VennDiagram Ad revise:M0638A 9/16/11 4:02 PM Page 1

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 JANUARY 2012 Volume 97, Number 1

INSPIRING QUALITY: Highest Standards, Better Outcomes

FEATURES Diane S. Schneidman Medical liability reform: Editor Evidence for legislative and alternative approaches 6 Lynn Kahn Ian S. Metzler and John G. Meara, MD, DMD, FACS Director, Division of Integrated Communications Sanctity and organ donation’s societal value 12 Tony Peregrin Michael R. Marvin, MD, FACS; Kenneth M. Prager, MD; Senior Editor Max V. Wohlauer, MD; and James G. Chandler, MD, FACS Stephen J. Regnier Invited commentary: Sanctity and organ donation’s Contributing Editor societal value in an opt-out country: The Austrian experience 24 Tina Woelke Matthias Biebl, MD, and Johann Pratschke, MD, PhD Graphic Designer CPT 2012 brings with it new codes and code changes 26 Charles D. Mabry, Linda Barney, MD, FACS; Mark Savarise, MD, FACS; MD, FACS and Jenny Jackson, MPH Leigh A. Neumayer, MD, FACS Highlights of the 97th Annual Clinical Congress 33 Marshall Z. Schwartz, MD, FACS ACS Officers,egents, R and Board of Governors’ Executive Committee 42 Mark C. Weissler, MD, FACS Editorial Advisors Tina Woelke DEPARTMENTS Front cover design

Looking forward 4 Editorial by David B. Hoyt, MD, FACS, ACS Executive Director Future meetings HPRI data tracks 46 Clinical Congress Urology workforce trends 2012 Chicago, IL, Simon Neuwahl; Kristie Thompson; Erin Fraher, PhD, MPP; September 30– and Thomas Ricketts, PhD, MPH October 4 Advocacy advisor 50 2013 Washington, DC, 2011 lobby day wrap-up: Ohio, Massachusetts, and Alabama October 6–10 Charlotte Grill 2014 San Francisco, CA, October 26–30

Letters to the Editor should be sent with the writer’s name, ad- dress, e-mail address, and daytime telephone number via e-mail to [email protected], or via mail to Diane S. Schneidman, Editor, Bul- letin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or clarity. Permission to publish letters is assumed unless the On the cover: The history of organ transplantation reflects society’s struggle to come to terms author indicates otherwise. with the possibilities presented by medical technology in relation to religion, science, and law (see articles, pages 12 and 24). NEWS Bulletin of the American College of Surgeons (ISSN J. David Richardson, MD, FACS, 0002-8045) is published monthly elected Chair of ACS Board of Regents by the American College of Sur- 52 geons, 633 N. Saint Clair St., Call for nominations for the ACS Board of Regents 53 Chicago, IL 60611. It is distrib- uted without charge to Fellows, A message from the Editor 53 Associate Fellows, Resident and Medical Student Members, Af- Call for nominations for ACS Officers-Elect 54 filiate Members, and to medical libraries and allied health person- Nominations sought for 2012 volunteerism and humanitarian awards 55 nel. Periodicals postage paid at Chicago, IL, and additional mail- College seeks nominations for Jacobson Promising Investigator Award 57 ing offices. POSTMASTER: Send address changes to Bulletin of the A look at The Joint Commission: American College of Surgeons, New standard for surgical accountability measures 59 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. Fellows in Archives photo identified 61 40035010. Canada returns to: Station A, PO Box 54, Windsor, International women in surgery symposium set for spring 2012 61 ON N9A 6J5. The American College of NTDB® data points: Surgeons’ headquarters is lo- Annual Report 2011: Eightfold over eight years 63 cated at 633 N. Saint Clair St., Richard J. Fantus, MD, FACS; and Michael L. Nance, MD, FACS Chicago, IL 60611-3211; tel. 312-202-5000; toll-free: 800- 621-4111; e-mail:postmaster@ facs.org; website: www.facs. org. Washington, DC, office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001- 6701; tel. 202-337-2701; web- site: www.tmiva.net/20fstreetcc/ home. Unless specifically stated oth- erwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons.

©2012 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior writ- ten permission of the publisher. Library of Congress num- ber 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

he nation’s medical liability system contin- ues to be one of the most troubling prob-

lems that surgeons must contend with. This

statement particularly applies to those of us whoT are in private practice and high-risk specialties. Many surgeons and other physicians believe that ’’ the current system of resolving medical malprac- tice claims—the tort system—provides incentives for patients, their families, and trial lawyers to sue and seek exorbitant financial awards, regardless of whether their cases have merit. In reality, though, most patients who are injured Because each state handles because of negligent care never file a lawsuit, and few patients who do sue ever receive compensation. medical liability issues in its So, this system is a failure from the perspectives of both patients and health care professionals. own way, patients and their Furthermore, the medical liability system has a negative effect on the nation’s sagging economy. physicians must deal with The Congressional Budget Office estimates that reforming the means of resolving medical liability the inequities that a lack of claims would reduce federal spending by $62.4 bil- lion over 10 years. These savings would come about federal legislation creates. largely because physicians would be less likely to practice defensive medicine and would order fewer tests and provide fewer unnecessary services. In an era of budget cuts, such savings should be quite ’’ meaningful to lawmakers. Moreover, as the number of liability cases and damage awards rise, physicians’ malpractice insur- ance premiums go up exponentially, adding to surgeons’ frustration. As a result, many surgeons avoid practicing in states where liability coverage of 1975. These reforms include a $250,000 cap on is costly and in specialties that are at a greater risk noneconomic damage awards, a statute of limita- for litigation, such as neurosurgery and obstetrics- tions, constraints on attorneys’ contingency fees, a gynecology. requirement that providers pay only their fair share Despite the fact that tort reform could reduce of damages, and collateral offsets that prevent du- health care spending and waste and improve access plicate payments to plaintiffs. to surgical care, efforts to pass federal legislation that Over the course of the nearly 37 years that have would change the system have repeatedly failed to passed since MICRA was enacted, many states have gain enough congressional support to pass. passed similar legislation with varying degrees of success. For example, several state Supreme Courts Traditional reforms have overturned noneconomic damage caps on In the article “Medical liability reform: Evidence constitutional grounds. for legislative and alternative approaches” (see page Because each state handles medical liability is- 6), Ian S. Metzler and John G. Meara, MD, DMD, sues in its own way, patients and their physicians FACS, provide a superb overview of all these issues. must deal with the inequities that a lack of federal They also address the benefits and limitations of tra- legislation creates. As Mr. Metzler and Dr. Meara ditional approaches to medical malpractice reform, note, until national standards are set, the treat- such as the provisions established in California’s ment of plaintiffs and defendants alike will remain 4 Medical Injury Compensation Reform Act (MICRA) inconsistent.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Nonetheless, MICRA-like liability reforms are the basis of the guidelines they will need to follow unlikely to pass at the national level anytime soon. to be shielded from malpractice claims. Hence, many health policy experts have begun ex- I encourage each of you to read the article that amining alternative means of resolving malpractice Dr. Meara and Mr. Metzler have written as one step claims. One option highlighted in the article by Mr. toward becoming better educated about this impor- Metzler and Dr. Meara is the disclosure and offer tant issue. I also would urge you to contact the ACS approach. When this option is applied, the health Washington Office at [email protected] to find out how care provider and the liability insurer proactively you can more effectively advocate for the types of identify adverse outcomes, investigate them, and of- reforms that will enable all Americans to have access fer compensation without seeking to establish fault. to high-quality, cost-effective care. Other alternative forms of resolving medical li- ability claims highlighted in the article include the following: • “Safe harbor” protections for physicians who adhere to established guidelines • Requirements that health care organizations bear some of the liability for malpractice David B. Hoyt, MD, FACS • Alternative dispute resolution under which a third-party mediator, rather than a court, works with the parties to create a binding agreement for resolving the case • Establishment of special “health courts” • No-fault resolution of claims • Standards that will assist in the prevention of adverse events The ACS perspective The American College of Surgeons (ACS) supports these alternative means of improving the medical liability system, as well as the following additional strategies: requiring plaintiffs to obtain certificates of merit, preventing “hired guns” from serving as “expert witnesses,” and ensuring that plaintiffs are barred from citing a surgeon’s apology for a nega- tive outcome as evidence of poor or negligent care. I want to commend Dr. Meara and Mr. Metzler for writing this article, which hopefully will stimulate other surgeons to think about and propose creative solutions to the liability problem. I further anticipate that this article will encourage surgeons to advocate for liability reform at both the national and the state levels. As lawmakers seek to develop a value-based health care system, they may be receptive to learning how tort reform and other means of resolving liabil- ity lawsuits can lead to cost savings, improved access to care, and better quality of care. For example, an argument could be made that “safe harbors” and similar protections may provide an incentive for physicians to participate in quality measurement If you have comments or suggestions about this or other issues, programs given that these studies will likely serve as please send them to Dr. Hoyt at [email protected]. 5

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to $6.2 million in 2002 from $3.9 million in 2001, largely due to Medical liability reform: noneconomic damages, which have no maximum in many states.6 The burden of increasing liti- gation pressure does not stop at Evidence for legislative the physician’s pocketbook; it and alternative approaches negatively affects the care phy- sicians provide to patients. A study examining quality of care in Pennsylvania as it entered a liability insurance crisis suggests that increased liability pressure reduces physician satisfaction and weakens the patient-physician relationship.7 Whereas the mal- practice system may discourage negligent or harmful care, it may go too far, altering the practice of physicians and provoking the by Ian S. Metzler practice of “defensive” medicine. Defensive medicine and John G. Meara, MD, DMD, FACS Defensive medicine can be positive or negative. Positive defensive medicine occurs when physicians order a test, study, or edical liability reform remains a point of contentious debate procedure that isn’t indicated or in the U.S. A growing base of literature shows that the cost-effective but may protect current system for litigating medical malpractice is incon- them from litigation. One survey sistent, wasteful, and damaging to physicians and patients. found that 93 percent of special- Most patients who sustain injuries due to negligent care never sue, and ists believe that they altered their M 1,2 only one in six who do sue ever receive compensation. Conversely, clinical practice due to malpractice nearly 40 percent of medical malpractice claims lack evidence of medi- concerns, and 43 percent ordered cal error or patient injury. Not easily dismissed, these non-meritorious clinically unnecessary imaging to cases account for 16 percent of medical liability costs. Furthermore, protect themselves from lawsuits.8 claims that are litigated have excessive administrative overhead. For every Negative defensive medicine oc- dollar spent on compensation to the injured patient, 54 cents are spent curs when physicians abstain from on lawyers, experts, and courts; yet despite the resources that are being providing necessary care in order poured into the system, patients must wait an average of five years after to mitigate the risk of litigation, or injury to achieve a resolution.2 when they leave states with higher The cost of this inefficient system ultimately falls to health care pro- litigation pressures or exit the pro- viders and their patients. Premiums for liability insurance have been fession altogether.9 A total of 42 skyrocketing in recent years. In 2006, 21 states were declared as being percent of surveyed physicians had in a liability insurance “crisis,” with premiums increasing by as much restricted their practice in some as 80 percent annually.3 Both affordability and availability have been way to reduce their exposure to compromised in these states as liability insurers abandon the market and litigation.8 The cost of this defen- the premiums charged by those who remain dramatically increase.4 The sive medicine has been estimated increasing severity and frequency of awards have contributed to rising to be 2.4 percent of health care 5 10 6 premiums. The national average jury award nearly doubled, increasing spending or $56 billion per year.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Despite President Obama’s call to “scale back the ex- the most beneficial effects. So far, the evaluations of cessive defensive medicine that reinforces our current traditional reforms have primarily focused more on system,” the Affordable Care Act does not explicitly measures of the liability system than on the down- address medical liability reform.11 Efforts to pass na- stream effects on patient care. Liability-related metrics tional tort reform legislation have long been stymied. include claims frequency; indemnity costs (amounts Some states, including California as early as 1975, paid in verdicts or settlements); overhead costs; and have implemented more progressive approaches, but the costs of malpractice insurance. Care-related met- success at the state level has been inconsistent. (The rics include the amount of defensive medicine, supply details of these federal and state liability provisions of physicians in an area, and patient outcomes.12 (See are discussed beginning on page 8.) In addition to the Table 1, this page, for a list of traditional legislative political contest surrounding medical liability reform, reforms and a summary of the evidence related to there is much debate about what policies would have each approach.)

Table 1. Effects of traditional malpractice liability reforms12 Proposed reform Description Effects

Caps on damages Limit amount of awards for non- • Reduces some defensive practices economic losses or punitive damages • Modestly improves physician supply • Reduces indemnity payments • Constrains growth of insurance premiums • Limited or equivocal evidence on claims frequency or care quality

Statute of limitation and Limit the amount of time a patient has • Associated with modestly lower premiums repose to file a claim • No effect on indemnity payments • Limited or equivocal evidence on defensive medicine, physician supply, quality of care, claims frequency, and overhead costs

Pretrial screening panels Expert panels review cases to determine • May reduce defensive practices merit • No effect on indemnity costs, claims, or premiums • Limited or equivocal evidence on physician supply and quality of care

Certificate-of-merit Requires an affidavit from a medical • Limited or equivocal effect on defensive medicine, physician requirement expert affirming merit supply, indemnity costs, overhead costs, claims frequency, and premiums

Limit on attorneys’ fees Limits amount plaintiff’s attorney may • No effect on indemnity costs, claims frequency, premiums, or charge as a contingency fee physician supply • Limited or equivocal evidence on defensive practices and quality of care

Joint and several liability When multiple defendants exist, liability • No effect on indemnity costs, premiums, overhead costs, or “fair share rule” is limited to the percentage of fault physician supply allocated to that defendant • Limited or equivocal evidence on defensive medicine, quality of care, and claims frequency

Collateral-source rule Allows deduction of an award if injured • No effect on defensive medicine, physician supply, quality of patient has received compensation care, indemnity costs, claims frequency, premiums, or overhead from another source costs

Periodic payment Allows awards to be paid over a period • No effect on physician supply or indemnity costs of time rather than lump sum • Limited or equivocal effect on defensive medicine, quality of care, claims frequency, premiums, and overhead costs 7

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS State legislation with the North Carolina General Assembly overriding Until the 1970s, public policies on medical li- the governor’s veto of the bill. Oklahoma and South ability were primarily determined by the state court Carolina successfully enacted more stringent caps.20 system as part of common law, but as the cost of malpractice insurance rose, health care profession- Federal legislation als began bringing the issue to the attention of Whereas successes at the state level have been state legislators.13 The types of reform passed in the notable this year, until national standards are set, states have varied, but legislation placing caps on reform will remain inconsistent. With some state damages has been gaining popularity. One of the constitutions explicitly limiting medical liability earliest state reform efforts, the 1975 Medical Injury reform and others having politically unfavorable Compensation Reform Act (MICRA) of California, environments, there is growing support for federal was established after Gov. Jerry Brown (D) called a action on this issue. Medical liability reform has long special session to address the medical liability crisis been a strongly partisan issue, in large part lauded in the state. Bipartisan California legislators enacted by Republicans and disparaged by Democrats. MICRA, which included a $250,000 cap on non- The House of Representatives has passed com- economic damages, limits on attorney contingency prehensive medical liability legislation more than fees, a statute of limitations, and a provision for a dozen times since 1995, as recently as 2005. periodic payments for awards. Since MICRA was However, from 2006 to 2010, legislation addressing enacted, malpractice premiums in California have liability never reached the House floor. In January increased at a third of the national rate, and it has 2011, the House Judiciary Committee held a special reduced health care spending, saving Californians hearing titled Medical Liability Reform: Cutting $6 billion dollars annually.14 Costs, Spurring Investment, Creating Jobs. During Currently, 35 states have established some sort of this session, experts testified on the damage that the cap on damages. Amounts of the caps vary between current liability system is doing to our health care $250,000 in California and $1.75 million in Ne- system and the need for comprehensive legislation braska. A total of 16 state courts have upheld caps, based on successful state reforms. Several profes- while 11 have overturned the limits on damage sional associations, including the American Medical awards, maintaining that they are unconstitutional. Association, American College of Surgeons (ACS), For instance, the Illinois Supreme Court ruled that and the American Congress of Obstetricians and caps on noneconomic damages were unconstitu- Gynecologists, submitted statements supporting tional in 2010. As a result, liability costs in Illinois reform.21 are expected to jump by 18 percent this year. The bill that has made the most progress in 2011 The constitutions of four states, Arizona, Ken- has been H.R. 5: The Help Efficient Accessible, Low- tucky, Pennsylvania, and Wyoming, explicitly pro- cost, Timely Healthcare (HEALTH) Act. This com- hibit caps on damages.15 A 2006 analysis showed prehensive bill comprises several traditional reforms, states that had successfully adopted caps on damages including a $250,000 cap on noneconomic damages, have 3 to 4 percent lower health care expenditures a three-year statute of limitations, joint and several than those states without caps.16 These reductions liability, limits on attorney contingency fees, a col- translated into increases in private health insurance lateral source rule, and limits on punitive damages. coverage.17 In states with reforms that directly reduce The House Energy and Commerce and Judiciary the expected malpractice award, such as caps on Committee has approved the legislation.22 In March damages, physician supply increases by 3.3 percent.18 2011, the nonpartisan Congressional Budget Of- For example, Texas had a 59 percent larger annual fice (CBO) conducted an analysis of hypothetical growth rate of newly licensed physicians in the two reform with provisions similar to those in H.R. 5. years following reform compared with the two years The CBO estimated that mandatory and discre- before reform.19 tionary spending by Medicare and other govern- This year has been remarkably successful for state- mental health care payors would be reduced by $50 level reform, with nine states passing some type of billion and $1.6 billion, respectively. The CBO also medical liability legislation. North Carolina and Ten- estimated that premiums paid by employers that 8 nessee established caps on damages for the first time, are tax-exempt would decrease, and the subsequent

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS increase in employee wages would generate $13 billion requires that a jury awarding punitive damages be in tax revenues. The CBO concluded that compre- unanimous in its decision. Additional proposed legis- hensive medical liability reform would save the U.S. lation, including H.R. 157: The Health Care Safety Net government a total of $65 billion dollars in 10 years.23 Enhancement Act, introduced by Rep. Pete Sessions Other comprehensive medical liability reform leg- (R-TX-32)—which protects health care professionals islation has been introduced by the 112th Congress. who provide medical services in emergency situations H.R. 2205, Ending Defensive Medicine and Encourag- from liability—has also been proposed, but does not ing Innovative Reforms, introduced by Reps. Charles address other aspects of liability reform.22 Dent (R-PA-15) and Erik Paulsen (R-MN-3), calls for caps on damages, allows periodic payments of Alternative dispute resolution awards, sets a fair-share rule, and requires that selected Due to the fact that significant political roadblocks experts determine the merit of each case. H.R. 896, continue to discourage passage of federal and state Medical Justice Act, introduced by Rep. Michael level tort reform legislation, advocates for medical Burgess (R-TX-26), caps noneconomic and total liability reform have turned their attention toward damages, allows for periodic payment of awards, sets alternative methods of resolving malpractice claims. a fair-share rule, enacts a statute of limitation, and In 2010, $25 million in federal funding was al-

Table 2. Alternatives to traditional legislation9,12 Program Description Comments

Guidelines protection Physicians practicing within established Pro: Encourages evidence-based medicine “safe harbor” guidelines would be presumed to be non- Con: “Cookbook” medicine, implies negligence for not following negligent guidelines

Enterprise liability Organizations bear some of the liability for Pro: Increased efficiency, direct physician monitoring malpractice Con: Little evidence, rarely done privately now so may not have benefit

Binding alternative Providers and patients submit disputes to a Pro: Compensation is faster, more equitable, and with lower dispute resolution third party instead of a court transaction costs Con: May be biased toward defendants due to relationships forming with third party, limited repeal options

Health courts Specialist judge and committee hears all Pro: More continuity and less variability, reduces erratic jury- malpractice cases determined settlements Con: May not lower overhead or transaction costs

No-fault Administrative body replaces court, grants Pro: Aims to compensate larger groups more equitably, with less awards without seeking to prove fault administrative costs Con: May lead to higher spending overall even if individual awards are less, may decrease disincentives to malpractice

Disclosure-and-offer Insurer and insured institution proactively Pro: Aims to compensate larger groups, reducing over- and disclose adverse outcomes, investigate, under-compensation, with less transaction costs apologize, and compensate Con: May lead to higher spending overall even if individual awards are less, may decrease disincentives to malpractice

Adverse-event Targets improvements in communication Pro: Greater effect on patient care measures prevention about potential adverse outcomes and Con: Does not improve the process of litigation when claims are focuses on attempts to reduce adverse made events from occurring

9

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS located to the Agency for Healthcare Research and Conclusion Quality (AHRQ) to develop demonstration projects The future of medical liability reform remains un- for programs that will improve patient safety, reduce certain, but the negative impact on physicians and defensive medicine, and reform the liability system at patient care of our current inefficient and ineffective the provider level. The Affordable Care Act authorized system worsens every year. In the current deficit an additional $50 million for demonstration projects reduction-focused environment, with Medicare addressing medical liability and patient safety. potentially on the chopping block, it is critical to An early champion of non-traditional approaches consider medical liability reform as a means of cutting to resolving liability claims is the University of health care spending, improving the patient-physician Michigan Health System in Ann Arbor, which relationship, and increasing access to care. Action developed a disclosure and offer model. Under this from medical professionals and patients is critical paradigm, the provider institution and liability to express the urgency and wide base of support for insurer proactively identifies adverse outcomes, reform efforts. The ACS supports medical liability investigates them, apologizes for them, and offers reform, and specifically recommends the following:21 reimbursement without seeking to establish fault. • Caps on noneconomic damages This program led to a 36 percent reduction in fre- • Alternatives to civil litigation, such as health quency of claims, a 30 percent reduction in time courts and disclosure-and-compensation offers until resolution, and a 44 percent reduction in cost • Protections for physicians volunteering services per lawsuit.12 The AHRQ has funded planning grants in an emergency situation and demonstration projects that would expand the • Shields for physicians who follow established, Michigan disclosure-and-offer model outside of self- evidence-based guidelines of care insured hospital environments. • Collateral source offsets that prevent duplicate Other approaches involve specialized branches of payments the judiciary system. For example, a small group of • Fair share rule judges—trained in malpractice and assisted by a court • Periodic payment of future damage awards attorney trained in nursing—adjudicate a claim, and totaling more than $50,000 the case is then seen to resolution by a single judge at • Limits on plaintiff attorney contingency fees a private hearing. Other projects focus entirely on pre- • Application of punitive damages only when vention of adverse events before harm or subsequent the evidence indicates that the defendant intended litigation ever occurs. These projects seek to improve to harm the claimant patient-physician communication about care plans, The growing number of demonstration projects in- care-team cooperation, and adherence to evidence- vestigating alternatives to medical liability legislation based guidelines.12 (See Table 2, page 9, for descrip- highlights the sustained interest on behalf of provid- tions of alternative approaches to liability reform.) ers, insurers, and patients to solve this problem with These alternative dispute resolution mechanisms or without legislative help. These novel approaches have the potential to discourage claims from going may provide solutions that tort reform is incapable or through the costly litigation process, and some proj- politically hindered from achieving. Although public ects aim to prevent the adverse events from occurring statements of support for medical liability reform are in the first place. Many of these alternatives keep still sparse, funding for these projects from the Obama mediation of claims within the hospital system. The Administration provides hope that both parties may hope is that by avoiding litigation, a greater number cooperatively address this issue.  of injured patients will receive compensation sooner and more equitably, even if the amount per patient is References less, and that adverse incidents can serve to inform the systems of care about what steps they need to take to 1. Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert avert future adverse events. Despite the fact that these LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Rela- tion between malpractice claims and adverse events due to alternatives could reduce the frequency of adverse negligence: Results of the Harvard Medical Practice Study events and malpractice, some providers and insurers III. N Engl J Med. 1991; 325(4):245-251. are still hesitant to take on risk without strong proof of 2. Studdert DM, Mello MM, Gawande AA, Gandhi TK, 9 Kachalia A, Yoon C, Puopolo AL, Brennan TA. Claims, 10 the benefits or protection from federal or state laws.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS errors, and compensation payments in medical malpractice Hearing before the committee on the judiciary House of litigation. N Engl J Med. 2006;354(19):2024-2033. Representatives one hundred twelfth congress. January 20, 3. American Medical Association. Another state added to li- 2011. Available at: http://judiciary.house.gov/hearings/ ability crisis list. March 6, 2006. Available at: http://www. printers/112th/112-1_63871_PDF. AccessedSeptember 20, ama-assn.org/amednews/2006/03/06/prca0306.htm. Ac- 2011. cessed September 20, 2011. 22. Tauberer J. Civic impulse, LLC. 2011. Available at: http:// 4. Mello MM, Studdert DM, Brennan TA. The new medical www.govtrack.us/congress/legislation.xpd. Accessed Sep- malpractice crisis. N Engl J Med. 2003;348(23):2281-2284. tember 20, 2011. 5. Thorpe KE. The medical malpractice ‘crisis’: Recent trends 23. Congressional Budget Office. Reducing the deficit: Spending and the impact of state tort reforms. Health Aff.2004; Web and revenue options. March 2011. Available at: http://www. exclusives:W4-20-30. cbo.gov/ftpdocs/120xx/doc12085/03-10-ReducingTheDef- 6. Weinstein SL. Medical Liability Reform Crisis 2008. Clin icit.pdf. Accessed September 20, 2011. Orthop Relat Res. 2009;467:392–401. 7. Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, Sage WM. Caring for patients in a malprac- tice crisis: Physician satisfaction and quality of care. Health Aff. 2004;23(4):42-53. 8. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA. Defensive medicine among high-risk specialist physicians in a volatile malpractice en- vironment. JAMA. 2005;293(21):2609-2617. 9. Kessler DP. Evaluating the medical malpractice system and options for reform. J Econ Perspect. 2011;25(2):93-110. 10. Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff. 2010;29(9):1569-1577. Dr. Meara is plastic 11. CBS News. Obama’s AMA speech on health care. June surgeon-in-chief, Children’s 15, 2009. Available at: http://www.cbsnews.com/sto- ries/2009/06/15/politics/main5090277.shtml. Accessed Hospital Boston, and as- September 20, 2011. sociate professor of surgery 12. Kachalia A, Mello MM. New directions in medical liability and director of the program reform. N Engl J Med. 2011;364(16):1564-1572. in global surgery and social 13. Budetti PP, Waters TM. Medical Malpractice Law in the change, Harvard Medical United States. The Henry J. Kaiser Family Foundation. May School, Boston, MA. He is 2005. Available at: http://www.kff.org/insurance/upload/ the Chair of College’s Legis- Medical-Malpractice-Law-in-the-United-States-Report.pdf. lative Committee. Accessed September 20, 2011. 14. Walters A. Medical liability reform and the states. Bull Am Coll Surg. 2010;95(3):29-30. 15. American Medical Association. Caps on damages. 2011. Available at: http://www.ama-assn.org/resources/doc/arc/ capsdamages.pdf. Accessed September 20, 2011. 16. Hellinger FJ, Encinosa WE. The impact of state laws limiting malpractice damage awards on health care expenditures. Am J Public Health. 2006;96(8):1375-1381. Mr. Metzler is a student 17. Avraham R, Schanzenbach M. The impact of tort reform on at Harvard Medical School private health insurance coverage. Am Law and Econ Rev. studying health systems 2010;12(2):263–264. improvement and health care 18. Kessler DP, Sage WM, Becker DJ. Impact of malpractice policy at Children’s Hospital reforms on the supply of physician services. JAMA. 2005 Boston. Jun 1;293(21):2618-2625. 19. American Medical Association. Medical Liability Reform Now! 2011. Available at: http://www.ama-assn.org/re- sources/doc/arc/mlr-now-2011.pdf. Accessed September 20, 2011. 20. Kuppens JF, Thompson JT. State tort reform in 2011. Sep- tember 16, 2011. Available at: http://nmrs-white.logicsouth. com/articles/state-tort-reform-in-2011. Accessed September 20, 2011. 21. U.S. government printing office. Medical liability re- form: Cutting costs, spurring investment, creating jobs. 11

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS by Michael R. Marvin, MD, FACS; Kenneth M. Prager, MD; Max V. Wohlauer, MD; and James G. Chandler, MD, FACS

12

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ndividual sanctity is an essential component of humanness with deep roots in culture, religion, and law. Indeed, an individual’s sanctity tran- scends even death, persisting in the minds of Ithose who knew or know of the decedent. Society’s valuation of whole organ donation began cautiously with the successful transplantation of a 23-year-old monozygotic twin’s kidney into his twin brother on December 23, 1954. The Peter Bent Brigham Hospital team sought to minimize its ethical issues by advance airing in public fora and preliminary skin graft exchanging to verify their compatibility. Yet, as noted by Joseph E. Murray, MD, FACS (see photo, this page), in his 1990 Nobel Prize address, “For the first time in medical history, a normal, healthy person was to be subjected to a major surgical operation not for his own benefit.”1 The recipient lived for eight years free of dialysis, and the donor lived to age 79, but Dr. Murray Dr. Murray would not achieve success with a cadaveric renal allograft until 1962. Whole organ allotransplantation for hearts began in December 1967, with dismal results. As of Oc- coma).4 By 1966, he had harvested and transplanted tober 23, 1968, only two of the world’s 65 heart kidneys from nine severely head-injured donors. allograft recipients had survived for five or more In 1968, a Harvard ad hoc review panel essentially months.2 Some viewed excising a donor heart as endorsed Alexandre’s work, defining irreversible tantamount to ripping out the soul, and with these coma as complete unresponsiveness, with no spon- results, one could argue, “For what purpose?” Most taneous movement, including breathing; and a flat early proponents paused to regroup, as Thomas electroencephalogram in the absence of confound- Starzl, MD, FACS, had done with livers in 1963.3 In ing factors such as drugs or hypothermia.5 the U.S., Norman Shumway, MD, FACS (see photo, Bruce Tucker was a 56-year-old intoxicated man, page 14), pressed on at Stanford, as did his former who sustained a basal skull fracture and was brought associate Richard Lower, MD, FACS, who had unaccompanied to MCV around 6:00 pm on May moved to the Medical College of Virginia (MCV) 24, 1968. An emergency craniotomy to evacuate a in 1965 to add hearts to the busy renal transplant subdural hematoma and tracheotomy for ventila- program headed by David Hume, MD, FACS (see tion failed to halt his deteriorating neurological photos, page 14). Technical hurdles still had to be status.6 Drs. Lower and Hume had been training overcome, but the real culprits were the marginal their team for three years and were actively seeking therapeutic index of available immunosuppressants a potential heart donor for a patient already in the along with donor warm ischemia time and its ulti- hospital. They asked other people involved in the mate companion, reperfusion injury. case, including the police, to search for Mr. Tucker’s family to discuss donation of his heart and kidneys, B-D and Tucker v. Lower but no contact was ever made. Shortly after noon Belgian surgeon Guy Alexandre, who had been on May 25, a neurologist concluded that Tucker’s a research fellow in Dr. Murray’s laboratory, mini- brain was dead, allowing the surgeons to move him mized warm ischemia by harvesting a kidney from to the operating room for removal of his heart and a beating-heart, severely head-injured, comatose kidneys. The respirator was temporarily discon- donor at Louvain’s Saint Pierre Hospital on June 3, nected and after five minutes of apnea, the medi- 1963, after convincing his chief, Jean Morelle, of the cal examiner agreed to begin the organ retrieval, irreversibility of the patient’s coma dépassé (beyond despite a Virginia law requiring a two-day waiting 13

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS William Tucker came to the enter

C hospital that evening, which was Y just down the street from his shoe TOR

S repair shop, to inquire about his I injured brother and was told that he had died in the afternoon, without mentioning his having been the world’s sixteenth heart transplant donor. Dick Lower was a remarkably sensitive and Stanford Medical H unassuming person, but in this situation he neither recognized nor respected Bruce Tucker’s sanctity. Bruce was black in a so- ciety that was still desegregating, but not the abandoned derelict he was presumed to be. The re- cipient of this ninth U.S. heart transplant was white and sur- Dr. Shumway (inset and at patient’s left) performing the first adult U.S. heart transplant vived for just seven days before with Edward Stinson, January 7, 1968. becoming the first heart recipient to die from acute rejection. This ethical debacle assured a e y h it

s lawsuit, if not a murder charge, and could have provoked massive for t y public disapproval. In fact, Prof. Univer h Jura Wada at Sapporo Medical ibrar L University in Hokkaido was aw

C charged with murder for not onwealt

-Mc doing more to revive a brain- mm s o in C death (B-D) donor, whose heart

mk was used in Japan’s first heart o T transplant on August 8, 1968. irginia t, V s

, The murder charge was eventu- s ivi h ally dropped due to insufficient rc

A evidence, but Japan would not te, Science allow another heart transplant s h for 31 years. In the U.S., Lower . Ko L

Healt continued to perform heart transplants and had the pleasure Jodie of seeing a later 1968 recipient Dr. Lower (left) and Dr. Hume live for an additional 6.5 years. The inevitable trial com- menced on May 25, 1972. Wil- liam Tucker, represented by period before disposing of unclaimed bodies. Mr. future Virginia Gov. Doug Wilder, sued Dr. Lower Tucker had been in the hospital for just 23 hours, and MCV, alleging that Dr. Lower had hastened and there is no record indicating whether his heart Bruce Tucker’s death by shutting off the ventilator ever ceased beating or was restarted when ventila- for the purpose of obtaining his heart and kidneys. 14 tion was resumed. The issue of consent was moot because the statute

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of limitations expired before the case was filed. Why they say “no” Members of Harvard’s ad hoc panel testified for the Neal Garrison, MD, FACS, of the University of defense, apparently persuading the judge to direct Louisville, KY, was the first to advocate decoupling the jury to consider “among other things the time discussions of being brain dead and organ dona- of complete and irreversible loss of all function of tion.9 He and his colleagues found that raising the brain” in determining the time of death. Drs. the two issues together, ostensibly to create some Lower and Hume must not have believed that the good out of a bad situation, resulted in only 18 neurologist’s declaration that Mr. Tucker’s brain was percent of 62 families consenting to donation; “dead” meant that Tucker was dead. Why else would whereas, proposing donation after the family had they have exposed a donor heart to five minutes of time to assimilate B-D’s implications resulted in a apnea? The jury did not have all the medical facts, significantly greater, 57 percent (53/93), consent including uncertainty about the pre-excision status conversion rate. Subsequent experience has repeat- of Mr. Tucker’s heart, and simply concluded that no edly validated this observation. wrongful death had occurred. The judge’s instruc- Some surgeons’ personal perspectives may taint tion to the jury ensured Dr. Lower’s exoneration, their ability to be convincing organ donation but did not redefine death as proclaimed in the advocates. A New York University and Albert contemporary press. Neither Harvard’s ad hoc com- Einstein College of Medicine survey of 30 surgical mittee, nor Tucker vs. Lower, could turn medically attendings, 41 surgical residents, and 35 medical defined B-D into a legal criterion of being dead.7 students revealed 61 percent overall willingness to be organ donors, with proportionally more older The dead donor rule and experienced respondents expressing refusal.10 The dead donor principle states that vital or- Among all responders, only 49 percent had declared gans should be taken only from dead patients and themselves as organ donors on their driver’s licenses. that retrieval of vital organs for transplantation Both institutions have busy transplant centers, and should not lead to death.8 B-D became compatible 13 percent of those who would not permit removal when it was codified by the Uniform Determina- of their own organs indicated that their refusal tion of Death Act (UDDA), drafted in 1980 by stemmed from observing or being involved in a the National Conference of Commissioners on procurement procedure. Uniform State Laws. The UDDA states that: “An Families’ concerns about whole organ donation individual who has sustained either (1) irrevers- include a basic core that should be anticipated and ible cessation of circulatory and respiratory func- discussed at points in the conversation when a fam- tions, or (2) irreversible cessation of all functions ily seems less forthcoming. Ambiguity about brain of the entire brain, including the brain stem, is death is the basis for many of their issues.11 They dead. A determination of death must be made in worry that consenting might result in withholding a accordance with accepted medical standards.” It treatment that could conceivably give the patient a was quickly endorsed by the American Bar and slim chance at recovery, that the patient will feel ad- Medical Associations, and adopted by 45 states. ditional pain from diminished medication or as part The others relied on precedent-setting court cases of the procurement procedure, and that they cannot but also cited the UDDA. Iterative improvements be with the patient at the time of death. Families in donor management, ex vivo preservation, im- also worry about additional hospital charges, prob- munosuppression, and diagnosing acute rejection, lems with preparation of the body for viewing, and along with a computer-based United Network for religious concerns about delaying burial. Organ Sharing (UNOS) had now advanced whole In 1978, Clive O. Callender, MD, FACS, an early organ transplantation to a predictable and widely transplanter and former chair of the department of applicable therapy. Burgeoning demand and an surgery at Howard University in Washington, DC, ever-widening gap between society’s need and convened a group of 40 individuals to address why organ availability now obliged ethicists, who had minorities, and African-Americans in particular, previously focused on protecting donor sanctity, to were reluctant to become organ donors.12 The re- also ponder means whereby an ethically defensible sult was the 1982 creation of a DC Organ Donor goal could be achieved with the least discomfort. Program that stressed “face-to-face presentations by 15

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS culturally sensitive and ethnically similar community messengers Ethnicity of organ donors and U.S. population who were health care providers, Percent of recovered donors transplant recipients, persons Proportional awaiting transplants, donors and Ethnicity Population % Deceased Living Combined donation rates donor family members.” Within White 72.4 66.6 69.6 67.9 0.94 one decade, these transplanta- African American 12.6 16.6 11.7 14.4 1.14 tion stakeholders increased the Hispanic 16.3 12.9 14.2 13.5 0.82 number of Washington residents signing donor cards from 25 to Asian 4.8 2.3 3.4 2.8 0.58 750 per month and raised the Sources: 2010 U.S. census and 2010 OPTN Annual Report. percentage of African-American organ donations from 3 percent to nearly 12 percent. In 1995, Dr. Callender lever- Are these data sufficiently compelling to warrant aged this success into a national Minority Organ the government shifting its stance from facilitating Tissue Transplant Education Program, known as organ donation to legislating presumed consent? MOTTEP. National Institutes of Health (NIH) A citizen wishing to avoid becoming a potential funding allowed MOTTEP to create specific pro- donor would then have to opt out by registering grams for Hispanics, Asian, Pacific Islanders, and refusal in a government-maintained database. Native Americans in community-based MOTTEPs, Austria, Belgium, Singapore, and Spain, among which stretch from Honolulu to the U.S. Virgin others, have this system. In Austria, where the law Islands. African-American donor rates now surpass was implemented in 1982, a pre-enactment seven- those of white donors, and Hispanics and Asian year baseline average of 4.6 donors per million of donor rates are moving toward parity with their population per year (DMY) rose to 27.2 DMY by proportional presence in the U.S. population (see the fifth “opt-out” year. table, this page). Mandated consent is a halfway step requiring only that all adults consider organ donation and Time to take the gloves off? enter their decisions into an electronic database. Although often initially viewed as contentiously The New Jersey Hero Act, passed on July 22, 2008, intrusive, the U.S. government’s role in advancing requires that starting in 2013 all New Jersey drivers organ donor management has been remarkably indicate whether they are willing to be a donor, or enlightened, beginning with its 1984 establishment acknowledge being adequately informed without of not-for-profit Organ Procurement Organizations consenting to be a donor.15 Interim measures en- (OPOs) and The Organ Procurement and Transplan- sure having an informed citizenry well before then. tation Network (OPTN).13 The U.S. Department Since 2009, New Jersey grades 9–12 public schools of Health and Human Services’ Health Resources and colleges must include information about organ and Services Administration (HRSA) underwrites and tissue donation in their core curricula, and all OPTN’s cost and contracts with not-for-profit UNOS New Jersey medical and nursing schools must in- to direct its programs. OPTN lists 112,447 persons clude organ donation and recovery as a condition waiting for organs in the U.S. as of December 2, for graduation. As of this year, physicians licensed 2011 (see Figure 1, page 17); 80.3 percent are before the act are encouraged to complete an online, waiting for a solitary kidney.14 Based on the last credit-based course, and previously licensed nurses two years, this need will be only partially fulfilled are required to take an online, one credit-hour by 8,000 deceased donors, providing a mean 2.75 course to be relicensed. organs transplanted per donor (OTPD), along with 6,600 living donors, yielding 28,600 organs for all B-D’s discomforting hegemony of 2011. Fewer than 17,000 (<60 percent) of these B-D’s broad acceptance is pragmatic, especially will be kidneys. Deceased donors peaked at 8,085 valued for the recovering of thoracic organs and, de- in 2007, and for the past decade, at least 7,000 spite some discomforting facts, served as the source 16 wait-listed people have died annually. of virtually all deceased donor organs throughout

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 1. for withdrawal of life support, or UNOS waiting list, December 2, 2011 for organ donation, as being sepa- rate but similarly proper ethical 112,447 patients bases for their respective actions. James Bernat and his Dartmouth colleagues diffused these concerns by separating detectable but “random and purposeless cel- lular physiologic activity” from the brain’s irreplaceable systemic integrated functioning, but some countries and the world’s three monotheistic religions have wres- tled with reservations about B-D’s parity with circulatory demise for years.17 The Danish Council on Ethics actually abrogated the dead donor rule in 1988, agreeing to the re- covery of organs once brain func- tion had ceased “during the death process” but reasserting that the time of death was when the heart later stopped.18 The council then promoted unprecedented public debate by widely distributing its deliberations. Public opinion was 80 percent in favor of the coun- cil’s minority recommendation of declaring death to have happened when B-D criteria were satisfied, the 1980s. The brain is not always completely dead. which led the Danish Parliament to endorse the Viable areas with neurologic functions unrelated to public’s sentiment in 1990. clinical B-D criteria remain, such as those regulat- Japan had difficulty overcoming repercussions ing hypothalamic hormone secretion. Patients with from the Jura Wada case, delaying passage of an irreversible coma look disconcertingly normal, as if Organ Transplant law until 1997. The prevailing they have adjusted to the ventilator and are asleep. attitude toward B-D remained tentative, so its quali- Mechanical ventilation and nutritional support fication for organ recovery was statutorily differen- can allow such individuals to metabolize enteric tiated from cardiac death. B-D donation required feedings, excrete waste, and survive for months, advanced written consent by the potential donor, for example, to give birth to near-term babies by and family members could override the donor’s caesarean section. intention, resulting in just 86 B-D donors over 12 Robert Truog, MD, an anesthesiologist-ethicist years. The law was revised in 2009 to accept family at Boston Children’s Hospital, and Franklin Miller, consenting for B-D donation if the potential donor MD, of the NIH’s Bioethics Department, concluded had not intentionally opted out. Despite retention of that “…although it may be perfectly ethical to re- the family veto, 16 B-D donor recoveries occurred move vital organs for transplantation from patients within the first three months under the new law.19 who satisfy the diagnostic criteria of B-D, the reason Judaism is generally supportive of B-D, but had that it is ethical cannot be that we are convinced that to subordinate the principle of “Ain dochin nefesh 16 they are really dead.” They viewed valid consenting mipnei nefesh—that one life may not be set aside to 17

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS assure another life applies with full force even where but comprise only a fraction of inhospital deaths. the life to be terminated is of short duration and seems Controlled DCD began with the University of to be lacking meaning or purpose” and to reinterpret Pittsburgh (PA) Medical Center’s 1992 “Policy for a responsibility into an empowerment. “…God has the Management of Terminally Ill Patients Who imposed on man the awesome responsibility of de- May Become Organ Donors After Removal of Life fining the moment of death…after which the needs Support.”26 These patients are ventilator- and often of the dead…must be subordinated to those of the pressor-dependent. The patient and family do not currently living.”20 wish to continue supportive care and would readily “In Islam, the killing of a terminally ill person, consent to its withdrawal. Their potential for organ whether through voluntary active euthanasia or donation depends on a separate consent to donate physician-assisted suicide, is judged an act of and the likelihood that support withdrawal will disobedience against God.”21 However, intent and shortly result in cessation of effective circulation. consideration for a patient’s well-being can create Cessation within an hour is in the best interests of a situation in which the act of disobedience is ac- all parties and is somewhat predictable based on

ceptable: Jordan’s Council of Islamic Jurisprudence the PaO2/FIO2 ratio, pressor requirements before (majma` al-fiqh al-islami) incorporated “complete withdrawal, and respiratory parameters 10 minutes cessation of all functions of the brain, when expert after withdrawal. physicians ascertain that the cessation is irreversible The potential donor’s physicians discontinue the and the brain is in the state of degeneration” into the support, provide comfort care, administer heparin, Shari`a guidelines to determine death.22 The council’s and in most instances, insert femoral cannulae amendment concludes with: “God knows the best!” under local anesthesia to be used for in-situ cool- The Catholic Church is unique in having a succes- ing. As originally described, they pronounce the sion of single, infallible, earthly leaders to limit wa- patient dead after no pulse can be appreciated for vering, yet its publicly aired views typify the ruffling a two-minute interval thought to be sufficient to effect of inherent contradiction. Lucetta Scaraffia, preclude cardiac autoresuscitation. The transplant professor of contemporary history at Rome’s La Sapi- team is then called to assume management of the enza University, authored the front page article of the decedent. This has to be a tightly protocoled se- September 3, 2008, L’Osservatore Romano, recounting quence of compassionate care and hand off that the Pontifical Academy of Science’s 2005 dissention considers the patient, the family, and the quality with the Vatican’s original 1985 posture endorsing of the organs that will transplanted. irreversible coma, reinforced by John Paul II in 1989 Health care professionals and families were dis- and again in 2000.23 On November 7, 2008, Benedict comforted by the imprecision of basing the end XVI, speaking to Rome’s international congress on of a life on two minutes without feeling a pulse. A Gift for Life: Considerations on Organ Donation, In 1997, the Institute of Medicine suggested that left some doubt as to his position by saying: “Over “accepted medical detection standards include recent years, science has made further progress in electrocardiographic changes consistent with absent ascertaining the death of a patient. It is good, then, heart function, [along with] zero pulse pressure [as that the achieved results receive the consensus of the monitored] through an arterial catheter,” and also entire scientific community in favor of looking for suggested that five, rather than two, minutes be solutions that give everyone certainty…and where adopted as an arbitrary, but reasonable, standard.27 total certainty has not been reached, the principle of Now almost all OPOs endorse five minutes. Elec- caution should prevail.”24 trocardiographic silence is not required, because the criterion determining death is the absence of Donation after cardiac death (DCD) effective circulation. Nonbeating heart donors were the primary source of cadaveric renal allografts for almost 20 “Irreversible”—the elephant in the room years and the source of the heart for Christiaan Irreversibility is not an absolute phenomenon. Barnard’s second, and the world’s first successful, Irreversible is a conditional adjective that needs heart transplant.25 Heart-beating, B-D criteria constraints specifying the situation surrounding 18 sourced organs are associated with better outcomes the noun that is being labeled. Its unconstrained

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS use introduces ambiguity into Harvard’s definition Figure 2. of profound coma and the UDDA’s stipulation of Proportional increase of DCD donors cessation of circulatory and respiratory functions and of all functions of the entire brain, including the brain stem, as the two legitimate routes to being declared dead. The controlled DCD process shines a bright light on the elephant. Two or five minutes without effective circulation from ventricular fi- brillation or stand still is typically reversible in an operating room. It is irreversible in DCD because the caregivers have determined with the family’s consent that the patient should die. Busy procure- ment coordinators say that they have experienced a resumption of a shallow pressure tracing when they began measures to curtail warm ischemia, which they address by asking the donor’s physicians to return for another five-minute countdown. Public acceptance of DCD is surprisingly good, as judged by the proportional increase of DCD donors (see Figure 2, this page). Registration to be a donor is not a consent to withdraw life support. T4 or its synthetic analog, L-thyroxine, act syner- Rarely is a suitable potential DCD donor able to gistically with vasopressors in brain injured patients, give valid consent for withdrawing his own life increasing their efficacy at lower doses to the point support, making DCD essentially a family affair, of sometimes being able to discontinue them.30 The affirming Truog-Miller’s consent-based ethicality. same study has shown that despite T4’s selective use in more unstable donors, its use was associated with Mitigation of brain injury’s systemic effects a significantly higher 3.9 OTPD rate versus 3.2 from Brain death is associated with vascular instability donors not requiringT4. and a leaky blood-brain barrier that unleashes a B-D’s sympathicomimetic inflammatory milieu barrage of inflammatory cytokines. Novitzky and increases both hepatic gluconeogenesis and periph- his colleagues at Cape Town’s Groote Schuur Hos- eral insulin resistance while impairing its release pital countered this with an intravenous “cocktail” from the pancreas. Free-water loss from depressed of 2μg of triiodothyronine, 100mg of cortisol, and or absent vasopressin secretion requires substantial 10–30 IU of insulin given as often as hourly to 26 dextrose water infusion to combat hypernatremia potential B-D donors from the time of consent until and doubles the imperative for closely monitored recovery of the heart.28 They observed significant im- intravenous insulin administration to prevent glu- provements in donor mean arterial pressure (MAP) cosuria compounding diabetes insipidus’ free water and base deficit, as well as a related halving of the clearance. A study is in progress using a computer- dopamine required. based insulin delivery system to target donor glucose Methylprednisolone has been prospectively stud- levels between 100 and 140mg/dL.31 The baseline de- ied in 100 B-D criteria liver donors randomized to livery protocol has been sufficient for nearly 75 percent receive or not receive a 250 mg bolus of methyl- of organ donors. The others have shown remarkable prednisolone at the time of consent and subsequent insulin resistance, frequently requiring 30–40U boluses infusion of 100 mg/h until organ recovery.29 Methyl- and infusion rates up to 40–50U/h. prednisolone resulted in significant downregulation of inflammatory signaling factors, less ischemia/ Protocol controlled donor management reperfusion injury, as evidenced by lower AST and HRSA launched an Organ Donation Break- ALT levels over the first 10 post-transplantation through Collaborative in 2003 to study retrieval days, and lower total serum bilirubin levels at 10 processes at high-performing institutions and to dis- days and out to six months. seminate best practices to what eventually became 19

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 950 of the nation’s largest hospitals. In 2004, the Normothermic perfusion avoids these cellular debili- collaborative set a 75 percent consent conversion ties and offers opportunities for ex vivo functional rate as a national goal, and in 2005, they added assessment, quelling inflammation, and restorative achieving a yield rate of 3.75 OTPD and a secondary conditioning. Although animal studies have shown goal that DCDs should comprise at least 10 percent that these benefits are applicable to all organs and of an institution’s deceased donors.32 a single clinical study of normothermic perfusion UNOS Region 11 (Kentucky, Tennessee, Virginia, of hearts has begun enrollment, clinical work has North Carolina, and South Carolina) developed a focused on the lung.35 Lungs do not tolerate DCD Donor Management Goal (DMG) panel of clinical associated ischemia and are prone to injury from B-D variables aimed at meeting HRSA’s target for organs related inflammation, aspiration, and barotrauma, transplanted per donor.33 Among 467 donors, 82 per- resulting in less than 20 percent of donated lungs cent of recovered organs were transplanted yielding being transplanted. an overall 3.34 OTPD. When all eight DMGs were In 2007, Stig Steen of Sweden’s Lund University achieved, the transplant yield was 3.45 OTPD versus reported the first clinical transplantation of an ex vivo 2.59 when they were not. Limited pressor use, followed reconditioned lung. The contused lung was recovered

by PaO2, and CVP were the primary predictors that a from a young B-D accident victim whose final PaO2 donor’s recovered organs would be transplanted. was 67mmHg with an FiO2 of 0.7 (P:F ratio of 95.7). The Los Angeles County Hospital and the Univer- The reconditioning began with a slow <20mmHg sity of Southern California Medical Center manage pulmonary artery perfusion of deoxygenated blood potential donors according to a protocol first intro- diluted in proprietary Steen solution* to a 15 percent duced in 1998 that requires floating a catheter into hematocrit at 25˚C, gradually warming the perfusate the pulmonary artery to monitor aggressive fluid to 37˚C and ventilating to maintain end-expiratory resuscitation. If volume replacement does not yield a pressure at 5cmH20.13 Mean pulmonary artery pres- MAP ≥70mmHg (true in most instances), they begin sures decreased from 12 to 7mmHg and pulmonary a vasopressor, moving up to a maximum 10μg/kg/ venous P:F stabilized at 500. The lung was implanted minute, and then turn to their 50 percent dextrose, in a 70-year-old man, raising his pretransplant FEV1 2g methylprednisolone, 20U insulin, 20μgT4 bolused from 20 percent of predicted to 74 percent and al- cocktail to be followed by continuous infusion of T4 lowing him to be quite active for 11 months until he at 10μg/h. The protocol stresses vigilance and quick died of immunosuppression related sepsis.36 intervening to treat expected 50 percent incidences Cypel and colleagues in Toronto, ON, have shown of diabetes insipidus and thrombocytopenic co- that as few as four hours of normothermic ex vivo lung agulopathy with desmopressin, fresh-frozen plasma, perfusion (EVLP) significantly improved P:F ratios to cryoprecipitate, and platelets. Protocol adoption was a median of 443 in 20 of 23 lungs with pre-perfusion associated with an 87 percent drop in potential donors <300 P:F ratios37 (see Figure 3, page 21). The out- lost from hemodynamic instability.34 The protocol not comes of transplanting these 20 reconditioned lungs, only saves lost organs, but also lost hospital revenue including nine from DCD donors, were compared because the Centers for Medicare & Medicaid Services with those of 116 contemporaneous normal-criteria pays all otherwise uncovered hospital charges back to lung recipients. The incidence of 72-hour primary when B-D was declared. graft dysfunction (P:F <300) was 15 percent in the EVLP conditioned lungs versus 30 in the control Normothermic ex vivo perfusion and repair group. Bronchial dilatation was needed for 5 percent Cold perfusion has been the mainstay of organ and 4 percent, and hospital stays were 23 and 27 days, preservation but is known to damage mitochondria respectively. Two DCD donor EVLP recipients died through Adensoine-5´-triphosphate (ATP) depletion of non-graft causes within 30 days, nearly doubling and alter plasma membrane lipids, cell structure, the 5.2 percent 30-day mortality accruing from six and microtubules, resulting in time-related cell lysis. control group deaths. At one year, 80 percent of EVLP recipients and 84 percent of control recipients were *Vitrolife, AB, an artificial hyperoncotic serum, containing an optimum amount of dextran to coat vascular endothelium and the surfaces of alive with their grafts. the perfusion circuit, used in this instance with 15 percent hematocrit Sadaria and her Denver, CO, and Nashville, TN, col- 13 20 autologous donor blood. leagues assessed oxygenation, histology, and cytokine

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS expression in seven transplant-un- Figure 3. suitable human lungs over 12 hours Cypel ex-vivo lung circuit of normothermic EVLP.38 P:F ratios improved significantly during the first two hours, and all lungs met transplant oxygenation criteria by 12 hours. Biopsies were obtained at one, six, and 12 hours for histology and cytokine concentrations. The histologic sections were all normal. Several pro-inflammatory cytokines were progressively upregulated, in- cluding MCP-1 (monocyte chemo- tactic protein -1), which has been clinically associated with primary graft dysfunction. Interleukin-10, a notable anti-inflammatory cyto- kine, was never detected.39 The latter finding was particular- ly interesting because the Toronto group has transfected transplant- EVLP normothermic lung circuit allowing both functional assessment and repair. Note unsuitable human lungs undergo- insert’s red tank indicating a hypoxic gas. Source: Cypel et al.40 ing normothermic EVLP with an airway-delivered adenoviral vector encoding human Interleukin-10. A similar EVLP only control group developed ac- is, should double the number of deceased U.S. ceptable P:F ratios; whereas, IL-10 transfected lungs donors and achieve HSRA’s goal of 3.75 OTPD.41 achieved significantly higher P:F ratios, lower pulmo- This unprecedented ratio of 51.8 donors per mil- nary vascular resistance, and a favorable shift from lion of population (312 million as of August 29, pro-inflammatory to anti-inflammatory cytokine ex- 2011) could yield 60,000 organs, but no more than pression. The authors have yet to report transplantation 32,000 kidneys, a shortfall that would require an of an IL-10 transfected human lung, but have shown unrealistic nearly nine-fold increase in live donors that ex vivo IL-10 gene therapy significantly inhibited for fulfillment. An implantable artificial kidney may swine IL-6 and IL-1b release from pig lung tissue after be on the horizon, but early intervention in causes four hours as an allotransplant.40 leading to end-stage renal disease is currently the Ex vivo organ reconditioning is a rudimentary only realistic solution and will always be the most example of regenerative medicine’s potential to per- cost-effective strategy.42  mit in-situ repair or replacement with autologous, 41 induced pluripotent stem cells. The genome of these Editor’s note reprogrammed cells will be edited to promote in vitro growth of a specified single stem cell type, which will This article is an abridged and updated revision of “Sanctity home to injured or diseased isogenous tissue when and the Societal Value of Organ Donation,” published in the Alumni News of the New York-Presbyterian Hospital/Columbia injected into an artery that serves the targeted organ. University Department of Surgery, Vol. 13, No 1, Summer 2010, which can be accessed at http://www.columbiasurgery.org/news/ Epilogue john/jjss_su10.pdf. Optimal donor management, ex vivo organ con- ditioning, opt-out legislation, and a cultural shift whereby organ donation becomes regarded as an References obligation stemming from the gift of life at birth 1. Nobelprize.org. The official website of the Nobel Prize. and an expansion of individual sanctity, which it Available at: http://nobelprize.org/nobel_prizes/medicine/ 21

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS laureates/1990/murray-lecture.html. Accessed August 28, to the shortage of organ donors. Surg Gynecol Obstet. 2011. 1991;173(5):391-396. 2. Haller JD, Cerruti MM. Heart transplantion in man: 10. Hobeika MJ, Simon R, Malik R, Pachter HL, Frangos Compilation of cases. January 1, 1964 to October 23, S, Bholat O, Teperman S, Teperman L. U.S. surgeon 1968. Am J Cardiol. 1968;22(6):840-843. and medical student attitudes toward organ donation. 3. Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti J Trauma. 2009;67(2):372-375. VA, Moon JB, Blanchard H, Martin AJ Jr., Porter KA. 11. Simpkin AL, Robertson LC, Barber VS, Young JD. Mod- Orthotopic transplantation of the human liver. Ann ifiable factors influencing relatives’ decision to offer or- Surg. 1968;168:392-414. gan donation: Systematic review. BMJ. 2009;338:b701. 4. Machado C. The first organ transplant from a brain-dead 12. Callender CO, Miles PV. Minority organ donation: donor. Neurology. 2005;64:1938-1942. The power of an educated community. J Am Coll Surg. 5. Beecher HK. A definition of irreversible coma. 1968. 2010;210:708-717. Int Anesthesia Clin. 2010 Fall;45(4):113-119. 13. Festle MJ. Enemies or allies? The organ transplant medi- 6. Converse R. But when did he die? Tucker v. Lower cal community, the federal government, and the public and the brain-death concept. San Diego Law Rev. in the United States, 1967-2000. J Hist Med Allied Sci. 1975;12:424-435. 2010;65:48-80. 7. Veatch RM. Transplantation Ethics: Brain Death: Welcome 14. U.S. Department of Health & Human Services. Organ Definition or Dangerous Judgement? Washington DC: Procurement and Transplantation Network. Available Georgetown University Press; 2000:43-52. at: http://optn.transplant.hrsa.gov/latestData/rptData. 8. Robertson JA. The dead donor rule. Hastings Cent Re- asp. Accessed December 9, 2011. port. 1999;29:6-14. 15. Donate Life New Jersey. New Jersey Hero Act summary. 9. Garrison RN, Bentley FR, Raque GH, Polk HC Jr., Available at: http://www.donatelifenj.org/Professional- Sladek LC, Evanisko MJ, Lucas BA. There is an answer Educators/Hero%20Act.pdf. Accessed December 1, 2011. 16. Truog RD, Miller FG. The dead donor rule and organ Dr. Marvin is chief of the transplantation. N Engl J Med. 2008;359:674-675. 17. Bernat JL. A defense of the whole-brain concept of division of transplantation at death. Hastings Cent Report. 1998; Mar-Apr;28:14-23. Jewish Hospital and associate 18. The Danish Council of Ethics. Organ Donation—Ethi- professor of surgery, in the cal deliberations and recommendations. Available at: department of surgery, Uni- http://etiskraad.dk/upload/publications-en/organ_do- versity of Louisville, KY. nation/organ_donation/index.htm. Accessed November 22, 2011. 19. Aita K. New organ transplant policies in Japan, includ- ing the family oriented donation clause. Transplantation. 2011;91:489-491. 20. Breitowitz Y. Brain death controversy in Jewish law. Jewish Action. 1992;Spring:61-6:66. 21. Sachedina A. End of life: The Islamic view. Lancet. 2005;366:774-779. 22. Sachedina A. Brain death in Islamic jurisprudence. Avail- able at http://people.virginia.edu/~aas/article/article6. htm. Accessed April 4, 2011. 23. Scaraffia L. I segni della morte. A quarant’anni dal Dr. Wohlauer is a fifth- rapporto di Harvard L’Osservatore Romano. 2008:Sept year surgical resident in the 3:1. Available at: http://chiesa.espresso.repubblica.it/ department of surgery, Uni- articolo/206476?eng=y. Accessed September 6, 2011. versity of Colorado, School of 24. Innovative Media Inc. Benedict XVI on organ do- Medicine, Denver, CO. nation. Available at: http://www.zenit.org/article- 24191?l=english. Accessed February 12, 2011. 25. Barnard CN. Human cardiac transplantation. An evaluation of the first two operations performed at the Groote Schuur Hospital, Cape Town. Am J Cardiol. 1968;22:584-596. 26. DeVita M, Snyder J. Development of the University of Pittsburgh Medical Center policy for the management of terminally ill patients who may become organ donors after removal of life support. Kennedy Inst Ethics. 1993 Jun;(3):131-143. 27. Institute of Medicine. Non-Heart-Beating Organ Trans- plantation: Medical and Ethical Issues in Procurement. 22

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Washington, DC: National Academy Press; 1997. renal disease. Panminerva Med. 2011 Sep;53(3):155-66. 28. Novitzky D, Cooper DKC, Reichart B. Haemody- Also see University of California San Francisco. UCSF namic and metabolic responses to hormonal therapy unveils model for implantable artificial kidney to re- in brain-dead potential organ donors. Transplantation. place dialysis. Available at: http://www.eurekalert.org/ 1987;43:852-854. pub_releases/2010-09/uoc--uum090210.php. Accessed 29. Kotsch K, Ulrich F, Reutzel-Selke A, Pascher A, Faber W, November 27, 2011. Warnick P, Hoffman S, Francuski M, Kunert C, Kuecuek O, Schumacher G, Wesslau C, Lun A, Kohler S, Weiss S, Tullius SG, Neuhaus P, Pratschke J. Methylpredniso- lone therapy in deceased donors reduces inflammation in the donor liver and improves outcome after liver transplantation: A prospective randomized controlled trial. Ann Surg. 2008;248(6):1042-1050. 30. Salim A, Martin M, Brown C, Inaba K, Roth B, Had- jizacharia P, Mascarenhas A, Rhee P, Demetriades D. Us- ing thyroid hormone in brain-dead donors to maximize the number of organs available for transplantation. Clin Transplant. 2007;21(3):405-409. 31. Marvin MR, Morton V. Glycemic control and organ transplantation. J Diabetes Sci Technol. 2009;3:1365- 1372. 32. Advisory Committee on Organ Transplantation, Fall Meeting, November 1, 2005. Available at: http://www. organdonor.gov/acotNov2005Notes.asp. Accessed Au- gust 30, 2011. 33. Franklin GA, Santos AP, Smith JW, Galbraith S, Dr. Prager is chairman Harbrecht BG, Garrison RN. Optimization of donor management goals yields increased organ use. Am Surg. of the ethics committee at 2010;76;587-594. Columbia University Medi- 34. DuBose J, Salim A. Aggressive organ donor management cal Center and professor of protocol. J Intensive Care Med. 2008;23:367-375. clinical medicine in the 35. TransMedics. Available at http://www.transmedics.com/ department of medicine, wt/page/PROCEED_II. Accessed November 29, 2011. Columbia University College 36. Steen S, Ingremansson R, Eriksson L, Pierre L, Algots- of Physicians and Surgeons, son L, Wierup P, et al. First human transplantation of a New York, NY. nonacceptable donor lung after reconditioning ex vivo. Ann Thorac Surg. 2011;83:2191-2194. 37. Cypel M, Yeung JC, Liu M, Anraku M, Chen F, Karolak W, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Eng J Med. 2011;364:1431- 1440. 38. Sadaria MR, Smith PD, Fullerton, DA, Justison DA, Joon HL, Puskas F, et al. Cytokine expression profile in human lungs undergoing normothermic ex-vivo lung perfusion. Ann Thorac Surg. 2011;92:389-396. Dr. Chandler is a clinical 39. Hoffman SA, Wang L, Shah, CV, Ahya VN, Pochettino professor of surgery in the A, Olthoff K, et al. Plasma cytokines and chemokines department of surgery, Uni- in primary graft dysfunction post-lung transplantation. versity of Colorado School of Amer J Transplant. 2009;9:389-396. Medicine, Denver, CO. 40. Cypel M, Liu M, Rubacha M, Yeung JC, Hirayama S, Anraku M, Sato M, Medin J, Davidson BL, de Perrot M, Waddell TK, Slutsky AS, Keshavjee S. Functional repair of human donor lungs by IL-10 gene therapy. Sci Transl Med. 2009;Oct 28:1(4):4ra9. 41. Mali P, Cheng L. Human cell engineering: Cellular re- programming and genome editing. Stem Cells. 2011;Sep- tember 8. Doi: 10.1002/stem.735. Accessed September 11, 2011. 42. Roy S, Goldman K, Marchant R, Zydney A, Brown D, Fleischman A, Conlisk A, Desai T, Duffy S, Humes H, Fissell W. Implanted renal replacement for end-stage 23

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Invited commentary Sanctity and organ donation’s societal value in an opt-out country: The Austrian experience

by Matthias Biebl, MD, and Johann Pratschke, MD, PhD

onbeating heart organ donation was re- tion’s societal value which still allow individuals to introduced in most developed nations in decline becoming a donor. This system is sometimes the early 1990s to expand the potential portrayed as encouraging the transplant community donor pool to include futile care with- to prey unethically upon severely brain-damaged Ndrawals for patients with irreversible brain injury trauma victims; however, the reality is far different. but persisting brain stem function and unsuccessful When a patient is declared brain-dead, the decision in- and out-of-hospital cardiac arrest resuscitations. whether organ donation will be considered is left The favored form of donation after cardiac death to the patient’s relatives, and their choice is always (DCD) is controlled withdrawal of intensive care respected. Although Austrian law would allow organ until the onset of circulatory arrest. In this situa- retrieval without involvement of the donor’s rela- tion, the transplant team’s awareness of organ warm tives, the negative publicity of even a single case ischemia vulnerability and their obligation not to where the family’s wishes were ignored would far deliberately transplant a severely damaged organ outweigh the benefit of the retrieved organs. Or- are pitted against the shortest ethically sustainable gan procurement organizations in opt-in countries “no-touch” time between circulatory arrest and the probe a potential donor’s thoughts about donation start of organ perfusion. by asking the relatives: this method is more similar This discomforting dilemma is a poor exit strategy than different from the Austrian opt-out system. for the imbalance of organ supply and demand. The Eurotransplant report for 2010 lists 22.6 The Belgian experience with DCD kidney retrieval donors per million inhabitants in Austria compared showed that it did not substantially increase the to- with only 15.4 donors per million in Germany, tal donor pool and, rather, resulted in a proportional where the culture and health care system are similar shift from brain-dead to DCD donors by not al- to ours.2 It is important to recognize that this huge lowing a potential donor to progress to brain-death difference in organ availability also affects the quality determining criteria.1 of the available organs. Our public perception of or- gan donation as a natural part of Austrian citizenship, Different European approaches rather than as private gifts to anonymous persons, has Opt-in and opt-out are diametric ethically valid a positive influence on family members’ decisions and concepts within the Eurotransplant region, which has a substantial effect on our higher donation rates. encompasses Belgium, the Netherlands, Luxem- In an opt-in system, healthy persons harbor a concept bourg, Germany, Austria, Slovenia, and Croatia. of their bodily integrity being violated, without its Austria and Belgium have implemented an opt-out balancing societal value, and simply turn their minds 24 approach as national endorsements of transplanta- away from this unsavory issue.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Organs from brain-dead patients 2. Eurotransplant 2010 Annual report. Available at: http:// www.eurotransplant.org. Accessed September 7, 2011. In almost all societies, the moment of death and 3. Weiss S, Kotsch K, Francuski M, Reutzel-Selke A, Mantou- the treatment of the earthly remains are handled valou L, Klemz R, Kuecuek O, Jonas S, Wesslau C, Ulrich with dignity and silence. The loss of central physi- F, Pascher A, Volk HD, Tullius SG, Neuhaus P, Pratschke ologic regulation as brain stem function ceases goes J. Brain death activates donor organs and is associated unnoticed and does not break the outward silence. with a worse I/R injury after liver transplantation. Am J Transplant. 2007;7:1584-1593. In reality, however, a violent cytokine storm is be- 4. Kotsch K, Ulrich F, Reutzel-Selke A, Pascher A, Faber W, ing unleashed that causes profound hemodynamic Warnick P, Hoffman S, Francuski M, Kunert C, Kuecuek instability and, if untreated, eventual cardiac arrest. O, Schumacher G, Wesslau C, Lun A, Kohler S, Weiss Fortunately, this is amenable to pharmacologic in- S, Tullius SG, Neuhaus P, Pratschke J. Methylprednisolone therapy in deceased donors reduces inflammation in the tervention. Many centers treat this expectantly with donor liver and improves outcome after liver transplanta- a preset cocktail of steroids, insulin, and thyroid tion: A prospective randomized controlled trial. Ann Surg. hormone, as experimental studies have demonstrated 2008;248(6):1042-1050. tremendous upregulation of pro-inflammatory cyto- 5. Moers C, Smits JM, Maathuis MH, Treckmann J, van kines in deceased donors in comparison with living Gelder F, Napieralski BP, van Kasterop-Kutz M, van der Heide JJ, Squifflet , JP van Heurn E, Kirste GR, Rahmel donors. These cytokines aggravate the organ’s sub- A, Leuvenink HG, Paul A, Pirenne J, Ploeg RJ. Machine sequent ischemia-reperfusion injury, which can be perfusion or cold storage in deceased-donor kidney trans- successfully mitigated by administering steroids.3,4 plantation. N Engl J Med. 2009;360(1):7-19. We have routinely administered 1g of methylpred- nisolone prior to cold organ perfusion during the retrieval procedure, and have now changed donor preconditioning to repeated steroid pulses from the Professor Pratschke is the chairman of the department time death is declared until organ retrieval. of visceral, transplant, and Hypothermic machine perfusion rather than static thoracic surgery, Innsbruck cold storage was once empiric, but now has a firm Medical University, Inns- 5 scientific basis for kidneys. In Austria, our compact bruck, Austria. geography usually equates to brief cold ischemia times, so static cold storage has been the standard. We now use hypothermic machine perfusion for an- ticipated longer cold ischemia times when the donor hospital and transplant center are unusually far apart and for grafts that were subjected to prolonged warm ischemia, typically in DCD situations, improving both early organ function and prolonged survival. Our transplant professionals deal every day with the tension between preserving the dignity and sanctity of the deceased donor and the life-extending Dr. Biebl is an associate value of each successfully transplanted organ. In that professor in the department process, we are always mindful of our obligation to of visceral, transplant, and use maximum diligence and every available tool to thoracic surgery, Innsbruck Medical University, obtain the best possible organ quality and function Innsbruck, Austria. in the recipient. 

References 1. Van Gelder F, Delbouille MH, Vandervennet M, Van Beeu- men G, Van Deynse D, Angenon E, Amerijkx B, Donckier V. An 11-year overview of the Belgian donor and transplant statistics based on a consecutive yearly data follow-up and comparing two periods: 1997 to 2005 versus 2006 to 2007. Transplant Proc. 2009;41:569-571. 25

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS CURRENT

he Current Procedural Terminology (CPT)* 2012 manual comprises several new codes and code changes pertaining to general surgery and its CPT 2012 closely related specialties. This article summa- rizesT these modifications. PROCEDURALbrings with it New modifier new codes The Affordable Care Act (ACA) requires all health care plans to begin covering immunizations and pre- ventive services without any cost sharing. Modifier 33 and has been added to CPT 2012 to identify preventive code changes services. This modifier allows providers to identify TERMINOLOGYthat the service was preventive under applicable laws and that patient cost sharing does not apply. by Linda Barney, MD, FACS; Evaluation and management The new and established patient definitions in the Mark Savarise, MD, FACS; evaluation and management (E/M) guidelines have and Jenny Jackson, MPH been revised to add additional granularity to the terms “specialties” and “subspecialties.” The term “exact sub- specialty” was added to specify that the professional services would be provided by a physician of the exact same specialty and subspecialty, who belongs to the same group practice, within the past three years. This revision clarifies that although the physician may be of the same specialty, differences between the subspe- cialty may require a significant new patient work-up and should therefore be considered a new patient visit rather than an established patient visit. Debridement As a point of clarification, in 2011 the debride- ment guidelines stated that add-on code 11045, Debridement, subcutaneous tissue (includes epidermis and dermis, if performed; each additional 20 sq cm, *All specific references to CPT (Current Procedural Terminology) terminology and phraseology are © 2012 American Medical Association. 26 All rights reserved.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS or part thereof, should be reported with modifier 59, as “skin substitute grafts.” However, some codes if multiple wounds are debrided on the same day. remain in the skin replacement surgery section, However, add-on codes do not require the use of a including surgical preparation; topical placement modifier. The 2012 revised guidelines now indicate of an autograft; tissue-cultured autograft; and skin that coders should use modifier 59 with either 11042, substitute homograft, allograft, and xenograft. The Debridement, subcutaneous tissue (includes epidermis guidelines instruct that the graft is anchored using and dermis, if performed); first 20 sq cm or less) or the provider’s choice of fixation, and when services 11044, Debridement, bone (includes epidermis, dermis, are performed in the office, routine dressing sup- subcutaneous tissue, muscle and/or fascia, if performed); plies are not reported separately. first 20 sq cm or less, as appropriate. Other flaps and grafts Skin replacement surgery A new add-on code 15777, Implantation of biologic Comprehensive changes have been made to the implant (eg, acellular dermal matrix) for soft tissue rein- skin replacement surgery subsection. The changes forcement (eg, breast, trunk), has been established. For include deletion of 24 codes, revision of six codes, bilateral breast procedures, report 15777 with modi- and the creation of eight new codes (15271–15278). fier 50. For implantation of synthetic mesh or other This article gives only a brief overview of the prosthesis for open incisional or ventral hernia repair changes; a more detailed skin replacement surgery or closure of a necrotizing soft tissue infection wound, article will be published in February. report 49568 in conjunction with 49560–49566 or Reference to the phrase “skin substitutes” has 11004–11006, as appropriate. Code 15777 is not to been removed as a subheading in the skin replace- be used for the topical application of skin substitute ment surgery section; the codes in this section are graft to a wound surface, which should be reported now in a new section in the manual, referred to with new codes 15271–15278. Hands and fingers Highlight Two new codes are available to report the treatment of Dupuytren’s contracture. Report code 20527 for CMS recently provided a clarification on observation the injection of an enzyme (for example, collagenase) codes. More specifically, Medicare now has explicit rules into the palmar fascial cord (ie, Dupuytren’s cord). related to the billing of subsequent observation codes Code 26341 is reported for the manipulation of the (99224–99226). These rules are specific to Medicare and palmar fascial cord performed on the next day and do not follow current CPT guidance. Note that private follow-up care within 10 days (for example, wound payors may or may not follow these guidelines. check). Fabrication and application of a custom or- Under Medicare’s guidelines, only the physician who thotic is separately reportable. admits a patient for observation may bill the subsequent observation codes. Thus, subsequent observation care is Lungs and pleura only rendered by the admitting physician on the day(s) other than the initial or discharge date. Physicians who Comprehensive changes were made to the lungs provide consultations while a patient is admitted to and pleura section of CPT, including a new section hospital outpatient observation services must bill the added to identify video-assisted thoracoscopic surgery appropriate outpatient evaluation and management (VATS). service (99201–99215). The guidelines provide specific instructions when Additionally, subsequent observation codes will be the services of intraoperative pathology are used. In included in the global surgical fee. Thus, only services these circumstances, if a more extensive procedure is that meet the criteria to append modifier 24, unrelated required due to the results of the consultation, then evaluation and management, post-operative, same physi- only the most extensive procedure code is reported. cian; 25, separate, significant evaluation and management, The new guidelines prohibit use of smaller procedure same physician and same day; or 57, decision for surgery, codes, such as biopsies, in addition to more extensive to the evaluation and management service may be billed lung procedure codes such as lobectomies, unless the to Medicare in a global period. procedures were performed on different lobes, or the contralateral lung. In these situations it would 27

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS be appropriate to append the 59 modifier (distinct code, which can only be reported in conjunction procedural service). with 32440, 32442, 32445, 32480, 32482, 32484, Code 32095—previously used to report biopsy 32486, 32488, 32503, 32504, 32505, 32663, procedures of the lungs or pleura via thoracotomy— 32666, 32667, 32669, 32670, and 32671. For pro- has been deleted. Three new codes are available to cedures on the right lung, mediastinal lymph nodes report incisional (thoracotomy) biopsy procedures: include the paratracheal, subcarinal, paraesophageal, 32096, Thoracotomy, with diagnostic biopsy(ies) of and those in the inferior pulmonary ligament. For lung infiltrate(s) (eg, wedge, incisional), unilateral; procedures on the left lung, mediastinal lymph 32097, Thoracotomy, with diagnostic biopsy(ies) of lung nodes include the subcarinal, paraesophageal, and nodule(s) or mass(es) (eg, wedge, incisional), unilateral; those in the aortopulmonary window, and inferior and 32098, Thoracotomy, with biopsy(ies) of pleura. pulmonary ligament. Therapeutic wedge resection procedures are now A surgeon plans to perform a VATS wedge biopsy reported with 32505, Thoracotomy; with therapeutic of two suspicious lesions in the right lung: one in wedge resection (eg, mass, nodule), initial. the upper lobe and one in the lower lobe. His plan Two new add-on codes for open wedge resection is to proceed with a therapeutic operation if the have been created: 32506, Therapeutic wedge resection frozen section biopsy of either lesion proves to be (eg, mass or nodule), each additional resection, ipsi- malignant. The upper lobe lesion is a non-small cell lateral (List separately in addition to code for primary carcinoma on frozen section of the wedge biopsy. The procedure), and 32507, Diagnostic wedge resection lower lobe lesion is a benign granuloma. The surgeon followed by anatomic lung resection (List separately in proceeds to perform a VATS upper lobectomy and addition to code for primary procedure). mediastinal lymphadenectomy. Reportable codes In CPT 2012, the term “video-assisted thoraco- include the following: scopic surgery” (VATS) replaces “thoracoscopy.” CPT code 32602, Thoracoscopy, diagnostic (separate 32663, VATS lobectomy procedure); lungs and pleural space, with biopsy, has +32668, VATS diagnostic wedge resection been deleted. Three new codes have been created +32667, VATS additional wedge resection to report lung or pleural space biopsy procedures: +32674, VATS mediastinal and regional lymphad- 32607, Thoracoscopy; with diagnostic biopsy(ies) of enectomy lung infiltrate(s) (eg, wedge, incisional, unilateral); 32608, Thoracoscopy; with diagnostic biopsy(ies) of Note: Code 32663 is the primary code. The other lung nodule(s) or mass(es) (eg, wedge, incisional), codes are add-on codes and do not require modifiers. unilateral; and 32609, Thoracoscopy; with biopsy(ies) of pleura. Codes 32607 and 32608 should not be IVC filter and ligation of the vena cava reported more than once per lung. Codes 37620, Interruption, partial or complete, Code 32666 identifies an initial therapeutic wedge of inferior vena cava by suture, ligation, plication, resection using VATS. If performed bilaterally, clip, extravascular, intravascular (umbrella device), modifier 50 may be appended to the code. and 75940, Percutaneous placement of IVC filter, Add-on code 32667 is used to report additional radiological supervision and interpretation, have thoracoscopic therapeutic wedge resections. Add- been deleted for 2012. Three new bundled codes on code 32668 is used to report diagnostic wedge were established to report insertion, reposition- resection that is followed by anatomic lung resection. ing, and removal of an inferior vena cava (IVC) Code 32668 can only be reported in conjunction filter: 37191, Insertion of intravascular vena cava with CPT codes 32440, 32442, 32445, 32480, filter, endovascular approach including vascular ac- 32482, 32484, 32486, 32488, 32503, 32504, cess, vessel selection, and radiological supervision and 32663, 32669, 32670, and 32671. interpretation, intraprocedural roadmapping, and New codes 32669–32674 are for VATS removal imaging guidance (ultrasound and fluoroscopy), when procedures that vary according to the amount of performed; 37192, Repositioning of intravascular vena tissue removed or in the difficulty of removal. CPT cava filter, endovascular approach including vascular code 32674, Thoracoscopy, surgical; with medias- access, vessel selection, and radiological supervision 28 tinal and regional lymphadenectomy, is an add-on continued on page 32

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Common general surgery procedure 2012 wRVUs versus 2011 wRVUs 2011 2012 % chg CPT Code Descriptor wRVU wRVU from 2011 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 0.80 1.01 26% 20 sq cm or less 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, 2.00 2.70 35 if performed); first 20 sq cm or less 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or 3.60 4.10 14 fascia, if performed); first 20 sq cm or less 11045 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each 0.33 0.50 52 additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, 0.70 1.03 47 if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or 1.20 1.80 50 fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands 2.20 2.00 -9 and feet); 2.5 cm or less 12035 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands 3.47 3.50 1 and feet); 12.6 cm to 20.0 cm 12036 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands 4.09 4.23 3 and feet); 20.1 cm to 30.0 cm 12037 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands 4.71 5.00 6 and feet); over 30.0 cm 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 2.42 2.10 -13 12045 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 3.68 3.75 2 20.0 cm 12047 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm 4.69 4.95 6 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.52 2.33 -8 2.5 cm or less 12055 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 4.47 4.50 1 12.6 cm to 20.0 cm 28820 Amputation, toe; metatarsophalangeal joint 5.00 5.82 16 28825 Amputation, toe; interphalangeal joint 6.01 5.37 -11 35800 Exploration for postoperative hemorrhage, thrombosis or infection; neck 8.07 12.00 49 35840 Exploration for postoperative hemorrhage, thrombosis or infection; abdomen 10.96 20.75 89 35860 Exploration for postoperative hemorrhage, thrombosis or infection; extremity 6.80 15.25 124 36819 Arteriovenous anastomosis, open; by upper arm basilic vein transposition 14.47 13.29 -8 36825 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate 15.13 14.17 -6 procedure); autogenous graft

continued on next page 29

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Common general surgery procedure 2012 wRVUs versus 2011 wRVUs 2011 2012 % chg CPT Code Descriptor wRVU wRVU from 2011 37140 Venous anastomosis, open; portocaval 25.23 40.00 59% 37145 Venous anastomosis, open; renoportal 26.24 37.00 41 37160 Venous anastomosis, open; caval-mesenteric 23.24 38.00 64 37180 Venous anastomosis, open; splenorenal, proximal 26.24 36.50 39 37181 Venous anastomosis, open; splenorenal, distal (selective decompression of 28.37 40.00 41 esophagogastric varices, any technique) 42415 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation 18.12 17.16 -5 of facial nerve 42420 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial 21.00 19.53 -7 nerve 42440 Excision of submandibular (submaxillary) gland 7.13 6.14 -14 43415 Suture of esophageal wound or injury; transthoracic or transabdominal approach 28.91 44.88 55 47563 Laparoscopy, surgical; cholecystectomy with cholangiography 12.11 11.47 -5 47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 14.24 18.00 26 49507 Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated 10.05 9.09 -10 49521 Repair recurrent inguinal hernia, any age; incarcerated or strangulated 12.44 11.48 -8 49587 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated 8.04 7.08 -12 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes 12.88 11.92 -7 mesh insertion, when performed); reducible 49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes 16.21 14.94 -8 mesh insertion, when performed); incarcerated or strangulated 49654 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); 15.03 13.76 -8 reducible 49655 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); 18.11 16.84 -7 incarcerated or strangulated 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy 12.37 11.19 -10 60240 Thyroidectomy, total or complete 16.22 15.04 -7 60500 Parathyroidectomy or exploration of parathyroid(s); 16.78 15.60 -7 99218 Initial observation care, per day, for the E/M of a patient, which requires these three 1.28 1.92 50 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

continued on next page 30

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Common general surgery procedure 2012 wRVUs versus 2011 wRVUs 2011 2012 % chg CPT Code Descriptor wRVU wRVU from 2011 99219 Initial observation care, per day, for the E/M of a patient, which requires these three 2.14 2.60 21% key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit. 99220 Initial observation care, per day, for the E/M of a patient, which requires these three 2.99 3.56 19 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit. 99224 Subsequent observation care, per day, for the E/M of a patient, which requires at least 0.54 0.76 41 two of these three key components: problem-focused interval history; problem-focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit. 99225 Subsequent observation care, per day, for the E/M of a patient, which requires at least 0.96 1.39 45 two of these three key components: an expanded problem-focused interval history; an expanded problem-focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit. 99226 Subsequent observation care, per day, for the E/M of a patient, which requires at least 1.44 2.00 39 two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit. 99235 Observation or inpatient hospital care for the E/M of a patient including admission and 3.41 3.24 -5 discharge on the same date, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) requiring admission are of moderate severity. 99236 Observation or inpatient hospital care for the E/M of a patient, including admission and 4.26 4.20 -1 discharge on the same date, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) requiring admission are of high severity.

31

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS and interpretation, intraprocedural roadmapping, value observation (outpatient) E/M codes equal to and imaging guidance (ultrasound and fluoroscopy), the corresponding inpatient E/M codes. when performed; and 37193, Retrieval (removal) of If you have additional coding questions, con- intravascular vena cava filter, endovascular approach tact the ACS Coding Hotline at 800-227-7911 including vascular access, vessel selection, and radio- between 7:00 am and 4:00 pm Mountain time, logical supervision and interpretation, intraprocedural excluding holidays.  roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed. Editor’s note New code 37619, Ligation of inferior vena cava, has been established to report the open surgical procedure Accurate coding is the responsibility of the provider. This sum- performed in trauma patients or other acute open mary is only a resource to assist in the billing process. ligation indications. Paracentesis and peritoneal lavage In 2012, codes 49080, Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeu- tic); initial, and 49081, Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeu- tic); subsequent, have been deleted and replaced with new codes that indicate whether it was done with or without imaging guidance: 49082, Abdominal para- centesis (diagnostic or therapeutic; without imaging guid- ance), and 49083, Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance. Additionally, a new code was created to report peritoneal lavage, 49084, Peritoneal lavage, including imaging guidance, when performed.

Medicare physician fee schedule In addition to coding changes for 2012, the final rule for the Medicare physician fee schedule makes many changes to the physician work relative value units (wR- VUs). The changes in wRVUs from 2011 values come after review of procedures and services that the Centers for Medicare & Medicaid Services (CMS) identified as “potentially misvalued,” and for procedures and services identified by specialties as undervalued and reviewed through the five-year review process. The American College of Surgeons was involved in the American Dr. Barney is associate professor and associate program director Medical Association/Specialty Society Relative Value for general surgery, department of surgery, Wright State University Scale Update Committee (RUC) survey and review of Boonshoft School of Medicine, and member, Wright State Surgeons, 95 codes. Although some of these codes decreased in Miami Valley Hospital, Dayton, OH. She is the ACS advisor at value by as much as 13 percent, other codes increased the American Medical Association CPT Editorial Panel meetings. by as much as 124 percent. Dr. Savarise is a general surgeon in private practice in Sandpoint, The table on pages 29–31 presents 42 general ID. He serves on the Advisory Council for General Surgery, and surgery codes and nine observation service codes is the ACS alternate advisor at the American Medical Association with wRVUs that CMS is changing in 2012. As CPT Editorial Panel. more hospitals assign patients to outpatient status for facility fee reimbursement instead of inpatient Ms. Jackson is Practice Affairs Associate, Division of Advocacy 32 status, it is important to note that CMS agreed to and Health Policy, Washington, DC.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Highlights of the 97th Annual Clinical Congress

t the 2011 Clinical Congress in San Francisco, CA, a wide selection of presentations covering subjects from education to practice to clinical considerations—in addition to poster presentations, papers sessions, and special-interest meet- Aings—were offered. The meeting was attended by 15,089 participants, including 9,512 physicians; the remaining attendees included exhibi- tors, spouses, guests, and convention personnel. Convocation Patricia J. Numann, MD, FACS—a general surgeon and Lloyd S. Rogers Professor of Surgery Emeritus, Distinguished Teaching Profes- sor Emeritus at the State University of New York (SUNY) Upstate Medical University, Syracuse—was installed as the 92nd President of the American College of Surgeons (ACS) during Convocation ceremonies that denoted the official opening of the Clinical Congress (see photo, page 34). Another officer installed during the Convocation was Robert R. Bahnson, MD, FACS, Columbus, OH, as Second Vice-President. A urologic surgeon, he is professor and chairman of the department of urology, and The Dave Longaberger Chair in Urology at the Ohio State 33

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS University College of Medicine, Columbus, OH. A Montori, MD, FACS; Cornelis J.H. van de Velde, Fellow of the College since 1990, Dr. Bahnson has MD, PhD, FRCS; and Yupei Zhao, MD, FACS. served on the Board of Governors (2004–2010), as a member of the Governors’ Committee on Physician Named Lectures Competency and Health (2006-2010), as Vice- As was the case last year, the Martin Memorial Chair of the Program Committee (2008–2010), Lecture and the American Urological Association and as Chair of the Advisory Council for Urology Lecture were combined for presentation during (2007–2011). the Opening Ceremony of the Clinical Congress. Honorary Fellowship was conferred on the following C. David Naylor, MD, D.Phil, FRCPC, FACP, six prominent surgeons: Kenneth D. Boffard, MB, delivered his lecture, Too Big to Fail? Health Care BCh, FACS, FRCS; Ara Darzi, MB, BCh, FACS, Reform in the U.S. and Canada, immediately fol- FRCS; Eilis McGovern, MD, DCh, FRCSI; Alberto lowing the Opening Ceremony on Monday morn- ing. Also on Monday, The Problem of Physician Payment Reform: A Surgical Solution was presented Where to find more information as the John H. Gibbon, Jr., Lecture by John E. May- er, MD, FACS, and Edward R. Laws MD, FACS, These highlights include news items that have been presented a lecture titled The Virtuoso Surgeon: discussed in more detail in previous issues of the Bulletin. Past, Present, and Future as the Charles G. Drake Following is a list of where to find these articles. History of Surgery Lecture. The Excelsior Surgical October 2011 Society Edward D. Churchill Lecture, convened Tuesday with Donald D. Trunkey, MD, FACS, Dr. McGrath’s Distinguished Service Award, page 28 presenting Changes in Combat Casualty Care in Full description of the humanitarian achievements of the Last 20 Years. Surgical Volunteerism Award recipients, page 30 Other Named Lectures that convened Tuesday November 2011 were the Scudder Oration on Trauma, during which Demetrios Demetriades, MD, FACS, presented Biography of Dr. Numann, page 40 Citations for Honorary Fellows presented at the Convoca- Pictured above, left: Distinguished Service Award recipient Dr. tion, page 42 McGrath (left) with Dr. Britt. December 2011 Center: Dr. Numann presenting her Presidential Address during Convocation ceremonies. Dr. Numann’s Presidential Address, page 24 Right: Volunteerism Award recipients Dr. Carter (second Dr. Eastman, Dr. Burns, and Dr. Daly were chosen as from left) and Dr. Tefera (second from right) with Jack Watters, Officers-Elect, page 51 MD, vice-president of external medical affairs, Pfizer, Inc (far left) and Timothy C. Flynn, MD, FACS, Chair of the Board 34 of Governors.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Thoracic Aortic Injuries: Crossing the Rubicon; of the Chair of the Board of Regents; Timothy and the Olga M. Jonasson Lecture, Effective Ad- C. Flynn, MD, FACS, presented the Report of vocacy, presented by ACS President Dr. Numann. the Chair of the Board of Governors; and David Wednesday’s Named Lectures included the Ethics B. Hoyt, MD, FACS, presented the Report of the and Philosophy Lecture, Ethical Foundations of Executive Director of the College. Hilary A. San- Health Care Reform: Implications for Policy and fey, MB, BCh, FACS, presented the Report of the Law presented by Robert M. Sade, MD, FACS; Chair of the Nominating Committee of the Board Translational Cancer Research: Playing to Win in a of Governors, during which the elected Regents and Team Sport, the Commission on Cancer Oncology Board of Governors Officers were announced; and Lecture presented by Monica M. Bertagnolli, MD, Jeffrey S. Upperman, MD, FACS, presented the FACS; the I.S. Ravdin Lecture in Basic Sciences, Report of the Chair of the Nominating Committee where Robert D. Howe, PhD, delivered Cathbots: of the Fellows and announced the nomination and Ultrasound Guidance for Robotic Beating Heart election of Governors and Officers. Surgery; The Herand Abcarian Lecture, Improving the Quality of Cancer Surgery in a Single Payor New Officers-Elect System: The Cancer Care Ontario Experience, was At the Annual Business Meeting of Members, offered by Robin S. McLeod, MD, FACS, FRCSC; new Officers-Elect were elected. A. Brent East- and Surgical Training and Surgical Practice: Are man, MD, FACS, was elected President-Elect and We Getting the Formula Right?, the Distinguished will begin his tenure as the 93rd ACS President at Lecture of the International Society of Surgery, the 2012 Clinical Congress in Chicago, IL. Dr. was presented by Eilis McGovern, MD, FRCSI, Eastman is a general, vascular, and trauma surgeon FRCS(Ed), DCh. from San Diego, CA. R. Phillip Burns, MD, FACS—a general surgeon College governance and professor of surgery at the University of Ten- At the Annual Business Meeting of Members on nessee College of Medicine, Chattanooga—was Wednesday, where Dr. Numann presided, Carlos named First Vice-President-Elect. Named as Sec- A. Pellegrini, MD, FACS, presented the Report ond Vice-President-Elect was John M. Daly, MD, FACS, a general surgeon and dean emeritus, Temple Above left: Distinguished Philanthropist Award recipients Drs. University School of Medicine, Philadelphia, PA. Thomas and Nona Russell (left), with Past-President LaMar S. McGinnis, Jr., MD, FACS, a member of the ACS Foundation Board of Directors. Awards, honors, celebrations Right: 2011 Meritorious Achievement Award, left to right: A number of ACS Members were recognized dur- Michael F. Rotondo, MD, FACS, Chair, Committee on Trauma; ing the Clinical Congress. Dr. Nancy Parks, Ben Parks, Patty Parks, and Raul Coimbra, MD, The 2011 Distinguished Service Award, the FACS, Vice-Chair, Committee on Trauma. College’s highest honor, was presented to Mary 35

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS H. McGrath, MD, MPH, FACS (see photo, page 2011 Meritorious Achievement Award was given in 34). The ACS Board of Regents recognized Dr. honor of Steven N. Parks, MD, FACS, who passed McGrath with this award for her “steadfast com- away August 21, 2010. Dr. Parks was the former mitment to the initiatives and principles embodied State Chair of the Northern California Commit- by the American College of Surgeons,” her numer- tee on Trauma (COT), former Chief of Region ous contributions to the College through service, 9, former COT member, and former Chair of the her work as a clinical and academic surgeon, and Advanced Trauma Life Support program. Accepting her dedication to improving the quality of surgical the award from Raul Coimbra, MD, PhD, FACS, patient care. Vice-Chair of the COT and Chair of the Regional The 2011 ACS/Pfizer Surgical Volunteerism and Committees on Trauma, were Dr. Parks’ wife, Mrs. Surgical Humanitarian Award winners were honored Patty Parks, daughter Nancy Parks, MD, and son at a general session on Monday, sponsored by the Ben Parks (see photo, this page). College’s Operation Giving Back program. Louis L. Carter, Jr., MD, FACS, was presented with the Top: Left to right: Surgical Forum Committee Chair Michael humanitarianism award, and Girma Tefera, MD, T. Longaker, MD, FACS, and Surgical Forum dedicatee Dr. FACS, received the volunteerism award (see photo, Fonkalsrud, MD, FACS; with Excellence in Research awardees page 34). Dr, James, Dr. Jadlowiec, Dr. Nagahashi, Dr. Coleman, Dr. Also Monday, Thomas R. Russell, MD, FACS, Chen, Dr. Speer, Dr. Babicky, Dr. Glotzbach, and Dr. Kubat. and Nona Chiampi Russell, MD, PhD, were Bottom left: CoC Outstanding State Chair award recipients Dr. Beatty (center left) and Dr. Landry (center right) with presented with the Fellows Leadership Society’s Aaron Bleznak, MD, FACS, Chair, CoC Committee on Cancer Distinguished Philanthropist Award. The Doctors Liaison (far left) and Philip Roland, MD, FACS, Vice-Chair, Russell have been generous and loyal benefactors CoC Committee on Cancer Liaison. of the College as evidenced by more than 100 Bottom right: Oweida Scholar Dr. Khan (center) with Mark philanthropic gifts since 1990 (see photo, page 35). T. Savarise, MD, FACS (left), member of the Advisory Council 36 At the annual Trauma Dinner Monday night, the for General Surgery, and Shahbano J. Khan.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The 2012 Owen H. Wangensteen Surgical Forum included Sonal Arora, MD, PhD; Michelle L. was dedicated to Eric W. Fonkalsrud, MD, FACS Babicky, MD; Evie Carchman, MD; Jerry S. (see photo, page 36). Residents honored with the Chen, MD; Melissa H. Coleman, MD; Jason P. Surgical Forum Excellence in Research Awards Glotzbach, MD; Caroline C. Jadlowiec, MD; Aaron W. James, MD; Eric Kubat, MD; Elise H. Top left: Jacobson Promising Investigator Award recipient Dr. Lawson, MD, MSHS, Masayuki Nagahashi, MD, MacKenzie (second from left) with Dr. and Mrs. Jacobson and PhD; Mathew D. Sorensen, MD; Allison L. Speer, (far right) Dr. Numann. MD; Richard C. Webb, MD; and Daniel Wu, MD. Top right: Best Scientific Exhibit co-author Dr. Potretzke The Committee on Cancer Liaison recognized (center) with Barbara L. Bass, MD, FACS, Chair of the ACS three Commission on Cancer State Chairs for out- Program Committee, and ACS Regent Leigh A. Neumayer, MD, standing performance and significant contributions FACS. to the Liaison Program in 2011. Honored were J. Bottom: Resident Award for Exemplary Teaching recipient Dr. David Beatty, MD, FACS, Washington State Chair, Jensen (third from right), with (left to right): Glenn T. Ault, MD, Jarrod FACS, Chair, Resident Award Program, Committee on Resident Swedish Cancer Institute in Seattle, WA; Education; Carlos A. Pellegrini, MD, FACS, Chair, Board of Kaufman, MD, FACS, New Jersey State Chair, Regents; David B. Hoyt, MD, FACS, Executive Director; Karen Advanced Surgical Associates of New Jersey, and Horvath, MD, FACS, Residency Program Director, University of Central State Healthcare System, Freehold, NJ; and Washington, Seattle; Dr. Numann; and Ajit K. Sachdeva, MD, Barry Landry, MD, FACS, Louisiana State Chair, FACS, FRCSC, Director, Division of Education. Thibodaux Surgical Specialists and Thibodaux Re- 37

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS gional Medical Center, Thibodaux, LA (see photo, panel of the Committee on Resident Education (see page 36). photo, page 37). Afaq Z. Khan, MBBS, FACS, a general surgeon The International Guest Scholar program wel- from Hays, KS, received the 2011 Nizar N. Oweida comed its 2011 guest scholars and exchange fellows, Scholarship at the Rural Surgeons meeting (see including the following: Peter J. Anderson, MB, photo, page 36). ChB, PhD, FRACS, FRCS (Eng), Adelaide, Aus- Tippi C. MacKenzie, MD, FACS, a pediatric tralia; Somprakas Basu, MB, BS, Varanasi, India, surgeon at University of California, San Francsico, International Education Scholar; Carlos Carcamo, Benioff Children’s Hospital and its Fetal Treatment MD, FACS, Valdivia, Chile; Pramod Devkota, Center, was presented with the Joan L. and Julius MB, BS, MS, Kathmandu, Nepal; Timothy W. H. Jacobson II Promising Investigator Award (see Eglinton, MB, ChB, FRACS, Christchurch, New photo, page 37). Zealand; Marcus Fokou, MD, FWACS, Yaounde, Neutrophil-Lymphocyte Ratio Is Associated with Cameroon, Doctor Louis Argenta Scholar; Pablo Increased Risk of Pathological Upstaging after Radical Santiago Frioni, MD, Montevideo, Uruguay; Amit Cystectomy for Clinical T2 Urothelial Carcinoma was Goyal, MD, MS, Derby, United Kingdom, Interna- named this year’s Best Scientific Exhibit at the 2011 tional Education Scholar; Beata Hemmelova, MD, Clinical Congress meeting This poster was authored Brno, Czech Republic, Abdol Islami Scholar; Jens by Tracy M. Downs, MD; Aaron M. Potretzke, Hoeppner, MD, Freiburg im Breisgau, Germany; MD; E. Jason Abel, MD; Wei Huang, MD; Jeremy Rajeev Kumar, MB, BS, New Delhi, India; Pradeep Cetnar, MD, MPH; and David F. Jarrard, MD, of Harkison Navsaria, MB, ChB, Cape Town, South the University of Wisconsin School of Medicine and Africa; Kehinde Sunday Oluwadiya, MBBS, FMCS Public Health, Madison, WI (see photo, page 37). (Orthop), Osogbo, Nigeria; Rauf Oqtay Shahbazov, More than 300 poster presentations were displayed MD, Baku, Azerbaijan; and Suguru Yamada, MD, at the meeting, with nine posters awarded the Poster PhD, Nagoya City, Aichi, Japan (see photo, this of Exception Merit designation. page). was unable to attend. The ninth annual ACS Resident Award for Exem- Medical students Melina Deban, McGill Univer- plary Teaching—which is sponsored by the Division sity Faculty of Medicine (see photo, page 39); Chris- of Education to recognize excellence in teaching by a resident, and to highlight the importance of teaching Above: International Guest Scholars, International Relations in residents’ daily lives—was presented to Aaron R. Committee (IRC) members, and guests. Front row, left to right: Fabrizio Michelassi, MD, FACS, IRC Chair; Kate Early, International Jensen, MD, MEd. Dr. Jensen completed his general Liaison; Dr. Fokou; Dr. Yamada; Dr. Navsaria; Dr. Kumar; Dr. surgery residency at the University of Washington in Devkota; Dr. Santiago Frioni; Dr. Oluwadiya; Dr. Anderson; and Seattle, and is currently a fellow in pediatric surgical Stephen A. Deane, IRC Chair. Not pictured: Dr. Hoeppner. critical care at the Children’s Hospital Los Angeles. Back row: Dr. Basu; Dr. Shahbazov; Dr. Eglinton; Dr. 38 Dr. Jensen was selected by an independent review Hemmelova; Dr. Goyal; and Dr. Carcamo.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS topher S. Graffeo, New York University School of video, titled Laparoscopic Right Hepatectomy and Medicine (see photo, this page); and Kassi Kronfeld, the Management of Vascular Lesions, authored by Oregon Health & Science University (photo not Brice Gayet, MD, PhD, and presented by Adrian available) were awarded first-place honors for their M. Nedelcu, MD, of Paris, France. posters and oral presentations during the Medical Additionally, Barbara L. Bass, MD, FACS, Hous- Student Program offered during the Clinical Congress ton, TX, was honored for her eight years of excep- by the Division of Education. Ms. Deban’s poster tional leadership as Chair of the Program Committee titled Creating a Surgical Care Report Card: The As- at its annual meeting (see photo, page 40). Thomas V. sociation between Adherence to Process-Based Qual- Whalen, MD, MMM, FACS, Vice-Chair, Board of ity Indicators and Postoperative Complications was Regents was recognized for his outstanding leadership awarded first-place in the Clinical and Educational as Course Director for the Surgery Resident Program, Research category. Mr. Graffeo’s poster titled The offered each year by the Division of Education at the Dichotomous Role of Dendritic Cells in Modulating Clinical Congress to help prepare residents for the Pancreatitis tied for first place in the Basic Science transition to practice (see photo, page 40). Research category with Ms. Kronfeld’s poster titled Brainstem Modulation of Cerebral Blood Flow Af- Board of Regents/Board of Governors ter Experimental Subarachnoid Hemorrhage. Their The Board of Governors has elected James K. Elsey, posters and oral presentations were selected from 40 MD, FACS, Lawrenceville, GA; Gerald M. Fried, posters featured at the Medical Student Program, MD, FACS, Montreal, QC; B. J. Hancock, MD, which spanned three days, featured approximately FACS, FRCSC, Winnipeg, MB; and Lenworth M. 25 speakers, and included more than 300 medical Jacobs, Jr., MD, FACS, Hartford, CT, to the ACS student participants. Board of Regents. The ACS Committee on Video-based Education Dr. Elsey is a general and vascular surgeon in sponsored a session to highlight videos authored by private practice in Atlanta, GA. He is affiliated with prominent international surgeons. At the conclusion Gwinnett Medical Center, Lawrenceville, GA, and of the session, panel members voted on the best video is a visiting professor of surgery at Emory Uni- presented at the meeting. Committee Chair Tonia M. versity School of Medicine, Atlanta. A Fellow of Young-Fadok, MD, FACS, and Pascal R. Fuchshu- the College since 1989, Dr. Elsey has served as a ber, MD, FACS, session coordinators, presented the member (2004–2010) and Secretary (2008–2010) Certificate of Merit Award for the most outstanding of the Board of Governors; as Chair of the Board Above: Medical Student Program poster winner Ms. Deban of Governors’ Committee to Study the Fiscal Af- (second from right in left-hand photo) and Mr. Graffeo (second fairs of the College (2008–2010); and as Secretary from right in right-hand photo), with (left to right) James F. (2003–2008) and President (2008–2010) of the McKinsey, MD, FACS, Chair, Committee on Medical Student ACS Georgia Chapter. Education; Dr. Sachdeva; and Dr. Pellegrini. Dr. Fried, a general surgeon, is Adair Family Pro- 39

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS fessor and chairman, department of surgery, McGill Top left: Dr. Bass (center), outgoing Chair of the Program University, and surgeon-in-chief, McGill University Commitee, with committee members, left to right: Craig S. Health Centre Hospitals, Montreal, QC. A Fellow Derkay, MD, FACS; Katie M. Anthony; Amy B. Reed, MD, of the College since 1986, Dr. Fried has served on FACS; Deborah A. Nagle, MD, FACS; Fabrizio Michelassi, MD, FACS; Dr. Sachdeva; David R. Jones, MD, FACS; Dr. Bass; David the Board of Governors (2002–2008); as a member M. Mahvi, MD, FACS; Valerie W. Rusch, MD, FACS; William (1992–1995) and senior member (1999–2002) of D. Spotnitz, MD, MBA, FACS; Henri R. Ford, MD, FACS; and the Committee on Video-Based Education; and as Quan-Yang Duh, MD, FACS. a member (2002–2006), Vice-Chair (2006–2008), Top right: Departing Surgery Resident Program Course and Consultant (2009 to present) for the Commit- Director Dr. Whalen (right) with Dr. Sachdeva. tee on Emerging Surgical Technology and Educa- Bottom: The ACS oundationF Board met during Clinical tion. Congress. Front row, left to right: Jon A. van Heerden, MD, Dr. Hancock, a general and pediatric surgeon, MBHB, FACS, FRCS; Charles M. Balch, MD, FACS; William F. is associate professor, departments of surgery and Sasser, MD, FACS; Amilu Stewart, MD, FACS, Secretary; Andrew pediatrics and child health, University of Manitoba, L. Warshaw, MD, FACS, Treasurer; LaMar S. McGinnis, Jr., MD, FACS; Christopher J. Daly, MD, FACS; Gay Vincent, ACS Chief Winnipeg, MB. She is also a pediatric surgeon and Financial Officer; and Norman M. Kenyon, MD, FACS. pediatric interventionist at Children’s Hospital of Back row: David B. Hoyt, MD, FACS, ACS Executive Winnipeg. A Fellow since 1996, Dr. Hancock has Director and Foundation President; Thomas R. Russell, MD, served as the Committee on Trauma (COT) State FACS, Chair; Richard A. Lynn, MD, FACS; Richard B. Reiling, Provincial Chair, Publications/Education (1999– MD, FACS, Vice-Chair; Kenneth W. Sharp, MD, FACS; Martin 2008), and as President (2006) of the Manitoba H. Wojcik, CFRE, Foundation Executive Director; and David Korajczyk, Director of Corporate and Foundation Relations. 40 Chapter of the ACS.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Jacobs, a general surgeon, is professor of sur- The Board of Governors elected Lena M. Na- gery and chairman of the department of traumatol- politano, MD, FACS, Ann Arbor, MI, as Chair of ogy and emergency medicine at the University of its Executive Committee; Gary L. Timmerman, Connecticut, and director of the trauma program MD, FACS, Sioux Falls, SD, as Vice-Chair; and at Hartford (CT) Hospital. A Fellow since 1978, William G. Cioffi, Jr., MD, FACS, Providence, Dr. Jacobs has served as COT State Provincial Chair RI, as Secretary. Also elected to the Board of Gov- (1998–2004); as Vice-Chair of the Executive Com- ernors’ Executive Committee were James Clinton mittee of the Board of Governors (2008–2009); as Denneny, III, MD, FACS, Knoxville, TN; and a member (2003–2006) and Chair (2007–2009) Fabrizio Michelassi, MD, FACS, New York, NY. of the Board of Governors’ Committee on Chapter Activities; and as a member of the Accreditation Clinical Congress 2012: Chicago, IL Review Committee (2009 to present). It’s never too early to start planning for the Elected to additional three-year terms on the 98th Annual Clinical Congress, scheduled for Board of Regents were Mark A. Malangoni, MD, September 30–October 4, 2012, in Chicago, IL. Be FACS, Philadelphia, PA; and Valerie W. Rusch, sure to visit http://www.facs.org in the coming months MD, FACS, New York, NY. for more details regarding the educational program, J. David Richardson, MD, FACS, a general, registration, housing, and transportation.  thoracic, and vascular surgeon from Louisville, KY, was elected Chair of the Board of Regents. Dr. Richardson is professor of surgery and vice-chair of the department of surgery at the University of Louisville School of Medicine (see article, page 52). Martin B. Camins, MD, FACS, was elected Vice-Chair of the Board of Regents. Dr. Camins is a neurological surgeon in New York, NY. Above top: Recipients of the Distinguished Service Award gathered. Front row, left to right (all MD, FACS): F. Dean Griffen; Josef E. Fischer; Amilu Stewart; Dr. McGinnis; Murray F. Brennan; and Frank Padberg. Back row: Paul E. Collicott; Dr. Flynn, luncheon host; Dr. McGrath; Dr. Numann; Richard B. Reiling; and Dr. Hoyt. 41

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Officers, Regents, and Board of Governors’ Executive Committee

Officers/Officers-Elect

Patricia J. Numann Robert R. Bahnson President First Vice-President General surgery Urology Professor emeritus, Professor and chair, department of State University of New York urology, and The Dave Longaberger Syracuse, NY Chair in Urology, The Ohio State University College of Medicine, Columbus Columbus, OH

Courtney M. Townsend, Jr. Andrew L. Warshaw Secretary Treasurer General surgery General surgery John Woods Harris W. Gerald Austen Professor Distinguished Professor, of Surgery, department of surgery, Harvard Medical School; and The University of Texas surgeon-in-chief and chairman, Medical Branch department of surgery, Galveston, TX Massachusetts General Hospital Boston, MA

A. Brent Eastman R. Phillip Burns President-Elect First Vice-President-Elect General surgery General surgery Corporate senior vice-president, Chairman and professor of surgery, chief medical officer, Scripps Health; department of surgery, University N. Paul Whittier Chair of Trauma, of Tennessee College of Medicine, Scripps Memorial Hospital, La Chattanooga Jolla, CA; and clinical professor of Chattanooga, TN surgery–trauma, University of Cali- fornia, San Diego San Diego, CA

John M. Daly Second Vice-President-Elect General surgery Dean emeritus, Temple University School of Medicine Philadelphia, PA

42

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Officers and Regents

Board of Regents

J. David Richardson Martin B. Camins Chair Vice-Chair Vascular surgery Neurological surgery Professor of surgery; vice-chairman, Clinical professor of department of surgery; neurological surgery, and chief of surgery service and Mount Sinai Hospital director, emergency surgical services, and Medical School University of Louisville Hospital New York, NY Louisville, KY

H. Randolph Bailey Bruce D. Browner Colon and rectal surgery Orthopaedic surgery Clinical professor and Gray-Gossling Professor and chief, division of colon chairman emeritus, and residency and rectal surgery, program director, department of University of Texas orthopaedic surgery, Health Science Center University of Connecticut Houston, TX Health Center, Farmington, CT; and director of orthopaedics, Hartford Hospital Hartford, CT

Margaret M. Dunn James K. Elsey General surgery General surgery Professor of surgery and Private practice, Atlanta, executive associate dean, GA; visiting professor of surgery, Wright State University Emory University School Boonshoft School of Medicine; of Medicine, Atlanta and chief executive officer, Atlanta, GA Wright State Physicians Dayton, OH

Julie A. Freischlag Gerald M. Fried Vascular surgery General surgery William Stewart Halsted Adair Family Professor and Professor and chairman, department of surgery, surgeon-in-chief, McGill University; The Johns Hopkins Hospital and surgeon-in-chief, Baltimore, MD McGill University Health Centre Hospitals Montreal, QC

43

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Officers and Regents

Board of Regents

Barrett G. Haik B.J. Hancock Ophthalmic surgery Pediatric surgery Chair, department of Associate professor, ophthalmology, departments of surgery University of Tennessee and pediatrics and child health, Health Science Center, University of Manitoba; College of Medicine and pediatric surgeon Memphis, TN and pediatric interventionist, Children’s Hospital of Winnipeg Winnipeg, MB

Lenworth M. Jacobs, Jr. Mark A. Malangoni General surgery General surgery Professor of surgery and chairman, Associate executive director, department of traumatology American Board of Surgery and emergency medicine, Philadelphia, PA University of Connecticut; and director, trauma program, Hartford (CT) Hospital Hartford, CT

Raymond F. Morgan Leigh A. Neumayer Plastic surgery General surgery Milton T. Edgerton Professor Professor of surgery, and chair, department University of Utah; of plastic surgery, Jon and Karen Huntsman Presiden- University of Virginia tial Professor of Cancer Research, Health Sciences Center Huntsman Cancer Institute; Charlottesville, VA and co-director, Integrated Breast Program, Huntsman Cancer Hospital Salt Lake City, UT

Karl C. Podratz Valerie W. Rusch Gynecology (oncology) Thoracic surgery Joseph I. and Barbara Ashkins Chief, thoracic service, Professor of Surgery, Memorial Sloan-Kettering and professor of obstetrics Cancer Center; and gynecology, and professor of surgery, Mayo Clinic Cornell University Medical College Rochester, MN New York, NY

44

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Officers and Regents

Board of Regents/Board of Governors’ Executive Committee

Marshall Z. Schwartz Howard M. Snyder III Pediatric surgery Urology Professor of surgery and pediatrics, Associate director Drexel University College of Medi- of pediatric urology, cine, Temple University School of The Children’s Hospital Medicine; and surgeon-in-chief, of Philadelphia; chief of pediatric surgery, and professor of urology, and director, Pediatric Surgery University of Pennsylvania Research Laboratory, School of Medicine St. Christopher’s Hospital Philadelphia, PA for Children Philadelphia Philadelphia, PA

Mark C. Weissler Thomas V. Whalen Otolaryngology Pediatric surgery Joseph P. Riddle Chair, department of surgery, Distinguished Professor of Lehigh Valley Health Network Otolaryngology, professor of Allentown, PA otolaryngology–head and neck surgery, and professor and chief of head and neck oncology, University of North Carolina Neurosciences Hospital Chapel Hill, NC

Michael J. Zinner Lena M. Napolitano General surgery Chair, Board of Governors Moseley Professor of Surgery, General surgery Harvard Medical School; Division chief, acute care surgery; clinical director, associate chair for critical care; Dana-Farber/BWH Cancer Center; and professor of surgery, and surgeon-in-chief, University of Michigan Brigham and Women’s Hospital Health Systems Boston, MA Ann Arbor, MI

Gary L. Timmerman William G. Cioffi, Jr. Vice-Chair, Board of Governors Secretary, Board of Governors General surgery General surgery Chair of surgery, J. Murray Beardsley Professor Sanford School of Medicine, and chairman, University of South Dakota, Alpert Medical School of Sioux Falls, SD Brown University; and surgeon-in-chief, Rhode Island Hospital and The Miriam Hospital Providence, RI

45

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS HPRI data tracks

Urology workforce trends by Simon Neuwahl; Kristie Thompson; Erin Fraher, PhD, MPP; and Thomas Ricketts, PhD, MPH

mid federal efforts to restructure health care, Geographic distribution and possible threats to graduate medical edu- To examine geographic variation in the urologic cation funding, it is important to understand surgeon supply, surgeon and population data were theA demographic and practice characteristics of the analyzed for all counties in the U.S. from 2004 to 2009. surgical health care workforce—whether it is growing In 2009, urologic surgeons practiced in 39 percent of or contracting—and whether supply will be adequate U.S. counties (1,209); representing an increase from to meet future demand. In the coming months, the 2004 of 20 counties. From 2004 to 2009, 24 percent American College of Surgeons Health Policy Research of counties (750) lost urologists relative to popu- Institute (ACS HPRI) will be producing a series of lation (see Figure 1, page 47). Of these counties, policy briefs illustrating workforce trends for 12 sur- 89 lost all urologic surgeons. During the same gical specialties (see Table 1, this page). The aim of period, 18 percent of counties (548) gained uro- these brief reports is to provide decision makers with logic surgeons relative to population. Of the counties important data on the workforce that can be used to that gained urologic surgeons, 109 had no urologists inform health policy. This article focuses on trends in in 2004 and gained at least one urologist by 2009. the urologic surgical workforce since 1981. Just more than 58 percent of counties (1,809) had no urologists in 2004 and 2009. For the period 1981 to Key findings 2009, the urban concentration of urologic surgeons There has been a decrease in the supply of uro- has remained stable, with seven urban urologic sur- logic surgeons relative to population growth, a geons for every one urologic surgeon in rural areas. slight increase in female urologic surgeons, an aging urology work- force (especially in rural areas), Table 1. U.S. surgeons per 100,000 population, and an increase in group practice. ordered by percent change since 1981 In 2009, 9,775 urologic surgeons were actively practicing in the 1981 1986 1991 1996 2001 2006 2009 % Change U.S. (not including residents General 12.56 11.74 11.33 10.32 10.38 9.86 9.51 -24.3% in training) (see Table 2, this Thoracic 1.71 1.84 1.83 1.80 1.79 1.62 1.54 -10.2% page). The supply of urologic Urologic 3.23 3.36 3.49 3.43 3.39 3.29 3.18 -1.3% surgeons per capita in the U.S. Ophthalmologic 5.41 5.69 6.05 6.09 6.21 5.96 5.86 8.2% has declined more than all surgi- Neurosurgery 1.37 1.46 1.57 1.66 1.64 1.63 1.61 17.6% cal specialties except for general OBGYN 11.03 11.76 12.68 13.05 13.55 13.23 13.21 19.8% surgery and thoracic surgery (see Otolaryngology 2.71 2.87 3.16 3.25 3.30 3.31 3.26 20.0% Table 1). During the period Orthopaedic 5.74 6.32 7.30 7.51 7.27 7.35 7.26 26.4% 1981–2009, urologic surgeons Colorectal 0.34 0.35 0.35 0.38 0.41 0.45 0.46 34.9% per 100,000 population declined by 1.3 percent. Until 1991, the Pediatric 0.18 0.21 0.23 0.23 0.25 0.26 0.26 43.2% supply of urologic surgeons grew Plastic 1.33 1.60 1.80 1.96 2.03 2.13 2.15 61.8% faster than the population. In Vascular n/a* 0.33 0.52 0.64 0.74 0.83 0.85 157.2% 1991, that trend reversed, and *Data were not available for vascular surgeons in 1981. since then, the decline has accel- erated. After 2006, the number Table 2. Supply of U.S. urologic surgeons, 1981–2009 of urologic surgeons fell below Year 1981 1986 1991 1996 2001 2006 2009 the 1981 ratio to 3.18 urologic Urologic surgeons 7,423 8,082 8,825 9,244 9,649 9,852 9,775 46 surgeons per 100,000 population.

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure 1. Change in urologic surgeons per 100,000 population: 2004–2009 Urologic Surgeons per 100,000 Population 2009

Alaska and Hawaii not to scale Percent Change in Urologic Surgeons, 2004-2009 (# of Counties) 100% Increase or Greater (31) 50.0% to 99.9% Increase (55) 0.1% to 49.9% Increase (353) Decrease per Population (661) None in 2004, at least 1 in 2009 (109) Lost all Urologic Surgeons (89) None Either Year (1809)

Produced By: American College of Surgeons Health Policy Research Institute, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Source: AMA Physician Masterfile, 2004 and 2009. Data include non-federal, non-resident, clinically active physicians less than 70 years old reporting a primary specialty classified by the ACS HPRI as "urological surgery."

Age and gender of female urologic surgeons has grown from 34 to 512, With an average age of 52.5 years, urologists are increasing their share of the total urology workforce among the oldest surgical specialists, second only to by nearly 5 percent (see Figure 2, page 48). Still, men thoracic surgeons (53.6 years). In 2009, the aver- continue to make up a strong majority of urologic age age for all surgical specialists was 50.9, and 14 surgeons representing 94.8 percent of the workforce. percent were 65 and older. More than 18 percent of Since 1981, the age gap between male and female urologic surgeons were 65 and older. This represents urologists has increased by more than four years to an more than a 10 percent increase in urologic surgeons average difference of 10.3 years in 2009 (with males 65 and older since 1981, when these physicians were being older). In 2009, female urologists were 42.7 just 7.69 percent of the urology workforce. years old on average, and males were 53 years old. For Urology is a male-dominated specialty. Women all surgeons, males are slightly younger at 52.5 years have been entering the surgical workforce with in- old, while females are older at 44.5 years of age on creasing frequency since 1981, although at different average. As seen in Figure 2, more female urologists rates in different specialties. Since 1981, the number have recently entered the urology workforce. 47

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Training in urologic surgery Figure 2. Gender and distribution of urologists, 1981 and 2009

According to the Accreditation 75-80 Council for Graduate Medical 70-74 Education’s (ACGME’s) data, 65-69 from 1994 to 2001, the number 60-64 of urology residents and accredited 55-59 programs declined by 2.3 percent 50-54 and 2.4 percent, respectively. 45-49 However, since 2001, urology 40-44 residents have increased by 7 per- 35-39 cent despite another 2 percent 30-34 decline in the number of programs 25-29 1,2 through 2009. At the end of 200 0 200 400 600 800 1000 1200 1400 training, urology residents achiev- ing American Board of Medical Female 2009 Female 1981 Male 1981 Male 2009 Specialties (ABMS) certifications declined by 19.7 percent from Figure 3. Practice type, U.S. urologists, 2001–2009 3 2000 to 2009. Annual trend data 100% are available from the 2010 ABMS 90% Certificate Statistics booklet. 80% The proportion of urologic 70% surgeons trained in the U.S. has increased. In 1981, 79 percent 60% of urologists were U.S. medical 50% graduates (USMGs). By 2009, this 40% percentage had increased to 83.3 30% percent. There has been a shift in 20% the average age of USMGs versus 10% international medical graduate 0% (IMG) urologic surgeons. USMG 2001 2006 2009 urologists were nearly three years Group Practice Solo Practice Hospital Employee Other Setting older than IMG urologists in 1981. By 2009, this trend had Figure 4. U.S. average age of urologists, reversed, and the average age of urban and rural counties, 1981–2009 USMGs is now more than eight years younger than IMGs. 57 Group practice growing— 55 but not in rural areas Following the trends for all 53 practicing surgeons, urologic sur- 51 Mean Age geons are increasingly likely to be Age employed in a group practice (see Urban Age Figure 3, this page).4 The percent 49 Rural Age of the urologic workforce in group practice increased from 42 percent 47 in 2001 to 60 percent in 2009. As 45 the number employed in group 1981 1986 1991 1996 2001 2006 practices increased, the percent- Time 48 age of surgeons employed in solo

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS practice sharply declined between 2001 and 2009. surgeons because they are, on average, 2.2 years closer In 2001, slightly more than one in four (26 percent) to retirement age than urologic surgeons in urban ar- urologic surgeons were in solo practice compared with eas. Consequently, rural patients may have decreased one in five (20 percent) in 2009. The percentage of access to screening, medical treatment, and surgical surgeons employed by health maintenance organiza- treatment for urologic conditions. tions, nonhospital government, and other entities While the growth in group practice for urban (defined in Figure 3, as “other setting”) also declined urologic surgeons provides benefits for call coverage, substantially between 2001 and 2009. quality of life, and subspecialization, this trend is Urban urologic surgeons have chosen to practice moving in the opposite direction in rural communi- in groups more often between 2001 and 2009, while ties. Older, rural urologists are more often in solo group practice among rural practitioners has actually practice and less often in group practice. As older declined slightly (less than 1 percent), and solo prac- urologists in rural areas retire, this maldistribution tice has increased by nearly 2 percent. Overall, urolo- of access will continue to rise. gists in group practice are almost nine years younger Urologist supply per capita is at its lowest point than urologists in solo practice. In general, urologic in 30 years. Removing the cap on Medicare GME surgeons practicing in rural areas (average age 54.7) funds, which remain at 1996 levels, would help all were 2.2 years older than those in urban areas, a trend medical and surgical specialties (including urology) to that has reversed since 1981 (see Figure 4, page 48). increase their training output. Further cuts to GME funds could create more access problems as even fewer Policy implications surgeons could be trained.  Research has demonstrated an association between a higher density of urologists and lower mortality from References prostate, bladder, and kidney cancer at the county level.5 The relative concentration of urologic surgeons 1. Brotherton SE, Etzel SI. Graduate medical education, 2008- in urban areas and an aging workforce is associated 2009. JAMA. 2009;302(12):1357-1372. 5 2. Miller DC, Link RE, Olsson CA. Trends in urology graduate with urology-related health outcomes. Despite small medical education: A brief update from the Urology Resi- recent gains in the number of residents in the urology dency Review Committee. J Urol. 2004;172(3):1062-1064. training pipeline, ABMS certifications have decreased 3. American Board of Medical Specialties. 2010 ABMS Cer- 3 tificate Statistic. Chicago, IL: American Board of Medical significantly since the 1970s. As overall supply con- Specialties. 2010, 1-48. tracts, rural areas are likely to lose even more urologic 4. Poley ST, Newkirk V, Thompson K, Ricketts TC. Indepen- dent Practice Becoming Increasingly Rare Among Surgeons. ACS HPRI Fact Sheet, 2011. Data and methodology 5. Odisho AY, Cooperberg MR, Fradet V, Ahmad AE, Car- roll PR. Urologist density and county-level urologic cancer Physicians were identified as surgeons and classified mortality. J Oncol Pract. 2010;28(15):2499-2504. into surgical groups using a combination of American Medical Association (AMA) primary and secondary Mr. Neuwahl is a graduate research assistant at the Cecil G. Sheps self-reported specialties and ABMS certifications. This Center for Health Services Research, University of North Carolina analysis only included active, nonresident, nonfederal (UNC),Chapel Hill. surgeons. “Active surgeons” are defined as individuals under the age of 80 who report working in adminis- Ms. Thompson is a research associate at the Cecil G. Sheps Center for tration, direct patient care, medical research, medical Health Services Research, UNC, Chapel Hill. teaching, other non-patient care activities, or who have an “unclassified” activity status. Physicians were Dr. Fraher is associate director, ACS HPRI. She is also director, North excluded from the analysis if they reported being re- Carolina Health Professions Data System, at the Cecil G. Sheps Center tired, semi-retired, temporarily not in practice, or not for Health Services Research, and holds joint faculty appointments active for other reasons. “Urban-rural” was defined as a in UNC-Chapel Hill’s departments of surgery and family medicine. county’s metropolitan statistical area status as defined Dr. Ricketts by the U.S. Office of Management and Budget. is professor of health policy and management and social medicine, UNC Schools of Global Public Health and Medicine, Chapel Hill. He is Co-Director of the ACS HPRI. 49

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Advocacy advisor

2011 lobby day wrap-up: Ohio, Massachusetts, and Alabama by Charlotte Grill

ast year, the American College of Surgeons (ACS) important bill addressed during the meeting was S.B. implemented a new program to encourage ACS 121, a bill to establish standards for physician designa- chapters to host lobby day programs at their state tion by health care insurers. Physician designation is Lcapitols. Endorsed by the Board of Governors and more defined in the bill as a means to grade, star, tier, or make than 27 chapters, the Board of Regents approved the any other rating to characterize or represent assessment proposal, which provides $50,000 over two years in or measurement of a physician’s cost efficiency, quality grants for state chapters to organize lobby days dur- of care, or clinical performance. ing the 2011 and 2012 legislative sessions. Chapters After an afternoon of successful meetings with were eligible to receive up to $5,000, and required to legislators, the chapter hosted a legislative reception match that grant with one dollar for every two dollars that was attended by a number of representatives and received. For the 2011 legislative grant program, 10 senators, as well as four Ohio Supreme Court Justices: chapters applied and received funding. In the August Justice Terrence O’Donnell, Justice Judith Ann Lanz- 2011 “Advocacy advisor” article titled “ACS State inger, Justice Robert Cupp, and Justice Yvette McGee Chapter Lobby Day Program,” seven chapter lobby Brown. day programs were addressed: Connecticut, Georgia, Northern California, Indiana, Virginia, Florida, and Alabama Chapter lobby day (May 31, 2011) New York.* As a follow up to that article, this wrap- Mark Jackson, the director of legislative affairs for up provides an overview for the remaining three 2011 the Medical Association of the State of Alabama, led the chapter lobby day grant participants: Ohio, Alabama, group in meeting with legislators. Chapter members and Massachusetts. who attended the meeting met senators and represen- tatives on the General Assembly floor and were able Ohio Chapter lobby day (May 25, 2011) to observe the session as well. During the Alabama Some of the highlights of the Ohio lobby day in- Chapter lobby day, surgeons discussed many prevalent cluded state representative Barbara Sears (R) leading issues that affect their ability to deliver surgical care a discussion on the state budget as well as important in Alabama. upcoming legislative activities that were aimed at ad- Chapter members used the ACS website (www.facs. dressing significant budget reforms. Mr. Aaron Crooks, org/fellows_info/bulletin/2011/fraher0511.pdf), where the legislative liaison from the Office of Ohio Health research from the Institute of Healthcare Policy and Plans, a state Medicaid agency, was also present to Research is posted. This research became an integral discuss budget reform issues. Mr. Crooks encouraged resource for this chapter in preparing for their meetings chapter members to stay active in their communication with legislators. with Medicaid agencies so that the state can more fully The chapter focused on an overarching problem comprehend the problems facing providers. in Alabama, which is a shortage of practicing sur- These presentations were followed by meetings with geons in the state. According to the most recent legislators during which prominent issues, such as S.B. data available, Alabama has a population of ap- 129—a bill that would offer liability protection for proximately 4.7 million people and approximately emergency care workers—were discussed. Another 1,960 surgeons, of which only 425 are classified as general surgeons. For a population of its size, it *Grill C. Advocacy advisor: ACS state chapter lobby day program. Bull Am is an accepted premise that a healthy surgeon-to- Coll Surg. 2011;96(8)57-58. ± ±Faher EP, Poley ST, Sheldon GF, Ricketts TC, Thompson KW. Shaping population ratio is 6/100,000. Therefore, Alabama surgical workforce through evidence-based analyses. Bull Am Coll Surg. ideally needs to recruit 2,800 additional surgeons 2011; 96(5):37-45. 50 in order to meet that preferred ratio of surgeons to

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS patients. Many counties in Alabama are currently 2012 chapter lobby days without a practicing surgeon. Based on the number of chapters applying for and The Alabama Chapter acknowledged that this receiving state lobby day grants, and the excellent shortage of surgeons is exacerbated by other legisla- lobby day programs hosted by these chapters, it is tive issues that affect surgical care. Resolving some of clear that the first year of this two-year program was these other issues could aid in recruiting additional a resounding success. Looking ahead this year, the surgeons. For instance, improving the surgical and ACS State Affairs team was thrilled to receive a total community infrastructure, reforming medical li- of 16 grant applications. This increase in chapter ability, addressing scope-of-practice issues, offering applications (six additional applications compared reciprocity for volunteer emergency health care pro- to the program’s first year) is an example of how ad- viders, addressing the legislative mandate to create a vocacy efforts are growing within the ACS chapters. statewide trauma system, and providing reimbursement The state chapters participating in the 2012 Lobby to hospitals that provide care to underinsured and Day include the following: Alabama, Connecticut, uninsured patients are some of the legislative issues Florida, Georgia, Illinois, Indiana, Kansas, Maine, that can affect surgeon shortages. The surgeons of the Massachusetts, Michigan, North Carolina, Northern Alabama Chapter voiced these concerns regarding California, Ohio, Oregon, Tennessee, and Virginia. patient access to surgical care in both rural and urban The State Affairs staff are excited to collaborate with portions of the state, as well as the need to address and the 2012 recipients on their lobby day programming, resolve these issues through legislative means. as we anticipate another important and decisive year in state level policy and legislation. For more informa- Massachusetts Chapter lobby day (June 21, 2011) tion on the legislation discussed in this article or the Members and staff of the ACS Massachusetts state lobby days described, contact Charlotte Grill at chapter joined in the pediatric residents and fellows [email protected].  residency lobby day at the statehouse. The event brought out a total of 75 people with a number of prominent speakers that included John Auerbach, Commissioner of the Massachusetts Department of Public Health; State Representative Ruth Balser (D); and John Straus, MD, vice-president of medical affairs for the Massachusetts Behavioral Health Partner- ship. Alex Calcagno of the Massachusetts Medical Society led a participatory workshop titled How to be an Effective Lobbyist, and attorney Ed Brennan led a question-and-answer segment on legislation and lobbying. Peter Masiakos, MD, FACS, Chair of the Massachusetts Chapter Legislative Advocacy Committee, spoke on the proposed Primary Seat Belt Ms. Grill is State Affairs Law, S.B. 1211/ H.B. 2401, which would allow law Associate, Division of Advocacy and Health Policy, enforcement to pull over vehicles and give citations Chicago IL. to drivers who are not wearing a seat belt (see related article in the February 2011 Bulletin‡). As the law currently stands, law enforcement can only pull over vehicles for other driving citations, and then issue a ticket for not wearing seat belts as a secondary of- fense. Moving the seat belt citation from a secondary offense to a primary offense would result in greater usage of seat belts and overall improved public safety in Massachusetts. ‡Masiakos PT. Advocating for state injury prevention laws. Bull Am Coll Surg. 2011;96(2):31. 51

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

J. David Richardson, MD, FACS, elected Chair of ACS Board of Regents

J. David Richardson, MD, a member of the COT’s Executive FACS, a general, thoracic, and vas- Committee (1992), Membership cular surgeon from Louisville, KY, Committee (1993), Verification/ was elected Chair of the American Consultation Committee (1993), College of Surgeons (ACS) Board and as Chair (1985–1987) and of Regents during the College’s Vice-Chair (1981–1985) of the 97th Annual Clinical Congress in Kentucky Committee on Trauma. San Francisco, CA. Dr. Richard- He was an ACS Governor-at- son is a professor of surgery and Large representing the state of vice-chair of the department of Kentucky (1989–1990) and served surgery at the University of Louis- as President (1989) and Secretary- ville School of Medicine. Treasurer (1987) of the College’s The College’s 22-member Board Kentucky Chapter. of Regents, which reflects the Dr. Richardson’s contributions diverse experiences and interests to the surgical profession include of its members, formulates policy leadership roles as director (1987) and is ultimately responsible for and chairman (1998–1999) of the managing the affairs of the College. Dr. Richardson American Board of Surgery; presi- Dr. Richardson will also chair the dent of the American Association Regents’ Finance and Executive for Surgery of Trauma (1999); Committees. president of the Kentucky Surgical A 1970 graduate of the Univer- Medicine since 1982 and 1985, Society (1987); president of the sity of Kentucky College of Medi- respectively. He has also been chief Kentucky Vascular Surgery Society cine, Lexington, Dr. Richardson of surgery service and director of (1989); and president of the South- completed a surgery internship and emergency medical services at the eastern Surgical Congress (1999). worked as a junior assistant resi- University of Louisville Hospital He has also served on the Asso- dent at the University of Kentucky. since 2005. ciation of American Medical Col- He completed a general surgery A Fellow of the College since leges’ Medical College Admission residency and a thoracic surgery 1980, Dr. Richardson began serv- Test Content Review Committee residency at the University of Texas ing on the Board of Regents in (1988), the Accreditation Council Medical School, San Antonio. He 2003 and served as a member of for Graduate Medical Education’s then returned to Kentucky and rose the Board of Regents Executive Residency Review Committee through the academic ranks at the Committee from 2010 to 2011. (2000–2007), and on the board of University of Louisville School of He has also served on a number of directors of the American Board of Medicine, holding the positions College committees, as Chair of the Emergency Medicine (1994). of assistant professor of surgery, Research and Optimal Patient Care A prolific scholar and author, associate professor of surgery, pro- Committee (2004–2011), and as Dr. Richardson has published 342 fessor of surgery, vice-chair of the Vice-Chair of the Health Policy articles in peer-reviewed publica- department of surgery, and chief and Advocacy Group (2011). He tions, 46 book chapters, and two of the division of general surgery. has been an active member of books of surgical literature. He He has held his current positions of the ACS Committee on Trauma also has served as editor of the professor of surgery and vice-chair (COT), and served as Chair of the journal The American Surgeon of the department of surgery at the Emergency Services-Prehospital since 2005. Dr. Richardson re- 52 University of Louisville School of Subcommittee (1992–1999) and as ceived the School of Medicine

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Distinguished Educator Master Association Red Apple Award for 2011, and he has been honored Teacher Award, the University of Excellence in Teaching at a Univer- four times as outstanding teach- Louisville Distinguished Faculty sity Level, the Ephraim McDowell ing faculty within the department Award for Teaching, the Alumnus Kentucky Physician of the Year of surgery.

Call for nominations for the ACS Board of Regents

The 2012 Nominating Commit- the highest principles of surgical • The College encourages con- tee of the Board of Governors has practice. sideration of women and other the task of selecting six nominees • Nominees must have dem- underrepresented minorities. for pending vacancies on the Board onstrated leadership qualities that • Individuals who are no longer of Regents, to be filled during the might be reflected by service and in active surgical practice should 2012 Clinical Congress in Chi- active participation on ACS com- not be nominated for election or cago, IL. The following guidelines mittees or in other components of reelection to the Board of Regents. are used by the Nominating Com- the College. The surgical specialties that mittee when reviewing the names • The Nominating Commit- should be given priority consid- of candidates for potential nomina- tee recognizes the importance of eration for the six seats are the tion to the Board of Regents: achieving representation of all who following: • Nominees must be loyal practice surgery. • Colon and rectal members of the College who have • Geography, surgical specialty • General surgery demonstrated outstanding integri- balance, and academic or commu- • Gynecology and obstetrics ty and medical statesmanship along nity practice are other factors taken • Neurological surgery with an unquestioned devotion to into consideration. • Orthopaedic surgery • Pediatric surgery Nominations should include a paragraph or two on the potential A message from the Editor contributions each candidate can offer in terms of what he or she can do for the members of the More than 500 of you responded any story ideas you may have. College. Submit nominations to to a readership survey that the We are particularly interested in officerandbrnominations@facs. Bulletin conducted last fall. Your developing and publishing articles org by Wednesday, February 29, responses were extremely helpful in on practice trends and innovations, 2012. determining what sorts of changes socioeconomic issues, and other If you have any questions, con- the Division of Integrated Com- nonclinical topics. We also would tact Patricia Sprecksel, Staff Liaison munications should implement to like to profile more Fellows who for the Nominating Committee ensure that the Bulletin is providing are not necessarily well-known, but of the Board of Governors, at members of the American Col- who are making a positive differ- [email protected] or by calling lege Surgeons (ACS) with timely, ence for their patients. 312-202-5360. user-friendly, relevant information. To share your story ideas, please For informational purposes In the months ahead, we will be contact Diane S. Schneidman, only, the current members of incrementally implementing these Editor, by e-mail at dschneidman@ the Board of Regents who will modifications. facs.org, or by phone at 312-202- be considered for re-election are To help ensure that the Bulletin 5327. Thank you for your loyal Julie Freischlag, MD, FACS; Ray- continues to serve as a valuable readership. I look forward to hear- mond Morgan, MD, FACS; Leigh resource to all ACS members, the ing from you. Neumayer, MD, FACS; Marshall Bulletin staff invites you to share Schwartz, MD, FACS; and Mark Weissler, MD, FACS. 53

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Call for nominations for ACS Officers-Elect

The 2012 Nominating Com- integrity and medical statesman- underrepresented minorities. mittee of the Fellows has the ship along with an unquestioned Nominations should include a task of selecting nominees for devotion to the highest principles paragraph or two on the potential the three Officer-Elect positions of surgical practice. contributions each candidate can of the American College of Sur- • Nominees must have dem- offer in terms of what he or she geons (ACS): President-Elect, onstrated leadership qualities that can do for the members of the First Vice-President-Elect, and might be reflected by service and College. Submit nominations to Second Vice-President-Elect. The active participation on ACS com- officerandbrnominations@facs. following guidelines are used by mittees or in other components of org by Wednesday, February 29, the Nominating Committee when the College. 2012. reviewing the names of potential • The Nominating Commit- If you have any questions, candidates for nomination as Of- tee recognizes the importance of contact Patricia Sprecksel, Staff ficers of the College: achieving representation of all Liaison for the Nominating Com- • Nominees must be loyal who practice surgery. mittee of the Fellows, at pspreck- members of the College who • The College encourages [email protected] or by calling 312- have demonstrated outstanding consideration of women and other 202-5360.

American College of Surgeons Official Jewelry & Accessories #S5 #S6 #S1 designed, crafted and produced exclusively by Jim Henry, Inc. #S2 Tie Tac/Lapel Pin Tie Bar Rollerball Pen - Chrome #S1 Single Gold-Filled $60 #S15 Gold-Filled Emblem $50 #S25 Cross Townsend #S2 Solid 14K Gold $375 Medalist with 23/K Necktie Gold Plated Emblem $120 Cuff Links #S16A Dark Blue $35 #S3 Single Gold-Filled $225 #S16B Light Blue $35 Money Clip (Not Shown) #S15 #S4 Solid 14K Gold $975 #S17 Maroon $35 #S26 With Gold-Filled Extra long add $5.00 emblem $60 #S3 Key (shown actual size #S4 of 3/40) Diploma Plaques Desk Set (Not Shown) #S5 Single Gold-Filled $85 #S18 Satin Gold Finish $300 #S27 Solid Walnut with Cross #S6 Solid 14K Gold $775 #S19 Satin Silver Finish $300 Gold-Filled Pen & Pencil/Gold- 8-1/20 x 120 metal plaque on Filled emblem; name and year Miniature Key 110x14-1/20 walnut. Specify name, elected a Fellow engraved on day, month, year selected. (Not Shown) gold polished plate $275 #S7 Single Gold-Filled $60 Women’s Bow Tie #S8 Solid 14K Gold $475 (Pretied) (Not Shown) Wallet (Not Shown) #S28 Black cowhide with #S11 #S20 Dark Blue $35 #S12 Charm (Not Shown) Gold-Filled emblem $75 #S17 #S13 #S9 Single Gold-Filled $75 #S21 Maroon $35 #S16A #S16B #S25 #S10 Solid 14K Gold $575 Men’s Bow Tie (Untied) Blazer Buttons (Not Shown) #S30 (Not Shown) #S29 Gold Electroplated Miniature Charm (set of 9) $35 #S11 Single Gold-Filled $50 #S22 Dark Blue $35 #S12 Solid 14K Gold $375 #S23 Maroon $35 Blazer Patch #S13 Sterling Silver w/ 180 Women’s Scarf - Silk #S30 Hand embroidered $35 Sterling Silver Neckchain $65 (Not Shown– Shipping/Handling/Insurance Ring NEW DESIGN!) Domestic (48 contingent states) $15 #S14 Solid 14K Gold $2350 #S24 360x360 cream $35 Alaska, Hawaii, Puerto Rico $30 #S14 #S18 w/ dark blue and maroon border #S19 #S14.1 Solid 10K Gold $1750 Foreign $40 (Indicate finger size) Form No. 918009-08/11

Jim Henry, Inc. Designed expressly for the American College of • Please use model # and item description when ordering 435 Thirty-Seventh Avenue Surgeons, these emblematic items are crafted to • Include payment with order St. Charles, Illinois 60174 • VISA, American Express, & MasterCard accepted perfection in the Jim Henry tradition of excellence. phone 630 584 6500 • Prices subject to major changes in gold prices The American College of Surgeons receives a royalty for fax 630 584 3036 JIM HENRY, INC. allowing Jim Henry, Inc. the use of the American College • Send order directly to Jim Henry, Inc. www.jimhenryinc.com Excellence in Awards and Recognition of Surgeons marks and other intellectual property. • Illinois residents add 8% sales tax e-mail: [email protected] Since 1938 54

VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Nominations sought for 2012 volunteerism and humanitarian awards

The American College of Sur- prospective, planned surgical care • Renomination of previous geons (ACS), in association with to underserved patients with no nominees is encouraged but re- Pfizer, Inc, is accepting nomina- anticipation of reimbursement or quires an updated application. tions for the 2012 Surgical Vol- economic gain. • Supplemental materials unteerism Award(s) and Surgical The ACS/Pfizer Surgical Hu- should be kept to a minimum and Humanitarian Award. manitarian Award is given in will not be returned. The ACS/Pfizer Surgical Volun- recognition of those ACS Fel- The nomination forms will be teerism Award—offered in four lows who have dedicated their available for download from the potential categories each year— careers to ensuring the provision “Announcements” section of the is given in recognition of those of surgical care to underserved Operation Giving Back website surgeons who are committed to populations without expectation during January and February at giving back to society by mak- of commensurate reimburse- http://www.operationgivingback. ing significant contributions to ment. This award is intended for org. Nomination forms can also surgical care through organized a surgeon who has dedicated a be requested by mail, if preferred. volunteer activities. The awards significant portion of his or her Contact Akiyo Kodera, Opera- for domestic, international, and surgical career to full-time or tion Giving Back Program Coor- military outreach are intended near full-time humanitarian ef- dinator, with such requests or any for ACS Fellows in active surgical forts rather than routine surgical questions ([email protected]). practice whose volunteerism ac- practice. This effort may reflect a Completed nomination forms tivities go above and beyond the career devoted to missionary sur- should be addressed to the at- usual professional commitments, gery, the founding and ongoing tention of Selwyn M. Vickers, or retired Fellows who have been operations of a charitable orga- MD, FACS, Chair, Board of involved in volunteerism during nization dedicated to providing Governors’ Socioeconomic Issues their active practice and into surgical care to the underserved, Committee, and may be submit- retirement. ACS members who or a retirement characterized ted electronically, or by mail c/o have been involved in signifi- by surgical volunteer outreach. Akiyo Kodera, American College cant surgical volunteer activities Having received compensation of Surgeons, 633 N. Saint Clair during their postgraduate surgi- for this work does not preclude St., Chicago, IL 60611; 312- cal training are eligible for the a nominee from consideration, 202-5458; fax 312-202-5021; resident award. Surgeons of all and, in fact, may be expected, [email protected], or ogb@facs. specialties are eligible for each of based on the extent of the profes- org. All nominations must be these awards. sional obligation. received by Friday, February 24, For the purposes of these Nominations will be evalu- 2012. awards, “volunteerism” is defined ated by the Socioeconomic Issues as professional work in which Committee of the ACS Board of one’s time or talents are donated Governors, with final approval for charitable clinical, education- of award winners by the Execu- al, or other worthwhile activities tive Committee of the Board of related to surgery. Volunteerism Governors. in this case does not refer to Potential nominees should uncompensated care provided make note of the following: as a matter of necessity in most • Self-nominations are per- practices. Instead, volunteerism missible but require at least one should be characterized by the outside letter of support. 55

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2012KZA-ACSad:Layout 1 8/24/11 3:10 PM Page 1

Are the ACS/KZA Coding Workshops worth it? Surgeons say, “YES!” Code It Right and Get Results

SAVE THESE 2012 DATES LAS VEGAS — February 16-17 CHICAGO — April 26-27 NEW YORK — May 3-4 NASHVILLE — August 16-17

98% of attendees this year say they would recommend the workshops to a colleague and 97% would attend a future ACS/KZA workshop! Come see why, can you afford not to?

Optimize legitimate collections and reduce your audit risk. “Outstanding as usual!” Gary Collins, MD, HealthPartners– Break the cycle of downcoding, delays, and denials. Regions, Minneapolis, Minnesota

Coding your office surgical cases correctly has a big potential payoff. Accuracy counts “Very informative — and audits are a hassle and can be expensive. Reimbursement matters. Regardless I always go back if you are in a private practice, academic practice or employed by a health system — to my practice and correctly coding office visits and surgery will result in better more accurate payments improve on what and work RVU production. we have done.” Hope Day, Business Office These workshops are a fast-paced, dynamic two-day event that mean you’ll leave with Manager, Utah County Surgical practical skills to take home and use immediately. If you follow our advice you’ll submit Associates, Provo, Utah more accurate, clean claims, reducing denials and claim rejections. “Always worth Our surgical coding experts can show you how to Code It Right and get results. the money.” Carolyn Messere, MD, Work smarter, not harder. Earn CME credits... Integrative Surgery PA, call 312-642-8310 to register today. Miami Beach, Florida “I attend this course OUR INSTRUCTORS annually and I always learn something new MARY LEGRAND BETSY NICOLETTI to bring back to my RN, MA, CCS-P, CPC, consultant MS, CPC, author, speaker with more than three decades and consultant with over office and physicians.” of nursing and administrative two decades engaged in Mary Ann Cross, General experience, including leadership coding education, billing Manager, California positions on several National and accounts receivable Bariatric & General Surgery Associates, Boards management Arcadia, California

© 2011 KarenZupko & Associates, Inc. College seeks nominations for Jacobson Promising Investigator Award

The American College of Sur- • Candidate must have re- careers with a track record indica- geons (ACS) is accepting nomina- ceived peer-reviewed funding such tive of early promise and potential tions for the eighth Joan L. and as a K-series award from the Na- (such as a degree program in Julius H. Jacobson II Promising tional Institutes of Health (NIH), research or K-award). Surgeon- Investigator Award to be conferred Veterans Affairs, National Science scientists who are well-established in 2012. This award has been Foundation, or U.S. Department (such as recipients of NIH R01 established to recognize outstand- of Defense merit review to support grants) are ineligible. ing surgeons engaged in research, their research effort. advancing the art and science of • Nomination documentation Nomination procedures surgery, and demonstrating early must include a letter of recom- To be considered for the award promise of significant contribu- mendation from the nominee’s de- in 2012, submissions must be tion to the practice of surgery and partment chair. Three additional dated no later than March 9, the safety of surgical patients. The letters of recommendation will be 2012. You may send your award award, funded through a generous accepted. criteria documentations and nom- endowment established by the do- • Only one application per ination materials electronically to nors, is in the amount of $15,000. surgical department will be ac- [email protected] or on a CD- The ACS Surgical Research Com- cepted. ROM and mail it to Rhoby Tio, mittee will administer the award. • Nomination documentation American College of Surgeons, must include an NIH-formatted 633 N. Saint Clair St., Chicago, Award criteria biographical sketch and copies of IL 60611-3211. • Candidate must be board- the candidate’s three most signifi- Please note that your essay and certified in a surgical specialty cant publications. biographical sketch must be sub- and must have completed surgical • Nominee must submit a mitted in a Word document. Ap- training in the last six years. one-page essay to the committee plicants are encouraged to verify • Candidate must be a Fel- explaining why he or she should that all necessary materials have low or an Associate Fellow of the be considered for the award and been received before the deadline. American College of Surgeons. discussing the importance of the For additional information, con- • Candidate must hold a research that he or she has con- tact Ms. Tio at jacobsonpia@facs. faculty appointment at a research- ducted/is conducting. org or 312-202-5319. based academic medical center. Special consideration will be Candidate holding a military given to surgeons who are at the service position is also eligible. “tipping point” of their research

57

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS AmericA n c ollege of SurgeonS • DiviS ion of eDucA tion 2011 CLINICAL CONGRESS WEBCASTS YOU CAN BE IN FIVE PLACES AT ONCE

Maximize your CME opportunities with an individual learning experience online

Earn additional AMA PRA Category 1 Webcast Pick 11 of 2011 Credits™ upon successful completion Choose 11 of the 33 webcast sessions of 2011 Clinical Congress of online exams and evaluations. Price: $250 ACS Member $290 Nonmember 2011 Complete Best Value Package All 33 webcasts of 2011 Clinical Congress More than 100 MP3s of Named Lectures and Panel Sessions BONUS: Access to 42 webcast sessions from past Clinical Con- gresses Price: $530 ACS Member $610 Nonmember 2011 Webcast Package All 33 webcasts of 2011 Clinical Congress Price: $395 ACS Member $460 Nonmember

Webcasts will be available for viewing from December 15, 2011, www.acs-resource.org until December 31, 2012.

Webcast ad - post CC pricing BULLETIN_09-11.indd 1 10/18/2011 10:48:58 AM A look at The Joint Commission New standard for surgical accountability measures

As of January 1, Joint Commis- 85 percent rate, and 92 percent met assist hospitals in providing safe and sion-accredited hospitals are now a 90 percent target. effective care of the highest quality, required to meet a new perfor- Although all of the hospitals that in addition to the new accountability mance improvement standard that reported data in 2010 achieved a measure standard. establishes an 85 percent composite 90 percent or better performance The current surgical care ac- compliance target rate for perfor- on most individual process of countability measures that will mance on all of the hospital’s se- care measures, and a surgical care be included in the 2012 annual lected accountability measures. The composite rate of 96.4 percent, report’s 2011 top performer’s list accountability measures include The Joint Commission’s 2011 an- are as follows: the following: surgical care, heart nual report on quality and safety, • Prophylactic antibiotic re- attack, heart failure, pneumonia, titled Improving America’s Hospitals, ceived within one hour before and children’s asthma care core contended that more improvement surgical incision measure sets. Most hospitals choose is needed on the accountability • Prophylactic antibiotic selec- the surgical care measure set as one measures. The report identified tion for surgical patients of their reported core measure sets. multiple opportunities for further • Prophylactic antibiotics dis- The new requirement is intended improvement. For example, hos- continued within 24 hours after to help further improve performance pitals finished 2010 with relatively surgery end time on these selected core measures of low performance on the following • Cardiac surgery patients with patient care. This standard does not two measures that were originally controlled 6:00 am postoperative apply to the critical access hospital introduced in 2005: blood glucose program. Accountability measures • Providing fibrinolytic ther- • Surgery patients with appro- are core process performance mea- apy within 30 minutes of arrival priate hair removal sures that have strong scientific evi- to heart attack patients; only 60.5 • Surgery patients on beta- dence to produce the greatest positive percent of hospitals achieved 90 blocker therapy prior to arrival who impact on patient outcomes when percent compliance or better received a beta-blocker during the hospitals demonstrate high rates of • Providing antibiotics to im- perioperative period compliance. The required 85 per- munocompetent intensive care • Surgery patients with recom- cent target rate is based on research unit pneumonia patients; only 77.2 mended venous thromboembolism of past performance data that show percent of hospitals achieved 90 prophylaxis ordered increasing levels of compliance with percent compliance or better • Surgery patients who re- the surgical care and other account- After January 1, an organization ceived appropriate venous throm- ability measures. that is not in compliance with the boembolism prophylaxis within 24 For example, in 2002, hospitals target composite rate of 85 percent at hours before surgery, to 24 hours achieved 81.8 percent composite the time of its full survey will receive after surgery performance on 957,000 opportuni- a “Requirement for Improvement” For more information on the ties to perform care processes related (RFI) in its accreditation report. new accountability measure stan- to accountability measures and, in Hospitals that receive an RFI based dard visit the following links on 2010, hospitals achieved 96.6 per- on the new standard will be given TJC website: cent composite performance on 12.3 an appropriate amount of time to • http://www.jointcommission. million opportunities–a nine-year submit a plan for improvement, and org/assets/1/6/TJC_Annual_Re- improvement of 14.8 percentage to reach the 85 percent composite port_2011_9_13_11_.pdf points. By the end of 2010, 98 per- compliance target rate. The Joint • http://www.jointcommis- cent of hospitals met an 80 percent Commission plans to continue sion.org/assets/1/18/jconline_ compliance rate, 96 percent met an seeking new methods to inspire and June_29_1111.PDF 59

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

CALL FOR SUBMISSIONS

2012 Clinical Congress of the American College of Surgeons

h Oral presentations The American College h Surgical Forum* Program Coordinator: Kathryn L. Matousek, of Surgeons 312-202-5336, [email protected] (15 Excellence in Research Awards Division of Education were given in 2011) welcomes submissions Accepted Surgical Forum abstracts will be published in the September Supplement of the Journal of the to the following programs American College of Surgeons (JACS) h Scientific Papers* to be considered Program Coordinator: Kay Anthony, 312-202-5325, [email protected] for presentation at Poster presentations h h Scientific Exhibits (Posters) the 98th Annual Program Coordinator: Carla Manosalvas, 312-202-5385, [email protected] Clinical Congress, Video presentations September 30– h Video-Based Education Program Coordinator: GayLynn Dykman, October 4, 2012, 312-202-5262, [email protected] Chicago, IL Submission information

h h Abstracts are to be submitted online only. h Submission period begins after November 1, 2011. h Deadline: 5:00 pm (CST), March 1, 2012. h Late submissions are not permitted. h Abstract specifications and requirements for each individual program will be posted on the ACS website at www.facs.org/education/. Review the information carefully prior to submission. h Duplicate submissions (submitting the same abstract to more than one program) are not allowed. *Accepted authors are encouraged to submit full manuscripts to JACS.

Call for Submissions 2012-Bulletin (full) .indd 1 9/22/2011 4:12:57 PM Fellows in Archives photo identified

The photo above was published in the September 2011 issue of the Bulletin, along with a request for help in identifying the individuals pictured. Susan Rishworth, Archivist at the American College of Surgeons, received responses from the following Fellows: Ronald Jones, MD, FACS; C. John Snyder, MD, FACS; Penfield Faber, MD, FACS; Fred Gau, MD, FACS; Raphael E. Pollock, MD, FACS; Herbert Robb, MD, FACS; Bruce Bacon, MD, FACS; LaMar McGinnis, Jr., MD, FACS; and Charles E. Schoenhals, MD, FACS. According to these respondents, the photo is of a meeting of the Executive Committee, Committee on Cancer, and was taken in 1959. Pictured from left to right are: James B. Mason (staff); Murray M. Copeland, MD, FACS; Harry Nelson, Sr., MD, FACS; Danley P. Slaughter, MD, FACS, Committee Chair; R. Lee Clark, MD, FACS; Howard Errol Snyder, MD, FACS; Ian McDonald, MD, FACS; and Charles Eckert, MD, FACS.

International women in surgery symposium set for spring 2012

The Third Annual International Lloyd S. Rogers Professor of Sur- interactions with surgical leaders Women in Surgery Career Sym- gery Emeritus at the State Univer- and pioneers who have advanced posium will take place May 31 sity of New York Upstate Medical the roles of women in surgery. through June 2, 2012, and will be University in Syracuse, will deliver Sharon B. Ross, MD, will serve as hosted by Johns Hopkins Univer- the keynote address. chair for the symposium, and Julie sity in Baltimore, MD. American The symposium will promote A. Freischlag, MD, FACS, will be College of Surgeons President personal and professional growth the co-chair. Patricia J. Numann, MD, FACS, in women surgeons and provide

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

61

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Save the Dates! September 30–October 4, 2012

Join us in Chicago for an educational opportunity you don’t want to miss! Go to www.facs.org in the coming months for details about the educational program, registration, housing, and transportation.

American College of Surgeons 98th Annual

StewardS hip of the p rofeSSion

Clincal Congress Ad 2012.indd 1 11/22/2011 9:34:02 AM NTDB® data points Annual Report 2011: Eightfold over eight years by Richard J. Fantus, MD, FACS; and Michael L. Nance, MD, FACS

The 2011 Annual Report of the hospital characteristics, such as center registry data. The purpose of National Trauma Data Bank® bed size and trauma level, as well this report is to inform the medical (NTDB) is an updated analysis of as registry inclusion criteria for community, the public, and deci- the largest aggregation of U.S. and participating hospitals. A few of sion makers about a wide variety of Canadian trauma registry data ever the inclusion criteria that are high- issues that characterize the current assembled. In total, the NTDB lighted include minimum length state of care for injured persons in now contains more than 5 million of stay, hip fractures, and death on our country. It has implications records. The 2011 Annual Report arrival. This information allows in many areas, including epide- is based on 722,824 records— the reader to consider differences miology, injury control, research, submitted by 697 facilities—from in case mix across hospitals while education, acute care, and resource the single admission year of 2010. reading the report. allocation. These facilities include 219 Level The mission of the American Each year the requirements for I trauma centers, 239 Level II College of Surgeons (ACS) Com- data submission quality have in- trauma centers, and 192 Level III mittee on Trauma (COT) is to de- creased. This data quality improve- or IV trauma centers. velop and implement meaningful ment effort started in earnest with For the third year, the report programs for trauma care. In keep- the introduction of the National features an expanded section on ing with this mission, the NTDB is Trauma Data Standard back in facility information. This section committed to being the principal 2007—the thought being that it includes the usual information on national repository for trauma was better to have fewer records of

Number of records from the most recent admission year Number of records from the most recent admission year 722,824 800,000 681,990

700,000 627,664

600,000 506,452

500,000 354,550 400,000 254,620 300,000 182,311

200,000 87,320

100,000

0 2004 2005 2006 2007 2008 2009 2010 2011 AnnualAnnual report report yearyear 63

JANUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS better quality than more records record submissions for the most is available on the ACS website as of poorer quality. This perspective recent admission year data. a PDF file and a PowerPoint pre- works to counteract the so-called Many dedicated members of the sentation at http://www.ntdb.org. In garbage in–garbage out concept. COT, as well as at trauma centers addition, information is available Additionally, starting with the around the country, have contrib- on our website about how to ob- 2008 Annual Report, records from uted to the early development of tain NTDB data for more detailed only the most recent admission the NTDB and its rapid growth study. If you are interested in sub- year were included, in contrast to in recent years. Building on these mitting your trauma center’s data previous reports that featured the achievements, the goals in the com- contact Melanie L. Neal, Manager, data from the previous five years. ing years include improving data NTDB, at [email protected]. Thus, the 2008 report contained quality, updating analytic methods, only records of patients that were and enabling more useful inter- Dr. Fantus is director, trauma services, and admitted in 2007, and so on. There hospital comparisons. These efforts chief, section of surgical critical care, Advocate was significant concern surround- will be reflected in future NTDB Illinois Masonic Medical Center, and clini- ing the accrual of records when reports, which are submitted to cal professor of surgery, University of Illinois College of Medicine, Chicago, IL. He is Past- the more stringent data quality participating hospitals, as well as Chair of the ad hoc Trauma Registry Advisory requirements were put into effect. in the Annual Reports. Committee of the Committee on Trauma. That concern is unfounded based Throughout the year, we will be upon the continual rise in record highlighting these data through Dr. Nance is Templeton Professor of Surgery submissions each year. There has brief reports that will be pub- and director, pediatric trauma program, been more than an eightfold in- lished monthly in the Bulletin. Children’s Hospital of Philadelphia, PA. crease over the past eight years in The NTDB Annual Report 2011

Now AvAilABlE from the American College of Surgeons

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

log into the member web portal MyCME at www.eFACS.org to get started Y o u r C M E @ Your ConvE niE n CE A MERi CAN CollE g E o F SuR g E o NS • DiviS ioN o F E D u CAtioN 64 CME to ABS ad - June 2010 BULLETIN (4 in deep) REVISED LOGO.indd 1 9/16/2011 1:59:32 PM VOLUME 97, NUMBER 1, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS