Special Operations commandos. At the base, commandos were deployed every night In the trenches together to capture or kill Taliban and Al Qaeda fighters. On the military front, Dr. Cole was active as a Flying numerous missions, Dr. Cole was required U.S. Navy officer from 1991 to 2000. Then, in July to accompany the commandos armed as any other of 2004, he got his orders to ship out to southern combat soldier, wearing body armor and weapons Afghanistan, his first deployment since rejoining the weighing 60 pounds. With just a few hours notice, the U.S. Navy Reserve following the terrorist attack on medical team would pack their gear, board a heavily the World Trade Center on September 11, 2001. For armed helicopter, and lift off into the black of night. Dr. Cole, a sense of duty brought him back into the Departing from the safety of camp, they would then military fold after a nearly three-year hiatus. “I felt touch down a distance from a battle scene and wait to a sense of obligation and even guilt for not being in receive gravely injured soldiers. During one mission, the service when our country was at war, knowing Dr. Cole sensed a danger so palpable that he readied that I had friends who were already deployed, and himself for ambush by encroaching adversaries. young soldiers and Marines and sailors that were in “My typical day was a typical night. We always did this combat zone getting injured. I thought, ‘this is all of our briefings, missions, and travels at night,” he my duty, I’m a surgeon, I’m supposed to be there said. “Every two to three days we would go out to the taking care of these people,’” he said. hinterland and support some sort of combat mission, At the Bagram Air Base in Afghanistan, he was and come back and decompress, then sleep during the assigned to the U.S. Special Operations Command day, and start the cycle all over again.” 43

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS surge—the worst of the fighting in Iraq. But in April of 2007, the civilian surgeon dropped what he was doing, and readied himself for the next mission. At the outset, he was assigned to the surgical hospital aboard Camp Taqaddum, which was one of several surgical facilities established close to the combat zones. Many of the military personnel suffered injuries from improvised explosive devices; therefore, the surgical team often operated on multiple body parts simultaneously. “In civilian trauma we do have some very devastating blunt traumas, but typically the penetrat- Dr. Cole’s FRSS team supporting Exercise African Lion in the Sahara desert, Morocco. ing traumas are pretty straight- The team treated four severely injured Marines. forward to deal with: one or a couple of holes from a fairly low-energy weapon, whereas At various makeshift surgical sites throughout in the military environment you have these blast the southern region of the country, Dr. Cole injuries where a casualty is peppered with 30, 40, operated on injured U.S. servicemen and United or 50 rounds from an explosive device of a massive Nations personnel, as well as captured prisoners, charge that just blows them up,” he said. “It’s pretty performing chest surgery, abdominal surgery, and overwhelming to deal with sometimes—one person extremity surgery. “Land mines were an espe- blown almost apart with numerous holes.” cially precarious enemy of the soldiers I treated, Dr. Cole was also put in charge of a mobile FRSS. and were the primary reason why I performed His handpicked medical team used equipment they so many completion amputations,” he said. He brought with them to follow Marines as they moved performed approximately 10 amputations in the through the Iraqi desert. The suite—including two combat zone. 15x18-foot tents, a portable oxygen generator, por- Despite the challenges of living in this desiccated table ventilators, cardiac monitors, two electrical wilderness, Dr. Cole says he took great satisfaction generators, and other medical equipment—could from knowing that he and his colleagues were able be set up or broken down within one hour. to have a hand in saving the lives of soldiers on the “When you are in the field, you literally have to battlefield. “It’s really heartbreaking when I see do everything yourself, from setting up the tents these young kids,” he said. “I feel good that we are to opening all of the containers. There’s a lot of able to do something for them, but a lot of the time minutia that needs to be directed,” he said. “If all I never know their definitive outcome because they your equipment is not set and the generator is not get sent to another echelon of care, and eventually working right, you can’t do your job.” back to the United States.” The mobile surgical unit lived out of tiny individual tents, sleeping on the ground, with their rifles Desert hot spots and other weapons always close by. As time wore Dr. Cole didn’t know what to expect when he got on, and mostly no way to bathe, they stayed coated another set of military orders to deploy with the U.S. with dirt and sand. The highest temperatures of 120 Marines of the Second Marine Expeditionary Force degrees did not offset the freezing temperatures they 44 to Al Anbar Province, Iraq, in support of the military shivered through at night.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Altogether, Dr. Cole spent nearly one year in The response is golden Iraq. “It’s tough to be away from home, away from Years have passed since his first major trauma my family for long periods of time,” the husband casualty. On that day, a four-year-old boy, who was of 25 years said. “The military Medical Corps is critically wounded by a shot in the head, arrived at getting smaller, and people are voluntarily separat- the hospital just after midnight. “I was a very junior ing because they are getting tired of the repeated surgeon, and of course I thought there was no way deployments; so there are fewer of us left and, as a that anybody could survive this. And as a matter of result, we are getting sent on these overseas support fact, I was told that this is a non-survivable injury, a operations more often.” trans-cranial gunshot wound,” he said. But the child By the time his assignment was up, Dr. Cole was did survive, and a year later the bashful boy walked glad to return home to suburban Chicago, IL. “The into the intensive care unit alongside his mother to transition home was strange. I had this heightened thank the trauma team, and throw a foam baseball sense of awareness for a while, hyper-perceptive Dr. Cole’s way. to various sounds, wondering what that noise is Trauma teams see sad endings. And miracles. “I outside,” he said. “It took me a while to get used to take care of devastatingly injured patients, but it’s the flowers and the trees, and so forth. It was like a lot more than a surgeon and a surgeon’s team that going to Disney World.” does save these patients’ lives and cures them,” he When it comes to making a smooth transition, said. “I have seen patients get better when I thought Dr. Cole offers this advice to other servicemen it was not possible from the perspective of medicine returning home: avoid big welcome home recep- and science.” tions for awhile and take a few weeks off from A man of faith, Dr. Cole has maintained a steady your regular job. Give yourself time to adjust to dialogue with God. “I tell my patients’ families in a the sights and sounds of your surroundings. And, very, very horrible situation that I think the likely to families and friends: try to avoid overwhelming outcome is going to be ‘X,’ but I never say always, your loved one with lots of questions about the war and I never say never, because every once in a while zone. “I know that I regressed socially for a while, the unexplainable happens,” he said. “So, I say, don’t but time and gradual reintroduction to everything ever lose hope, and don’t ever lose faith.”  brought me around,” he said. Dr. Cole credits these feats and more to his wife, “an amazing woman who supported me through it all.” Surgeon without borders Stateside, Dr. Cole is the assistant director of trauma services at Advocate Good Samaritan Hos- pital in Downers Grove, IL, where he treats victims of accidents, shootings, stabbings, and other trauma. Throughout his career, he has operated on a few thou- sand patients, as both a civilian and military surgeon. Not surprisingly, he believes that his deep experience with combat medicine and other sufferings over the years taught him to think differently. “I think a lot of times we can just be frustrated by our trauma patient population. But being in Iraq and being one of them, a homeless person essentially, made me feel more compassion for them. When you go without for a long period of time—I’m talking food, shelter, warmth, and protection—it brings you down to a lower level,” he said. “I’ve learned that all people pretty much want to live another day. And they want to be treated compassionately.” Ms. Rasich is a freelance writer based in Bethlehem, PA. 45

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Training Global ccess to surgical care is a necessary public health provision and, in many people’s opin- Surgery ion, a basic human right. While access to medical care in resource-poor countries has Fellows increased with the global health movement, surgical A 1 care has largely been neglected. This article discusses • the authors’ experiences in developing a global surgery by fellowship and delivering surgical care in rural Haiti. Stephen R. Sullivan, MD, MPH; Establishing clinics Christopher D. Hughes, MD, MPH, FACS; Haiti is the poorest country with the worst health and human development statistics in the Western Maxi Raymonville, MD; Hemisphere.2 In the book Mountains Beyond Moun- Selwyn O. Rogers, MD, FACS; tains, Tracy Kidder documented the work in Haiti by Paul Farmer, MD, and his colleagues at Partners Michael L. Steer, MD, FACS; Pictured above: Surgeons from around the globe and at all levels and John G. Meara, MD, DMD, FACS work together and have an exchange in surgical education. Haitian attending surgeon Dr. Marie May Louisfils (center) repairs the cleft • lip of a young boy while surgery residents from Canada and Haiti, a Cuban nurse anesthetist, and an American global surgery fellow learn 46 and assist. (Haiti map courtesey of the United Nations.)

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS in Health (PIH), Boston, MA, and its sister organization Zanmi Lasante (ZL), which operates in Haiti.3 In 1985, PIH/ZL mobilized around basic health needs in the Central Plateau of Haiti. ZL opened a free medical care clinic called Clinique Bon Sauveur, and in 1986 physicians at the facility documented the first known case of AIDS in Haiti’s Central Plateau. ZL focused its efforts on HIV prevention and education during the early years of the epidemic, and they offered free health care services to patients in need. Over time, the Clinique evolved into a sociomedical complex offering comprehensive inpatient and outpatient health care. More than 250,000 patient visits occur each year in Cange, which is linked to a network of 12 hospitals and clinics in rural Haiti.4 Expanding surgical care With growing recognition that these clinics provide high-level medical care, patients with a wide range of surgical diagnoses also travel to these facilities.5 Some of the conditions patients have are beyond the scope of practice and training for most local surgeons. For example Sara,* a 63-year-old woman from a remote farming village in Haiti, woke early each morning in the darkness of her small hut. In her usual routine, she stood, leaned over a kerosene lamp, and struck a match. Tragically, the lamp had accidentally been filled Sara, upon presentation to Clinique Bon Sauveur in Cange in 2008, the day before with gasoline instead of kerosene. with open wounds extending across her upper body and scar con- It exploded, and Sara suffered severe burns to her tracture of her neck, arm, and hand 18 months after being burned. face, arms, and upper body. She was a several-hour walk from the nearest medical clinic and was suf- fering from life-threatening burns. Had it not been for the care delivered by nurses in a clinic in rural rural Haiti as part of a global surgery fellowship, Haiti, Sara likely would have died.6 Sara traveled to Cange, a village in central Haiti, For weeks, Sara teetered on the brink of dying. for the surgical care she so desperately needed (see Despite renal failure, respiratory distress, and photo, this page). extreme pain, she was slowly and literally nursed Existing models of medical care have demon- back to life. The deep burns left massive wounds strated that hospitals in poor countries can work in with raw flesh extending across her upper body. tandem with academic medical centers and visiting Such was Sara’s existence for the next 18 months. physicians to expand access to care. PIH/ZL rec- She desperately needed specialized surgical care, ognized the growing number of patients requiring but unfortunately, these services were unavailable, surgical care, such as Sara, and in 1996, built an a theme that is common in poor and rural areas operating room (OR) at the Clinique. Since then, around the world. Unable to care for herself or her PIH/ZL has built additional ORs (see photo, family, meaningful life seemed uncertain. In 2009, page 48), and surgeons from around the world following rumors of plastic surgeons working in have donated time, skills, and equipment while working closely with Haitian surgeons to develop *Name has been changed to protect confidentiality. a surgical care system. 47

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Inspired by colleagues in internal medicine, an increasing number of surgeons have recognized the need for global surgical care and are taking action. The American College of Surgeons’ Operation Giving Back program is one example of global surgery advocacy and provides a gateway for surgeons interested in this area.8 The Alliance for Surgery and Anesthesia Presence Today is developing a collaborative of surgeons, anesthesiologists, and public health specialists who are advocating for surgery to be a key component of efforts to improve global surgery outreach.9 The World Health Organization has partnered with the Ministries of Health, local and international Operating room in the PIH/ZL hospital in Boucan Carré, Centre organizations, and academic medical centers to form District, Haiti. the Global Initiative for Emergency and Essential Surgical Care (GIEESC).10 The GIEESC is working to reduce death and disability from vehicular crashes, trauma, burns, falls, pregnancy-related complications, domestic violence, disasters, and other surgical conditions in more than 34 low- and middle-income countries. Medical students, residents, and fellows are also eager to experience and address global surgery needs as part of their education. When surveyed, a majority of U.S. anesthesia, general surgery, and orthopaedic surgery residents express an interest in having a global surgery humanitarian experience during their training.11-17 Many residents are willing to have such an experience even if it is part of vacation time. Despite interest, few programs offer a structured global surgery opportunity for residents. As a model of surgical accompaniment, global surgery fellows work closely with local surgeons in places such as Cange, Haiti. From Global surgery fellowship left to right, Dr. Sullivan with Haitian Zanmi general surgeons Dr. In 2008, surgeons affiliated with Harvard Univer- Marie May Louisfils, Dr. Lucien Baptiste, and Dr. Josue Augustin. sity teaching hospitals and PIH/ZL founded a global surgery fellowship for surgeons who have completed their training and are interested in dedicating 12 to 24 months as a surgeon in a developing country. The Expanding global surgery opportunities clinical experience is coupled with a curriculum in Although global health has become an increas- public health and surgical education.18 The purpose ingly recognized field of medicine, surgical care of the fellowship is to train surgeons to be leaders remains largely ignored in many poor countries. in promoting surgical care, education, and research Institutes, departments, and programs in global pertinent to global surgery in resource-poor regions health care are developing at leading medical schools around the world. throughout the U.S., but students are usually Global surgery fellows work closely with local trained in internal medicine and infectious disease surgeons and, together, have an exchange in surgical rather than in global surgery.7 Educational oppor- education while learning, teaching, and performing tunities in the emerging field of global surgery are operations ranging from oncologic, pediatric, plastic, limited. If overall improvement in global health is burn, obstetric, ophthalmologic, orthopaedic, uro- to be achieved, both medical and surgical education logic, and general surgery (see photo, this page). In a 48 opportunities must be available. given week, these fellows have performed a spectrum

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of operations, including release of burn scar con- Acknowledgment tracture, skin cancer resection, pediatric lymphatic malformation resection, facial neurofibromatosis Mesi anpil (thank you very much) to our patients and col- excision, keloid excision, cleft lip repair, palatoplasty, leagues in Haiti. breast reduction, inguinal herniorrhaphy, closure of myelomeningocele, and hydrocelectomy. Dr. Sullivan is a plastic and Over the course of one year, fellows have performed reconstructive surgeon for up to 65 operations for cleft lip and palate. Fellows Partners in Health, Boston, also expand their operative skill set by helping with MA, assistant professor of such procedures as cesarean section, splenectomy, surgery and pediatrics, War- cholecystectomy, appendectomy, colostomy, explor- ren Alpert Medical School atory laparotomy, repair of imperforate anus, uro- of Brown University, and genital repair, hysterectomy, mastectomy, hand and member of the Global Health extremity repair, amputation, and fracture fixation. Initiative at Brown Univer- In the traditional model of an academic medical sity, Providence, RI. He is a center, fellows not only provide surgical care, but can surgeon with the department of plastic and reconstructive add to nascent research areas, such as exploring the surgery, Rhode Island Hos- use of implementation science in surgical delivery; pital and Hasbro Children’s enhancing educational curricula for local surgery Hospital, Providence, RI. residents, medical students, and other health care providers; strengthening public health systems; and Dr. Hughes is a general building an infrastructure for preventative and trauma surgery resident, Univer- care. In the last two years, the fellowship has expanded sity of Connecticut, and a to include clinical and research opportunities with Paul Farmer global surgery PIH in Rwanda. research fellow, Children’s As for Sara, with this model of surgical part- Hospital, Boston, MA. nership as exhibited by PIH/ZL, members of the collaborative worked with Haitian surgeons to provide the surgical care she desperately needed. Using skin grafts, the physicians treated her open wounds and scars and restored movement to her neck. For the first time in almost two years, Sara is now free of dressings, wound care, and excruciat- ing pain. She can independently care for herself and, hopefully, now has a long and bright future as a member of her family and community. Ad- ditionally, through this experience, our Haitian Dr. Raymonville is director of women’s health, Zanmi colleagues have learned more about caring for Lasante and Partners in patients with burns and those in need of plastic Health, Cange, Haiti. surgery. Sara is just one patient who has suffered from the burden of untreated surgical disease and the need for essential surgical care in Haiti and other resource-poor countries around the globe. Through our partnership between PIH/ZL, the global surgery fellowship provides young surgeons with an opportunity to become involved in the global health movement, and it serves as a model for collaboration between hospitals in resource-poor countries and  academic medical centers. 49

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS References Fellowship. Available at: http://www.childrenshospital. org/clinicalservices/Site1935/mainpageS1935P70.html. 1. Farmer PE, Kim JY. Surgery and global health: A view Accessed September 2, 2011. from beyond the OR. World J Surg. 2008;32:533- 536. 2. World Bank. World Development Indicators database. 2011. Available at: http://data.worldbank.org/data- catalog/world-development-indicators. Accessed June Dr. Rogers is chief, division 28, 2012. of trauma, burn, and surgi- 3. Kidder T. Mountains Beyond Mountains: The Quest of Dr. cal critical care, department Paul Farmer, a Man Who Would Cure the World. New York, of surgery, Brigham and NY: Random House; 2003. Women’s Hospital, BWH 4. Partners in Health. The situation in Haiti. Available at: center for surgery and public http://www.pih.org/where/Haiti/Haiti.html. Accessed: health, Boston, MA. September 2, 2011. 5. Ivers LC, Garfein ES, Augustin J, Raymonville M, Yang A, Sugarbaker D, Farmer P. Increasing access to surgical services for the poor in rural Haiti: Surgery as a public good for public health. World J Surg. 2008;32:537-542. 6. Real Hope for Haiti. Available at: http://realhopeforhaiti. org/. Accessed September 2, 2011. 7. Einterz RM, Kimaiyo S, Mengech HN, Khwa-Otsyula BO, Esamai F, Quigley F, Mamlin JJ. Responding to the HIV pandemic: The power of an academic medical partnership. Acad Med. 2007;82:812-818. 8. American College of Surgeons. Operation Giving Back. Dr. Steer is surgical direc- Available at: http://www.operationgivingback.facs.org/. tor, Partners in Health, and Accessed September 2, 2011. professor of surgery, Tufts 9. The Alliance for Surgery and Anesthesia Presence. Avail- University School of Medi- able at: http://asaptoday.org/blog/. Accessed September 2, 2011. cine, and professor of surgery 10. World Health Organization. Global initiative for emer- emeritus, Harvard Medical gency and essential surgical care. Available at: http://www. School. Boston, MA. who.int/surgery/globalinitiative/en/. Accessed January 1, 2012. 11. Hayanga AJ. Volunteerism in general surgical residency: Fostering sustainable global academic partnerships. Arch Surg. 2007;142(6):577-579. 12. Jense RJ, Dunbar P. Should we support a global shift in residency training? American Society of Anesthesiologists Newsletter. 2008;72(3):22-24. 13. Jense RJ, Howe CR, Bransford RJ, Wagner TA, Dun- bar PJ. University of Washington orthopedic resident experience and interest in developing an international Dr. Meara humanitarian rotation. Am J Orthop (Belle Mead NJ). is plastic 2009;38(1):E18-20. surgeon-in-chief at Boston 14. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer Children’s Hospital, and D. Surgery in developing countries: Essential training director, program in global in residency. Arch Surg. 2005;140(8):795-800. surgery and social change, 15. Ozgediz D, Roayaie K, Wang J. Surgery and global health: Harvard Medical School. He The perspective of UCSF residents on training, research, is Chair of the ACS Legisla- and service. Bull Am Coll Surg. 2006;91(5):26-35. tive Committee. 16. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312. 17. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: A survey of resident interest. J Am Coll Surg. 2007;205(1):162-168. 50 18. Boston Children’s Hospital. Paul Farmer Global Surgery

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Dr. W. Hardy Hendren III receives 2012 Jacobson Innovation Award

Dr. Jacobson (left), and Dr. Hendren, in front of the College’s Murphy Memorial Building (also pictured at right), site of the dinner honoring Dr. Hendren.

W. Hardy Hendren III, MD, reconstruction of the urinary and for his pioneering work in the FACS, FRCS(Ire, Eng, Glas[Hon]), genital tract in patients with se- development of microsurgery. a pediatric surgeon from Boston, vere urogenital abnormalities. Dr. In the 1950s and 1960s, children MA, received the 2012 Jacobson Hendren is the Distinguished with severe urogenital abnormali- Innovation Award of the Ameri- Robert E. Gross Professor of Sur- ties were treated using multiple can College of Surgeons (ACS) at gery at Harvard Medical School, diversionary procedures, such as a dinner in his honor on June 8 Boston; emeritus chief of surgery nephrostomy, ureterostomy, cys- in Chicago, IL. An ACS Fellow at Children’s Hospital, Boston; tostomy, and ileal loop opera- since 1963, Dr. Hendren was and an honorary surgeon at tions. However, as a practicing honored with this prestigious in- Massachusetts General Hospital, surgeon, Dr. Hendren recognized ternational surgical award in rec- Boston. that infant abnormalities (such as ognition of his pioneering work The Jacobson Innovation esophageal atresia, bowel atresia, in developing urinary undiver- Award honors living surgeons and cardiac abnormalities) could be sion surgical techniques. Several who have been innovators of a repaired during infancy. He began of Dr. Hendren’s colleagues and new development or technique in to surgically fix, rather than divert, patients testified movingly at the any field of surgery and is made dilated ureters and kidneys. He dinner to his innovative and life- possible through a gift from Julius devised a repair for megaureters, altering contributions to surgery. H. Jacobson II, MD, FACS, and and a repair of complex cloacal His work revolutionized the his wife Joan. Dr. Jacobson is a anomalies, as well as a series of practice of pediatric surgery in general vascular surgeon known operations to reconstruct children 51

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS with disorders of sexual differentia- erations, Dr. Hendren and his A highly active Fellow of the tion. The next step was to repair team removed the collection bags College, Dr. Hendren served as problems in children who had from more than 200 children and Second Vice-President (1997– undergone diversion procedures, young adults. 1998), a member of the Advisory an operation that went by the His surgical approach has since Councils for Surgical Specialties word “undiversion.” been refined to a level of sophis- (1981–1986), an ACS Governor Dr. Hendren has also enhanced tication such that children born (1980–1986), and a Past-Presi- the quality of patients’ lives by with urogenital abnormalities dent of the Massachusetts Chapter ending the use of collection show almost no physical abnor- of the ACS. bags for diversionary proce- malities and are able to function Dr. Hendren credits Eleanor, dures. Through undiversion op- without multiple stomas. his wife of 65 years, with the

Jacobson Innovation Award recipients

1994 Professor Francois Dubois, Paris, France: Laparoscopic cholecystectomy 1995 Thomas Starzl, MD, FACS, Pittsburgh, PA: Liver transplantation 1996 Joel D. Cooper, MD, FACS, St. Louis, MO: Lung transplantation and lung volume reduction surgery 1998 Juan Carlos Parodi, MD, Buenos Aires, Argentina: Treatment of arterial aneurysms, occlusive disease, and vascular injuries by using endovascular stent grafts 1999 John F. Burke, MD, FACS, Boston, MA: Development and implementation of a number of innovative techniques in burn care, including the codevelopment of an artificial skin (IntegraTM) 2000 Paul L. Tessier, MD, FACS(Hon), Boulogne, France: Development and establishment of the surgical specialty of craniofacial surgery 2001 Thomas J. Fogarty, MD, FACS, Portola Valley, CA: Design and development of industry standard minimally invasive surgical instrumentation, especially for cardiovascular surgery 2002 Michael R. Harrison, MD, FACS, San Francisco, CA: Creator of the specialty of fetal surgery and developing techniques of fetoscopy for minimally invasive fetal technology 2003 Robert H. Bartlett, MD, FACS, Ann Arbor, MI: Pioneer in the development and establishment of the first extracorporeal membrane oxygenation (ECMO) program 2004 Harry J. Buncke, MD, FACS, San Francisco, CA: Pioneer in the field of microsurgery and replantation 2005 Stanley J. Dudrick, MD, FACS, Waterbury, CT: Innovator of specialized nutrition support and a pioneer in the field of clinical nutrition 2006 Judah Folkman, MD, FACS, Boston, MA: Pioneer in the field of angiogenesis 2007 William S. Pierce, MD, FACS, Hershey, PA: Pioneer in the conception and development of mechanical circula- tory support and the total artificial mechanical heart 2008 Donald L. Morton, MD, FACS, Santa Monica, CA: Pioneer in research efforts toward the development and clinical application of sentinel lymph node biopsy 2009 Bernard Fisher, MD, FACS, Pittsburgh, PA: Development and implementation of a new course for the treatment of breast cancer by proposing that it is a systemic disease that metastasizes unpredictably and would best be treated with lumpectomy combined with adjuvant chemotherapy 2010 Lazar J. Greenfield, MD, FACS, Ann Arbor, MI: Development of the Greenfield filter, a vena cava filter implanted under fluoroscopic guidance to prevent pulmonary embolism in susceptible surgical patients 2011 George Berci, MD, FACS, FRCS(Ed)(Hon), Los Angeles, CA: Pioneering contributor to the art and science of endoscopy and laparoscopy, resulting in the high level of technology used to perform many endoscopic and laparoscopic surgical procedures

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS raising of their five children: geons); and David, an attorney. including Dr. Hendren, have Sandra, a teacher and nurse Dr. Hendren and Eleanor have received the Jacobson Innovation (deceased); Douglas, an or- 11 grandchildren. Award, established in 1994. thopaedic surgeon; William, Administered by the Board To view a press release about a cardiac surgeon; Robert, a of Regents Honors Committee this year’s Jacobson Award, go to urologist (all three are Fellows of the American College of Sur- http://www.facs.org/news/2012/ of the American College of Sur- geons, 18 prestigious surgeons, jacobson0612.html.

New leadership at the helm of ACSPA-SurgeonsPAC by Chantay Moye

Robert R. Bahnson, MD, system works, and you recognize FACS, First Vice-President of the the ramifications of not being in- American College of Surgeons, volved, it is obvious we must be at has been named the new Chair the table to influence the delivery of the Board of Directors of the of health care.” ACSPA-SurgeonsPAC (the Ameri- Another area of focus for Dr. can College of Surgeons Profes- Bahnson as Chair is to encourage sional Association’s political action all College members to enhance committee). Dr. Bahnson succeeds their advocacy efforts and get to John H. Armstrong, MD, FACS, know their senators and repre- who resigned from the post to as- sentatives. Personally delivering a sume the role of Surgeon General campaign contribution, hosting a and Secretary of Health for the local fundraiser, leading members State of Florida in May. of Congress on a facility tour to Dr. Bahnson is chief of staff demonstrate how surgeons save at The Arthur G. James Cancer lives, participating in the ACS Hospital and Richard J. Solove Re- Advocacy Summit, and meeting search Institute in Columbus, OH. Dr. Bahnson with legislators on Capitol Hill He also is the Dave Longaberger are some of the ways Dr. Bahnson Chair in Urology and professor recommends that Fellows become and chairman of the department PAC helps elect champions who engaged. “I was surprised to find of urology at The Ohio State Uni- will join the campaign for the best out how simple it is to develop versity. possible policy outcomes.” these relationships, and how much The mission of the ACSPA- One of Dr. Bahnson’s immedi- our College’s Washington Office SurgeonsPAC is to advocate for ate goals is to increase Fellows’ facilitates these efforts,” he said. surgeons and surgical patients knowledge of both the ACSPA- Dr. Bahnson speaks from personal through bipartisan financial sup- SurgeonsPAC and political pro- experience, having hosted local port for pro-surgery candidates and cesses. “Although awareness and physician fundraisers for Sen. political education that elevates participation have grown signifi- Sherrod Brown (D-OH) and Rep. surgical practice. “A well-funded cantly in the past 10 years, only 4 Pat Tiberi (R-OH) during this PAC sends a clear message of our percent of ACS Fellows invest in election cycle. involvement,” said Dr. Bahnson. SurgeonsPAC,” he stated. “I hope This year and beyond is a piv- “It provides the political clout to educate all surgeons about the otal time for the future of health necessary to positively influence the critical importance of advocacy. care. “It is a fact that health policy composition of Congress. A strong When you understand how the changes will dramatically alter the 53

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS health care delivery system in the ward to working with Dr. Bahn- elected First Vice-President, he United States,” said Dr. Bahnson, son and seeing his knowledge and served in several key leadership but “we must be poised for ac- leadership skills at work,” said positions in the College. He was tion, participate in the process, Christian Shalgian, Director of a member of the Board of Gover- and protect our patients and our the ACS Division of Advocacy nors from 2004 to 2009, chaired practices. As leaders and surgeons, and Health Policy. the Urologic Advisory Council we must become fully engaged A graduate of Carleton College, from 2007 to 2011, and the Advi- stakeholders in the legislative and Dr. Bahnson received his medical sory Council Chairs from 2009 to political process to secure a viable degree in 1979 from Tufts Univer- 2011, and was Vice-Chair of the future for the practice of surgery.” sity in Boston, MA. He completed Program Committee from 2009 to Dr. Bahnson is considered to his residency at Northwestern 2010. He is presently a Consultant be highly qualified to meet the University in Chicago, IL. He to the Program Committee. challenges ahead. “His reputation previously held faculty positions for dedication and his understand- at Washington University in St. Ms. Moye is Communications Manager, ing of the legislative and political Louis, MO, and at the University ACS Division of Integrated Communica- processes precedes him. I look for- of Pittsburgh, PA. Prior to being tions, Washington, DC.

Dr. Armstrong named Florida Surgeon General, Secretary of Health

John H. Armstrong, MD, signment was director of the U.S. FACS, a member of the Ameri- Army Trauma Training Center in can College of Surgeons (ACS) Miami, FL. He led the develop- Board of Governors and past ment and implementation of a Chair of the American College two-week award-winning team of Surgeons Professional Associa- training program in trauma care tion’s political action committee for military medical units de- (ACSPA-SurgeonsPAC) assumed ploying to Iraq and Afghanistan. the role of Florida Surgeon Gen- Dr. Armstrong earned a medi- eral and Secretary of the Florida cal degree from the University Department of Health on May of Virginia School of Medicine, 23. Florida Gov. Rick Scott (R) Charlottesville. He completed appointed Dr. Armstrong to the his surgical residency at Tripler position. Army Medical Center in Hawaii, A trauma surgeon, Dr. Arm- his fellowship in trauma/surgi- strong is chief medical offi- cal critical care at the Univer- cer of the University of South sity of Miami/Jackson Memorial Florida (USF) Health Center Dr. Armstrong Medical Center in Florida, and for Advanced Medical Learning completed the master educators and Simulation and associate of medical education program professor of surgery at the USF mittee on Disaster Management. at the University of Florida, Morsani College of Medicine in He served as the Army (State) Gainesville. He is a graduate of Tampa. He chairs the ACS Del- COT Chair from 2003 to 2006 the U.S. Army Command and egation of the American Medical and is a member of the Residency General Staff College and re- Association’s House of Delegates, Review Committee for Surgery. mains on faculty in the Norman is a member of the ACS Health Dr. Armstrong served in the M. Rich Department of Surgery Policy and Advocacy Group, and U.S. Army Medical Corps for 17 at the Uniformed Services Uni- is a consultant to the ACS Com- years, concluding his service at versity of the Health Sciences, 54 mittee on Trauma Ad Hoc Com- the rank of Colonel. His final as- Bethesda, MD.

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NQF endorses SQA’s Patient-Focused Care Survey

The National Quality Forum the recovery process. Responses Critical gaps in the assessment (NQF) issued its endorsement will help surgeons deliver more of surgical care from the patient of the Consumer Assessment of patient-centric care by identify- perspective initiated the devel- Healthcare Providers and Sys- ing areas for practice improve- opment of the CAHPS Surgical tems (CAHPS®) Surgical Care ment. The CAHPS Surgical Care Survey. Preceding its de- Survey on June 1. The American Care Survey is the only NQF- velopment, proponents opined College of Surgeons (ACS) led endorsed measure designed to that critical surgical areas, such the effort to develop the survey, assess surgical quality from the as consent, shared decision mak- working in partnership with patient’s perspective. ing, anesthesia care, postopera- other members of the Surgical “Paramount to ACS is assess- tive instructions, and access were Quality Alliance (SQA) and the ing surgical care based on what absent among previous evidence- Agency for Healthcare Research is important to the patient,” based, validated surveys in the and Quality’s (AHRQ) CAHPS said Frank Opelka, MD, FACS, public domain. Consortium. Associate Medical Director, The development of the survey The survey will assess surgical ACS Division of Advocacy and followed AHRQ’s standardized patients’ experiences before, dur- Health Policy. “This surgical and evidence-based methods ing, and after surgical procedures care survey is unique. It is the that are used in the creation of all to adequately identify opportu- only NQF-endorsed measure CAHPS surveys. The NQF en- nities to improve quality of care, designed to assess surgical qual- dorses quality measures through surgical outcomes, public report- ity from the patient’s perspec- scientific and evidence-based ing, and patient satisfaction. It tive. Its development shows the review and a multi-stakeholder will capture patients’ thoughts College’s strong commitment to consensus development pro- on several factors that affect the actively partner with organiza- cess with the aim of improving patient care experience, includ- tions focused on improving quality of care. Measures that ing how well their surgeons pre- the patient experience and to are endorsed must meet NQF’s pared them for their operations, developing high levels of quality criteria, which include a rigorous communicated, and explained improvement guidance.” review of the measure’s ability to make significant gains in health care quality, scientific accept- ability, usability, feasibility, and Trauma meetings calendar reliability. The surgical care survey is one of nine new quality measures on The following continuing Acute Care Surgery, March surgical care performed in hos- medical education courses in 17–20, 2013, Las Vegas, NV pitals and in outpatient facilities trauma are cosponsored by the that recently received NQF en- American College of Surgeons Complete course informa- dorsement. The set of measures Committee on Trauma and tion can be viewed online (as it are part of NQF’s Surgery En- Regional Committees: becomes available) through the dorsement Maintenance, Phase American College of Surgeons 2 Addendum report. • Advances in Trauma Con- website at http://www.facs.org/ For more details and informa- ference, December 7–8, trauma/cme/traumtgs.html, or by tion about other organizations Kansas City, MO. contacting the Trauma Office at involved in development of the • Trauma, Critical Care and 312-202-5342. survey, go to http://www.facs.org/ news/2012/surgical-survey0612. html. 55

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS An Inside Glimpse of Our First 50 Years

Three volumes of retirement scrapbooks compiled by Eleanor K. Grimm, long recognized as the pivotal recorder of the first 50 years of the American College of Surgeons (ACS), have been scanned and are available for viewing in PDF format on the ACS Archives webpage. Hired by Franklin H. Martin, MD, FACS, when the College was founded in 1913, Ms. Grimm quickly became his trusted assistant. She was influential during Dr. Martin’s efforts to guide the organization through its formative years, and even more so after his death in 1935, when she served as the secretary to the Board of Regents and, in effect, chief administrative officer, until she retired in 1951. The volumes contain Ms. Grimm’s correspondence with many ACS leaders of the first 50 years, such as Charles and William Mayo, George Crile, Albert Ochsner, Allan Kanavel, Ernest Codman, Alfred Blalock, Owen Wangensteen, Frederick Besley, John Bowman, and Malcolm McEachern. To view the Eleanor K. Grimm Resources and the scrapbook volumes, go to: www.facs.org/archives/ekgrimm.html Florida initiative uses ACS NSQIP® processes to measure and improve care

At its 2012 annual meeting on identified areas where they are proximity to an academic medical May 18 in Sarasota, the Florida doing well and where there are center. The College recently revised Chapter of the American College opportunities for improvement. ACS NSQIP to expand its avail- of Surgeons released preliminary Ideally, every Florida hospital will ability to smaller hospitals. data from the Florida Surgical join this program so that we can Dr. Tepas emphasized that Care Initiative (FSCI), a collabo- begin to work as a single entity to all participating hospitals are ration of the Florida Hospital As- guarantee all surgical patients the continuing to improve their out- sociation, Blue Cross Blue Shield best quality humanly possible,” comes. High performers get even of Florida, and the American Dr. Tepas said. “Better quality better, and those that want to College of Surgeons (ACS). Ap- means less cost and much better improve find ways to achieve plying the ACS National Surgical value for everyone.” that goal through this program. Quality Improvement Program Frank Evans, BSN, JD, sur- Because the data reported back to (ACS NSQIP) processes, data gical clinical nurse reviewer, hospitals are risk-adjusted, hospi- from 26,824 operations reported South Miami Hospital, added tals can assess their performance by the first 50 of 65 participating that his institution depends using real-time clinical informa- hospitals were compared with on the ACS NSQIP to manage tion rather than pooled adminis- a national sample of 313,529 quality and save millions of dol- trative or claims data. procedures. Analysis of Florida lars through the development The Florida initiative will participating hospitals’ rates of of strategies aimed at avoiding bring another dimension to the postoperative occurrences cat- complications. process of quality improvement. egorized by such critical issues “Before beginning to address Now that an appropriate baseline as wound and bladder infections, our surgical problems, we had to of state performance for com- pneumonia, blood use, and post- first identify what they were. ACS parison with the leading national operative organ system failure NSQIP was the tool we were able hospitals has been established, demonstrated a level of perfor- to use to immediately allow us specific regions within the state mance equal to that reported by to identify those problems,” said can aggregate de-identified data all hospitals participating in the Mr. Evans. to determine areas where supe- program nationwide. John P. Rioux, MD, FACS, rior performance may be used to J.J. Tepas III, MD, FACS, a member of the ACS Board of develop best practices. state FSCI surgical coordinator, Governors in surgical practice at “We have only just begun, welcomed these findings as the three community hospitals in Port but we have begun well, and are starting point for continuous Charlotte, noted the importance clearly on a path that will enable quality improvement in Florida. of assessing surgical outcomes in us to guarantee all Floridians the “The hospitals are performing smaller community hospitals so highest quality of surgical care comparably to the ACS NSQIP that all Floridians can receive state- every time and all the time,” Dr. hospitals and, importantly, have of-the-art care, regardless of their Tepas said.

Read this month’s Bulletin online at www.facs.org/fellows_info/bulletin/bullet.html

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From surgeon to grassroots advocate: Chapter leaders engage in advocacy development by Alexis Macias and Oscar Guillamondegui, MD, FACS

The American College of Sur- geons (ACS) presented the State Leadership Advocacy Conference in April at the College’s headquarters in Chicago, IL. A total of 20 chapter leaders attended, including Governors, administrators, and Executive Directors from eight chapters: Arizona, California, Connecticut, Geor- gia, Indiana, Massachusetts, New York, and Ohio. Attendees had the opportunity to network, learn how to structure their chapter to maximize advocacy efforts, explore innovative ways to motivate chapter members, identify best practices for communicating with legislators, and consider programs State Leadership Advocacy Conference attendees. Front row: Susan Lee, MD, FACS; on building effective legislative Manmeet Malik, MD; and Marcie Leeds, MD. Second row: Ms. Macias; James Hinsdale, messages and coalitions. MD, FACS; Paula Hammer; Ms. Starkey; Karen Rieger, MD, FACS; William Nowlin, The conference was part of MD, FACS; and Dr. Masiakos. Back row: Chris Tasik; Dr. Schwarz; Dr. Guillamonde- gui; Dr. McAneny; Kimberly Lieber, MD, FACS; Kristin Poppalardo; Charlotte Grill; the College’s ongoing effort to and Jon Sutton. enhance and support chapter advocacy in the states. In a 2010 ACS member survey, 65 percent of the Fellows surveyed reported that state-level advocacy is an speakers. The presenters, includ- of Key Management Solutions “essential” and “very important” ing College staff members, chap- in Columbus, OH, discussed benefit of ACS membership. ter Executive Directors, surgeon advocacy programs that could Ninety-two percent of those sur- advocacy leaders, and staff from be instituted at the state level. veyed “strongly agree” or “agree” the American Medical Associa- Ms. Browning highlighted the that advocacy should be a prior- tion offered a variety of content importance of having a structured ity for the ACS.* perspectives. advocacy agenda. She suggested Attendees were introduced that chapter leaders raise member Program highlights to numerous state advocacy awareness by highlighting advo- Throughout the day-and-a- programs that ACS chapters cacy when prioritizing chapter half conference, various topics could readily implement. Kathy needs. She also recommended were covered by a wide array of Browning, Executive Director that chapters publish an advocacy *Anderson, Niebuhr, & Associates, Inc. of the Georgia Society of the newsletter to establish regular American College of Surgeons 2010 Fellow American College of Surgeons, communication with chapter 58 Survey. 2010. and Jennifer Starkey, president members, create a state politi-

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cal action committee, effectively describing his multi-year cam- attending the conference with use social media, and create and paign to pass all-terrain vehicle David McAneny, MD, FACS, participate in legislative “calls to (ATV) age restriction legislation ACS Governor from Massachu- action.” Ms. Browning reminded in his state. During his presenta- setts, surgeons in Tennessee now attendees of the importance of tion, Dr. Masiakos highlighted have an opportunity to develop advocacy with a quote she attrib- several key facets of a successful a program that connects active uted to Plato: “Those who are advocacy campaign: members of the chapter with too smart to engage in politics • Think outside of the box when less active members at a local are punished by being governed developing resources and co- level to ensure physicians have by those who are dumber.” alitions a voice with representatives in Ms. Starkey’s presentation • Don’t reinvent the wheel their home districts. focused on the importance of • Use research and data already Although the State Leader- organizing and hosting a state available ship Advocacy Conference was lobby day. She provided tips for • Don’t give up focused on a defined group of a successful lobby day, including Dr. Masiakos’ inspiring pre- chapter leaders, the advocacy working with the state medi- sentation and tireless efforts have development information cov- cal society to collaborate on an encouraged representatives from ered during the conference is agenda, creating a program that Washington, West Virginia, and universal in application. All is structured to benefit chapter Virginia, as well as several ACS surgeons can benefit from a ba- members and members of the chapter leaders, to become in- sic knowledge of advocacy and state legislature, and creating terested in passing ATV laws in by supporting their respective materials that enhance the mes- their respective states chapter advocacy activities. sage for both lobby day attend- For more information on the ees and legislators. Ms. Starkey A surgeon’s perspective topics discussed in this article, also suggested engaging chapter As the President-Elect for the including copies of handouts members through programs out- Tennessee Chapter, Dr. Guil- or presentations, contact Alexis side of a formal lobby day, such lamondegui, a co-author of this Macias, Regional State Affairs as Doctor of the Day meetings, article, attended the recent State Associate, at [email protected] telephone marathons, and White Leadership Advocacy conference or 312-202-5446. Coat Rallies. to gain some understanding of John Schwarz, MD, FACS, the process involved in engag- Ms. Macias is the Regional State Af- an otolaryngologist from Battle ing members of Congress in a fairs Associate, Division of Advocacy and Creek, MI, provided illuminat- dialog regarding the laws that Health Policy, Chicago, IL. ing insights into the political affect their surgical patients. He process drawing on his own po- also sought to develop a plan to Dr. Guillamondegui is associate professor, surgery and neurological surgery, litical career serving as the mayor encourage the state membership and trauma medical director, division of Battle Creek, a Michigan state to become active participants at of trauma and surgical critical care, senator, president pro tempore of the local level. Vanderbilt University Medical Center, the Michigan Senate, and a U.S. Every year, the Tennessee legis- Nashville, TN. representative. Dr. Schwarz re- lature introduces legislation that galed attendees with stories from would repeal the state’s motorcycle his days serving in Congress and helmet law. The advocacy confer- highlighted the importance of ence allowed Dr. Guillamondegui becoming involved even while the opportunity to gain perspec- continuing to practice surgery. tive on how to actively partici- Peter Masiakos, MD, FACS, pate and successfully oppose the Legislative Chair, Massachusetts repeal legislation by using the Chapter of the ACS, showed at- guidelines established by Drs. tendees how he implemented a Masiakos and Schwarz. By lever- successful advocacy campaign by aging the relationship built while 59

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS HPRI representatives visit Lord Ribeiro at U.K.’s House of Lords

Erin P. Fraher, PhD, MPP, and Thomas C. Ricketts III, PhD, MPH, of the American Col- lege of Surgeons (ACS) Health Policy Research Institute (HPRI), were guests of Sir Bernard F. Ribeiro, KtCBE, FACS(Hon), FRCSEng, FRCPEng, May 22–23 at the United Kingdom’s House of Lords. Several doctoral students from the University of North Carolina (UNC), Chapel Hill, accompanied Drs. Fraher and Ricketts on the trip, where they witnessed firsthand the art of legislative compromise. Lord Ribeiro was appointed in 2010 to the House of Lords as a Life Peer. During a distinguished career, Lord Ribeiro has contributed significantly to the surgical Meeting at the House of Lords (from left): Baroness Jolly, Dr. Fraher, Lord Ribeiro, and profession in the U.K., where he Dr. Ricketts. has worked to modernize surgical training and introduced a new surgical curriculum. He served as of ACS Past-President George F. observers described the changes president of the Royal College of Sheldon, MD, FACS, conducts as the English health system’s Surgeons of England from 2005 research on surgical issues, includ- most extensive reorganization. to 2008. ing the geographic distribution of Lord Ribeiro was really one of In 2008, he joined the ACS general surgeons in the U.S. Dr. the key people who negotiated the leadership in presenting testimony Sheldon presented Dr. Ribeiro for process and compromise that was on resident work hours and work Honorary Fellowship in the ACS finally reached.” The newly created schedules to the Institute of Medi- in 2008. public body that will manage the cine of the National Academy of At the time of the visit, “The health service, the NHS Commis- Sciences panel on resident hours British Parliament had just gone sioning Board, will officially begin and work schedules. “He helped through a very long process of its work on April 1, 2013.* panel members understand the reforming the English health and The new plan restructures health ramifications of restricting resi- social care systems (the Health service in England, giving groups dent hours,” said Dr. Ricketts. and Social Care Act 2012, which of general practitioners (GPs—the The HPRI, established in 2008 passed on March 27). It was a equivalent of family physicians in at the UNC under the direction serious overhaul of the National the U.S.) and other health care Health Service (NHS) and a very professionals 60 percent control of *Triggle N. BBC News. Analysis: What next for the NHS? Available at http://www.bbc. difficult one,” explained Dr. Rick- the health service’s annual budget. co.uk/news/health-17448838. Accessed June etts. “The actual bill was longer “Basically, what it does is give fam- 60 22, 2012. than the Affordable Care Act, and ily doctors the purse strings to

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS care for patients,” explained Dr. major health care issues, she said, mittee on Health and Social Care Fraher. “Clinicians will make the centers on the evolving standards in England, who was instrumental decisions on whether, for example, of quality health care and how in passing England’s health service a patient needs a hip replacement.” quality can be measured and bill, and Earl Howe, Parliamen- “The legislation also introduces reported. “These are the same tary Under Secretary of Sate at the competition into the health ser- concerns that the ACS addresses Department of Health. vices,” Dr. Fraher continued. As today. “The whole experience was in the U.S., the goal is to reduce “The English parliament is look- very useful in helping us under- administrative costs and the rising to their professional groups for stand health reform in the U.S.,” ing costs of caring for an aging input in a process that has engaged said Dr. Ricketts. “Lord Ribeiro population, she said. clinicians in helping to transform said he wants to continue to share “Even though our systems are the NHS,” she added. information and communicate different, it was striking to me The U.S. visitors also met with regularly with us. He asked that how similar the challenges are,” Baroness Judith Jolly, co-chair of we keep him informed about said Dr. Fraher. One of England’s the Liberal Democrat Party Com- what we’re working on here.”

Surgical quality forum focuses on how QI can help curb health care costs

The American College of Sur- geons (ACS) hosted a Surgical Health Care Quality Forum in Boston, MA, on June 4, with health care policy and clinical experts discussing how quality surgical care leads to better patient and financial outcomes. The ACS Surgical Health Care Quality Forum Boston is part of the College’s Inspiring Qual- ity initiative, which is designed to promote critical elements required in successful quality improvement programs that can measurably improve outcomes and reduce health care costs. “If we can get to a place where improving quality reduces pre- Forum participants, left to right: Drs. Slavin, Gawande, Warshaw, Altman, Zinner, Fin- ventable complications, we will layson, and Hutter. have found part of the solution to the vexing problem of controlling costs in an equitable, sity, Waltham, MA. “In the past were part of the problem—a big humane, and efficient way,” said we didn’t include physicians and mistake. We need them as part keynote speaker Stuart Altman, surgeons in discussions on how of the solution because they are PhD, economist and health to fix the American health care American health care. Everyone policy expert, Brandeis Univer- system because we thought they needs to play, and physicians 61

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS and surgeons are really on the improvement as a critical com- database. The program has been right track, focusing on quality ponent of the profession,” said credited as “Best in the Nation” improvement as one viable means ACS Treasurer and event cohost for surgical quality by the Insti- to address the cost issue.” Andrew L. Warshaw, MD, FACS, tute of Medicine, and is currently According to ACS Regent and W. Gerald Austen Distinguished used in approximately 400 hos- forum cohost Michael J. Zinner, Professor of Surgery, Harvard pitals across the U.S. MD, FACS, “If physicians, Medical School; surgeon-in-chief, “When economic realities surgeons, and hospitals are en- emeritus, Massachusetts General dictate that we can’t spend more, gaged in the important dialogue Hospital (MGH); Chair, Ameri- and our population demands around improving surgical qual- can College of Surgeons Health that we do a better job of main- ity programs that advance patient Policy and Advocacy Group. taining their health, the only outcomes, we will be in a better “In surgery, we know what needs solution is to increase the value position to deliver better value, to be done to improve results and of what we do,” said panelist because we believe that appropri- reduce costs,” added panelist Atul Samuel Finlayson, MD, MPH, ate care delivered the first time Gawande, MD, MPH, FACS, FACS, Kessler Director, Center lowers cost.” Dr. Zinner is Mose- a surgeon at BWH, professor for Surgery and Public Health at ley Professor of Surgery, Harvard at Harvard Medical School and BWH. “To ensure that surgery is Medical School; clinical director Harvard School of Public Health, appropriately used, our current of the Dana Farber/Brigham and lead advisor on surgery to World systems of care delivery have Women’s Cancer Center; and Health Organization Patient relied on hurdles and blocks in surgeon-in-chief, Brigham and Safety, and prolific author. “The the form of insurance preap- Women’s Hospital (BWH). problem is doing it. But we are provals, paperwork, and extra Surgical care takes up half of starting to see answers.” clinic visits. We need to rede- the annual commercial health “Truly focusing on quality im- sign surgical care in a way that care expenditures nationwide.* provement requires good data— reflects a ‘make it easy to do the The ACS views improving quality data that surgeons trust—and right thing’ approach. We need as instrumental to adding value we have that with ACS NSQIP® to develop ways to deliver better to health care systems because it [American College of Surgeons information, streamline and co- reduces costs and improves care. National Surgical Quality Im- ordinate care flow, and structure “Surgical quality matters ev- provement Program],” said pan- surgical decision-making so that erywhere in the country, but elist Matthew Hutter, MD, providing the most efficient, we’ve taken special pride here MPH, FACS, director of the most appropriate surgical care in Boston because this is where Codman Center for Clinical Ef- is actually the easiest thing for a Ernest A. Codman, MD, FACS, fectiveness in Surgery at MGH, surgeon to do.” the founder of the quality move- and assistant professor in surgery “We’ve found at MGH that ment, made his stand on quality at Harvard Medical School. there are three key institutional Known as a model for outcomes- fundamentals for continuous *Health Care Cost Institute Annual Expenditure Summary: 2007 to 2010. based quality improvement, the quality improvement to thrive: Available at: http://www.healthcostinstitute. ACS NSQIP collects clinical, leadership, infrastructure, and org/files/HCCI_HCCUR2010_Appendices. risk-adjusted, 30-day outcomes incentives,” added panelist Peter pdf. Accessed July 16, 2012. data in a nationally benchmarked Slavin, MD, president, MGH. “The institution can drive qual- Correction ity by implementing programs and protocols, but it’s up to the The article “Team approach minimizes risk in separating conjoined twins: An collaboration among all team interview with Gary Hartman, MD, FACS” (Bull Am Coll Surg, 97[6]:24-27), incor- members—from hospital admin- rectly states, “Only about two dozen conjoined have been successfully separated istrators to clinicians—and their in medical history....” The article should have reported that approximately 200 of willingness to strive for culture those procedures have been performed. The Bulletin staff regrets the error. change and progress that makes 62 quality improvement ‘real.’”

VOLUME 97, NUMBER 8, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS A look at The Joint Commission SafeCare offers quality framework in resource-restricted settings

As health care professionals, of operations are primarily per- facilities by imposing unreach- surgeons are aware of the gap formed in regional and national able international absolute qual- between the care patients in tertiary hospitals. Referrals to ity norms. Instead, SafeCare resource-restricted countries these surgical settings will be offers a step-wise approach, first receive and the ideal standard more timely, with better assess- confronting facilities with incre- of care. The reasons for such ment information and communi- mental challenges with respect disparities include a lack of quali- cation to the receiving surgeons to quality and patient safety, fied personnel, scarce financial and coordination of care when and eventually rewarding and resources, and the enormous the patient returns to the clinic. encouraging these facilities with burden of disease. To help pro- To date, the SafeCare program recognition through its certifica- viders deliver safe care to their has been successfully initiated tion system. patients—regardless of available in more than 107 clinics in six The impact of the SafeCare resources—the new SafeCare countries—Ghana, Kenya, Le- Foundation’s interventions will Foundation is offering surgeons sotho, Nigeria, South Africa, be monitored through data analy- and other health care profession- and Tanzania. The facilities par- sis, and operational research als a comprehensive system that ticipating in SafeCare have com- and findings will be published can be used to improve outcomes. mitted to improving the quality in peer-reviewed journals. The The SafeCare Foundation of their services as part of their SafeCare Foundation will also is a cooperative comprising participation in various insurance publish information on the tools, Joint Commission International and medical credit programs. The goals, and results of the pro- (JCI), the South African-based first 10 of these facilities recently gram and will make information Council for Health Service Ac- obtained Certificates of Improve- and standards publicly available creditation of Southern Africa ment, which were awarded based through its website. In addition, (COHSASA), and the Phar- on reaching predefined levels of a SafeCare Knowledge Institute mAccess Foundation of the standard compliance. will be established to provide Netherlands (PharmAccess). Certificates range from level 1 health intelligence data on health The foundation provides a step- to 5, which allows for demon- care quality improvement in by-step framework based on strating incremental achievement Africa, provide benchmarks, internationally recognized stan- in compliance with the SafeCare perform gap analyses, and study dards for improving health care Foundation standards. Health the associations between quality delivery. Through automation of care facilities are rewarded with a improvement certification and data entry, verification analysis, certificate every time they reach medical output and outcome. and computerized Web-based the next predefined SafeCare step. These vital analyses can be used to reporting, SafeCare will offer If executed completely (SafeCare inform donors and governments large-scale quality improvement Level 5), the facility will qualify about the status of health care in programs and certification op- for formal accreditation tra- specific regions or countries. tions. jectories, for example, through For more information about The SafeCare program is fo- COHSASA or JCI. What makes SafeCare, go to www.jointcom- cused on rural clinics and dis- this program unique is the fact missioninternational.org/Other- trict hospitals where health care that the SafeCare route is cen- Alliances/. professionals may perform minor tered on relative improvement surgical procedures. Other types and does not demotivate African 63

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AmE riCAN CO llEg E OF SU rgEONS ♦ DiV iSi ON OF E DUCATi ON UltrasoU nd for sUrgeons: T HE B ASi C C OUr SE, 2nd E D i T i ON

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UltrasoundAd BULLETIN rev 02-2012.indd 1 2/23/2012 2:56:47 PM ACS Clinical Research Program What’s new in renal cell carcinoma by Maxwell V. Meng, MD, FACS, and Heidi Nelson, MD, FACS

Over the past decade, signifi- standard initial intervention. How- tients in September 2010. The trial, cant changes have occurred in the ever, patients with advanced or activated April 24, 2006, has en- presentation, understanding, and metastatic disease are rarely cured rolled 1,865 patients randomized treatment of renal cell carcinoma. through surgical procedures alone, to one year of sunitinib, sorafenib, Increased imaging has led to the and systemic treatments often or placebo therapy after surgical incidental identification of most benefit these patients. Historically, excision of the primary tumor. The renal masses, with a concomitant traditional chemotherapy has had current standard of care, even for migration of tumors to a lower poor response rates and systemic patients with high-risk pathologic stage at the time of diagnosis. options have been focused on im- features, is surveillance after surgi- This, in turn, has led to the op- munotherapy with cytokines, such cal procedures when no evidence of portunity to change the surgical as interleukin-2 and interferon alfa. residual disease can be found. Thus, management of renal cancers so Hence, new targeted agents that the study is designed to determine that many tumors can now be are routinely used for metastatic whether adjuvant targeted therapy managed in a minimally invasive disease and being tested in the neo- improves cancer-specific survival. fashion with either laparoscopic adjuvant and adjuvant settings have Eligible patients included those or robotic-assisted surgery. Poten- created some excitement among having: (1) intermediate risk of tially of greatest importance is the urologists and medical oncologists. relapse (≈33 percent) with pT1G3- elucidation of the biological basis Improvements in the under- 4, pT2, or pT3aG1-2 tumor; (2) of sporadic as well as hereditary standing of the molecular patho- high risk of relapse (50 percent to forms of renal carcinomas. physiology of renal cell carcinoma 60 percent) with pT3aG3-4, +ad- Most renal tumors arise from have led to the development of renal involvement, pT3b-c, pT4; loss of function of the von Hippel- several novel targeted agents, with or (3) very high risk of relapse (≈66 Lindau (VHL) gene and resultant seven approved by the Food and percent) with N+ disease. Results activation of the hypoxic response, Drug Administration (FDA) and are expected to be available in the including upregulation of hypoxia currently available for patients next few years, and the study was inducible factor leading to vascular with metastatic disease. These designed to demonstrate a 25 per- endothelial growth factor induc- agents include the tyrosine kinase cent reduction in the hazard rate of tion and ultimately angiogenesis. inhibitors sorafenib (approved in disease-free survival events. The trial In addition to the VHL syndrome, 2005), sunitinib (2006), pazo- also included correlative science to other hereditary forms include he- panib (2011), and axitinib (2012); examine items such as microvessel reditary papillary renal carcinoma mTOR inhibitors temsirolimus density and associated markers of (MET gene), Birt-Hogg-Dubé (2007) and everolimus (2009); angiogenesis; pharmacokinetics and (FLCN gene), and hereditary and VEGF-inhibiting monoclonal effect of cytochrome p3A4/5, B-raf, leiomyomatosis-renal cell cancer antibody bevacizumab (2009). The and VEGF polymorphisms on out- (fumarate hydratase gene). role of these therapies in either the come; and DNA hypermethylation The most revolutionary change neoadjuvant or adjuvant setting of P16 and VHL. in the management of renal cell remains unclear and is an active A recently endorsed trial is the carcinoma may be the approach area of investigation. EVEolimus for Renal Cancer Ensu- and options for advanced disease. The Adjuvant Sorafenib or Suni- ing Surgical Therapy (EVEREST) Surgical resection of localized renal tinib in Unfavorable Renal Cell study (SWOG 0931). Similar in cell carcinoma can be curative for Carcinoma (ASSURE; ECOG design to ASSURE, EVEREST lower-stage disease and remains the 2805) trial completed accruing pa- examines the benefit of adjuvant 65

AUGUST 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS systemic therapy after surgical are significant differences in side ef- is expressed on the cell surface of procedures in patients with inter- fect profile, and which population clear renal cell carcinomas. Future mediate high-risk (pT1b G3-4; benefits the most. trials may extend the potential pT2 G1-4; pT3a G1-2) or very Similar ongoing adjuvant tri- role of cell-based immunotherapy, high-risk disease (pT3a G3-4; als include the Pfizer-sponsored such as RNA-loaded autologous +adrenal involvement; pT3b-c; S-TRAC trial (n=720) comparing dendritic cells, from patients with pT4; N+). Although sorafenib, sunitinib with placebo and the metastatic disease to the adjuvant sunitnib, and everolimus are all Medical Research Council SORCE setting. used clinically, sorafenib and suni- trial (n=1,656) comparing sorafenib tinib are tyrosine kinase inhibitors, with placebo. Other agents are also Dr. Meng is associate professor of urology, de- whereas everolimus is an mTOR being tested in the adjuvant setting, partment of urology, University of California, inhibitor. An estimated 1,218 pa- including pazopanib (PROTECT), San Francisco, and director of the fellowship tients will be randomized to either as well as those that exploit the pur- in urologic oncology. everolimus or placebo, stratified ported immunogenicity of renal cell Dr. Nelson is Fred C. Andersen Professor by pathologic stage, histologic carcinoma. of Surgery and chair, division of surgery subtype, and performance status. An accrued phase III trial has research, Mayo Clinic College of Medicine, It will be interesting to see which tested the antibody girentuximab, Rochester, MN, and Program Director of agent(s) proves to be beneficial in which binds specifically to carbonic the Alliance/American College of Surgeons the adjuvant setting, whether there anhydrase IX (G250 antigen) that Clinical Research Program.

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ACS Higher National Quality Surgical Quality Care Lower Improvement Program Costs

We’ve found common ground for health care.

Our National Surgical Quality Improvement Program prevented 250-500 complications per year, per hospital. Improving care – and reducing costs. You can do both. The ACS National Surgical Quality Improvement Program – a national effort to improve surgical care and cut costs run by the American College of Surgeons – is helping to prevent thousands of surgical complications each year, according to a study of 118 hospitals. The hospitals experienced a reduction of 250-500 complications per hospital, per year. If these methods were used in every hospital in the nation, we could reduce health care costs by $13 to $25 billion every year, or $130 to $250 billion over the next decade – and help literally millions of patients avoid preventable complications. So let’s stop focusing on the issues that divide us, and work together to make sure Congress rewards providers who deliver better care at lower costs by using measures like these.

Learn more about the ACS NSQIP® program at acsnsqip.org

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