NEWS Bulletin of the American College of Surgeons (ISSN 0002-8045) is published College establishes education task forces 31 monthly by the American Col- lege of Surgeons, 633 N. Saint 2003 ANZ Travelling Fellow selected 32 Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, to Associate Fellows, 2003 International Guest Scholars selected 32 to participants in the Candi- date Group of the American College of Surgeons, and to College focuses on critical issues at AMA meeting 34 medical libraries. Periodicals Jon H. Sutton postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send ad- Clowes research award given 35 dress changes to Bulletin of the American College of Surgeons, Practice management course 633 N. Saint Clair St., Chicago, IL 60611-3211. to be featured at Spring Meeting 37 The American College of Surgeons’ headquarters is lo- Randolph Fellowship in Pedatric Surgery established 39 cated at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312/202-5000, fax: 312/202- Trauma meetings calendar 40 5001; e-mail: postmaster@ facs.org; Web site: www.facs.org. Washington, DC, office is lo- Letters 42 cated at 1640 Wisconsin Ave., NW, Washington, DC 20007; tel. 202/337-2701, fax 202/ Highlights of the ACSPA Board of Directors and 337-4271. the ACS Board of Regents meeting, October 5, 6, and 11, 2002 46 Unless specifically stated Paul E. Collicott, MD, FACS otherwise, the opinions ex- pressed and statements Chapter news 54 made in this publication re- flect the authors’ personal Rhonda Peebles observations and do not im- ply endorsement by nor offi- cial policy of the American College of Surgeons.

©2003 by the American Col- lege of Surgeons, all rights re- served. Contents may not be re- produced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. The American College of Surgeons is dedicated to improving the care of the 1564382. surgical patient and to safeguarding standards of care in an optimal and ethical practice environment. Officers and staff of the American College of Surgeons

Officers Rene Lafreniere, MD, FACS, Calgary, AB Courtney M. Townsend, Jr., MD, FACS, Galveston, TX Richard R. Sabo, MD, FACS, Bozeman, MT President Advisory Council to the Board of Regents Amilu S. Rothhammer, MD, FACS, Colorado Springs, CO (Past-Presidents) Second Vice-President John O. Gage, MD, FACS, Pensacola, FL W. Gerald Austen, MD, FACS, Boston, MA Secretary Oliver H. Beahrs, MD, FACS, Rochester, MN John L. Cameron, MD, FACS, Baltimore, MD John M. Beal, MD, FACS, Valdosta, GA Treasurer Harvey W. Bender, Jr., MD, FACS, Nashville, TN Thomas R. Russell, MD, FACS, Chicago, IL George R. Dunlop, MD, FACS, Worcester, MA Executive Director C. Rollins Hanlon, MD, FACS, Chicago,IL Gay L. Vincent, CPA, Chicago, IL James D. Hardy, MD, FACS, Madison, MS Comptroller R. Scott Jones, MD, FACS, Charlottesville, VA M. J. Jurkiewicz, MD, FACS, Atlanta, GA Officers-Elect (take office October 2003) LaSalle D. Leffall, Jr., MD, FACS, Washington, DC William P. Longmire, Jr., MD, FACS, Los Angeles, CA Claude H. Organ, Jr., MD, FACS, Oakland, CA* Lloyd D. MacLean, MD, FACS, Montreal, PQ President William H. Muller, Jr., MD, FACS, Charlottesville, VA Anna M. Ledgerwood, MD, FACS, Detroit, MI David G. Murray, MD, FACS, Syracuse, NY First Vice-President David C. Sabiston, Jr., MD, FACS, Durham, NC Murray F. Brennan, MD, FACS, New York, NY Seymour I. Schwartz, MD, FACS, Rochester, NY Second Vice-President George F. Sheldon, MD, FACS, Chapel Hill, NC G. Tom Shires, MD, FACS, Las Vegas, NV Frank C. Spencer, MD, FACS, New York, NY Board of Regents Ralph A. Straffon, MD, FACS, Shaker Heights, OH James C. Thompson, MD, FACS, Galveston, TX Edward R. Laws, Jr., MD, FACS, Charlottesville, VA Chair* Edward M. Copeland III, MD, FACS, Gainesville, FL Executive Staff Vice-Chair* Barbara L. Bass, MD, FACS, Baltimore, MD Executive Director: Thomas R. Russell, MD, FACS L. D. Britt, MD, FACS, Norfolk, VA Division of Advocacy and Health Policy: William H. Coles, MD, FACS, New Orleans, LA Cynthia A. Brown, Director A. Brent Eastman, MD, FACS, La Jolla, CA American College of Surgeons Oncology Group: Richard J. Finley, MD, FACS, Vancouver, BC Samuel A. Wells, Jr., MD, FACS, Group Chair Josef E. Fischer, MD, FACS, Boston, MA Communications: Linn Meyer, Director Alden H. Harken, MD, FACS, Denver, CO* Division of Education: Gerald B. Healy, MD, FACS, Boston, MA Ajit K. Sachdeva, MD, FACS, FRCSC, Director Charles D. Mabry, MD, FACS, Pine Bluff, AR Executive Services: Barbara L. Dean, Director Jack W. McAninch, MD, FACS, San Francisco, CA* Finance and Facilities: Gay L. Vincent, CPA, Director Mary H. McGrath, MD, FACS, San Francisco, CA* Human Resources: Jean DeYoung, Director Robin S. McLeod, MD, FACS, Toronto, ON Information Services: Howard Tanzman, Director Carlos A. Pellegrini, MD, FACS, Seattle, WA Journal of the American College of Surgeons: John T. Preskitt, MD, FACS, Dallas, TX Wendy Cowles Husser, Executive Editor Ronald E. Rosenthal, MD, FACS, Wayland, MA Division of Member Services: Richard R. Sabo, MD, FACS, Bozeman, MT * Paul E. Collicott, MD, FACS, Director Maurice J. Webb, MD, FACS, Rochester, MN Division of Research and Optimal Patient Care: *Executive Committee R. Scott Jones, MD, FACS, Director Cancer: David P. Winchester, MD, FACS, Medical Director Board of Governors/Executive Committee Trauma: David B. Hoyt, MD, FACS, Medical Director J. Patrick O’Leary, MD, FACS, New Orleans, LA Executive Consultant: Chair C. Rollins Hanlon, MD, FACS Timothy C. Fabian, MD, FACS, Memphis, TN Vice-Chair Julie A. Freischlag, MD, FACS, Los Angeles, CA Secretary Steven W. Guyton, MD, FACS, Seattle, WA 2 Mary Margaret Kemeny, MD, FACS, Jamaica, NY

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS From my perspective

n this column, I generally write about the pressing issues that affect us as we attempt to practice our profession and take care of Iour surgical patients. Some of the topics that I have addressed include reimbursement and the Medicare fee schedule, the medical professional liability crisis, and the burdens associated with regulatory acts and agencies. The College, inde- pendently and as a member of several coalitions of surgical and medical organizations, works persistently to address these issues and to cre- ate meaningful change. As frustrating and fu- tile as these efforts may seem at times, they are important in ensuring that we have a seat at I believe that the College the table when policymakers deliberate over needs to makmakneeds e a long-termlong-terme these matters, which significantly affect all sur- ‘‘ geons and their patients. Payment, malpractice insurance, regulatory commitment to assessing hassles, and other modern-day “challenges” are ongoing, specific problems that affect each of us the effectiveness of surgical as we work to deliver the best care for our pa- tients. Hence, the College will continue to ad- procedures and providers. dress these concerns with devotion and dili- gence. ’’ Facing the future While these types of immediate problems de- mand a great deal of attention, all of us need to be cognizant of the broader issues that will be- Outcomes analysis come increasingly relevant as the health care For many years, we’ve been hearing about plans system transforms. Thus, we need to focus not to analyze outcomes, to use the data drawn from only on the issues that affect us today, but on these evaluations to determine which procedures what is likely to play out in the future. and medical interventions are effective, and to is- The next generation of surgical care will very sue report cards for physicians and other provid- likely emphasize quality care and the reduction ers. There now seems to be increased movement of errors through improved patient safety. in this area. For example, the federal government, Hence, as we move into the future, the question through the Centers for Medicare & Medicaid Ser- we need to be thinking about is this: What types vices, has endorsed the concept of developing a re- of skills and knowledge will competitive sur- porting system to evaluate medical institutions geons need to possess in the coming years, and and, eventually, physicians. The government’s first what can surgical organizations like the College venture into this arena centers on the evaluation do to help prepare them for impending changes? of nursing homes and is being promoted through The shifting emphasis toward quality of care national television. concerns has arisen largely in response to in- In the private sector, confederations like the creased scrutiny of errors in medicine and in our Leapfrog Group have started looking at outcomes hospitals. Fueling this reaction was the Institute and, as a result, are directing their subscribers to of Medicine report, To Err Is Human: Building a high-volume institutions and facilities that meet Safer Health System, which indicated that tens of certain criteria, such as having an intensivist on thousands of deaths occur each year in hospitals staff in the ICU. Unfortunately, these types of ef- due to medical error. forts are based on weak outcomes data and inad- 3

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS equate analysis of all the systems that are involved in the program. ACOSOG offers a marvelous op- in the delivery of care. To help ensure that out- portunity for surgeons of various backgrounds comes analysis is conducted in a sound way, I be- (academic and community-based) to enter patients lieve that the College needs to make a long-term in trials that will yield evidence with respect to commitment to assessing the effectiveness of sur- what constitutes best practices in oncology. The gical procedures and providers. College envisions an expansion of activity in this As outcomes analysis becomes a more integral arena to include clinical trials in other areas, such part of our health care delivery system, surgeons as trauma. will need to become more involved in the concept Many of the projects mentioned in this column of practice-based learning. Moreover, the evalua- are clearly long-range in nature. Their ultimate tion of one’s own outcomes is going to be a signifi- objective will be to produce a better health care cant component of improving quality. Surgeons system—one that is safer for our patients and that will need to work from a qualitative perspective applies the best scientific evidence available to and be able to prove to their patients and other medical decision making. There is no question that interested parties that they offer beneficial care. the science of medicine and surgery is evolving Conceptually, moving ahead in this area is simply markedly. We believe that these efforts will allow an extension of continuing one’s medical educa- surgeons not only to keep abreast of, but to be tion and ongoing professional development. It’s ahead of, the curve regarding such changes. about confronting and responding to problems within one’s own practice.

College’s assistance The College wants to assist in every possible way as the concept of practice-based learning contin- ues to evolve. As many of you know, we have formed Thomas R. Russell, MD, FACS a partnership with the National Surgical Quality Improvement Program (NSQIP), which takes the knowledge attained through the Veterans Administration’s quality assessment program and applies it to the private sector. More specifically, NSQIP looks at surgical outcomes in a risk-ad- justed way and determines outcomes based on an observed-to-expected ratio. In addition, we have two databases at the Col- lege—the National Cancer Data Base and the Na- tional Trauma Data Bank™—which will hopefully generate the information we need to gain further insight into best outcomes and best practices in these two important areas. Finally, we are expanding our efforts to conduct clinical trials that are aimed at eliminating some of the uncertainty with regard to cancer treatments that are most effective. In 1998, we launched the American College of Surgeons Oncology Group (ACOSOG), which administers clinical trials in cancer care. Currently, ACOSOG has 13 open trials, and more than 3,000 health care professionals—including If you have comments or suggestions about this or surgeons, medical oncologists, pathologists, radia- other issues, please send them to Dr. Russell at 4 tion oncologists, nurses, and others—participate [email protected].

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS FYI: STAT

The ACS Health Policy Steering Committee and ACSPA- ❖ SurgeonsPAC held a joint meeting in Chicago on January 13 to re- view the current status of and outlook for legislative issues of concern to surgeons. Details of initiatives coming out of that session and other meetings of the committee will be reported in future issues of the Bul- letin and ACS NewsScope.

❖ Can’t think of your ACS ID number when you want to visit the “Mem- bers Only” side of the College’s Web site? Your days of frustration are now over. The College has updated the “Members Only” section to allow you to set your own user ID and password to access its many features. To make that change, go to the College’s home page at http: //www.facs.org and click on the “Members Only” link at the top of the page. You will still need your ACS ID when you log in for the first time. You can then enter your user ID, password, and security ques- tions. If you forget your password the next time you visit the page, you can recover your password online by answering your previously set up security questions. While you are in the “Members Only” area, please check to be sure that your mailing address, telephone numbers, and e- mail address are current and accurate. Be assured that the College does not provide your e-mail address to outside entities. E-mail ad- dresses are used only for College communications.

❖ A new Quarterly Prevention Summary has been added to the series that is being published by the Committee on Trauma’s Subcommittee on Injury Prevention and Control. “Skiing and Snowboarding In- jury” outlines the epidemiology and injury and prevention efforts re- garding downhill (Alpine) skiing, snowboarding, and cross-country (Nordic) skiing. A bibliography is included in the summary, which can be found on the College’s Web site at http://www.facs.org/dept/trauma/ skiing.html.

❖ Seven general sessions from the 2002 Clinical Congress are now avail- able via a Web cast on the American College of Surgeons Web site. Sponsored by the College’s Division of Education, the program offers practicing surgeons a flexible and convenient way to obtain Cat- egory 1 CME credits and is the first step in establishing a compre- hensive E-Learning Program. Sessions include: New Technology: What’s Proven, What’s Not; Patient Safety; Damage Control in Trauma and Emergency Surgery: New Applications; Programa Hispanico, Sec- tion 1: Surgical Management of Breast Cancer, Section 2: Status of Liver Transplantation in Latin America, Section 3: Bariatric Surgery Update, and Section 4: Management of Pancreatic Cancer; The Ethics of Entrepreneurialism in Surgery; Should Axillary Dissection Be Aban- doned?; and Management of Metastatic Disease of the Liver. For fur- ther details and to view the program catalog, visit http://www.facs- ed.org/. 5

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS DatelineWashington prepared by the Division of Advocacy and Health Policy

The Centers for Medicare & Medicaid Services (CMS) released the Delayed Medicare 2003 Medicare fee schedule for physician services on December 20, 2002. rule raises new As a result, the payment update for physician services has been de- layed until March 1. The regulation, which was published in the Fed- concerns eral Register on December 31, 2002, includes an across-the-board 4.4 percent reduction in the fee schedule conversion factor, which is caused by the flawed formula used to calculate the annual pay updates. How- ever, the delay in implementation has had other effects that surgeons and their practice managers need to understand. These ill effects are summarized below. Enrollment period. The enrollment period (that is, the period in which physicians can decide whether to be “participating” or “nonparticipat- ing”) will now run from January 9 through February 28, 2003. The enrollment notice sent by carriers incorrectly states that changes in participation status must be made by December 31, 2002. Carriers will not send another mailing to provide the correct dates. Surgeons who want to retain their existing participation status need not take any action. However, those who do want to change their status should consult the material they received from their carrier. Any par- ticipation decisions made will be irrevocable for 2003 services. (See “Selecting the best Medicare payment option” in the August 2002 Bul- letin for details about these options, or view the article on the College’s Web site at http://www.facs.org/dept/hpa/pubs/bullet.html.) Surgeons who change their participation status should start to pre- pare claims using that status immediately after submitting their par- ticipation agreement or disenrollment request to the carrier. Claims that are misprocessed will be automatically adjusted after July 1, 2003. Claims processing. The delay in implementing the lower 2003 pay- ment rates applies only to claims paid under the physician fee sched- ule. Claims for other services, such as drugs, diagnostic clinical labo- ratory tests, and durable medical equipment, will be paid at 2003 rates effective January 1, 2003. Claims for physician fee schedule services in January and February will be paid at the higher 2002 rates. The new, lower rates will become effective for services provided on or after March 1, 2003. The higher 2002 rates also will be applied to the deductible for services rendered in January and February, and the 2003 rates will be applied on or af- ter March 1. Copayments, of course, will be 20 percent of Medicare’s allowed amount regardless of when the service is rendered. Local carriers ask that claims for services provided in January and February be submitted as quickly as possible. Rapid claims sub- mission will allow carriers to process and use 2002 pricing before March 1. Claims submitted in January and February using new CPT codes will not be processed until after March 1 and will be paid at the 2003 rate. Because surgeons have until April 1 to convert to CPT 2003, they should avoid using new CPT codes until sometime in March. A direct link to the Medicare program memorandum describing these changes can be found at http://cms.hhs.gov/manuals/pm_trans/ 6 AB02181.pdf.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Shortly after the 108th Congress was sworn in on January 7, two New Congress bills were introduced to address the impending 4.4 percent cut in Medi- proposes Medicare care physician payments scheduled to take effect on March 1. House Ways and Means Committee chair Rep. Bill Thomas (R-CA) introduced fixes a joint resolution that would invoke the Congressional Review Act and essentially dismiss the 2003 fee schedule—effectively freezing 2003 pay- ments at 2002 rates. Rep. Ben Cardin (D-MD), a member of the Ways and Means Committee, introduced the “Medicare Payment Restora- tion and Benefits Improvement Act,” which would revise the physi- cian payment update for three years, beginning with a 2 percent up- date for 2003. While these actions strongly indicate that members of Congress are aware of the serious effects that the Medicare payment situation is having on physicians, the outlook for passage before the reductions take effect on March 1 is uncertain.

It is clear that the rapid increase in the cost of medical liability insur- Medical liability ance continues to be a looming crisis for surgeons across the nation. A insurance crisis breaking point was reached recently in West Virginia, where a number of surgeons took leaves of absence from their hospitals. continues Congress is expected to begin debating this issue early this year. Last year, the House passed a strong medical liability reform bill, but the Senate rejected a weaker proposal, and a compromise was never reached. President Bush and new Senate Majority Leader Bill Frist, MD, FACS (R-TN), have said liability reform is a major legislative priority for the new Congress. There will also be an effort in many state legislatures to enact reforms similar to those passed in California in 1975. The College applauded the President’s call to address medical liabil- ity insurance reform and increased funding for the Medicare program in the State of the Union address. Thomas R. Russell, MD, FACS, said, “Congress must pass legislation that halts runaway litigation and guar- antees that injured patients are fairly compensated.” Noting that “the liability lottery is driving surgeons out of business,” Dr. Russell added that “the liability reform called for by the President in his State of the Union address must work toward stabilizing premiums and keeping surgeons in the operating room where they belong.”

The National Center for Minority and Health Disparities recently Loan repayment announced the availability of programs that would provide repayment programs of educational loan debt for qualified health professionals who agree to conduct either health disparities or clinical research for two years. announced The objective is to recruit and retain highly qualified health profes- sionals for research careers that focus on minority health or other health disparities issues. The program provides for the repayment of the principal and interest of the educational loans, up to a maximum of $35,000 per year. The online application and additional informa- tion regarding both programs may be obtained at www.lrp.nih.gov. RM7

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Whats surgeons should know about...

The 2003 Medicare fee schedule

by Jennifer Razor, JD, Government Affairs Associate, Division of Advocacy and Health Policy

n December 31, 2002, after a two-month How is the conversion factor calcu- delay, the Centers for Medicare & Medic- Q. lated? Oaid Services (CMS) published final regu- lations concerning the 2003 Medicare fee sched- According to a complex formula pre- ule. The regulations include a reduction in the A. scribed by law, CMS must revise the fee fee schedule conversion factor, resulting from schedule conversion factor annually. Each year, the the inaccurate estimates CMS used to calculate conversion factor is equal to the conversion factor the annual pay update. Due to a delay in the for the previous year multiplied by the update as publication of the final rule, these regulations determined by law. CMS bases the Medicare con- will not take effect until March 1. version factor updates on three components: (1) All eyes have shifted to the newly elected 108th the Medicare Economic Index (MEI), designed to Congress, which convened last month, to fix the reflect Medicare inflation; (2) an expenditure tar- Medicare payment problem. Because CMS dis- get performance adjustment based on a compari- putes its legal authority to correct the estimates, son of actual and target expenditures, known as a legislative fix appears to be physicians’ last the sustainable growth rate; and (3) miscellaneous opportunity to stop the cut before it actually adjustments, which include shifts to account for occurs. budget neutrality. The following questions and answers should help clarify the concerns that surgeons may have What is the sustainable growth rate? about the new regulation and its impact on Q. Why is it so critical? Medicare payments and policies in 2003. The sustainable growth rate (SGR) is a What is the fee schedule conversion A. prospectively determined annual expendi- Q. factor for 2003? ture target that applies to physicians’ services paid by Medicare. The use of the SGR is intended to By law the payment amount for each control growth in aggregate Medicare expenditures A. service paid by the physician fee sched- for physicians’ services. The physician fee sched- ule is the product of three factors: (1) a nation- ule update is adjusted for “performance” based on ally uniform relative value for the service; (2) a a comparison of allowed expenditures, determined geographic adjustment factor that is intended using the SGR, and actual expenditures. If actual to reflect local variations in costs; and (3) a na- expenditures exceed the targeted expenditure tionally uniform dollar conversion factor. This amount, the update is reduced. If actual expendi- year, the conversion factor that is used to trans- tures are less than the target, the update is in- late fee schedule RVUs into payments was re- creased. duced by 4.4 percent for 2003, to $34.59. In 2002, Specifically, the SGR is calculated on the basis the conversion factor fell 5.4 percent to $36.20, of the weighted average percentage increase in the

8 down from $38.26 in 2001. fees for physicians’ services, growth in fee-for-ser-

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS vice Medicare enrollment, growth in the real per year’s fee schedule compensate for the dra- capita gross domestic product (GDP), and the matic increases in surgeons’ liability premi- change in expenditures for physicians’ services re- ums? sulting from changes in laws or regulations. For 2003, the preliminary estimate of the SGR is 7.6 The professional liability component ac- percent. A. counts, on average, for 3.2 percent of the total payment amount under the fee schedule. This Why does the SGR formula need to year, recognizing the growing liability crisis and Q. be revised? its ramifications on physicians’ practices, CMS in- creased the MEI update for professional liability Over the last several years, the College insurance by 11.3 percent. A. and other organizations representing To track the ever-changing liability market physicians have urged CMS to correct the flawed each year, CMS solicits physician professional numbers in the SGR formula for two reasons. liability premium data from commercial carri- First, CMS insists that it does not have the au- ers for $1 million/$3 million mature claims-made thority to substitute actual data for estimates in policies. After collecting information for every the formula. The second factor is the statutory state by physician specialty and risk class, CMS requirement for the use of GDP as part of the for- aggregates the information by premium date to mula. compute a national total using counts of physi- As it stands, the formula applies faulty data from cians by state and specialty. projections made about GDP and fee-for-service These data include effective premium rates enrollment growth for 1998 and 1999. Because the through the second quarter of 2002, which is con- SGR is based on cumulative data, these errors un- sistent with the timeliness of other data used in fairly removed $20.4 billion from the allowed determining the update. Though state insurance spending target. If the baseline were corrected commissioners have the most comprehensive data with actual data for those years, higher physician on professional liability costs, the most recent data fee schedule conversion factors would have re- they could provide were from 2000 and thus would sulted for 2000 and all the subsequent years. Al- not reflect the evolution of the current crisis. though the law specifically requires CMS to use Because rising costs for individual physicians actual, after-the-fact, data to revise estimates used may not be reflected in changes to the RVUs or to set the SGR beginning in 2000, the agency main- geographic adjustments for several years, the pro- tains that the statute does not permit it to revise fessional liability crisis highlights the problem the incorrectly estimated SGRs for 1998 and 1999. with the adequacy of the conversion factor. Theo- Furthermore, as the costs associated with medi- retically, when liability premiums increase for cal practice continue to increase rapidly, particu- most specialties, these increased expenses would larly for pharmaceuticals and liability insurance, be reflected in the annual update to the MEI, the SGR formula’s reliance on the changes in GDP which is used to calculate the conversion factor. renders it increasingly less relevant to trends in Alternatively, when premiums spike in a particu- physician practice expenses. lar specialty, those increases could be reflected in the RVUs every five years when CMS updates the How does the fee schedule account three-year average on premium data. The College for liability premiums? Does this continues to urge CMS to more fully address the Q. 9

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS problem of rising costs of liability insurance by Yes. Previously Medicare paid only the in- seeking additional funds from Congress. A. cremental intraservice work and practice expense RVUs associated with the add-on service What is the “productivity adjust- for a code with a ZZZ global indicator. Beginning Q. ment,” and why did CMS revise it? in 2003, Medicare has changed the definition of the ZZZ global indicator to include pre- and post- A productivity adjustment is applied to service work and practice expenses associated with A. the MEI to account for the fact that in- the add-on code. This change was caused by the creased practice costs due to inflation are some- addition in 2003 of the add-on CPT code 33225, what offset by increases in physician productiv- Insertion of pacing electrode, cardiac venous sys- ity. Until this year, the productivity adjustment tem, for left ventricular pacing, at time of inser- used by CMS reflected an estimated offset that tion of pacing cardioverter-defibrillator or pace- reflected physician labor only. CMS has now re- maker pulse generator (including upgrade to dual vised the productivity adjustment to appropriately chamber system), which has the post-service work reflect other factors that affect productivity, such of monitoring and perhaps programming. as capital, office space, medical materials and sup- plies, and equipment. For several years, surgeons have ar- As a result, the productivity adjustment ap- Q. gued that CMS should include in the plied to the calculated Medicare inflation rate calculation of physician practice expenses is smaller and produces a higher MEI. Because the costs of physician-employed clinical staff the MEI is one of the key factors used to calcu- who provide services in hospitals and other late the annual conversion factor update, the facility settings. Did CMS finally make this end product is a less severe conversion factor change? reduction for 2003. If CMS had not revised the productivity adjustment, the fee schedule con- No. CMS continues to exclude the consid- version factor would have been reduced by at A. erable costs that some surgeons incur least a full percentage point this year, as opposed from employing nonphysician clinical staff who to the 4.4 percent cut that was published in the assist in the hospital from practice expense reim- regulations. bursement. CMS continues to maintain that the services of these staff are paid to physicians Did CMS remove the noninvasive through the work RVUs to the extent they serve Q. vascular diagnostic study codes (CPT as physician extenders, to the mid-level practitio- codes 93875-93990) from the so-called zero ners directly, or to the hospital through DRG pay- work pool? ments or as part of the Ambulatory Payment Clas- sification system for outpatient services. Yes. CMS has removed these codes at the A. request of vascular surgeons, and they are Does CMS continue to include drug the ones who predominantly perform the services Q. prices in the calculation of expendi- in this family of codes. tures for physicians’ services?

Has the definition of ZZZ global pe- Yes. CMS continues to inappropriately riods changed? include drugs furnished incident to a 10 Q. A.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS physician’s service when it calculates the SGR. in 2002 without addressing House-passed Medi- CMS assumes that physicians are able to control care payment reforms. In an eleventh-hour at- use of, and therefore spending on, drugs. Physi- tempt to avert this cut, the House passed a provi- cian groups have argued, however, that the growth sion that would have given CMS legal protection in Medicare spending on drugs is not driven pri- from retroactive lawsuits should the Administra- marily by physicians, but rather by the introduc- tion make revised determinations in the physician tion of expensive new drugs to the Medicare popu- payment formula for previous fiscal years. Con- lation. Furthermore, the actual prices for new or cerned that the temporary solutions passed by the existing drugs are not set or controlled by physi- House would have helped physicians without as- cians. sisting other health care providers—such as hos- pitals, nurses, and home health care providers— Why wasn’t the fee schedule pub- Senators from both sides of the aisle actively Q. lished earlier? blocked a fix for doctors.

On November 1, 2002, the statutory dead- What role is the College playing in A. line for publishing final regulations to Q. the fight to achieve adequate Medi- implement the 2003 Medicare physician fee sched- care payment for surgical services? ule, CMS issued a notice of delay, citing concerns about data used to establish payments and the In addition to direct advocacy from its need to further assess the accuracy of the data. A. leadership and staff, the College encour- Reportedly, the data in question pertained to new aged Fellows to pressure the House and Senate relative values that were calculated for certain during the 107th Congress. Thousands of Fellows anesthesia services. used the College’s Web-based Legislative Action Center to write lawmakers and encourage imme- Why doesn’t CMS fix the payment diate action on payment issues. As a result, the ma- Q. update formula? jority of legislators are well-educated about the is- sue and its importance to their physician constitu- CMS claims that it would like to fix the ents and their Medicare patients. A. errors in the formula administratively but The College remains an active member of Medi- cannot find the statutory authority to do so. Twice, care payment coalitions that support changing the the College briefed CMS on possible sources of ad- flawed physician payment update formula. When ministrative authority and repeatedly asked CMS the newly elected 108th Congress convened in to exercise that power. Nevertheless, the agency January, the College redoubled its efforts to enact agrees that the negative update is inappropriate a legislative solution before the cut actually occurs because the current update system does not re- on March 1. flect actual data from earlier years. For more information about this issue, contact Jennifer Razor at [email protected]. ⍀ Why doesn’t Congress fix the for- Q. mula?

For the second year in a row, the Senate abandoned physicians when it adjourned A. 11

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Easing the transition to retirement:

When, where, how?

by Robert E. Condon, MD, MSc, FACS, Clyde Hill, WA

12

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ost retirement planning guides are is- Where to live sued by stockbrokers or mutual funds. M As a result, they are all about money The choices are staying put, moving, or doing and nothing else. While money obvi- a bit of both. Like money, this is a very personal ously is an important consideration when plan- issue. The decision will be based on individual ning for retirement, it’s not the whole package. views about summer and winter weather in vari- There are a number of other factors to weigh in ous parts of the country, as well as plans for ac- planning your retirement. Because money issues tivities in retirement. are unique to each individual, I’ll leave advice In considering this issue, remember that mov- about this aspect of retirement to you and your ing is very stressful. On the other hand, a move financial consultants. I offer only this caveat: can also be useful because it usually forces people the notion that living expenses decrease after to get rid of accumulated junk. Moving to a new retirement just isn’t true; an unchanged lifestyle locale where you are unknown means some time probably will require just about as much money will pass before making new social acquaintan- after retirement as was coming in before. ces, so loneliness may be a problem. If moving Some of the other topics to consider during seems necessary, try to develop contacts in the the transition into retirement include when to desired community by living there a few years retire, retirement locale, and health insurance. before really retiring. However, the most important questions to con- sider are: Who will you be, and what you will do Health insurance in retirement? This article is intended to offer some guidance on these issues before surgeons If you’re over 65, you can’t avoid Medicare. walk out of their offices for the last time. It’s illegal for any insurance company to issue to a retiree any sort of health insurance policy When to retire except for one of the congressionally mandated Medicare supplements. These “Medigap” poli- The short answer is to retire before you cies may or may not fit an individual’s circum- start making uncorrected mistakes in the op- stances, but you have no other choices. The erating room. We all make mistakes—it’s part Medigap law was passed because some elderly of being human. And, nearly always we people were being victimized by unscrupulous quickly recognize our mistakes and correct insurance carriers that were selling them mul- them before there are any adverse conse- tiple “cancer” policies, and Congress wanted to quences. But as we get older, our ability to stop this abuse. Unfortunately, the result is that recognize errors in a timely way diminishes. no one may buy a non-Medicare-affiliated health Greenfield and colleagues are working on the insurance policy, such as a high-deductible ma- development of a psychomotor test that will jor medical policy, that is better tailored to the help to identify when a surgeon’s capacities individual’s needs. It’s Medigap or nothing. are no longer up to par.* But the conclusion Be very careful about entering a so-called of that quest may come far in the future. Medicare+Choice HMO or PPO plan. If one of In the meantime, remember that even your these plans drops out of Medicare, or a benefi- best friends may be unwilling to tell you when ciary later decides to quit the plan, standard you start slipping. It’s embarrassing and discon- Medicare will be reinstated, but, depending on certing to see a great surgical reputation tar- timing and other circumstances, the choice of nished by a bad end. So, plan to quit while you’re Medigap policies may be restricted or coverage ahead, while still in top form. Don’t wait to be may be denied. This area is a real minefield, so told it’s time to go. Choose a date that’s a lot be careful what you do. sooner than you think it needs to be. Once you’re 65 and are covered by Medicare, be prepared for the blizzard of notices that will ar- * Greenfield LJ: Cognitive changes and retirement among senior rive in the mail. A notice is sent every time any surgeons. Bull Am Coll Surg, 87(6):19, 2002. claim, however small, is processed. These notices 13

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS carry a prominently displayed reminder, right at the top of the page in bold type, about reporting fraud. Further down the page, in less attention- getting type, are the numbers indicating how “ For those who much was billed, what Medicare “approved,” and what was actually paid to the providers of the define themselves medical care. Additionally, the insurance carrier of the Medigap policy may pay only what Medi- care approved but didn’t pay. Your physicians will only or primarily by never receive a reasonable and customary fee un- der Medicare. If you think this situation is inap- propriate and try to pay the difference yourself, their profession, the physician may not accept the check—that’s il- legal! Long-term care insurance is expensive, but it ‘what I do’ becomes brings some peace of mind. More than half of women and one-third of men over 65 years of age can expect to need long-term care either at home the same as ‘who I or in a nursing home. One-fifth of these folks will need care for at least five years. Nursing home care can be fiercely expensive, eating up all of one’s am.’ ” financial resources in a relatively short time. For individuals who need these services, long-term care insurance is probably the only way to keep your savings and your home, and leave anything for the kids. Hence, an unhappy “retirement” becomes in- Who will you be? evitable. And then the supposedly “retired” sur- geon, with nothing else to do, hangs out in the Surgeons work in a meritocracy, a world in which hospital coffee shop just to “stay in touch.” It’s a recognition and reward go to those individuals who little desperate and pathetic. It’s certainly a sad perform in superior fashion. One characteristic of way to end a great surgical career. a meritocracy is that participants identify who they Such individuals need to accept that surgery is are by what they do. Think of the common cock- a wonderful career, but it is not their only life. tail party conversational gambit between strang- They need to get a new life, to develop new inter- ers: “What do you do?” For those who define them- ests and activities, to create a new persona that selves only or primarily by their profession, “what makes them satisfied, even enthusiastic. If they I do” becomes the same as “who I am.” can’t succeed in doing so by themselves, they For surgeons who define themselves only as sur- should seek counseling early in the process of plan- geons, and who have not developed any other ning their retirement. major interests, retirement implies the end of sur- gical existence. It is a kind of death that is very What to do? difficult to accept. After all, who wants to be dead? So, surgeons who can’t really give up their surgi- There’s a lot of time available in retirement, and cal role feel uncomfortable not being addressed as some activity needs to fill that void. Otherwise, too “doctor,” continue to go to the office, and some- much time will be spent sleeping, and then, with times keep operating beyond when they should. no great purpose or involvement in life, the retiree Such surgeons have no idea how to fill up their will become depressed. Also, at this stage of life days except to keep doing what they no longer do it’s “use it or lose it” time; it is very important to 14 as well as they once did. keep your mind as well as your body active.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The availability of time and of much more con- especially if you are not seen to be developing plans trol over how it is spent provides an opportunity for other activities, your companion will be terri- to fulfill ambitions that may have been deferred fied that you will try to invade his or her domain. while engaged in an active surgical practice. For This is the short road to a late-life divorce. those so inclined, retirement brings a chance to In my own case, I continue to do a little teach- lend their surgical skills and knowledge to a vari- ing and consulting, but I’m now primarily a gar- ety of volunteer programs—to share their exper- dener and a cook, a continuation of lifelong hob- tise and their time helping others. The College is bies. In retirement, I’ve finally had the time to do in the early stages of organizing a register of such something I had wanted to do for years: take the possibilities.† required course and become certified as a master Many surgeons find that their transition into gardener. I have about a third of an acre in a cut- retirement is eased by a period of a year or two ting garden and find great satisfaction in helping during which they continue to assist their associ- things grow. Then, in the evening, I turn my at- ates in the operating room, and sometimes do some tention to the kitchen. I have a terrific collection informal consulting of the “curbstone” variety, but of recipes that would be a well-received cookbook not take call or otherwise assume primary respon- if I could find a willing publisher! My wife does sibility for patient care. Even so, in the end, every what she does best, leading educational tours at a surgeon who retires has to accept that his or her nearby art museum. We both enjoy travel with role as a surgeon has to come to an end. groups and now have time for the symphony and Doing things together with one’s life compan- the theater. We are doing what we enjoy and re- ion is a common romantic goal, and it is possible mind each other daily that “life is good!” to do this for some of the time. Activities that have Retirement takes a little planning and some been shared together for years before retirement adjustments, but it can be a wonderful, fulfilling are easily continued. Travel is the obvious togeth- time of your life. So get another life before quit- erness route, but it’s impossible to be on the road ting surgical practice. If you do, you’ll find retire- all of the time. And the challenge of golf only lasts ment as enjoyable, or even more enjoyable, than so long. your previous surgical career. ⍀ Many retired surgeons find they can start a new career by expanding a hobby into an occupation. It need not produce income; in fact, it may be a bit of an expense. What’s important is that the activity provide real satisfaction and a sense of accomplishment. A new “career” obligates you to get out of bed and to work at it nearly every day. It should be something enjoyable and that brings, at the end of the day, the reward of having done something worthwhile. Dr. Condon is a More importantly, the new career should be retired general surgeon something that gets you out of the house. The enjoying life in Clyde Hill, WA. major unspoken fear of spouses is that the retiree will be in their space all the time, trying to reor- ganize things his or her way. Remember that your spouse had an independent life and managed the household or a job without your presence much of the time. Your spouse will ask for your help when needed, but most of the time will get along very well without your assistance. As retirement looms,

†Warshaw AL: Study of volunteerism among surgeons. Bull Am Coll Surg, 87(1):40, 2002. 15

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS CPT changes in 2003: An overview

by John T. Preskitt, MD, FACS, Dallas, TX, and Jean A. Harris, Associate Director, and Irene Dworakowski, Regulatory and Coding Associate, Division of Advocacy and Health Policy 16

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS his article provides an overview of the new and revised Current Procedural Terminology (CPT) codes for 2003 that are of special inter- Test to general surgeons and closely related subspecialties.* Medicare traditionally has allowed physicians a three-month window, from January 1 to March 31, to switch to the new codes. However, the program will not implement the 2003 fee schedule and new codes until March 1. Most of the work to install new codes can be done before then, but the codes can- not be “turned on” until claims are being prepared for dates of service on or after March 1. Claims using new 2003 CPT codes submitted before March 1 will be held and processed after that date. Skin procedures The introductory notes and codes for the exci- sion of benign and malignant skin lesions have been revised to clarify that the code should be se- lected and reported based on the size of the exci- sion (lesion plus margins). Some organizations, • In the event a frozen section pathology re- including the College, taught physicians to report port shows the margins were inadequate and ad- the size of the lesion, which is what was formerly ditional excision(s) is performed in the same set- stated in CPT. However, other organizations taught ting, use only one code, selected based on the total physicians to report the size of the defect created, diameter of the excised lesion plus all excised mar- and that language was adopted for CPT 2003. The gins (that is, what the excised size would have been language in the code descriptors has been changed if it all been removed initially). from “lesion diameter” to “excised diameter,” but • If the re-excision is performed in a separate codes and the sizes in the code descriptors have operative session but is within the global period of not changed. This means that physicians will re- the first excision, report the second excision with port a higher level code in many instances. This a -58 modifier to indicate that more extensive sur- upward shift will be especially pronounced in the gery was done within the global period. (Use a -59 series of codes for the excision of malignant lesions. modifier to indicate that the surgery was done at a The introductory notes have been changed to separate operative session if both procedures are make the following points: done on the same day.) • The measurement of the lesion plus excised The CPT manual contains three drawings ex- margins should be made before the lesion is re- plaining how to measure the defect. Unfortunately, moved. the wrong text is attached to the drawings in some • For irregular lesions, the measurement editions of the book, making it difficult to under- should be made at the lesion’s widest point and at stand the illustrations. The correct text is shown the most narrow margin required to adequately in the box on the next page. Make pen and ink excise the lesion (for example, when you use an changes in all copies of CPT in the office. elliptical excision to permit better closure). See the Code 15756, Free muscle or myocutaneous flap illustration on this page of measuring a lesion us- with microvascular anastomosis, has been revised ing an elliptical excision. to clarify that the code should be used to report a skin flap procedure rather than a skin-graft pro- *All specific references to CPT terminology and phraseology are: cedure. The old descriptor contained the language CPT only © 2002 American Medical Association. All rights re- “with or without skin” which was misinterpreted served. as describing skin grafts. 17

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Pediatric procedures A new modifier -63 reflects the additional work of surgical procedures performed on infants weigh- ing less than four kilograms. The modifier may Skin lesions be used on codes 20000-69999 in the surgery sec- tion of CPT except for those procedures that are Check CPT and make the following corrections, done only on small infants. Reimbursement for if necessary, in the captions of the drawings that procedures done only on small infants already re- appear on the first page of the surgery section. flects the increased work associated with the pro- A. Example: excision, malignant lesion of the cedure. back, 1.0 centimeters [sic]. Code 11606. Two codes have been added for minimally inva- sive repair of pectus excavatum (Nuss procedure). B. Example: excision, of benign lesion of the Code 21742 is for a procedure that does not in- neck, 1.0 centimeter by 2.9 centimeters. Code clude a thoracoscopy and 21743 is for a procedure 11423. that does include a thoracoscopy. Finally, an edi- torial change has been made to code 21740, to C. Example: excision, malignant lesion of the clarify that it is the open procedure to repair pec- nose, 0.9 centimeters with skin margins of 0.6 cen- tus excavatum or carinatum. timeters. Code 11642. Pacemaker, related procedures Coding for the insertion and revision of a pace- maker or pacing cardioverter-defibrillator has changed for 2003. Until this year, codes 33216 and attachment to previously placed pacemaker or pac- 33217 were used to report both insertion and re- ing cardioverter-defibrillator pulse generator (in- positioning of pacing electrode(s) 15 days after the cluding revision of pocket, removal, insertion and/ initial insertion. Codes 33216 and 33217 are now or replacement of generator). The second is add- limited to describing insertion of the device(s). on code 33225, Insertion of pacing electrode, car- Two new codes were established to report electrode diac venous system, for left ventricular pacing, at repositioning or replacement any time after the time of insertion of pacing cardioverter-defibrilla- initial insertion. They are code 33215 for reposi- tor or pacemaker pulse generator (including up- tioning of transvenous electrode(s) implanted in grade to dual chamber system). Finally, code 33226, the right atria or right ventricle, and code 33226 Repositioning of previously implanted cardiac for repositioning of cardiac venous system venous system (left ventricular) electrode (includ- electrode(s) implanted in the left ventricle. Code ing removal, insertion and/or replacement of gen- 33226 includes removal, insertion, and/or replace- erator), has been added. ment of a generator. Previous coding guidance was that procedures Vascular surgery in this section included repositioning and replace- A new code, 34900, Endovascular graft replace- ment during the first 14 days after insertion or ment for repair of iliac artery (e.g., aneurysm, reinsertion of a device. That language has been pseudoaneurysm, arteriovenous malformation, deleted from the introductory notes. If a reinser- trauma), makes coding repair of iliac artery an- tion or repositioning procedure does occur within eurysms analogous to aortic aneurysms. Balloon the postoperative period of the initial insertion, angioplasty within the target treatment zone is then the appropriate CPT modifier (such as modi- included in the code and is not separately report- fier -78) should be appended to the procedure code. able. Open femoral or iliac artery exposure, in- Two new codes and related introductory notes troduction of guidewires and catheters, and exten- have been added to report insertion of pacing elec- sive repair of an artery is not included in code trodes for left ventricle pacing. The first is stand- 34900 and may be separately reported. Procedure alone code 33224, Insertion of pacing electrode, car- 34900 is a unilateral code, so for a bilateral proce- 18 diac venous system, for left ventricular pacing, with dure the -50 modifier must be attached. Code

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS riers and endoprostheses used in repairing infrarenal and iliac artery aneurysms. Code 34833 contains the descriptor Open iliac artery exposure Laparoscopic colectomy procedures with creation of conduit for delivery of infrarenal aortic or iliac endovascular prosthesis, by abdomi- 44206 Laparoscopy, surgical; colectomy, par- nal or retroperitoneal incision, unilateral. Note tial, with end colostomy and closure of distal segment (Hartmann type proce- that code 34820, Open iliac artery exposure for dure) delivery of infrarenal aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal inci- 44207 Laparoscopy, surgical; colectomy, par- sion, unilateral is the same as code 34833, except tial, with anastomosis, with coloproc- tostomy (low pelvic anastomosis) it does not include “with creation of conduit.” Be sure you select the correct code. Code 34820 should 44208 Laparoscopy, surgical; colectomy, par- be used if the iliac artery is exposed but a conduit tial, with anastomosis, with coloproc- is not sutured in place, while code 34833 should tostomy (low pelvic anastomosis) with be reported if a conduit is added. Remember that colostomy all of the work of code 34820 is included in code 44210 Laparoscopy, surgical; colectomy, total, 34833, and the two codes should never be reported abdominal, without proctectomy, with simultaneously for work on one iliac artery. ileostomy or ileoproctostomy Code 34834 is new and should be used to report 44211 Laparoscopy, surgical; colectomy, total, open brachial artery exposure when required for abdominal, with proctectomy, with deployment of infrarenal aortic or iliac ileoanal anastomosis, creation of ileal endovascular prosthesis. This code is analogous reservoir (S or J), with loop ileostomy, to the existing and much more commonly reported with or without rectal mucosectomy open femoral artery exposure, code 34812. 44212 Laparoscopy, surgical; colectomy, total, There is a new add-on code, 35572, Harvest of abdominal, with proctectomy, with femoropopliteal vein, one segment, for vascular ileostomy reconstruction procedure (including the aortic, vena caval, coronary, peripheral artery). This code may 44238 Unlisted laparoscopy procedure, intes- tine (except rectum) be used with coronary artery bypass graft (CABG) procedures using venous grafting (codes 33510- 44239 Unlisted laparoscopy procedure, rec- 33523), venous reconstruction (codes 34502 and tum 34520), certain open aneurysm repairs (codes 35001-35002, 35011-35022, 35102-35103, and 35121-35152), vessel repairs using a vein graft (codes 35231-35256), bypass graft with vein (codes 35501-35587), open revision of a lower extremity bypass graft (codes 35879-35881), and excision of 75954 was added for the radiological supervision an infected graft (codes 35901-35907). and interpretation of an endovascular iliac artery Code 37500, Vascular endoscopy, surgical, with aneurysm repair. In addition, some conforming ligation of perforator veins, subfascial (SEPS), was changes were made in existing codes. Code 34812 added and the descriptor for code 37760 was re- was revised by deleting the word “aortic” to allow vised to indicate that it is for the open procedure. use of this code for open exposure of the femoral Code 37501, Unlisted vascular endoscopy proce- artery during endovascular iliac aneurysm. Code dure, was added as well. The introductory notes 34825 was revised to include the placement of an indicate that a vascular endoscopy always includes extension prosthesis during iliac aneurysm repair a diagnostic endoscopy. as well as the infrarenal abdominal aortic aneu- Category III codes have been established for new rysm repair. technology or for services that are not widely ac- One new code was added to describe the creation cepted. Eight codes were added to the Category of a conduit to allow the introduction of large car- III section of CPT for endovascular thoracic aor- 19

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS tic aneurysm (TAA) repair. Five surgical codes ences have been added to the new codes indicating were added for TAA repairs (codes 0033T-0037T) that they should not be used with transendoscopic and three codes were added for the radiological stent placement codes 45345 and 45387 because supervision and interpretation of the procedure predilations are already included in the stent codes. (codes 0038T-0040T). To facilitate proper report- Code 46706 has been added to allow reporting of ing, if a Category III code is available for a proce- anal fistula repair with fibrin glue. dure, it must be used instead of an unlisted Cat- egory I code. Peritoneum and omentum procedures Code 49419, Insertion of intraperitoneal cannula Colon-rectal procedures or catheter, with subcutaneous reservoir, permanent A new series of codes was established to describe (i.e., totally implantable), has been added to describe partial and total laparoscopic colectomy proce- the insertion of a permanent indwelling, totally dures. See the box on page 19 for a complete list- implantable catheter without external access ports. ing of the new codes. Note that the code to report To report device removal, use code 49422. unlisted intestinal laparoscopic procedures, code New code 49904, Omental flap, extra-abdominal 44209, has been deleted and replaced by a new (e.g., for reconstruction of sternal and chest wall code, 44238. Finally, code 44239, Unlisted defects), was added by the plastic surgeons to re- laparoscopy procedure, rectum, has been added for port extra-abdominal reconstruction of sternal and 2003. Cross-references have been added to the cor- chest wall defects using an omental flap. There- responding open colectomy and open unlisted rec- fore, the add-on code 49905, Omental flap, intra- tal procedure codes to guide users to the laparo- abdominal, was editorially revised to describe in- scopic codes. tra-abdominal reconstruction procedures. There is A new add-on code 44701, which describes in- an error in the “Do not report” note that follows traoperative or on-table colonic lavage performed code 49905. The note should read: “(Do not report in conjunction with colectomy procedures, should 49905 in conjunction with 44700).” ⍀ be reported in addition to the appropriate open colectomy procedure code. The authors wish to express their appreciation to Four new codes for sigmoidoscopy and Robert Zwolak, MD, FACS, and John P. Crow, MD, FACS, colonoscopy procedures using directed submucosal for their editorial assistance. injection(s) and balloon dilation of the colon have been introduced this year. Codes 45335, Sigmoi- doscopy, flexible; with directed submucosal injection(s), any substance, and 45381, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance, will allow reporting when a submucosal injection of sub- stances such as India Ink, botulinum toxin, saline, Dr. Preskitt is in and corticosteroid solutions is administered as part private practice in Dallas, TX, and is a of a sigmoidoscopy or colonoscopy, respectively. The member of the College’s fact that the descriptor says “injection(s)” means Board of Regents. that these codes may only be reported once regard- less of the number of injections done. Codes 45340, Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures, and 45386, Colonoscopy, flex- ible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures, will be used to report a sigmoidoscopy or a colonoscopy with balloon di- lation, respectively. Note that codes 45340 and 45386 are only reported once, regardless of the 20 number of strictures that are dilated. Cross-refer-

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS “Whither goest?”: A look at Britain’s National Health Service by Josef E. Fischer, MD, FACS, Boston, MA

he U.S. is a wonderful country, especially that country much more civilized than here. For to those of us whose immigrant experience example, the British still queue up without line- is not that far in the past. The opportuni- crashing, although that is less common than it T ties, the freedom, the ability to participate, used to be. the meritocracy, and the ability to get where one There are some aspects of American culture that needs to go through hard work, perseverance, and are difficult to comprehend, not the least of which a little bit of luck are beyond compare with any is self-hate, which is evidenced periodically by the other nation in the world. I point out to my chil- younger generation or some members of the in- dren, and generally anyone else who will listen, tellectual elite and liberal left. To these individu- what a wonderful opportunity we have to succeed als, it seems everything is better everywhere else, in this country if we will only try. although this attitude is less stylish than it was However, other countries have my admiration before September 11, 2001. as well. Food is better in Paris and, indeed, In the 1980s, we were told that we were headed throughout all of France. It seems very difficult for economic disaster and that Japan was going to get a bad meal there. Although the culinary sta- to overtake us and become the dominant economic tus of the U.S. has improved dramatically with the power in the world. I suppose the same group of training of young, enthusiastic American chefs, people will shortly be telling us that China is about still one must admit that France and Belgium to overtake us as well. Periodically, a malaise outdo us in this area. I happen to like England sweeps through the country, fanned by the aggres- and find, despite the passing of its homogeneity, sive and liberal media. 21

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS One of the most flagrant signs of American self- wooed into joining the NHS with financial and hate is our love for other medical systems that do other benefits. And, to an extent, despite the fact not perform as well as ours. The continued infatu- that the NHS was chronically underfunded, some ation with the Canadian system, despite the whole- investment and the enthusiasm of many of the sale flight of anyone who can afford to come south practitioners held the NHS together reasonably of the border to receive care, is utterly beyond me. well for about 30 years. Long waiting lists, inadequate opportunities to The reason it lasted that long, I believe, is be- treat, continued restrictions on lifesaving technol- cause early recruits to the NHS had been trained ogy, the gutting of premier medical programs and as professionals and continued to practice as pro- institutions, and a florid “brain drain” continue fessionals. It is unlikely that they would change to be a part of the Canadian medical landscape. their modus operandi to that of employees. Also, Although the infatuation with the Canadian sys- up until the late 1970s, the aging system had not tem is less prominent that it used to be, the media, seen the debility of outmoded facilities, lack of in- and to some extent those economic gurus who think vestment in technology, and aging infrastructure they know everything about the medical system, to the extent that one sees now. continue to trash what once was a pretty good con- Toward the middle of the 1960s, the almost uni- struct in the U.S. My question to them is, What versal approval of the NHS among Britain’s pa- border would they cross to obtain their health care? tient population began to change, and signs of dis- At the present time, we can’t go south, although content were emerging. Accident floors began to perhaps with improvement in Mexico, that may close throughout London. In fact, a patient with a one day be possible. head injury at this time may have traveled for an In my view, the most egregious admiration for a hour before getting reasonable care at an accident medical system is for England’s National Health floor. Physicians’ and surgeons’ salaries did not Service (NHS). It is true that the NHS has some keep pace with inflation. Waiting lists began to wonderful qualities. It is totally free, not only for lengthen. My guess is that the emergence of these residents and citizens, but for visitors as well, and indicators of discontent paralleled the appearance it is regionalized. People have their own family within the workforce of physicians who had never physician, and so they are not deprived of their been trained as professionals, but who had been support systems when they are most in need of employees throughout their entire experience in medical care. It is civil and civilized. the medical profession. Nonetheless, I have always said that if one wants There is a difference between a professional and to see where this county is going, then take a look an employee. A professional gets the job done re- at the NHS. The NHS has been suffering from gardless of hours and circumstances. An employee chronic malnutrition. Only 6.8 to 6.9 percent of does his or her job in the time allotted. Some “phy- the gross domestic product of the U.K. has been sician employees,” to be sure, realize they are deal- allocated to the NHS. This starvation diet has fi- ing with human lives and go far beyond the ex- nally wreaked sufficient havoc in the system that pected effort, but others just do their job. Indeed, its problems—continuous undercapitalization, in- given the tax structure in the U.K., a number of ability to improve physical facilities, lack of expan- the physician employees, when offered time-and- sion of facilities, and loss of medical personnel at a-half or double-time to work, for example, over- the same time the population is aging and present- time at accident floors or to keep accident floors ing increased needs—have finally come home to open, simply said that as employees they had no roost. The result is not pretty. obligation to do so, and besides, most of it would be taken by taxes. They would rather be home with History their families or at the local pub with their friends. First, a look back. The NHS, organized in 1948, This particular distinction between profession- was a bold step well ahead of its time. At the time, als and employees has been completely lost on the physicians in the U.K. occupied a position in soci- economists and the self-appointed gurus who con- ety not quite the same as that held by physicians trol what happens to American medicine. They fail 22 in the U.S., but not terribly different. They were to understand that if you treat people as employ-

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ees, even if they may have been trained as profes- 2. The waiting lists are now out of control. Waits sionals, they will no longer act like professionals of a year are common for just about everything in but like employees, and, indeed, if one looks around the U.K. Indeed, the government has finally taken the U.S., there are signs of this shift in attitude steps to make certain that patients get needed op- throughout the health care system. erations. Where? Not within the U.K. The capac- In the mid-1970s, when the last of those indi- ity, the skill, and the facilities simply do not exist. viduals who had entered the NHS as professionals Forty thousand patients will probably go to the retired, England had a physician workforce con- continent for surgery.3 What a disgrace. A country sisting largely of individuals who had always been that holds itself as a second-tier world power can- trained as employees and had always worked as not take care of its own sick, and has to export employees. The cracks began to widen and the in- them to the European Union. Does anyone really frastructure began to come apart. realize what this says about a system that has to- tally failed? Current status 3. Long waits on accident floors. Long waits in Fast-forward 25 years. By this time, the chronic waiting rooms on accident floors now lead to deaths underfunding has become so pervasive that the that seem to be avoidable. The Times of London Blair government has promised £1.5 billion invest- indicates a death that was an accident waiting to ment in infrastructure, technical equipment, and happen in a hospital that everyone viewed as a new facilities. There are those who think that af- “hell-hole” and that was chronically accused of hav- ter the five decades of chronic underfunding, this ing—in addition to horrid physical facilities, urine- is a drop in the bucket and will never restore what stained walls, unbelievable stench in the corridors, was lost. Of greater concern are three themes that and filth throughout—the inability to care for its seem to be surfacing simultaneously and that ap- patients.4 A patient with a relatively minor arm pear to signal a real crisis. The third is a symptom burn lay on a gurney for nine hours and bled out of the first two. from a Cushing’s ulcer. Apparently the question is 1. Lack of physicians. Britain’s economy, after whether he had been seen and monitored during decades of stagnation, is now undergoing a rebirth the period of time on an accident floor. with the advent of opportunities in technology, fi- The nature of having to send patients to a for- nance, and light industry. The traditional smoke- eign country, and even worse, having to rely on stack industries, such as coal, iron, and steel, have foreign countries to furnish physicians, leads to an been driven into the ground by militant union- interesting quandary with respect to the NHS. Will ism, very much as in this country. Automobile interpreters be furnished? manufacturing seems to be undergoing the same The U.K. government now promises a massive steady decline in the U.K. as in the U.S., in which infusion of funds in order to be able to rectify the the share of the U.S. market which American-made situation. However, many, including a former cars now comprise is less than 60 percent for the health minister for a former Labor Party adminis- first time in history.1 But now the U.K. has a short- tration (and therefore not a member of the oppo- age of medical students and physicians. Where sition), believe that no amount of money can res- choices abound, people vote with their feet. The cue the system in its current form. Blair government has now requested 10,000 for- eign physicians to join the NHS. Mind you, these Parallels to U.S. are not physicians at the ordinary level. These are Does this all sound familiar? Perhaps. I assume consultants—the individuals who occupy the high- that no one who is really monitoring the situa- est level in the NHS and who apparently cannot tion for the federal government, including those be drawn from endogenous British medical self-appointed gurus and economists who seem schools.2 The chronic “brain drain,” the lack of to control American medicine, is really con- attractiveness of the NHS, and the persistent in- cerned about a 21 percent drop in medical school ability to pay physicians adequately has finally hit applicants from a high of 46,968 in 1996-1997 home. The parallel with what is happening in the to 37,092 in 2001,5 a year (2001) in which 68 U.S., as I will detail below, is frightening. places in general surgery programs remained 23

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS unfilled, and not only in mediocre training pro- References grams, but now in good training programs as well.6 1. Author, title unknown. The Wall Street Journal, The level of indebtedness of medical students is September 7, 2001. such that many of them, in my humble opinion, 2. Sherman J, Landale J: Ministers’ plea to foreign doctors. Times of London, August 20, 2001, p. 1. will never be able to repay their debt. The 3. Carr-Brown J, Rufford N: Patients win fight for criminalization of medicine and the assumption surgery abroad. Sunday Times of London, August that a physician is a criminal until proven oth- 20, 2001, p. 1. erwise has taken its toll in the standing of the 4. Marsh B, Irwin J: The great hospital trolley scan- dal. Daily Mail, August 23, 2001, p. 1. medical profession. One cannot hope for physi- 5. AAMCA Data Book: Statistical Information Re- cians who are paid less and unable to educate lated to Medical Schools and Teaching Hospitals, their children in the schools they themselves Association of American Medical Colleges, 2001. attended (which is probably the line in the sand) 6. National Residency Matching Program 2001. to urge other people, including their children, to go into medicine. No one wants to get paid less than the neighborhood plumber and at the same time be subject to the barbs and arrows of society. There is a crisis coming in the U.S., a crisis in access. My guess is that it will be here in less than five years, particularly at a time when the number of elderly is increasing and the needs are increasing as well. The gurus do not believe me, but there are lots of other individuals who are not MDs in medical care who do. Indeed, on the coasts, there are increasing numbers of phy- sicians who refuse to see Medicare patients. It’s a shame that this action will be necessary in order to have some redressing of the situation. My guess is that given the way the government responds to things, there will be more draconian laws, penalties, fines, imprisonment, and so on. These efforts will only make the matter worse. Unless and until those societal leaders and politicians who have savaged a pretty good sys- tem come to their senses and look “across the pond,” as the English say, and see what has hap- Dr. Fischer is chair- pened to a once fine medical system, the same man, department of surgery, and will happen here. No amount of criminalization, Mallinckrodt Professor harassment, litigation, and downright threat of Surgery, Beth Israel will rectify this situation unless physicians feel Deaconess Medical better about themselves and their profession. It Center, Boston, MA. He will be interesting to see which way this coun- is a member of the try will turn, but I certainly would not want to College’s Board of bet that sensible reforms, increased payment, Regents and Chair, decreased hassle, tort reform, elimination of Health Policy Steering unfunded mandates such as the Emergency Committee. Medical Treatment and Active Labor Act, and decreased criminalization of medical practice ⍀ 24 will occur. We will then reap the whirlwind.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS In compliance...

...with HIPAA rules by the Division of Advocacy and Health Policy

his month, we’re going to take a break from The technical assistance Web page of the OCR specific Health Insurance Portability and Web site (http://www.hhs.gov/ocr/hipaa/assist.html) TAccountability Act (HIPAA) privacy re- provides links to sample business associate con- quirements to offer some clarification about the tract provisions and answers to frequently asked regulation. We have listed some free resources questions (FAQs) about privacy standards in easy- available from the federal government that may to-understand language. The initial series of ques- be useful in your compliance efforts. tions posted in October 2002 have been included in a document, “OCR Guidance Explaining Sig- Does my office have to comply with HIPAA? nificant Aspects of the Privacy Rule,” which can The College would like to clarify whether all sur- be downloaded from the Web site. In addition to geons’ offices are required to be HIPAA compli- explaining the purpose and history of the refine- ant. You must remember that there are multiple ment of the HIPAA regulations, the OCR guidance parts to the HIPAA rule. All physicians’ offices are will offer some real-life scenarios of the practical required to comply with the standards in the applications of the rules. HIPAA privacy rule. Originally the HIPAA stat- The CMS HIPAA Web page (http://cms.hhs.gov/ ute did not contain any requirement that physi- hipaa/hipaa2/default.asp) provides a database of cians’ offices bill electronically. However, amend- FAQs to help you understand the HIPAA transac- ments to the statute did provide that, with cer- tion provisions. The Web site gives an online test tain exceptions, practices begin to bill Medicare to help determine if you are a covered entity un- electronically by October 16, 2003. The amend- der HIPAA and the first of a series of 10 papers ments specified that small practices, defined as about electronic transactions and code set require- those with fewer than 10 full-time equivalent em- ments written specifically for health care provid- ployees, are exempt. Practices may continue to bill ers. (The subsequent papers will be posted at the other insurers on paper. CMS is still developing same site as they become available). You can also the method by which small providers can obtain a download copies of the Provider HIPAA Readiness waiver from the electronic claims provision for Checklist and the HIPAA Complaint Submission Medicare claims. When that information is avail- Form. able, the College will provide additional back- Although the College will continue to notify Fel- ground for Fellows. lows of additional guidance from the federal gov- ernment on HIPAA issues, your privacy officer Internet resources may want to check both of the HHS Web sites on There are two agencies within the U.S. Depart- a regular basis for new tools to assist with compli- ment of Health and Human Services (HHS) that ance. ⍀ have oversight of HIPAA compliance activities. The Office of Civil Rights (OCR) is responsible for en- ACS guidance on HIPAA issues is based on informa- forcement of issues that are ruled by the privacy tion contained in the “Small Practice Implementation standards. Enforcement of activities that fall Guide,” version 2.0 (http://www.wedi.org/snip/public/ within the transactions and code set standards, as articles/200211012.0final.pdf), © 2002, The Workgroup well as systems security and identifiers standards on Electronic Data Interchange. (when those are published) are the responsibility of the Centers for Medicare & Medicaid Services (CMS). Both agencies are actively developing In- ternet Web sites and useful tools to help practices better understand and comply with HIPAA. 25

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Keeping current

What’s new in ACS Surgery: Principles and Practice

by Erin Michael Kelly, New York, NY

ollowing are highlights of recent additions VI. Special perioperative problems to the online version of ACS Surgery: Prin- 1. Pulmonary insufficiency. Robert H. Bartlett, Fciples and Practice, the practicing surgeon’s MD, FACS, and Preston B. Rich, MD. In their first and only Web-based and continually updated newly updated chapter, Drs. Bartlett and Rich surgical reference. See the box below for a special discuss the care of patients at risk for pulmo- announcement for ACS Fellows, Associates, and nary complications, as well as the clinical pre- Candidates. sentation, prevention, and treatment of pulmo- nary insufficiency. One such pulmonary complication is atelecta- sis. As the authors point out, ventilation with

Keeping current in 2003 with 100 percent O2 before intubation is standard practice, and a fraction of inspired oxygen (FiO ) ACS Surgery: Principles and Practice 2 higher than 90 percent is commonly used dur- ACS Surgery 2003 will be available in Febru- ing operation. However, elimination of inert ni- ary. Save $30 and receive a free three-month trial trogen in the alveoli leads to absorption atelecta- to www.acssurgery.com (a $50 value) by reserv- sis very rapidly. Accordingly, before extubation ing your copy today. For only $199 (regularly $229) it is very helpful to restore normal alveolar ni- you can be among the elite group of surgeons that trogen levels and volume through sustained in- subscribes to the only continually updated sur- spiratory pressure with air. gery textbook, ACS Surgery. Updated monthly online and annually in print, the ACS Surgery Some general measures against atelectasis 2003 volume features 40 percent new and updated that Drs. Bartlett and Rich describe in their information to provide you with the most contem- chapter include oxygen and nutritional support. porary views on best practice and technique. Mini- If supplemental oxygen has been instituted as mize complications, lower expenditures, and in- general support, the amount of oxygen should crease patient satisfaction with this unique ref- be kept as low as possible to avoid displacing erence. Call 1-800/545-0554 today to reserve your nitrogen from alveoli and causing absorption copy, and be sure to request offer number atelectasis. Nutritional support should be insti- S32S8G1C. tuted to achieve a positive nitrogen balance so Prefer online access only? For ACS Fellows, as to maintain respiratory muscle strength and Associates, and Candidates, we are pleased to of- fer a $20 discount on annual subscriptions to the optimize host defenses. To prevent overfeeding, online version of the textbook; you pay only $179, the amount of nutrients given should be based instead of the customary $199 rate. Visit on measured energy expenditure. Overfeeding www.acssurgery.com/learnmore.htm for more in- with carbohydrate causes an excess CO2 load formation and to save $20 now. that may exacerbate pulmonary insufficiency. Free, convenient ACS Surgery updates by e- In the case of pulmonary edema, the authors mail—no subscription necessary. Each month state that adequate treatment of increased lung we’ll bring you a synthesis of the latest contribu- water must include removing excess extravas- tions from the ACS Surgery team of master sur- cular fluid (that is, returning the patient to geons. And we’ll do it for free. Simply visit http:// baseline weight). Diuresis is continued until the www.samed.com/wnis/wnis_sign.htm to register to receive What’s New in ACS Surgery by e-mail. patient is close to dry weight and is maintained in this condition. The major decrease in total 26 extracellular fluid volume is accompanied by a

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS minor decrease in pulmonary extracellular fluid tions. The recommended antibiotic regimen in- volume, but this change is usually enough to cludes both penicillin, 12 to 24 million units/day, improve pulmonary function greatly. Diuretic and clindamycin, 900 to 1,200 mg every six drugs remove water, sodium, and potassium at hours in adult patients. The addition of different rates; thus, all of these must be moni- clindamycin is believed to reduce toxin produc- tored carefully and frequently. Usually, more wa- tion by inhibiting protein synthesis in the rap- ter is removed than electrolytes; as a result, ex- idly multiplying bacteria. Another reason why treme forced diuresis leads to a hypernatremic, clindamycin is useful is that large inocula of hyperosmotic state. Serum sodium concentrations group A streptococci are believed not to express should be monitored closely: when they are be- penicillin-binding proteins. Subscribers may tween 145 and 150 mEq/L, diuresis has reached view the full text of “Blood cultures and infec- its limit. Subscribers may view the full text of tion in the patient with the septic response” at “Pulmonary insufficiency” at www.acssurgery. www.acssurgery.com. com. VI. Special perioperative problems VI. Special perioperative problems 3. Endocrine problems. Robert H. Bartlett, 11. Blood cultures and infection in the patient MD, FACS, and Preston B. Rich, MD. The au- with the septic response. Donald E. Fry, MD, thors describe the approach to preventing and FACS. Dr. Fry examines the relationship be- managing the common endocrine conditions tween the presence of organisms and the occur- that occur as complicating factors in the perio- rence of a systemic inflammatory response, in- perative period. cluding: how to deal with a positive blood cul- A major portion of their chapter deals with dia- ture both in patients with infection and in those betes. For example, they state that the degree of without infection; how to deal with a negative control of diabetes may be assessed by recording blood culture in patients with infection; and blood glucose measurements at frequent intervals what to do in the event of a septic response in during fasting and at other times during the day the absence of microorganisms. His discussion and by determining the percentage of total hemo- section covers sepsis as a nonspecific systemic globin that is combined with carbohydrate (such inflammatory response, the natural history of as glycosylated). Normally, glycosylated hemoglo- the septic response, and new approaches to man- bin (commonly called HbA1c) accounts for 4 per- agement of the septic response. cent to 7 percent of total hemoglobin. HbA1c lev- A positive blood culture in a patient with the els increase when hyperglycemia occurs, and the septic response identifies the putative cause of increases are cumulative over time. The value of the infection. This identification not only per- measuring HbA1c in a preoperative patient known mits institution of appropriate systemic antibi- to have diabetes is that it gives the attending phy- otic therapy, but facilitates assessment of poten- sicians some idea of how well hyperglycemic epi- tial primary sources of the infection because of sodes are being controlled by insulin or oral the established associations between specific hypoglycemics. Monthly measurements yield a anatomic sites and specific microbial isolates. good picture of the adequacy of glucose control

Although it is not always possible to identify the over extended periods. HbA1c percentages higher microorganism or microorganisms responsible than 10 to 20 percent indicate that the hypergly- for the septic response, organization of the dis- cemic aspect of diabetes has been poorly con- cussion according to the proven or suspected trolled. Chronic diabetic complications are re- pathogen that may be recovered in a blood cul- duced when good control of blood glucose is main- ture is a convenient way of addressing treatment tained; patients with diabetes are advised to mea- options. sure their blood glucose levels frequently, which

Therapy requires aggressive local debridement should result in normal HbA1c levels. HbA1c per- of necrotic tissue, systemic antibiotic therapy, centages higher than 15 percent suggest that the and systemic supportive therapy for the shock diabetes is quite brittle and that more frequent and organ failure characteristic of severe infec- monitoring of blood glucose levels and closer con- 27

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS trol of insulin administration are indicated dur- • “Surgical incisions,” by Karen Fogelberg, ing and after operation. As long as the patient is MD, and F. William Blaisdell, MD, FACS. carefully monitored, there is no evidence that high • “Nosocomial infection,” by E. Patchen

levels of HbA1c are associated with any increased Dellinger, MD, FACS. risk of impaired glucose control or complications • “Emergency department evaluation of the after operation. patient with multiple injuries,” by Felix The other important laboratory study in pa- Battistella, MD, FACS. tients with diabetes is measurement of serum crea- • “Multiple organ dysfunction syndrome,” by tinine levels (or, perhaps, creatinine clearance) as John C. Marshall, MD, FACS. ⍀ an indicator of renal function. Renal insufficiency is a common complication of diabetes that may not be recognized during normal preoperative test- ing. Additionally, hypoglycemia can be difficult to detect in critically ill patients. Blood glucose lev- els in these patients are often elevated for any of a number of reasons. Accordingly, it has been common practice to accept blood glucose levels ranging from 150 to 200 mg/dl in these patients. This practice, however, was called into question by a 2001 randomized study of 1,548 ICU pa- tients in which liberal glucose control (blood glucose level, 180 to 200 mg/dl) was compared with tight control (blood glucose level, 80 to 110 mg/dl). ICU survival was significantly better in the tight control group (95.4%) than in the lib- eral control group (92%). In addition, the tight control group had a lower incidence of systemic infection, had less need of antibiotic therapy, required fewer transfusions, and were less sub- ject to hypobilirubinemia. These findings sup- port the view that tight regulation of glucose and insulin to maintain normal blood glucose levels is desirable in critically ill patients. Subscrib- ers may view the full text of “Endocrine prob- lems” at www.acssurgery.com.

Looking ahead New and revised chapters scheduled to appear as online updates to ACS Surgery: Principles and Practice in the coming months include the follow- ing: • “Ultrasonography: Surgical applications,” by Grace S. Rozycki, MD, FACS. • “Perioperative considerations for anesthe- sia,” by Steven B. Backman, MDCM, PhD, FRCP(C); Richard M. Bondy, MDCM, FRCP(C); Alain Deschamps, MD, PhD, FRCP(C); Anne Moore, MD, FRCP(C); and Thomas Schricker, MD, Mr. Kelly is editor, What’s New in ACS Surgery: Prin- 28 PhD. ciples and Practice, WebMD Reference, New York, NY.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Socioeconomic tips of the month

Late career changes require new practice plan by the Division of Advocacy and Health Policy

fter a successful surgical career, many Fel- lows plan to enjoy a comfortable retirement Around the corner A with time to travel, enjoy their families, and pursue long-delayed hobbies. In the late 1990s, the February prospects of having the financial security to pur- • Medicare reminder: The enrollment period sue these retirement activities looked rosy because for Medicare participation ends February 28, 2003. stock market investments were paying off well. The decision that you make about participation But that bubble has burst because of the economic in the Medicare program will be irrevocable for downturn, and now many physicians who had 2003. If you change your participation option, you looked forward to not just a financially secure re- should immediately start to prepare claims un- tirement, but even the possibility of early retire- der your new option. ment, had to go back and reevaluate those plans. Claims for services provided in January and February should be submitted as quickly as pos- At the recent ACS Clinical Congress in San sible to ensure reimbursement at the 2002 pay- Francisco, the Division of Advocacy and Health ment level. Policy sponsored complimentary practice manage- ment consultations to assist ACS Fellows in a va- March riety of related areas. It was surprising that so • The implementation period for the 2003 many surgeons near retirement were telling the CPT and HCPCS codes ends March 31, 2003. same story. Of course, it was not surprising that • ACS-sponsored basic and advanced coding the markets of the last two years had devastated workshops for surgeons in Los Angeles, CA, on portfolios and required investment changes. What March 27-28. Visit the ACS coding workshop Web was noteworthy were the unexpected challenges page at http://www.facs.org/dept/hpa/workshops/ cdwkshop.html to register. facing surgeons who had focused on retirement • ACS-sponsored practice management and who now find they must retrace their steps. course for surgeons on March 15 in Phoenix, AZ. Several surgeons said that they had already be- Visit the ACS Web page at http://www.facs.org/ gun slowing down their practices, putting continu- dept/hpa/workshops/pmworkshop.html to register. ing medical education priorities on a back burner, and developing exit strategies from their practices. April In some cases, group practices had already started • Quarterly update to 2002 correct coding ed- to recruit new surgeons in preparation for the se- its become effective April 1. nior surgeon’s departure. In other cases, surgeons • ACS Postgraduate Courses on advanced had ceased cultivating new referring sources or surgical coding and practice management will be presented during the ACS Spring Meeting in New even maintaining their traditional referral net- York, NY. Course descriptions and online regis- work. Some surgeons even asked referring prac- tration can be found at http://www.facs.org/ tices to send their patients elsewhere. Contracts 2003springmeeting/reginfo/reginfo.html. with third-party payors were dropped as the sur- geon slowed down. By virtue of age and tenure, some surgeons had been relieved of community call responsibilities and even group call responsibili- Some surgeons now say that they need to refo- ties. The picture painted was of a surgeon who was cus on their financial security and continue work- minimizing his or her practice in a planned and ing to rebuild their portfolios to ensure a secure deliberate way...and their community knew it. retirement. So, how do they undo the damage and 29

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS rebuild a practice? Following are some suggestions dreary office into an inviting space that indicates that may help surgeons who find themselves in you are not leaving anytime soon. this predicament. 7. Surgeons in group practice should be realis- 1. Get some professional help with your port- tic and honest with their colleagues about their folio. If the value of the portfolio dropped signifi- plans. More often than not, they can and will help, cantly, it was probably not well balanced in the but they need to know your expectations. first place. Put the assets into safe and prudent 8. Finally, work on your mental and physical investments with some professional guidance. De- fitness. Exercise, eat properly, dress professionally, termine where you are financially and where you pay attention to grooming, and have a strong, posi- need to be. Decide how much money to save over tive mental outlook. People who are upbeat about a defined period of time to reach your financial their situation find others respond in kind. ⍀ goal. Looking at the formula from a different angle, find out how long you have to continue This month’s column was prepared by Tom working if a specific amount of money is invested Loughrey, chief executive officer of Economedix, a na- each month. In either case, determine a time frame tional practice management consulting and education for how long to continue in practice. company with offices in Pittsburgh, PA, and southern 2. Keep clinical skills up to expected standards. California. Mr. Loughrey can be reached at tel. 714/ Some referring sources may assume that a sur- 633-2251, or via e-mail at [email protected]. geon who has been intent on retiring may have let his or her skills and knowledge decline. Ask This column helps answer questions from Fellows yourself the tough questions about your skills. If and their staffs and provides useful tips for surgical the state of the art is endoscopy, and you did not practices. Developed by the College staff and consult- bother to attend those courses to learn the proce- ants, this information will be accessible on our Web dures, you may need to do some retraining. If you site. If you would like to see specific topics addressed in future columns, please contact the Division of Ad- do engage in continuing education, inform refer- vocacy and Health Policy by fax at 202/337-4271, or e- ring physicians. mail [email protected]. 3. Get back in the call schedule. This is prob- ably the toughest thing to do. Call is one element of a surgeon’s practice that almost everyone looks forward to ending, but it is the way many surgeons develop a practice from the very beginning. It may be necessary to go back to what worked from the start. 4. Be available. Often referrals go to the sur- geon who can take care of the patient the soonest. Schedule new patient referrals quickly and be available in the office for at least a portion of each workday. Make a priority of getting the new pa- tient into your office within two days. 5. Critically evaluate work habits. Build on the positive ones and strive to eliminate or reduce the negative habits. For example, a surgeon who is habitually behind schedule should evaluate why and make an effort to get back on it. 6. How do the office and the staff appear? In some instances, when people prepare to retire, their offices’ appearance suffers. Do a walk- through of the office and make a list of those things that need to be cleaned, repaired, or replaced. A 30 little paint and some modest attention can turn a

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

College establishes education task forces

The American College of Sur- geons’ Division of Education has established four special task forces to address the competen- cies of interpersonal and com- munication skills, systems-based practice, practice-based learning and improvement, and profes- sionalism. These competencies have been adopted by the Ac- creditation Council for Graduate Medical Education and the American Board of Medical Spe- cialties. The task forces will ad- The Education Task Force on Interpersonal and Communication Skills. Front row, left to right: Linn Meyer; Carol Scott-Conner, MD, PhD, FACS; dress the spectrum of educa- Thomas R. Russell, MD, FACS; Dr. Anderson; and Thomas R. Gadacz, MD, tional items relating to the afore- FACS. mentioned competencies within Back row: Patrice G. Blair, MPH; Steven C. Stain, MD, FACS; Barbara K. the context of both residency Temeck, MD, FACS; Dr. Kodner; Thomas F. Dodson, MD, FACS; Alasdair training and maintenance of cer- K. T. Conn, MD, FACS; Dr. Britt (Chair); Richard E. Welling, MD, FACS; tification. Educational models John J. Coleman III, MD, FACS; Richard K. Spence, MD, FACS; Linda K. will be developed to serve the Stewart; Dr. Sachdeva; Rosemary Morrison; and Cherylnn Sherman. needs of learners across the vari- ous surgical specialties. The Education Task Force on Interpersonal and Communica- tion Skills met at the College’s headquarters in Chicago, IL, November 24-25, 2002 (see photo, above right). The task force was chaired by L.D. Britt, MD, MPH, FACS. Small groups addressed interpersonal and communication skills as they relate to interactions between various professionals in the dif- ferent surgical environments The Education Task Force on Systems-Based Practice. Front row, left to and interpersonal and commu- right: Dr. Healy (Chair); Jeffrey B. Cooper, PhD; Dr. Russell; Matina Horner, nication skills as they relate to PhD; and Mary H. McGrath, MD, MPH, FACS. interactions with patients and Back row: Ms. Blair; J. Donald Monan, SJ; Josef E. Fischer, MD, FACS; their families in the different James P. Bagian, MD; Maurice J. Webb, MD, FACS; Richard J. Gusberg, surgical environments. The MD, FACS; David W. Roberson, MD; Dr. Gaba; Dr. Sachdeva; Dr. Steele; Dr. Gordon; Ms. Stewart; Ms. Sherman; and Ms. Morrison. groups were led by Kathryn D. Not pictured: Julie A. Freischlag, MD, FACS; Thomas M. Krummel, MD, Anderson, MD, FACS, and Ira J. FACS; J. Patrick O’Leary, MD, FACS; and Carlos A. Pellegrini, MD, FACS. Kodner, MD, FACS, respectively. 31

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The Education Task Force on patient safety, simulations and The productive discussions Systems-Based Practice met at simulators, and new technology. during the meetings of both task the College’s headquarters De- A third small group addressed forces yielded a large number of cember 8-9, 2002 (see bottom innovative educational ap- major recommendations, which photo, p. 31). The task force was proaches and redesign of surgi- will serve as the foundation for chaired by Gerald B. Healy, MD, cal conferences, and specifically the next steps. FACS. During the meeting, a focused on the morbidity and For further information on the small group addressed health mortality conference. These competencies task forces, please care systems, optimum resource groups were led by Glenn D. contact Ajit K. Sachdeva, MD, utilization, patient advocacy, Steele, Jr., MD, FACS; David M. FACS, FRCSC, Director, Division and interprofessional teamwork. Gaba, MD; and Leo A. Gordon, of Education, at 312/ 202-5405 or A second small group addressed MD, FACS, respectively. via e-mail at [email protected].

2003 ANZ Travelling Fellow selected

Christopher R. Forrest, MD, of Surgeons in Brisbane, Aus- FRCSC, FACS, medical director tralia, May 5-9, 2003. He will of the Craniofacial Program of attend the ANZ Chapter meet- the Hospital for Sick Children, ing during that congress, and Toronto, ON, has been selected as will then travel to several sur- the 2003 Travelling Fellow of the gical centres in Australia and Australia and New Zealand New Zealand. (ANZ) Chapter of the American Requirements for the 2004 College of Surgeons. Travelling Fellowship ap- As the Travelling Fellow, Dr. peared in the January 2003 Forrest will participate in the Bulletin. They are also posted annual Scientific Congress of on the College’s Web site, the Royal Australasian College www.facs.org. Dr. Forrest

2003 International Guest Scholars selected

Eight International Guest institutions of their choice in Kuo, MD, Kaohsiung, Taiwan; Scholarships for 2003 were North America. The program is Marie Carmela M. Lapitan, awarded by the Board of Re- administered by the College’s MD, FPCS, Manila, Philip- gents during the 88th annual International Relations Com- pines, Maria A. Matamoros, Clinical Congress in San Fran- mittee. MD, San Jose, Costa Rica; and cisco, CA. The 2003 International Guest Hans Rahr, MD, Odense, Den- The scholarship program en- Scholars are: Emmanuel A. mark (Abdol Islami Scholar). ables talented young academic Ameh, MBBS, Zaria, Nigeria; The requirements for appli- surgeons from countries other Felipe A. Catan, MD, San- cants for the 2004 International than the U.S. or Canada to at- tiago, Chile; S.V. Suryanara- Guest Scholarships appeared in tend and participate in the ac- yana Deo, MBBS, New Delhi, the January Bulletin. They can tivities of the Clinical Con- India; Arnulfo F. Fernandez, also be viewed on the College’s 32 gress, then to tour surgical MD, Havana, Cuba; Yur-Ren Web site at www.facs.org.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS CREATE YOUR OWN ID/PASSWORD for “Members Only” area of ACS Web site

Can’t think of your ACS ID number when you want to visit the “Members Only” side of the College’s Web site? Your days of frustration are now over.

The College has updated the Members Only section to allow you to set your own user ID and password to access its many features. To make that change, go to the College’s home page at http://www.facs.org and click on the “Members Only” link at the top of the page.

You will still need your ACS ID when you log in for the first time. You can then enter your user ID, password, and security questions. If you forget your password the next time you visit the page, you can recover your password online by answering your previously set up security questions.

While you are in the “Members Only” area, please check to be sure that your mailing address, telephone numbers, and e-mail address are both current and accurate. Be assured that the College does not provide your e-mail address to outside entities. E-mail addresses are used only for College communications. 33

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College focuses on critical issues at AMA meeting

by Jon H. Sutton, State Affairs Associate, Division of Advocacy and Health Policy

The College succeeded in pass- (CMS) to adjust the Medicare fee strong prompt payment laws to ing all three of the resolutions schedule methodology to ensure avoid preemption by the Em- it sponsored during the 2002 In- that actual liability costs and ployee Retirement Income Secu- terim Meeting of the American increases in those costs are re- rity Act; and efforts at the state Medical Association House of flected in physician payments. level to prohibit smoking in Delegates (AMA HOD), which The resolution also asks CMS to public places and businesses. took place December 7-11 in use more current data to assess New Orleans, LA. As directed by the impact of professional liabil- Surgical caucus a previous action of the HOD, ity premiums on the resource The surgical caucus of the this meeting focused on issues costs involved in providing phy- AMA met during the HOD and related to legislative and regu- sician services. focused on improved collabora- latory advocacy. The result was tion in advocacy. LaMar S. a streamlined and more efficient Quality McGinnis, Jr., MD, FACS, ACS agenda for the HOD. Finally, the College took a Delegation Chair, highlighted leadership role in encouraging the cooperative efforts that the Office-based surgery the house of medicine to become College is undertaking with Probably the most controver- more heavily involved in the de- other surgical specialty societies sial proposal from the College velopment of evidence-based and the AMA. In addition, he called for the AMA and the ACS quality measures. The College’s showcased the new Surgery to convene a workgroup of in- last resolution calls on the AMA State Legislative Action Center terested specialty societies and to “advocate for wider support (SSLAC)—an Internet advocacy state medical societies, which and funding for adequate collec- tool that the College and 11 would use a consensus approach tion of clinical data needed for other surgical specialty societies to develop uniform require- the development of quality stan- are now using for state-level ad- ments for office-based surgery. dards.” In addition, it urges the vocacy (www.facs.org/sslac). As The end result of this AMA-coordinated Physician a result of Dr. McGinnis’s pre- workgroup’s activity would be Consortium for Performance sentation, College staff have model legislation that physi- Improvement “to move ahead in been approached by three addi- cians could propose at the state a proactive and highly visible tional surgical specialty societ- level. manner to address quality and ies that want to support the safety concerns.” SSLAC. Liability and reimbursement In addition to Dr. McGinnis’s The second College-sponsored Other issues leadership, the College also ben- resolution addressed medical li- In other matters, the AMA efitted during the HOD meeting ability reform and reimburse- HOD adopted a number of other from the input and expertise of ment—two issues that are resolutions on issues of interest its other delegation members: weighing heavily on delegates to surgeons, including support Drs. Charles Logan, Richard from all regions of the country. for: continued graduate medical Reiling, Tom Whalen, and The resolution, which was education funding by Medicaid; Amilu Rothhammer (all Fellows unanimously affirmed by the an immediate update by CMS of of the College). Chad Rubin, HOD, calls on the Centers for the ambulatory surgery center MD, FACS, also continued his ef- 34 Medicare & Medicaid Services list of covered procedures; fective service as the College’s

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS representative to the AMA AMA HOD activities, please Chicago Office, tel. 312/202- Young Physicians Section. contact Jon Sutton, State Af- 5358, fax 312/202-5031, or e- For further information about fairs Associate, in the College’s mail [email protected].

Clowes research award given

The George H.A. Clowes, Jr., The purpose of the Clowes MD, FACS, Memorial Research Award is to provide support for Career Development Award for promising young surgical in- 2003 was granted to Bhuvanesh vestigators. The award is spon- Singh, MD, FACS, assistant at- sored by The Clowes Fund, tending, Memorial Sloan- Inc., of Indianapolis, IN, in the Kettering Cancer Center, New amount of $40,000 for each of York, NY, and assistant profes- five years, beginning July 1, sor of surgery, Weill Medical Col- 2003. lege, Cornell University, Ithaca, Information regarding the NY, for his research project en- Clowes Award and the other titled “Functional characteriza- scholarships, fellowships, and tion of the novel oncogene awards offered by the College SCRO (squamous cell carci- appear on the ACS Web site, Dr. Singh noma related oncogene).” www.facs.org.

Coding workshops The American College of Surgeons will sponsor a series of basic and advanced CPT and ICD-9-CM coding workshops during 2003. Foundations in CPT and ICD-9-CM Coding and Mastering Surgical and Office-Based Coding will be offered back-to-back in five locations. These one-day workshops are designed for all surgeons and their staffs and will be presented by representatives of KarenZupko and Associates.

Level Date City Level Date City Basic March 27, 2003 Los Angeles, CA Basic July 17, 2003 Boston, MA Advanced March 28, 2003 Los Angeles, CA Advanced July 18, 2003 Boston, MA Basic May 29, 2003 Atlanta, GA Basic September 18, 2003 St. Louis, MO Advanced May 30, 2003 Atlanta, GA Advanced September 19, 2003 St. Louis, MO

The American College of Surgeons designates each coding workshop for up to a maximum of seven hours in Category 1 credit towards the Physician’s Recognition Award of the American Medical Association. Visit the ACS Web site for more information about the workshops, locations, and online registration at http://www.facs.org/dept/hpa/workshops/cdwkshop.html. ACS coding workshops will also be offered as postgraduate courses during the College’s 2003 Spring Meeting and Clinical Congress, so watch your mail for them in the coming weeks and months.

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FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 36

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Practice management course to be featured at Spring Meeting

A didactic postgraduate course entitled Charting a Sound Course for Surgical Practices: A Course in Practice Management for Surgeons by Surgeons will be featured at this year’s annual Spring Meeting in New York, NY. ACS Regent Charles D. Mabry, MD, FACS, Pine Bluff, AR, and Frank G. Opelka, MD, FACS, Boston, MA, will serve as co-chairs and instructors. The sessions will take place Monday, April 14, 8:00-11:30 am (Session I) , and 12:30-4:30 pm (Session II). The fee for the postgraduate course is $450. The program will address improvements in management Dr. Mabry Dr. Opelka and efficiencies of surgical practice operations. It will in- volve discussion of business practices and overall compo- nents of operations. The in- • Organizing Your Office • Benchmarking. structors will provide insights for Optimal Efficiency. Breakout sessions for small to solve real-life practice man- • Financial Reports and In- surgical practices will consider agement problems. surance Claim Processing. managing personnel, fees/insur- Scheduled topics include: • Corporate Compliance. ance/collections, compliance and HIPAA issues, and practical computer systems. Breakout ses- sions for large surgical practices will consider financial manage- Additional course opportunities ment for large/academic prac- tices, fee/insurance/collections, Charting a Sound Course for Further information regard- activity-based costing, and other Surgical Practices: A Course in ing these courses may be ob- issues for large practices. Practice Management for Sur- tained from Irene Dworakowski, Further information and a geons by Surgeons will also be ACS Washington Office, 1640 registration form appeared in offered in 2003 as follows: Wisconsin Ave., Washington, DC the January Bulletin, and is March 15—Phoenix, AR, May 2007, tel. 202/672-1507, e-mail currently available on the 31—Atlanta, GA, August 23— [email protected]. College’s Web site, www.facs. St. Louis, MO. org/dept/hpa/workshops/ pmworkshop.html. 37

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Offered by the American College of Surgeons Division of Education

In an effort to meet the growing and ever-changing needs of our Fellows and a diverse surgical community, the Division of Education is offering seven online general sessions from the Clinical Congress. These sessions are offered in the form of a Web cast at www.facs-ed.org

Each session is offered separately and contains written transcripts, audiovisual displays, a post-test, an evaluation, and, upon successful completion of each session, an online Announcing... printable CME certificate.

Available courses: GS 08: New Technology: What’s Proven, What’s Not CME GS 10: Patient Safety GS 21: Damage Control in Trauma and Emergency Surgery: New Applications GS 23: Programa Hispanico online GS 33: The Ethics of Just Entrepreneurialism added! Web casts of general sessions in Surgery GS 34: Should Axillary Dissection from the Clinical Congress Be Abandoned? GS 40: Management of Metastatic NOW ONLINE Disease of the Liver

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Randolph Fellowship in Pediatric Surgery established

The Children’s National Medical Center, Washington, DC, recently established the Dr. Judson G. Randolph Fel- lowship in Pediatric Surgery, honoring the founder of its nationally renowned pediatric surgery training program. In November of last year, the Joseph E. Robert, Jr., Center for Surgical Care at the center welcomed Judson G. Randolph, MD, FACS, current surgical staff, and alumni for a recep- tion and grand rounds lecture delivered by LaSalle D. Leffall, Jr., MD, FACS, professor of surgery at Howard University College of Medicine, Washing- ton, DC. Joined by many of the 30 pediatric surgeons he trained during his 28-year ca- reer at Children’s, Dr. Randolph named Christopher Dr. Randolph (left) and Dr. Coppola. P. Coppola, MD, FACS, the first recipient of this endowed fel- lowship, which aims to provide superior education to emerg- ing leaders in pediatric sur- gery. Children’s National Medical ric Surgery Fellowship Training “The endowment of this fel- Center raised more than $1 Program and went on to men- lowship ensures that Dr. million to establish the tor over 30 pediatric surgeons, Randolph’s legacy will con- hospital’s first Pediatric Sur- many of whom became chairs tinue here at Children’s for gery Fellowship Endowment. and training directors at other generations to come,” said All funds will be directed to- children’s hospitals. “It has al- Kurt Newman, MD, FACS, as- ward enhancing the hospital’s ways been my belief that a good sociate chief of surgery, who already well-established surgi- pupil will always outshine his trained under Dr. Randolph cal training program. teacher,” Dr. Randolph said. from 1984 to 1986. “Dr. In 1963, Dr. Randolph began “The success of this training Coppola and future Randolph his career at Children’s as the program relies on Children’s fellows will benefit from his first pediatric surgeon dedicated ability to offer superior educa- outstanding leadership and solely to the care of children in tional opportunities to the commitment to children’s Washington, DC. The following country’s finest young sur- health care,” he said. year he established the Pediat- geons.” 39

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Coppola, the 2002 recipi- ent of the fellowship, began his surgical training at Children’s in 2001 after completing a gen- eral surgery residency at Yale University School of Medicine, New Haven, CT. He received his MD degree from Johns Hopkins University School of Medicine, Baltimore, MD, and his undergraduate degree from Brown University, Providence, RI. A native of Washington, DC, Dr. Coppola is a Major in the U.S. Air Force and has lent his medical expertise to volun- teer projects in the U.S. and abroad. Dr. Randolph’s commitment to health care and education was reflected in the selection of Dr. Leffall as the featured lec- turer. Dr. Leffall has served as Dr. Newman (left), Dr. Randolph, and Dr.Leffall. a member of Howard Univer- sity College of Medicine’s fac- ulty for over 40 years and has taught over 4,500 medical stu- dents and trained nearly 250 the chairman of the President’s Practice,” addressed “end of general surgery residents. He Cancer Panel by President life” discussions, clinical trials, is a Past-President of the Col- George W. Bush. Dr. Leffall’s and alternative therapeutic lege and was recently named lecture, “Ethics in Surgical measures.

Trauma meetings calendar

The following continuing Las Vegas, NV. tion can be viewed online (as medical education courses in • Trauma and Critical it becomes available) through trauma are scheduled. Care 2003—Point/Counter- the American College of Sur- The courses are sponsored by point XXII, June 2-4, 2003, At- geons Web site at http:// the American College of Sur- lantic City, NJ. www.facs.org/dept/trauma/ geons Committee on Trauma • Advances in Trauma, cme/traumtgs.html or by con- and Regional Committees. December 12-13, 2003, Kansas tacting the Trauma Office at • Trauma and Critical City, MO. 312/202-5342. 40 Care 2003, March 24-26, 2003, Complete course informa-

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 41

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The following comments were tool for the job exists in the thou- pital services. As a result, many received in the mail or via e-mail sands of tort reform legislative ini- states have entered an era wherein regarding recent articles published tiatives that have been proposed the tort system is causing far more in the Bulletin and the “From my nationwide over the past quarter- harm than benefits. The net effect perspective” columns written by century. The net effect of these ef- is to increasingly deny citizens ac- Executive Director Thomas R. Rus- forts is a fragmented system that cess to quality health care. While sell, MD, FACS. is increasingly dysfunctional and exorbitant insurance premiums are displays characteristics of a nega- not the root cause of the problem, Tort reform tively reinforcing process that is some form of immediate symptom The growing medical malpractice driven further from effective re- relief is needed in many jurisdic- crises across our nation are the re- structuring with each new wave of tions. Out-of-control premium as- sult of a tort system that encour- state tort reform efforts. Quality sessments portend a meltdown in ages and rewards behaviors that management theorists recognize health care delivery across wide ar- are detrimental to the delivery of this as tinkering and the predict- eas of our nation. quality health care to patients. able result is increasing dysfunc- In the larger view, if we are to Characterized by inconsistency, tion. Systems analysts recognize preserve and enhance what is good unpredictability, and exorbitant this as a failed paradigm that does about the health care professions costs, the medical malpractice sub- not take into consideration second- in service to our nation, it will be field of the law of torts has shown ary effects and externalities. necessary to look beyond treating itself to be ill-suited as a legal rem- Persons who are familiar with the symptoms of a system that has edy either for compensating indi- medical malpractice cases under- run amok. The current tort system, viduals who have sustained injury stand that such cases are fre- as it applies to medicine, serves as at the hands of medical providers quently won or lost due to the per- a money magnet that attracts or for deterring further similar suasiveness of the respective attor- people from diverse groups who harm to others. Tort law is a legal neys and not because of the actual parlay positions of regulatory, legal, tool that is mismatched to these merits of the case. This situation and medical advantage into finan- tasks. benefits neither the public nor the cial gain and outright cash awards. Tort is like a carpenter’s hammer health care system. More often Placing blame on individuals or in the hand of an optician. Its use than not, it does not even benefit groups misses the more fundamen- can do little to correct a loose lens the plaintiff. The search for truth tal truth that it is the tort system by tightening a hinge screw on a in these cases is often lost in a itself that is at fault. Individuals pair of glasses. Regardless of the flurry of zealous advocacy. Truth, and groups operating within and modifications made to the hammer, as generally understood, is neither gaming the system are simply clearer vision will not result unless the goal nor the driving motivation availing themselves of golden op- the hammer is placed aside and in the litigation process. The ava- portunities provided by a flawed more appropriate tools are em- ricious pursuit of inordinate shares system at the expense of the com- ployed. Stubborn insistence on us- of the monies intended for the com- mon good. A tragedy is playing out ing the hammer, even after innu- pensation of patients who have sus- that will increasingly place the merable modifications, will only re- tained genuine maloccurrences has public’s health in jeopardy. sult in further visual distortion. escalated to the point where we are The problems that we are en- That the evolving hammer of tort experiencing a profound decline in countering were both predictable has been with us for over a century the ability of physicians and hospi- and predicted by physicians and is no excuse for perpetuating the tals to deliver quality health care physician groups decades ago. application of a system that is fail- to our citizens. This result has been While most jurisdictions largely ig- ing and threatens to bring down a underwritten by what amounts to nored these warnings, a few states large sector of our service economy legalized extortion of unreasonable managed to forestall the onslaught as it flounders. and burgeoning liability premiums of the tort juggernaut through leg- Recent studies cited in public ads from health care providers to fuel islative initiatives designed to dis- by attorneys suggest that the num- a failed tort system. courage abuse of tort. The major- ber of injuries among hospitalized Like a dangerously high fever, ity of states failed to successfully patients is alarming. These find- which is a symptom of an underly- address even the symptoms, let ings coincided with remarkable in- ing illness, unreasonable and sky- alone the root causes, of the prob- creases in the tort burdens imposed rocketing liability premiums have lems. Most fundamentally, as a na- on health care providers. Further surpassed the point of peril for tion we will not be able to reverse 42 evidence that tort law is the wrong many physician practices and hos- the vortex of adversarial legalism

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS that holds our health care system Medical Society and chapters of the Medical education/mentors hostage until we come to grips with ACS—that will change the situa- I am now and have been for the the fact that the tort system itself, tion. past four years assisting in the as it applies to medicine, is the As a member of the house of del- gross anatomy lab at UCLA School problem. There must be a willing- egates of the Medical Society of the of Medicine. Prior to my retirement ness to recognize that there are State of New York, I am submitting in 2000, I had been at Kaiser more just, less costly, and a resolution recommending a Permanente in Panorama City, CA, nonadversarial ways of compensat- week of mandatory medical edu- for 40 years, chief for 17 years, and, ing individuals and families who cation for New York physicians; in those years, residents from the have sustained maloccurrences in during that week their only pro- surgical service at UCLA rotated the health care field. Additionally, fessional obligations will be learn- through our department (and still there are more just, less costly, and ing about the latest medical ad- do) at both the junior and senior more effective means of preventing vances and about how to avoid levels. harms that occur in the health care malpractice liability claims. Dur- It is clear to me that we all have arena. Ultimately, it is the public ing that week, the people of New an obligation to participate in who stands to gain the most York—except for those with truly teaching medical students and resi- through symptom relief and sys- emergent medical conditions— dents. Were it not for volunteer tem supplantation. will have to learn to do without surgeons, most programs would Dan F. Kopen, MD, FACS medical care, or to see their leg- suffer greatly. Someone did it for islators for changes that will re- us; we should give back. There is little question that sult in the ability of physicians to I truly think that every medical medical liability costs and the lack practice medicine without the school would greatly appreciate of meaningful tort reform are very threat of groundless suit or of ex- and benefit from having surgeons important issues to practicing phy- orbitant insurance premiums. participate in teaching history and sicians and surgeons in this coun- It is time that our crisis becomes physical examination sessions for try. As past-president of the everyone’s crisis. Then, and only students, now almost exclusively Westchester County, NY, Medical then, will we see meaningful tort populated by internists and family Society, I have participated in nu- reform. practitioners. This is another point merous meetings with legislators Peter S. Liebert, MD, FACS early in the careers of medical stu- and public demonstrations about dents when they can be influenced these issues. Nothing has been ac- Optimal patient care to consider the surgical specialties. complished in New York State, be- I agree fully with Dr. Russell’s How to accomplish this will vary cause the Democratic speaker of comments in the Bulletin (October from one community to the other. the state assembly has vowed that 2002) regarding professionalism I don’t know if the College would there will be tort reform only “over and was glad to see him close his consider approaching the medical my dead body.” remarks with emphasis on “opti- school administrations nationwide The impetus for tort reform mal patient care.” We need to about this, to jointly recruit sur- must come from the general pub- stress in all our communications geons for this purpose. lic. They need to know that there with the public and politicians that Of course, many of us have been is a crisis in health care that will the American College of Surgeons asked to participate in science fairs immediately affect them—a lack of was founded primarily to improve in high schools, but how many of physicians and surgeons willing to the quality of surgical care and that us have done so? give them care because of the is our continued concern. It’s a Richard A. Braun, MD, FACS abuses and costs of the current tort message we need to repeat over and system. over. The American Medical Asso- Resident hours As you know, the people of Penn- ciation has never recovered its I read with great interest your sylvania are now being subjected to prestige because in the debate over article on house staff hours (No- the loss of physicians’ services in Medicare their stance became too vember 2002). As an intern and offices, clinics, hospitals, and emer- closely identified with doctors’ eco- resident at Bellevue Hospital be- gency departments. Doctors who nomic interests. It must be clear fore and after my time in service, I cannot obtain or cannot afford li- that our actions are sincerely heartily concur with your conclu- ability insurance are no longer of- driven as advocates for quality sur- sions. fering care. It is the crisis of no gical care—not our own pocket- As an intern, I had to have the available health care—not the con- books. history and physical on the chart certed efforts of the Pennsylvania Stuart A. George, MD, FACS along with a CBC and urine by 8:00 43

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS am. This is to say nothing about the fore the state legislature. Those The first patient died, but the other routine daily urines on diabetics. I people felt that, after medical two did very well. For all I know, it worked on average over 90 hours a school, they deserved a life of ease. may have been the cardiac surgeon, week, but much of that time I was An example of the ability to carry Sir Magdi Yacoub, FRS, FRCS(Eng, able to rest adequately. on after stress is the Egyptian Ed, Glas), FACS(Hon), who was At no time was I confused or hal- heart doctor who worked in Lon- honored in the November 2002 is- lucinating as so many New York don and decided to return to Cairo sue of the Bulletin. Obviously, this house staff complained to the leg- to donate his services to the land particular surgeon was not and did islature. The New York laws are all of his birth. He performed three not appear to be harmed by his long wet, and have been influenced by procedures, starting at 7:00 am and hours. the house staffs that testified be- finishing at 3:00 am the next day. John S. Hooley, MD, FACS ○○○○○○○○○○○○○○○○○○○○○○

PG 15: Endocrine Surgery

PG 16: Diseases of the Liver, Biliary Tract, and Pancreas

PG 17: Vascular Surgery: Technical Tips That Enhance Surgical and Endovascular Outcomes

PG 18: Thoracic Surgery

PG 19: Gastrointestinal Disease

Fourteen Big Courses PG 20: Minimal Access Surgery That Fit In Your Pocket PG 21: Essential Technical Elements in Trauma They fit not only in your pocket, but into your busy schedule as PG 22: Cardiac Surgery well. You can take the 2002 Syllabi Select courses wherever you PG 24: Colon and Rectal Surgery

have access to a computer...at home, at work, or even on the road. ○○○○○○○○○○○○ PG 26: Surgical Infection and Antibiotics Syllabi Select is a CD-ROM containing 14 postgraduate course PG 27: Breast Disease syllabi from the 2002 Clinical Congress. These syllabi—selected PG 28: Plastic Surgery: Management of and packaged for your convenience—can be purchased by calling Devastating Defects of the Abdomen 312/202-5474 or through the College’s Web site at and Perineum http://secure.telusys.net/commerce/current.html PG 29: Pediatric Surgery: Esophageal Disorders and Anomalies in Infancy and Childhood The 2002 Syllabi Select CD-ROM is priced at $75. There is an additional $12 shipping and handling charge PG 30: A Surgeon’s Personal Guide to Risk for international orders. Management and Trial Participation

AMERICAN COLLEGE OF SURGEONS ● DIVISION OF EDUCATION

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 45

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS American College of Surgeons Profes- sional Association (ACSPA)

The ACSPA Board of Directors approved the appointments of a Vice-Chair and two addi- tional members to the political action commit- tee (PAC) Board. They are Jean Hausheer, MD, FACS (Vice-Chair); L.D. Britt, MD, FACS; and Paul Weiss, MD, FACS. There are now 19 mem- bers of the PAC Board. The PAC Board’s com- position reflects a broad range of surgical spe- cialties, and no additional appointments are anticipated in the near future. A few of the items on the agenda for the PAC Board’s first meeting included: • Approval of necessary organizational resolutions. • Adoption of committee bylaws. • Consensus on a legislator scoring system. • Approval of a donor recognition system.

American College of Surgeons (ACS)

Ad Hoc Committee to Review the Structure, Composition, and Terms of the Board of Regents Highlights W. Gerald Austen, MD, FACS, presented the committee’s recommendations to the Board of of the ACSPA Regents. The Board approved the following Board of Directors recommendations: • Regents may continue to serve three and the ACS three-year terms. • Individuals who are no longer in active Board of Regents surgical practice should not be nominated for an initial term on the Board of Regents. If a meeting Regent retires from active clinical practice while serving on the Board, he/she should not be nominated for reelection when the current term expires. • A public member will not be added to the Board of Regents at this time. October 5,6, • An international Fellow will be invited and 11, 2002 to attend one year of Board meetings as a guest. by Paul E. Collicott, MD, FACS, • The size of the Board of Regents will be increased from 18 to 21, to allow for adequate Director, specialty representation, with the President Division of Member Services serving as the twenty-second Regent.

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Erie Street properties studies should be a real attempt to find valid The Board of Regents approved the reten- solutions to the problem of organ donations tion of the Nickerson Mansion and the John without making the issue one of compensa- B. Murphy Memorial Auditorium. The Board tion. The American Society of Transplant also approved the recommendation that the Surgeons has referenced the College’s position Murphy Auditorium be used as the American in communications with federal lawmakers College of Surgeons Center for Patient Safety. who are studying the issue.

Communications Development Program The following projects are just a few of Com- The Board of Regents was updated on the munications’ recent as well as ongoing activities of the program. It was reported that projects: as of September 5, 2002, the Committee on • A press release citing the College’s posi- Development received 1,357 contributions to- tion on compensation for organ donations was taling $515,661. These figures exceed those of developed and distributed. the same period in 2001. • A press kit highlighting new develop- ments in surgery that were to be presented at Journal of the American College of the Clinical Congress was prepared and dis- Surgeons (JACS) tributed to reporters around the world. The Board of Regents was apprised of • The revised and updated versions of the JACS’s activities. Owen H. Wangensteen patient information brochures are now avail- Surgical Forum participants received a let- able in print and online on the College’s Web ter inviting them to submit a full manuscript site. The review process for the last three of from their accepted abstracts. Several young the existing 13 brochures that have not yet investigators called personally to thank been updated has been initiated. JACS for the upcoming supplement and for • The ACS Smart Site™ program was the chance to provide a manuscript. launched in August for interested chapters of The Elsevier Web site for JACS will migrate the College. An online presentation has been to a new platform and provide a more custom- provided for chapters that would like to evalu- ized site. Among other features, the new Web ate its viability as an alternative to their cur- site will be able to display multimedia content rent systems. including operative videos with sound and will • Current articles featured or to be pub- also be able to provide important new capa- lished in the Bulletin include charitable im- bilities to alert Fellows to forthcoming articles munity protection for volunteer surgeons, sur- on selected topics, as articles appear. geons and Washington, DC, a historical per- Elsevier is hoping to be able to provide spective of SESAP, the origins of regulated online subscriptions to MDConsult for medi- resident work hours, and using data as a cal students. Details of this project are not yet weapon to reduce gun-related violence, among complete. many other subjects. As of September 9, 2002, a total of 17,949 Regarding organ donations, the work of the CME-1 credits were provided to ACS Fellows. Rapid Response Group was initiated on June 20 in response to an AMA House of Delegates Information Services action concerning the question of compensa- The Board of Regents approved several tion for organ donations. The College does not strategic projects. They are: agree with payment of any kind for organs to • Fellowship portal: A Web page that al- be used for purposes of transplantation. The lows viewers to see a wide variety of topics group agreed that valid studies of this ques- and allows viewers to select the topics they tion are in order, but that a major part of those want to see.

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FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • CD-ROM and Web-based CME programs. The Leapfrog Group. The group, an alliance • Expansion of patient education materi- of purchasers of health care, is dedicated to the als by providing a searchable Web site with ex- development of quality measures that will help tensive and up-to-date medical information. contain cost and foster quality patient care. In • Development of online communities in the past, the College has had some concerns which our members can interact with each about the group’s emphasis on volume and other about areas of common interest. mortality measures but has agreed to provide • Provide basic computer training for our insight and expertise for their ongoing clini- members. cal reviews.

Conventions and Meetings Division of Education It was reported that during the last few years, Bariatric surgery course. The Board of Re- overcrowding has been experienced in some of gents approved a proposal to establish a the general sessions. The sessions were moni- bariatric surgery course and to create an elec- tored and as a result a few were moved to larger tronic primer. Obesity and morbid obesity have rooms. This step was taken to eliminate any reached epidemic proportions in the U.S. and safety issues and to allay any dissatisfied at- in many parts of the western world. Surgery tendees. is the treatment of choice for morbid obesity and may soon become so for obesity. The ACS, Joint Commission on Accreditation of in association with the American Society for Healthcare Organizations (JCAHO) Bariatric Surgery and the Society of American Two of the College’s commissioners to Gastrointestinal Endoscopic Surgeons JCAHO, Irwin N. Frank, MD, FACS, and Rob- (SAGES), will present the course at the Spring ert E. Hermann, MD, FACS, will complete their Meeting and Clinical Congress and also offer service in 2002. Drs. Frank and Hermann will freestanding courses at major cities through- be replaced by David L. Nahrwold, MD, FACS, out the year. These skills-oriented courses will and Kurt D. Newman, MD, FACS. The be complemented by an electronic primer (CD- College’s third commissioner, Robert B. Smith ROM) that will be distributed by the ACS. In III, MD, FACS, will serve through 2004. These addition, an interactive Web site will be estab- appointments were made by the Executive lished to share timely information between Committee of the Board of Regents. past participants of the course and other in- terested parties. Division of Advocacy and Health Policy Resident work hours. The Board of Regents Surgery State Legislative Action Center received a report on division activities. Among The Board of Regents approved a business them, it was reported that the Subcommittee plan to establish a Surgery State Legislative on Resident Education plans to work closely Action Center (SSLAC). The SSLAC is an elec- with the new Ad Hoc Committee on the Envi- tronic advocacy tool. Under this new initiative, ronment of Residency Education to address the a Web site has been set up that will match sur- impact of reduced resident work hours as well geons (by zip code) with their elected state rep- as other critical issues. resentatives. New technologies and surgical procedures. In Practice management programs. The Board another area, the Committee on Emerging approved a business plan to establish a series Surgical Technology and Education will ad- of practice management programs for ACS dress two sets of activities. The first set involves Fellows. The division will present two series the development, implementation, and rigor- of courses to aid Fellows in their understand- ous evaluation of programs to train surgeons ing of practice management and the require- in new technologies. The second set involves ments to maintain compliance with HIPAA. the evaluation and adoption of new surgical

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS procedures. Patient safety will remain the uct at a competitive rate. There will be a sepa- overarching goal in this process. rate risk pool for Fellows in each state, which Licensing/credentialing. A special certificate will affect premiums in each state. The ACSIT will be awarded to individuals who attend the also established an affinity partnership with Ethics Colloquium. This may be of value to Liberty Mutual Group for auto, home, and per- surgeons during the processes of local creden- sonal liability policies. In addition, the ACSIT tialing and license renewal. offers an International Travel Medical Insur- Medical student program. The program for ance Plan. medical students has been completely rede- ACS toll-free number. The American College signed. An open invitation was sent to all medi- of Surgeons now has a toll-free number. The cal schools in the U.S. and Canada, inviting number (800/621-4111) has been assigned to each school to send interested students from the central switchboard. any level to attend the Clinical Congress. One- Practice management Web site. Through its hundred-eighty-one students registered—170 Committee on Young Surgeons, the College has from the U.S., 10 from Canada, and one from established a link to a practice management Germany; 83 of them were fourth-year stu- Web site for surgical residents and young sur- dents, 54 were third-year students, 37 were geons. The Web site, created and maintained second-year students, and seven were first-year by the department of surgery at the Univer- students. Special activities conducted from sity of Washington, features topics that include: Sunday through Wednesday included: compensation, contract negotiations, time • Lectures combined with receptions to management, insurance requirements, patient promote interaction between speakers and stu- satisfaction, coding and reimbursement, hir- dents. ing and interviewing staff, and personal fi- • More interactive and informal events to nances and tax planning. Additional topics will allow students additional time to network with be posted in the future. surgeons and other students. New Fellows. The Board of Regents approved • Topics of special interest to first- and sec- the induction of 1,512 Initiates into Fellowship: ond-year students such as planning summer 1,360 from the U.S. and its possessions; 30 from research projects. Canada; and 122 from 43 international coun- SESAP. Sales of Surgical Education and Self tries. Assessment Program (SESAP) 11 continue to Chapters. There continues to be an increas- remain robust. The development of SESAP 12 ing interest in chapter mergers either with lo- continues to progress well. The opportunity to cal surgical organizations, other chapters create surgery case simulations continues to within a state, or chapters of other states. The be pursued. division is actively assisting those chapters that SAGES. Dialogue is continuing with the wish to pursue this activity. Society of American Gastrointestinal Endo- Multi-country chapters. Some international scopic Surgeons (SAGES) to collaborate in the countries have too few Fellows to qualify for a implementation of the Fundamentals of Lap- Governor and, therefore, a chapter. ACS edu- aroscopic Surgery course. cational programs can only be introduced into international countries through a recognized Division of Member Services surgical society in that country or an estab- Member benefits. It was reported to the Board lished ACS chapter in that country. The Board of Regents that the American College of Sur- of Regents approved a request to allow coun- geons Insurance Trust (ACSIT) finalized a tries to petition the Executive Committee of contract with The Doctors Company. The spon- the Board of Governors in applying for a multi- sored product will be available soon. Fellows country chapter for the purpose of introduc- will benefit by having a quality insurance prod- ing ACS educational programs.

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FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Board of Governors’ Committees’ Division of Research Structure and Optimal Patient Care The Board of Regents approved the proposed Cancer. The Commission on Cancer (CoC) re- changes to the structure of the Governors’ com- leased its Web-based National Cancer Data mittees. Four of the eight committees were con- Base (NCDB) Benchmark Reports application solidated and renamed, reducing the total in mid-March 2002 and updated the applica- number of committees to six. In addition, each tion with more recent data toward the end of committee will have a mission statement and July. This easy-to-use application is available terms of reference. for public use and consists of reports that in- clude patient demographics, tumor character- Governors’ Committees’ Programs istics, treatment, and survival outcomes data The Board of Regents approved proposed for 14 major cancer sites. programs submitted by three of the Governors’ Trauma. The Board of Regents reviewed a committees. They are: report on the activities of the Committee on • “Agents of Bioterrorism” and “Newer Trauma. Some of its key activities are: Transmissible Pathogens in the Surgical Care • Regional Committees are collecting ad- of Patients,” submitted by the Committee on ditional legislative information and working Blood-Borne Infection and Environmental with state legislative efforts to compile a pro- Risk. file of state legislation activity regarding • “Volunteerism by American Surgeons,” trauma, to be used to work with the Washing- submitted by the Committee on Socioeconomic ton office in developing trauma systems. Issues. • The CD-ROM project, Trauma Patient • “Safety for Office-Based Surgery,” sub- Management Problems, continues to do well mitted by the former Committee on Ambula- and the committee continues to explore other tory Surgical Care, now the Committee on ways in which video and CD-ROM technology Surgical Practice in Hospitals and Ambulatory can be used for ongoing continuing education. Settings. • Trauma Registry—Version 3.11 has been released for beta testing and is doing well. Scholarships • ATLS®—The new version of the course The Society of Thoracic Surgeons has book has been completed. partnered with the American College of Sur- • The Education Committee is working on geons to award an annual Health Policy Schol- a curriculum for a surgical skills course. arship. This scholarship will be offered initially • The Trauma Systems Consultation Com- in 2003. The scholarship is to subsidize atten- mittee has accomplished two complete site vis- dance and participation in the Harvard course, its and both were well received. Understanding the New World of Healthcare: • The Optimal Care Resource Document is A Healthcare Policy Program for Physicians, being revised. The targeted publication date Trustees, and Healthcare Leaders. The scholar is 2004. is required to serve one year as a pro temp • National Trauma Data Bank™—Federal member of the health policy steering commit- agencies have looked to this as an example of a tees of both organizations. compiled national database and this program is referred to directly in the proposed Title XII Statement on correct site surgery legislation for reappropriation of trauma sys- The Board of Regents approved an ACS tems development funding. Health Resources Statement on Ensuring Correct Patient, Cor- and Services Administration has supported rect Site, and Correct Procedure Surgery. The this during FY 2002-2003 with another statement was published in the December 2002 $200,000 grant. issue of the Bulletin (p. 26).

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 51

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS CALL FOR SUBMISSIONS

The Committee for the Forum on Fundamental Surgical Problems The American College of Surgeons

For the 2003 Owen H Wangensteen 58th annual Surgical Forum Journal of the American College of Surgeons

Accepted abstracts* Who • Young surgical investigators (principal investigator is first will be presented at: named author). • • Up to eight (8) co-authors allowed. American College What of Surgeons • 250 maximum word abstract that presents a concise sum- mary of research done and in progress, but not presented Clinical Congress or published previously. Title must be brief; body of ab- • stract must include Introduction, Methods, Results, Con- clusions. One-page table may be submitted separately (see October 19-23, 2003 Author Instructions on Web site) if absolutely necessary; Chicago, Illinois table does not count toward the 250 maximum word count. When • Abstracts accepted from December 1, 2002, through March 1, 2003.

Where • Online submissions ONLY: http://www.facs.org/sfabstracts/

• Final Decision: May 2003 (principal author will be con- tacted).

52 * Abstract Supplement published • Format: Follow Author Instructions, Online Submission. in JACS September 2003 issue. •Questions: [email protected] or: 312.202.5336. VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 53

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chapter news

by Rhonda Peebles, Chapter Services Manager, Division of Member Services

To report your chapter’s news, please contact Rhonda Peebles toll-free at 888/857-7545, or via e-mail at [email protected]. Chapters combine to create new Keystone Chapter

In mid-November 2002, the final procedures and paperwork were completed to create the new Key- stone Chapter of the College. This new domestic chapter consists of the former Central Pennsyl- vania Chapter and the former Eastern Pennsyl- vania Chapter. The Keystone Chapter will com- The past and present leaders of the Eastern prise more than 1,000 Fellows. With regard to gov- Pennsylvania Chapter join the incoming leaders of the ernance and representation, the Keystone Chap- newly formed Keystone Chapter. Pictured left to right: ter will be divided into eight geographic regions, Charles Scagliotti, MD, FACS; Dr. Myers; Dr. Sinnott; each having at least one councilor; regions with Dr. Close; Dr. Bleznak; Linda Lapos, MD, FACS; John one or more teaching hospital(s) will be repre- LaManna, MD, FACS; and Thomas R. Russell, MD, sented by additional councilors. Finally, there will FACS, the College’s Executive Director. be two at-large council positions. According to its mission statement, the new Key- stone Chapter will “...provide a regional voice for surgeons in all specialties, be an advocate for its members and the patients they serve, provide edu- cational opportunities for its members, and en- tries where small numbers of Fellows reside. Pro- courage the highest standards of ethical surgical cedures to form multi-country chapters will be practice.” similar to those for single-country chapters, which The new officers of the Keystone Chapter in- must represent at least 15 Fellows before a Gov- clude: Richard A. Close, MD, FACS, President; ernor may be elected. After the Governor is elected, Aaron David Bleznak, MD, FACS, President-Elect; the Governor petitions the Board of Regents to Collin Lewis Myers, MD, FACS, Secretary/Trea- form a new chapter. For additional information surer; and Immediate Past-Presidents Robert on forming new chapters, contact the author. Sinnott, DO, FACS, and Narayan Deshmukh, MD, FACS. Charlene Wandzilak will serve as the Update on chapter Web sites chapter’s Executive Director (see photo, right). In early January 2003, two additional chapters Regents approve went online—the Southern California Chapter multi-country chapters and the New Jersey Chapter—bringing the total number of chapter Web sites to 38. All of the chap- At its October 5-6 meeting, the Board of Regents ters’ Web sites are accessible at: http:// approved the formation of multi-country chapters. www.facs.org/about/chapters/chapmenu.html. Currently, there are 27 international chapters that In addition, a new SmartSite™ program was are organized by country, and there are three in- made available last fall to the chapters through ternational chapters in Mexico (Federal District, one of the College’s Internet service providers. The Nor-Occidental, and Northeast). The Regents’ ac- new SmartSite program substantially simplifies 54 tion will permit the formation of chapters in coun- the development and maintenance of Web sites.

VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS As of January 2003, five chapters had switched to land, Nebraska, Brooklyn-Long Island (NY), Ohio, new SmartSites: Florida, Colorado, Connecticut, South Carolina, and North Texas. Metropolitan Chicago, and Virginia. In addition, Annual Members of the Fellows Leadership So- the Indiana Chapter anticipates transitioning its ciety: Alabama, Florida, South Florida, Georgia, Web site to the SmartSite very soon. For more in- Hong Kong, Metropolitan Chicago, Michigan, formation or assistance with the SmartSite pro- Southwest Missouri, North Carolina, Oregon, Met- gram, visit http://www.facs.org/chapters/webprog/ ropolitan Philadelphia, Virginia, and Washington proglist.html. State. Contributors: Alberta, Hawaii, Missouri, Mon- Chapter anniversaries tana-Wyoming, and New York. Month Chapter Years Leadership conference for officers and young surgeons January Northern California 51 Louisiana 51 The 2003 Leadership Conference for Chap- February Arizona 51 ter Officers and Young Surgeons will take place Australia-New Zealand 18 June 22-24 in Washington, DC, at the Washing- South Florida 49 ton Court Hotel. A special education program is Iowa 35 planned, which will examine four topics: profes- Italy 17 sional liability, uninsured and underinsured pa- Lebanon 40 tients, trauma, and physician reimbursement. In Montana-Wyoming 38 addition, all chapter officers, young surgeons, and Eastern Long Island, NY 35 administrators will have an opportunity to attend Westchester, NY 51 a congressional reception and to meet with their Peru 26 members of Congress on Capitol Hill. A prelimi- South Korea 16 nary schedule includes: Washington State 51 • Sunday, June 22: Afternoon: Special session for young surgeons; Special session for chapter ad- Chapters continue ministrators and executive directors. Evening: to support College funds Welcoming reception for participants, spouses, and guests. Last year, 25 chapters contributed a total of • Monday, June 21: All-day plenary and spe- $35,500 to the College’s Endowment Funds. The cial education program sessions. Evening: Con- chapters’ donations to the various funds support gressional reception. the College’s pledge to surgical research and edu- • Tuesday, June 22: Morning: Breakfast and cation. Chapters may contribute to several differ- briefings; visits with members of Congress. After- ent funds, such as the Annual Fund, the Fellows noon: Debriefings, lunch, and adjourn. Endowment Fund, or the Scholarship Fund. The chapters that contributed during 2002 are as fol- Surgical specialty societies lows: launch state action center Life Members of the Fellows Leadership Society*: Arizona, Southern California, Louisiana, Mary- The College has joined in a collaborative effort with 11 other specialty societies to launch a new *The Fellows Leadership Society (FLS) is the distinguished Surgery State Legislative Action Center (SSLAC) donor organization of the College. Chapters that contribute at least $1,000 annually are members. Chapters that have The SSLAC is an electronic advocacy tool that uses contributed $25,000 are FLS Life Members. the same software program and zip code match- 55

FEBRUARY 2003 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ing technology that the ACS and many other na- center at www.facs.org/sslac and look for alerts tional specialty societies use for federal advocacy from the College and other surgical specialty soci- efforts. This system matches surgeons with their eties. For more information about the SSLAC, or elected state representatives—allowing them to if your chapter would like to post an alert on the reach out to members of their state legislatures action center, contact Christopher Gallagher, Man- on an ad hoc basis or through a coordinated grass- ager of State Affairs, at [email protected]. roots campaign. Check out the new state action

ext month in JACS NThe March issue of the Journal of the American College of Surgeons will feature:

Commission on Cancer Oncology Lecture: Esophageal Cancer: What Price Swallowing?

Original Scientific Articles: •Gender and Coronary Bypass Graft Surgery •Cost Analysis of Intraoperative Cholangiography •Decision Analysis of Gastric Bypass versus Diet

What’s New in Surgery: Plastic and Maxillofacial Surgery

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VOLUME 88, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS