in the time of covid-19

J U L Y 2 0 2 0 | V O L U M E 1 0 5 N U M B E R 5 | A M E R I C A N C O L L E G E O F S U R G E O N S

Surgeon leadership in the time of COVID-19

Bulletin

20MAYBULL cover 1.indd 120MAYBULL cover 1.indd 1 6/17/2020 10:02:24 AM6/17/2020 10:02:24 AM

VIRTUAL

#acsqsc

facs.org/QualitySafetyConference

July 24–27, 2020 | FREE REGISTRATION

ACS QUALITY and SAFETY CONFERENCE

Raise the Bar for Quality Care.Achieving surgical quality starts with a commitment to quality improvement. Register for this year’s ACS Quality and Safety

Conference—free to the U.S. and international surgical community— to learn about how to achieve surgical quality, timely surgical updates

surrounding COVID-19, and other hot topics related to surgery.

25

Contents

FEATURES

16 The role of the site reviewer: Ensuring patient-centered standards for optimal patient outcomesTony Peregrin

25 The Surgical Metrics Project: What was achieved, and where is it headed?Carla Pugh, MD, PhD, FACS; Cassidi Goll; Anna Witt; Hossien Mohamadipanah, PhD; and Brett Wise

31 Surgeons appointed by Spanish royalty contributed to development of oldest U.S. city: St. Augustine, FLJohn D. Ehrhardt, Jr., MD, and J. Patrick O’Leary, MD, FACS

40 2019 ACS Governors Survey: Surgeons wanted: Workforce challenges in health careDavid J. Welsh, MD, FACS; Hiba Abdel Aziz, MBBCH, FACS; Juan C. Paramo, MD, FACS; John Kirby, MD, FACS; Dhiresh Rohan Jeyarajah, MD, FACS; David W. Butsch, MD, FACS; Christopher DuCoin, MD, MPH, FACS; Joann Lohr, MD, FACS; and Shilpa Shree Murthy, MD, MPH

46 2019 ACS Governors Survey: ACS Governors: Bidirectional communication ambassadorsDavid W. Butsch, MD, FACS; David J. Welsh, MD, FACS; Hiba Abdel Aziz, MBBCH, FACS; Juan C. Paramo, MD, FACS; John Kirby, MD, FACS; Dhiresh Rohan Jeyarajah, MD, FACS; Christopher DuCoin, MD, MPH, FACS; Shilpa Shree Murthy, MD, MPH; Julian A. Smith, MB BS, FACS; and Joann Lohr, MD, FACS

51 2019 ACS-COSECSA Women Scholars describe how they and their patients benefit from the scholarships: Part INatalie Bell and Girma Tefera, MD, FACS

16

JUL 2020 BULLETIN American College of Surgeons | 1

40 continued on next page

COMMENTARY

11 COVER STORY: Looking forward

David B. Hoyt, MD, FACS

14 Letters to the Editor

FOR YOUR PATIENTS

71 ACS quality and safety case studies: Virtual acute care for older patients reduces hospital length of stay

Melanie Morris, MD, FACS; Lauren Wood, MPH;Emily Simmons, MSN, RN, CNL, FGNLA; Shari Biswal, MSN, RN, PCCN, CNL; David James, DNP, RN-BC, CCNS, LSSGB; Jasmine Vickers, MPH, CHES; John Russell, MBA, CPA; Katrina Booth, MD; and Kellie Flood, MD

DEPARTMENTS

76 ACS Clinical Research Program: Ga-68 imaging changes clinical management of GI and pancreatic neuroendocrine tumors

Clancy J. Clark, MD; J. Bart Rose, MD; Judy C. Boughey, MD, FACS; and Flavio G. Rocha, MD, FACS

79 NCDB cancer bytes: Neoadjuvant and perioperative chemotherapy for localized pancreatic cancer: Leveraging small and large databases in the absence of Level 1 evidence

Timothy L. Fitzgerald, MD, FACS

55 A call into the distance: How quality review can change a rural cancer patient’s outcomeMary O. Aaland, MD, FACS, and Karen W. Luk, MD

58 Surprise billing, trauma, and cancer top state legislative agendas in 2020Christopher Johnson, MPP

64 Filling the gap: Using 3-D printing to overcome critical equipment shortages during the COVID-19 crisisDaniel T. Lammers, MD; Matthew J. Eckert, MD, FACS; and Jason R. Bingham, MD

67 Community hospital’s losing battle with COVID-19: A surgery resident’s accountJustin Gauthier, MD

64

55

FEATURES, continued

V105 No 5 BULLETIN American College of Surgeons2 |

Contents continued

67

continued on next page

FOR YOUR PRACTICE

83 A look at The Joint Commission: Recommendations pour in as surgeons navigate COVID-19 pandemic

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

FOR YOUR PROFESSION

87 From residency to retirement: ACS offers opportunities for increased specialty resident participation in the College

Sonia Bhandari Randhawa, MD, and Enrique Hernandez, MD, FACS, FACOG

89 From the Archives: German influences on U.S. surgery and the founding of the ACS

David E. Clark, MD, FACS

DEPARTMENTS, contd. NEWS

91 Letter from the Editor

Diane Schneidman, Editor-in-Chief

92 Announcing the new Cancer Surgery Standards Program

Matthew H.G. Katz, MD, FACS; Kelly K. Hunt, MD, FACS; Heidi Nelson, MD, FACS; and Amanda Francescatti, MS

94 ACS remembers Howard M. Snyder III, MD, FACS, trailblazer in pediatric urology

96 ACS mourns the passing of Francis Robicsek, MD, PhD, FACS, a dedicated humanitarian surgeon

98 ACS issues call to action on racism as a public health crisis: An ethical imperative

99 Memoir recounts “golden age” of surgical innovation Dr. Wangensteen led at University of Minnesota

102 Report on ACSPA/ACS activities, February 2020

Ronald J. Weigel, MD, PhD, FACS

108 Lessons from a virtual chapter annual meeting

John H. Armstrong, MD, FACS; Jay Redan, MD, FACS; and Brian Hart, JD

112 Chapter news

Luke Moreau and Brian Frankel

MEETINGS CALENDAR116 Calendar of events

94

98


Contents continued

87

Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, and Affiliate Members. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5.

The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295; tel. 312-202-5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202-337-2701.

Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons.

©2020 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher.

Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

EDITOR-IN-CHIEFDiane Schneidman

SENIOR GRAPHIC DESIGNER/PRODUCTION MANAGER

Tina Woelke

SENIOR EDITORTony Peregrin

NEWS EDITORMatthew Fox

EDITORIAL AND PRODUCTION ASSISTANT

Kira Plotts

EDITORIAL ADVISORSDanielle A. Katz, MD, FACSDhiresh Rohan Jeyarajah, MD, FACSCrystal N. Johnson-Mann, MDMark W. Puls, MD, FACSBryan K. Richmond, MD, FACSMarshall Z. Schwartz, MD, FACSAnton N. Sidawy, MD, FACSGary L. Timmerman, MD, FACSDouglas E. Wood, MD, FACS

FRONT COVER DESIGNTina Woelke

ACSCLINICAL

CONGRESS 2020

The Best Surgical Education. All in One Place.

facs.org/clincon2020

OCTOBER 4–7VIRTUAL

The American College of Surgeons is dedicated

to improving the care of the surgical patient

and to safeguarding standards of care in an

optimal and ethical practice environment.

4 |

Letters to the Editor should be sent

with the writer’s name, address,

e-mail address, and daytime telephone

number via e-mail to dschneidman@facs.

org, or via mail to Diane S. Schneidman,

Editor-in-Chief, Bulletin, American

College of Surgeons, 633 N. Saint Clair St.,

Chicago, IL 60611. Letters may be edited

for length or clarity. Permission to publish

letters is assumed unless the author

indicates otherwise.

Officers and Staff of the American College of Surgeons*

OfficersValerie W. Rusch, MD, FACSNew York, NYPRESIDENT

Ronald V. Maier, MD, FACSSeattle, WAIMMEDIATE PAST-PRESIDENT

John A. Weigelt, MD, FACSSioux Falls, SDFIRST VICE-PRESIDENT

F. Dean Griffen, MD, FACSShreveport, LASECOND VICE-PRESIDENT

Tyler G. Hughes, MD, FACS,Salina, KSSECRETARY

Don K. Nakayama, MD, MBA, FACSChapel Hill, NCTREASURER

David B. Hoyt, MD, FACS Chicago, ILEXECUTIVE DIRECTOR

Gay L. Vincent, CPAChicago, ILCHIEF FINANCIAL OFFICER

Officers-Elect (take office October 2020)J. Wayne Meredith, MD, FACSWinston-Salem, NCPRESIDENT-ELECT

H. Randolph Bailey, MD, FACSHouston, TXFIRST VICE-PRESIDENT-ELECT

Lisa Ann Newman, MD, MPH, FACSNew York, NYSECOND VICE-PRESIDENT-ELECT

Board of RegentsBeth H. Sutton, MD, FACSWichita Falls, TXCHAIR

L. Scott Levin, MD, FACSPhiladelphia, PAVICE-CHAIR

Anthony Atala, MD, FACSWinston-Salem, NCJohn L. D. Atkinson, MD, FACSRochester, MNJames C. Denneny III, MD, FACSAlexandria, VATimothy J. Eberlein, MD, FACSSaint Louis, MOJames K. Elsey, MD, FACSAtlanta, GADiana Lee Farmer, MD, FACS, FRCSSacramento, CA

Henri R. Ford, MD, FACSMiami, FLGerald M. Fried, MD, FACS, FRCSCMontreal, QCJames W. Gigantelli, MD, FACSOmaha, NEB.J. Hancock, MD, FACS, FRCSCWinnipeg, MBEnrique Hernandez, MD, FACSPhiladelphia, PALenworth M. Jacobs, Jr., MD, FACSHartford, CTFabrizio Michelassi, MD, FACSNew York, NYLena M. Napolitano, MD, FACSAnn Arbor, MILinda G. Phillips, MD, FACSGalveston, TXKenneth W. Sharp, MD, FACSNashville, TNAnton N. Sidawy, MD, FACSWashington, DCSteven C. Stain, MD, FACSAlbany, NYGary L. Timmerman, MD, FACSSioux Falls, SDSteven D. Wexner, MD, FACSWeston, FLDouglas E. Wood, MD, FACSSeattle, WA

Board of Governors/Executive CommitteeRonald J. Weigel, MD, PhD, FACSIowa City, IACHAIR

Taylor Riall, MD, PhD, FACSTucson, AZ VICE-CHAIR

Mika Sinanan, MD, PhD, FACSSeattle, WASECRETARY

Andre R. Campbell, MD, FACSSan Francisco, CAMark Alan Dobbertien, DO, FACSOrange Park, FLNancy Lynn Gantt, MD, FACSYoungstown, OHDhiresh Rohan Jeyarajah, MD, FACSRichardson, TXMartin A. Schreiber, MD, FACSPortland, OR

Advisory Council to the Board of Regents(Past-Presidents)Kathryn D. Anderson, MD, FACSEastvale, CAW. Gerald Austen, MD, FACSBoston, MABarbara Lee Bass, MD, FACSHouston, TXL. D. Britt, MD, MPH, FACS, FCCMNorfolk, VAJohn L. Cameron, MD, FACSBaltimore, MDEdward M. Copeland III, MD, FACSGainesville, FLA. Brent Eastman, MD, FACSRancho Santa Fe, CAGerald B. Healy, MD, FACSWellesley, MAR. Scott Jones, MD, FACSCharlottesville, VAEdward R. Laws, MD, FACSBoston, MALaMar S. McGinnis, Jr., MD, FACSAtlanta, GADavid G. Murray, MD, FACSSyracuse, NYPatricia J. Numann, MD, FACSSyracuse, NYCarlos A. Pellegrini, MD, FACS Seattle, WAJ. David Richardson, MD, FACSLouisville, KYRichard R. Sabo, MD, FACSBozeman, MTSeymour I. Schwartz, MD, FACSRochester, NYCourtney M. Townsend, Jr., MD, FACSGalveston, TXAndrew L. Warshaw, MD, FACSBoston, MA

Executive StaffEXECUTIVE DIRECTOR

David B. Hoyt, MD, FACSDIVISION OF ADVOCACY AND HEALTH POLICY

Frank G. Opelka, MD, FACSMedical Director, Quality and Health PolicyPatrick V. Bailey, MD, MLS, FACS Medical Director, Advocacy

Christian ShalgianDirector

AMERICAN COLLEGE OF SURGEONS FOUNDATION

Shane HollettExecutive Director

ALLIANCE/AMERICAN COLLEGE OF SURGEONS CLINICAL RESEARCH PROGRAM

Kelly K. Hunt, MD, FACSChair

CONVENTION AND MEETINGSRobert HopeDirector

DIVISION OF EDUCATIONAjit K. Sachdeva, MD, FACS, FRCSCDirector

EXECUTIVE SERVICESLynese KelleyDirector, Leadership Operations

FINANCE AND FACILITIESGay L. Vincent, CPADirector

HUMAN RESOURCES AND OPERATIONS

Michelle McGovern, MSHRIR, CPSPDirector

INFORMATION TECHNOLOGYBrian HarperDirector

DIVISION OF INTEGRATED COMMUNICATIONS

Cori McKeever AshfordDirector

JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS

Timothy J. Eberlein, MD, FACSEditor-in-Chief

DIVISION OF MEMBER SERVICESPatricia L. Turner, MD, FACSDirectorM. Margaret Knudson, MD, FACSMedical Director, Military Health Systems Strategic PartnershipGirma Tefera, MD, FACSDirector, Operation Giving Back

PERFORMANCE IMPROVEMENTWill Chapleau, RN, EMT-P Director

DIVISION OF RESEARCH AND OPTIMAL PATIENT CARE

Clifford Y. Ko, MD, MS, MSHS, FACSDirectorHeidi Nelson, MD, FACSMedical Director, CancerRonald M. Stewart, MD, FACSMedical Director, Trauma


*Titles and locations current at press time.

d


DR. BOUGHEY (h) is W.H. Odell Professor of Individualized Medicine, professor of surgery, and vice-chair, research, department of surgery, Mayo Clinic, Rochester, MN. She is Chair, ACS Clinical Research Program (CRP) Education Committee.

DR. BUTSCH (i) is a volunteer clinical associate professor of surgery, Robert Larner, MD, College of Medicine, University of Vermont, Burlington. He is Chair, ACS B/G Survey Workgroup, and Past-President, ACS Vermont Chapter and Vermont Medical Society.

DR. CLANCY CLARK (j) is assistant professor of surgery and associate program director for general surgery, department of surgery, Wake Forest Baptist Health, Winston-Salem, NC. He is a member, ACS CRP Education Committee and the Alliance Cancer in the Elderly Committee.


Author bios*

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

DR. AALAND (a) is associate professor of surgery, University of North Dakota School of Medicine and Health Sciences (UND SMHS), Grand Forks, and director, UND Rural Surgery Support Program.

DR. ABDEL AZIZ (b) is an acute care surgeon, Hamad General Hospital, Doha, Qatar, and member, American College of Surgeons (ACS) Board of Governors (B/G) Survey Workgroup. She is the founding Governor of the ACS Qatar Chapter.

DR. ARMSTRONG (c) is associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa; adjunct professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; and Immediate Past-President and former Governor, ACS Florida Chapter.

MS. BELL (d) is Program Manager, Operation Giving Back (OGB), ACS Division of Member Services, Chicago, IL.

DR. BINGHAM (e) is a general and bariatric surgeon, director of medical student education, and co-director, surgical research, Madigan Army Medical Center, Tacoma, WA. He is a Major in the U.S. Army Medical Corps.

MS. BISWAL (f ) is nursing professional development specialist/nurses improving care for healthsystem elders coordinator, University of Alabama at Birmingham (UAB) Hospital.

DR. BOOTH (g) is regional medical director, Landmark Health, Ohio/Kentucky.

f

a

e

b c

h i j

g

n

v

r

DR. DAVID CLARK (k) is faculty scientist, department of surgery, Maine Medical Center, Portland. He was the recipient of the 2018–2019 ACS History and Archives Committee Archives Fellowship.

DR. DuCOIN (l) is associate professor of surgery, chief of minimally invasive and bariatric surgery, and fellowship director, University of South Florida Morsani College of Medicine, Tampa. He is a member, ACS Young Fellows Association Governing Council and ACS B/G Survey Workgroup.

DR. ECKERT (m) is trauma medical director, chief of general surgery clinics, and co-director, surgical research, Madigan Army Medical Center. He is an active-duty Lieutenant Colonel in the U.S. Army Medical Corps.

MR. EHRHARDT (n) is a first-year general surgery resident, Kendall Regional Medical Center, Miami, FL.

DR. FITZGERALD (o) is director, division of surgical oncology, Tufts University School of Medicine–Maine Medical Center, Portland.

DR. FLOOD (p) is associate professor, division of gerontology, geriatrics, and palliative care, University of Alabama at Birmingham.

MS. FRANCESCATTI (q) is Senior Manager, ACS CRP and Cancer Surgery Standards Program, Cancer Programs, ACS Division of Research and Optimal Patient Care, Chicago, IL.

MR. FRANKEL (r) is Manager, International Chapter Services and Special Initiatives, ACS Division of Member Services.

DR. GAUTHIER (s) is chief surgery resident, postgraduate year 5 (PGY-5), Mount Sinai-South Nassau, Oceanside, NY, and Lieutenant, U.S. Navy.

MS. GOLL (t) is marketing and administrative coordinator, Technology Enabled Clinical Improvement (T.E.C.I.) Center, Stanford University School of Medicine, CA.

MR. HART (u) is Executive Director, ACS Florida Chapter.

DR. HERNANDEZ (v) is a gynecologic oncologist, and professor and chairman, department of obstetrics and gynecology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. He is an ACS Regent.


Author bios continued

po q

k

s t u

l m


aa cc

w

bb

x y

ee ff gg

dd


z

hhgg

DR. HUNT (w) is Hamill Foundation Distinguished Professor of Surgery in honor of Dr. Richard G. Martin, Sr., and chair, department of breast surgical oncology, University of Texas MD Anderson Cancer Center, Houston. She is Program Director, ACS CRP, and Vice-Chair, Cancer Surgery Standards Program.

MR. JAMES (x) is nursing professional development specialist, UAB.

DR. JEYARAJAH (y) is assistant chair, clinical sciences, and head of surgery, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth; and director of gastrointestinal (GI) surgical services, and director, hepatopancreatobiliary/advanced GI fellowship program. He is a member and Communications Pillar Lead, ACS B/G Executive Committee.

MR. JOHNSON (z) is State Affairs Associate, ACS Division of Advocacy and Health Policy, Washington, DC.

DR. KATZ (aa) is associate professor of surgical oncology, University of Texas MD Anderson Cancer Center, Houston; Chair, Cancer Surgery Standards Program; and Chair, ACS CRP Cancer Care Standards Development Committee.

DR. KIRBY (bb) is director, wound healing programs, and associate professor of surgery, department of surgery, Washington University St. Louis School of Medicine, MO. He is Vice-Chair, ACS B/G Survey Workgroup.

DR. LAMMERS (cc) is a PGY-4 general surgery resident, Madigan Army Medical Center, and active-duty Captain, U.S. Army Medical Corps.

DR. LOHR (dd) is a staff member, William Jennings Bryan Dorn VA Medical Center, Columbia, SC. She is a member, ACS B/G Survey Workgroup.

DR. LUK (ee) is chief surgery resident, UND SMHS.

DR. MOHAMADIPANAH (ff) is senior research engineer, T.E.C.I. Center, Stanford University School of Medicine.

MR. MOREAU (gg) is Manager, Domestic Chapter Services, ACS Division of Member Services.

DR. MORRIS (hh) is associate professor of surgery, UAB.



jjii kk

DR. MURTHY (ii) is a general surgeon and recent graduate of Indiana University, Indianapolis, general surgery residency program. She is a member, ACS B/G Survey Workgroup.

DR. NELSON (jj) is emeritus chair, department of surgery, and past-chair, division of colon & rectal surgery, Mayo Clinic, Rochester, MN. She is Medical Director, Cancer Programs, ACS Division of Research and Optimal Patient Care.

DR. O’LEARY (kk) is founding executive associate dean of clinical affairs and assistant vice-president for strategic planning, Florida International University Herbert Wertheim College of Medicine, Miami.

DR. PARAMO (ll) is a surgical oncologist, Mount Sinai Medical Center Comprehensive Cancer Center, Miami Beach; associate professor of surgery, Florida International University Werbert Wertheim College of Medicine, Miami; and clinical professor of surgery, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Ft. Lauderdale. He is a member, ACS B/G Survey Workgroup.

DR. PELLEGRINI (mm) is professor and chair emeritus, department of surgery, University of Washington, Seattle. He is Past-President, ACS, and member, Board of The Joint Commission.

MR. PEREGRIN (nn) is Senior Editor, Bulletin of the American College of Surgeons, ACS Division of Integrated Communications, Chicago, IL.

DR. PUGH (oo) is professor of surgery and director, T.E.C.I. Center, Stanford University School of Medicine.

DR. RANDHAWA (pp) is a third-year obstetrics-gynecology resident, Reading Hospital, PA, and a member, Resident and Associate Society of the ACS.

DR. REDAN (qq) is chief of surgery, Advent Health-Celebration, FL; professor of surgery, University of Central Florida, Orlando; and President and Governor, ACS Florida Chapter.

DR. ROCHA (rr) is a staff surgeon, surgical oncology and hepatopancreatobiliary surgery, Virginia Mason Medical Center, and associate medical director, the Floyd and Delores Jones Cancer Institute, Seattle, WA.


oo


ll

pp qq rr

mm nn


ss uutt vv

aaa cccbbb ddd

zz

DR. ROSE (ss) is assistant professor of surgery, UAB, division of surgical oncology, and director, UA Pancreatobiliary Disease Center.

MR. RUSSELL (tt) is associate vice-president, business analytics and decision support, UAB Hospital.

MS. SCHNEIDMAN (uu) is Editor-in-Chief, Bulletin of the American College of Surgeons, ACS Division of Integrated Communications.

MS. SIMMONS (vv) is a nursing professional development specialist, UAB Hospital.

DR. SMITH (ww) is head, department of surgery, and head, department of cardiothoracic surgery, School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia. He is President and Governor, ACS Australia and New Zealand Chapter.

DR. TEFERA (xx) is professor of surgery, department of surgery, University of Wisconsin, Madison; and vice-chair, division of vascular surgery, and chief of vascular surgery, Middleton Veteran Affairs Hospital in Madison. He is Medical Director, OGB.

MS. VICKERS (yy) is research technician, department of health behavior, UAB.

DR. WEIGEL (zz) is the E.A. Crowell, Jr. Professor and chair of surgery, professor of surgical oncology and endocrine surgery, professor of biochemistry, professor of anatomy and cell biology, and professor of molecular physiology and biophysics, University of Iowa, Iowa City. He is Chair, ACS B/G.

DR. WELSH (aaa) is a general surgeon, Batesville, IN. He is a member, American Medical Association (AMA) Council on Science and Public Health, and chair, Organized Medical Staff Section Governing Council, AMA. He is a consultant, ACS B/G Survey Workgroup.

MR. WISE (bbb) is researcher, T.E.C.I. Center, Stanford University School of Medicine.

MS. WITT (ccc) is lab manager, T.E.C.I. Center, Stanford University School of Medicine.

MS. WOOD (ddd) is researcher, division of gastrointestinal surgery, UAB.


ww xx yy


Times of crisis call for leadership. During the coronavirus disease 2019 (COVID-19) pan-demic, surgeons and other health care pro-

fessionals have demonstrated their extraordinary dedication to maintaining quality care. More re-cently, we have witnessed and responded to tur-moil in the nation after the tragic death of an unarmed black man, George Floyd, while in the custody of Minneapolis, MN, police officers.

The American College of Surgeons (ACS) has provided resources and guidance to its members who have been battling COVID-19 on the front-lines. Much of this information was reported through a twice-weekly e-newsletter, Bulletin: ACS COVID-19 Updates. As the curve f lattened in many areas of the nation in the middle of May, we moved to weekly publication of Bulletin Brief, an e-newsletter that highlights not only the Col-lege’s leadership in caring for patients who have been affected in some way by the pandemic, but also patients who had to reschedule a nonemer-gent operation.

The College also issued comments condemn-ing racism and police brutality after the deaths of Mr. Floyd and Breonna Taylor, a 26-year-old African-American emergency medical technician in Louisville, KY. We stated:

The ACS stands in solidarity against racism, vio-lence, and intolerance. Our mission is to serve all with skill and fidelity, and that extends beyond the operating room.

Racism, brutal attacks, and subsequent violence must end. We will help any injured, and we will use our voice in support of the health and safety of every person.

Furthermore, the ACS Committee on Ethics and the Board of Regents issued a call to action June 9, stating that racism is a public health cri-sis, resulting in health care inequities and asking

Sensing the direct involvement of the

leader is reassuring. Being visible is

possibly the most important thing

a leader can do in a time of crisis.


by David B. Hoyt, MD, FACS

Looking forward

EXECUTIVE DIRECTOR’S REPORT

all members of the organization to treat all patients, regardless of race, ethnicity, religion, or sexual pref-erence with compassion, skill, and fidelity.

How to lead during a crisisEarly on in the COVID-19 crisis in the U.S., I was in contact with Carlos A. Pellegrini, MD, FACS, FRCSEd(Hon), FRCS(Hon), FRCSI(Hon), Past-President of the ACS. He noted, “This is not leader-ship as usual—this is leadership on the edge,” and offered the following tenets for leaders in the diffi-cult days ahead:

• Be present. Crises engender anxiety and fear among all those affected. Sensing the direct involvement of the leader (by written communications, personal out-reach to the members of the organization known to be more vulnerable, visibility through social networks, and so on) is reassuring. Being visible is possibly the most important thing a leader can do in a time of crisis.

• Communicate frequently. The best way to avoid panic among those who are fearful and anxious is to hear from the leader frequently with updates on what is hap-pening and what actions are being taken/considered to ameliorate the crisis.

• Communicate thoroughly. Share with the group more rather than less. This situation calls for more talk, for storytelling, rather than “cold instructions.” Connecting with the constituency is more important than issuing dictates. Communications should explain clearly and concisely what is expected. The challenge for the leader is to strike the right balance, bearing in mind that con-stituents will remember when they heard their leader speak from the heart. This type of connection is how people build relationships.

• Communicate truthfully. Most members of a team will have collected information from a range of sources

and will have a pretty good idea of where the situation stands. Being truthful, even if that means providing information that may not be desired, is important. In as much as the leader remains credible, followers will respect him/her as a leader and do what they are asked to do. Err on the side of overinforming, recognizing that sometimes truly confidential information may need to be kept private. Because most people are terrible at keep-ing a secret, a leader should be the first one to provide the news. By being the first to communicate good and bad news, a leader ensures that accurate information is shared and is seen as the trusted source.

• Exercise pragmatic optimism. Remain true to the facts and anchor the message in reality, but sound a note of optimism. Remind people that there is a “way out of the crisis,” and describe a future worth pursuing.

• Delegate and empower. Exercising authority at a time of crisis may help ensure that decisions contribute to solving problems, but it also can become obstructive, creating a bottleneck when all decisions and responsibili-ties go through one person. A good leader has chosen his or her associates well and must empower them. Trusted allies will support their leader and enable that individ-ual to achieve much more than one can achieve alone.

Of course, delegation and empowerment of other team members can have a downside. If other members of the team develop solutions and move ahead with a plan that is not aligned with the leader’s vision, the rest of the workforce will have unclear direction and receive mixed messages about their responsibilities and roles. Thus, constant communication with allies and the team is necessary and should emphasize gratitude for what they are doing and the need, while in crisis mode, to communicate their actions and intentions to the leader. In moments of crisis, most leaders want to be completely informed and to have a chance either to be the official conduit for communication or to have the opportunity to modulate the discussion, so the message matches their vision.



.

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

• Generate support from the constituency. Buy-in from all individuals affected will hasten achievement of the goal. Consultation and engagement to the extent possible will contribute to feelings of ownership. A key element will be appealing to constituents’ shared values, the sense that they are involved in a worthy and just cause, and that the cause is aligned with the mission/vision of the organization. Crisis management requires identifying the “north star” and following it.

• Manage the relationship with superiors and constit-uents. In times of crisis, a leader must show support for the decisions of the leadership of the entire organization and simultaneously listen to constituents and decide when and how to communicate upward their feelings. The more intense the crisis, the more difficult it will be to question the top officials’ decisions, and the leader may have to “sell” them to his or her constituency.

• Define the magnitude of the crisis. Leaders and their constituents feel comfortable following strategies that they have helped to craft. Crisis management, par-ticularly in severe crisis, may require that we ignore elements of a strategic plan that until that time have been guiding our actions (key performance indica-tors, finances, volume of patients seen, and so on). One should be very careful about declaring a “crisis” as such, but COVID-19 is unprecedented and will require that we concentrate on “navigating through these difficult storms” rather than following the path decided upon. During the management of a crisis, leaders must strike the balance between two differ-ent activities: those related to the management of the crisis and those associated with more routine business. It must be clear to the followers whether the leader’s actions are related to management of the crisis or conduct of business. The former will be asso-ciated with a more authoritarian style, whereas the latter lends itself to a more democratic style. Clarity regarding management mode will allow everyone to function effectively.

• Be resilient (and patient). The anxiety and the fears that followers feel as a result of the crisis will fre-quently manifest as criticism of the actions the leader takes. The leader’s authority, judgment, and style may be questioned. Leaders must muster all the resilience possible to maintain inner calm, confidence, and the ability to take the high road. This is not a time to feel hurt, victimized, or to seek justice. This is a time to stand tall, acknowledge the criticism, and move for-ward without thoughts of retaliation. Taking the high road will inspire followers and provide support and an example to all.

I want to commend the College’s officials, mem-bers, and staff for taking the high road throughout the COVID-19 outbreak and the mostly peaceful protests this summer. You have repeatedly shown a commit-ment to doing what is best for the surgical patient. The long-term effects of these crises may linger for some time. I have every confidence that we will get through this period together because of your leadership. ♦

Leaders and their constituents feel comfortable following strategies that they have crafted. Crisis management, particularly in severe crisis, may require that we ignore elements of a strategic plan that up to that time have been guiding our actions.



Letters to the Editor@

To whom it may concern,

Dear sir or madam,@

@ To whom it may concern,

Dear sir or madam,@


Dear sir or madam,@

Editor’s note: The following comments were received regarding recent articles published in the Bulletin.

Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to [email protected], or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.

Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.

The future of surgery is female Over the last decade, the number of women entering surgical training has increased. In the U.S., the number of women in general surgery residency programs has doubled from 20 years ago.1 On the other side of the globe, the College of Surgeons of East, Central and Southern Africa saw a drastic increase in women trainees from 8 percent to 23 percent just in the last three years (see related story, page 51).2 Moreover, aspiring and new surgical trainees are emerging leaders, as shown in the student session on trainee involvement in global surgery at the American College of Surgeons Clinical Congress 2019, which was entirely organized by women medical students and residents.

Thanks to many trailblazing women, progress is clearly being made toward parity. With women often outnumbering men in medical schools, the future is promising for gender balance in surgery. However, has the surgical training environment and culture kept pace with this change? Can these women climb the ladder from trainee, to consultant, to professor in the same way as their male counterparts do?

A recent survey of practicing women surgeons in the U.S. showed that nearly 60 percent reported having experienced sexual harassment, versus 25 percent of men.3 Another study revealed gender bias in evaluations of women residents in surgical training programs.4 Beyond gender-based discrimination and aggression at the micro-level, systemic inequities and structural sexism persist in surgery.

Women are still paid significantly less than men. In Canada, women surgeons were found to be paid 24 percent less per hour spent operating than men.5 Itum and colleagues also found that only half of U.S. residency programs offer paid parental leave.6 These disparities create a toxic working environment that makes balancing surgical training with family life more difficult for women. It is no surprise that the attrition rate for women surgical trainees is higher than for men.7

The further we look on the hierarchical ladder, the fewer women we find. In the U.K., the percentage of women consultant surgeons in 2019 was 12.9 percent.8 In 2017, Epstein analyzed the literature on full professorships in surgery and found that the number of


COMMENTARY


Dear sir or madam,@

COMMENTARY

women was so low, and the increase so slow, that it would take 120 years to reach gender parity.9

It is important to celebrate the increase in the number of women entering surgery. However, we need to do more to retain, nurture, and maximize their potential. Women trainees and surgeons must be treated better. Accountability measures for sexual harassment, microaggressions, and all forms of gender-based discrimination must be implemented.

Policy changes should be made to accommodate family planning and to prevent the penalization of childbearing. This step will not only encourage more women to climb the career ladder, but also may improve their male colleagues’ quality of life because men also benefit from parental leave. The relationship between physician wellness and patient outcomes is clear.10 Thus, surgical training programs owe it to patients to make surgical training a period when trainees can thrive both professionally and personally, regardless of gender.

As we start a new decade, we should acknowledge that the future of surgery is female. It is time for surgery to shift away from its patriarchal norms and better accommodate the new, eager female workforce. Bringing gender parity to the surgical workforce is an opportunity to increase the attractiveness of surgical training and improve patient care.

Zineb Bentounsi, MD Oxford, U.K.Eliana E. Kim

San Francisco, CAXiya Ma, MSc

Montréal, QC

REFERENCES1. Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H.

The climb to break the glass ceiling in surgery: Trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-572.

2. Odera A, Tierney S, Mangaoang D, Mugwe R, Sanfey H. Women in Surgery Africa and research. Lancet. 2019;393(10186):2120.

3. Nayyar A, Scarlet S, Strassle PD, et al. A national survey of sexual harassment among surgeons. American Surgical Congress 2019. Abstract 85.06. Available at: www.asc-abstracts.org/abs2019/85-06-a-national-survey-of-sexual-harassment-among-surgeons/. Accessed June 5, 2020.

4. Gerull KM, Loe M, Seiler K, McAllister J, Salles A. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg. 2019;217(2):306-313.

5. Dossa F, Simpson AN, Sutradhar R, et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA Surg. 2019;154(12):1134-1142.

6. Itum DS, Oltmann SC, Choti MA, Piper HG. Access to paid parental leave for academic surgeons. J Surg Res. 2019;233(1):144-148.

7. Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist study. Lancet. 2019;393(10171):541-549.

8. The Royal College of Surgeons of England. Statistics. Women in surgery. Available at: www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics/. Accessed June 5, 2020.

9. Epstein NE. Discrimination against female surgeons is still alive: Where are the full professorships and chairs of departments? Surg Neurol Int. 2017;8:93.

10. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. Int J Behav Med. 2015;22(6):683-698.



The role of the site reviewer:

THE ROLE OF THE SITE REVIEWER

by Tony Peregrin

Ensuring patient-centered standards for optimal patient outcomes



Editor’s note: Because of the coronavirus disease 2019 (COVID-19) pandemic, the American College of Surgeons (ACS) Quality Programs are exploring innovative virtual options for the traditional in-person site visit. Each ACS Quality Program suspended on-site visits during the pan-demic and has developed a proposed plan and agenda for conducting these reviews in the future. Pilot sites for alternative approaches are being identified this summer. The ACS will provide updates on these programs as they become available.

Each of the ACS quality improvement (QI) accred-itation and verification programs is a singular entity tasked with the responsibility of verifying

compliance with the standards established for that particular specialty. All of the programs feature the same general structure: application, pre-review ques-tionnaire (PRQ), site visit, assessment, and facility report.

This article focuses on requirements for the site reviewer role, characteristics shared by productive reviewers, and real-world examples of process improve-ments tied to reviewer assessment.

At present, 388 surgeons serve as site reviewers for the following ACS accreditation and verification programs, collectively known as the ACS Qual-ity Programs: the Accredited Education Institutes, the Children’s Surgery Verification (CSV) Quality Improvement Program, the Commission on Cancer

(CoC), the Metabolic and Bariatric Surgery Accredita-tion and Quality Improvement Program (MBSAQIP), the National Accreditation Program for Breast Cen-ters (NAPBC), the National Accreditation Program for Rectal Cancer (NAPRC), and Trauma Verification and Review Committee (VRC) (see Figure 1, page 20). Pro-gram standards criteria range from 20 to 200 standards or more depending on the specialty (CSV and Trauma have the highest number of standards because of the complex nature of those specialties).

According to the Optimal Resources for Surgical Qual-ity and Safety manual (also known as the Red Book), “In high reliability organizations (HROs), the focus is on development and implementation of effective sys-tems, transparency, and teamwork. The intent is to bring process failures and systemic issues to light and to solve them in a nonpunitive way. Lessons learned from analysis of errors are shared as best practices in order to mitigate future errors.”1

The Red Book also identifies specific concepts that reinforce the principles of high reliability, including standardization of best practices that reduce unwar-ranted variation and optimizes reproducible outcomes.1

“When care is standardized, variation arises only because of differences in patient needs or resources,” according to the manual. “Standardization accentuates deviations from best practices, making them easier to spot than if every health care provider used a different approach to deliver care.”1

Site reviewers, previously referred to as “surveyors,” are trained members of the health care team that assist facilities in identifying gaps in their adherence to stan-dards, enabling HROs to continue to provide consistent, high-quality care to the surgical patient.

Accreditation standards enhance quality of careThe ACS Quality Programs collectively accredit and/or verify more than 3,000 hospitals. Studies examining the effectiveness of these programs suggest that the

HIGHLIGHTS• Identifies how accreditation standards

enhance quality of care

• Describes the qualities of effective site reviewers

• Provides examples of process improvements developed from reviewer feedback

• Summarizes the College’s initiative to align ACS Quality Programs to enhance client experience



levels of care necessary to meet accreditation standards lead to improved quality of care.

For example, a study published in the Journal of Trauma examined the effect of preparing for and achieving ACS Level I trauma verification on patient outcomes and hospital performance. After evaluating 1,098 trauma patients admitted to a facility in 1994, and 1,658 patients admitted in 1998, the authors con-cluded, “Trauma system improvement as related to achieving ACS Level I verification appeared to have a positive impact on survival and patient care,” with a notable decrease in mortality for severely injured patients, a marked decrease in average length of stay, and an estimated cost savings for 1998 of more than $4,000 per patient.2

Another study published in the Journal of the Amer-ican College of Surgeons compared bariatric surgery outcomes in U.S. accredited versus nonaccredited centers based on a review of 13 studies that covered more than 1.5 million patients. Researchers found that “10 of the 13 studies identified a substantial benefit of Center of Excellence accreditation for risk-adjusted outcomes, and six of the eight studies reported a con-siderable reduction in mortality in patients operated on in Centers of Excellence.”3

ACS CoC accreditation programs also have been linked to improved outcomes. A survey of the CoC and NAPBC program participants revealed more than 90 percent of respondents displayed a “high level of agreement that accreditation is regarded as important in improving oncologic outcomes through compli-ance with standards that include continuous quality improvement.”4

Although the literature suggests that accreditation standards are linked to improved quality of care, the Red Book notes a “paucity of research that evaluates accreditation status and surgical quality” and states, “...further research to specifically address outcomes at accredited institutions will better illuminate the specific structural components of care that may be associated with improved outcomes.”1

Requirements to serve as a reviewerThe minimum qualifications for the site reviewer role vary by program, but generally the requirements are organized into three main components: credentials/affiliations and skills and knowledge.5-8 A site reviewer must be in active practice in a clinical, academic, or administrative role and employed or affiliated with the corresponding ACS-accredited program. As for the skills and knowledge component, reviewers should have an extensive and demonstrable knowledge of the current standards, significant knowledge of specialty registries where applicable, and strong verbal and written com-munication skills.5-8 The site visit team typically includes one to five members, depending on the program and site request (the average is a three-person team), with one individual designated as the lead reviewer.

“Certain requirements are in place that are unchangeable,” including that the reviewer is active in the specialty, according to Daniel Margulies, MD, FACS, professor of surgery, Cedars-Sinai Medical Center; chief section of trauma, emergency surgery and surgical intensive care, University of California-Los Angeles, David Geffen School of Medicine; and Chair, ACS VRC Program Committee. “An older sur-geon who is no longer active will not be allowed to continue to do reviews. We actually remove them as reviewers within one year of retirement. In terms of the young reviewers, there’s a requirement that they have to have been a trauma director or director of a service like the surgical intensive care unit, and gener-ally a very young, inexperienced person is not going to be in that role,” said Dr. Margulies, who became a VRC reviewer in October 2011.

Teresa LaMasters, MD, FACS, FASMBS, DABOM, medical director, bariatric surgery, UnityPoint Clinic Weight Loss Specialists, Des Moines, IA, and a reviewer for MBSAQIP since September 2014, noted that capable reviewers generally have been in practice seven to 15 years.

Someone who has been in practice for five to seven years and is invested in learning about quality

Dr. Margulies

continued on page 21


could definitely be a good site reviewer, Dr. LaMas-ters added. “But a lot of surgeons early in their careers are focused on practice building. And some of them have not really learned the principles behind quality improvement. I think that seven-year mark is ideal because these physicians have some experi-ence, they’re excited to learn, and they have some time to commit to doing this.”

Site reviewers must be willing to commit six to 12 hours per site visit, with an additional two to four hours for preparation and f inal review. Depending on the program, each reviewer should plan on participating in four to eight site visits a year as specif ied in the individual specialty site reviewer agreement.

Linda Farkas, MD, FACS, a site reviewer for NAPRC, and professor of surgery with University of Texas-Southwestern, Dallas, noted that time-related barriers are a significant challenge in recruiting new reviewers. “There are a lot of surgeons whose salaries are based on revenue, or they’re in a busy practice where they’re just not afforded the time to take off to be on a site visit,” explained Dr. Farkas. “In those instances, surgeons would have to use their vacation time, or the revenue’s going to be down. If we had more reviewers, especially if we could get more surveyors distributed across the country, then maybe the time commitment wouldn’t be so bad—so the reviewer in Florida doesn’t have to f ly to Washington if we can have a reviewer who lives in Oregon.”

Site reviewers are compensated for their time and effort. The College provides an honorarium to each reviewer, which generally is used to cover the cost of travel expenses. Although the honorarium is a prac-tical benefit, reviewers are motivated to take on this role for a variety of reasons—from an interest in refin-ing the accreditation/verification process to learning best practices employed at other institutions.

“I had undergone a site review in a previous system, and that site review was really unsatisfying

for me,” said Dr. LaMasters. “The previous system would isolate each member of the team in something like an interrogation room in an effort to identify problems rather than work with the whole team together to talk through processes and understand the reasoning behind the processes. When I came in as a site reviewer, I felt like that approach should be completely f lipped on its head. The team should be kept together. The physician leadership should be there, and it should be an open, collaborative pro-cess for learning rather than an isolating process.”

Peter Hopewood, MD, FACS, a site reviewer for both the CoC and NAPBC, and a surgeon with Cape Cod Healthcare Cancer Programs, Falmouth, MA, said he became a reviewer to gain exposure to inno-vative quality improvement practices.

“I’m in Cape Cod, so I’m a little out of the main-stream,” Dr. Hopewood said. “I’m not in an academic hospital, I’m in a community hospital, and the initia-tives (clinical trials, community outreach activities) that are happening in the academic teaching centers can take years to filter down into the community hospitals. However, as a reviewer, I’m visiting these centers and I’m observing cancer conferences as part of the site visit, and I’m talking to all the specialists. I learn a lot. So, it’s helping my practice and improv-ing the care I give to my patients.”

Qualities of effective reviewersEffective site reviewers share specific personality and leadership traits, including a collaborative approach to and an innate interest in quality improvement starting at the local level. For example, site reviewers often are involved in their hospital’s QI committee or are peer reviewers or case reviewers for a medical board or jour-nal before taking on the site reviewer role.

“When selecting a reviewer, we look for some-one who is actively doing this in their own center,” said Douglas C. Barnhart, MD, MSPH, FACS, FAAP,


Dr. LaMasters



FIGURE 1. ACS QUALITY PROGRAMS


who started his role as a CSV reviewer in January 2017. Dr. Barnhart is a professor, division of pediat-ric surgery, University of Utah School of Medicine, and medical director for surgical patient safety and quality, Primary Children’s Hospital, Salt Lake City, UT. “Reviewers should know from their own experi-ence which standards are hard and which ones are aspirational. Effective reviewers will recognize the struggles involved in solving some of these problems and will appreciate the work that’s been done, rather than focusing only on the gap. I always introduce the fact that I come from a center that’s been through the verification part, and that we appreciate all the work that they’ve gone through. Reviewers should also be actively practicing clinicians. Our foremost goal is improving patient care, and in order to do that, reviewers should have ongoing, direct experience in caring for patients.”

“As a site reviewer, you have to be patient and a little charismatic,” said Dr. Farkas. “Team members at the site may be a little nervous when you come in because you’re a surgeon and a site reviewer, and they may be program nurse coordinators, for example, and feel like their job is on the line with this survey.” She added, “The purpose of the survey is not to be puni-tive; it is to give hospitals feedback so that they can get over any impediments necessary for accreditation.”

According to Dr. LaMasters, “You have to be able to articulate the entire vision of the accreditation pro-cess and goals and spirit on the positive side, not just the negative side, and to do it in a way that I think really inspires them to want to continue to improve their quality, to see where they can go next, to not be complacent or content simply because they passed.”

“It’s just not about checking a box, indicating the hospital was compliant or not compliant, and that’s why it’s so critical for us, across all of our programs, that we pick the right people to do these site visits, be they surgeons, nurses, other physician specialists, or others,” said Teresa Fraker, MS, RN, Program Admin-istrator, MBSAQIP. “Because that’s what our sites are

paying for, more than data registries or anything else—the education, the consultation, the mentoring, and the sharing of best practices that our reviewers offer them.”

Preparing for a site visitACS accreditation/verification programs share some similar practices based on compliance with patient-centered standards. For example, each program has a manual that outlines the optimal resources for care of the patient served in each program.9-11

Each program also employs varying business pro-cesses for verifying and accrediting participating facilities. For example, during the verification review process, a trauma center is assessed on criteria out-lined in the ACS Trauma Programs’ standards manual, including volumes of severely injured patients, 24-hour availability of trauma surgeons and other specialists, surgical capabilities, and availability of specialized equipment. Based on the review, the trauma center is categorized as Level I, II, or III.12

The site review process generally occurs in four phases: reviewer selection, pre-site visit preparation, site visit, and report generation.

A notable component of the pre-site verification process is the completion of a pre-review document. For most programs, such as trauma and CSV, this document is the PRQ. These questionnaires inform reviewers of the existing care capabilities of the hos-pital or center before the on-site review.13

“These site visits aren’t intended to be a surprise inspection with some element for which people aren’t prepared,” said Dr. Barnhart. “For example, when we had our site visit here, I knew we had some areas of weakness, having read the criteria and having been on some of these site visits. I knew we had some prob-lem areas that we were in the process of solving but had not completely solved. And in my introductory comments to our site visit, I said, ‘Look, I want to tell you about our place. I want to tell you about our strengths, and I want to show you two things that


Dr. Farkas


we’ve struggled with. I’m going to show you our audit data.’ That’s really what we’re looking for places to do. If you know your weaknesses, and you’re committed to performance improvement, you’ll solve your weak-nesses,” Dr. Barnhart said.

“We’re not saying that you have to be perfect, but we are saying you should have a process in place to look at your mistakes, think critically about them, and work to make a sustainable change in your program that addresses problems more generally than just look-ing at outcomes,” added Dr. Margulies.

“I tell the team that throughout the day I’m going to look for things that they can do better, and that doesn’t mean that they’re not doing a great job. We all can learn to do things better,” said Dr. LaMasters. “I try to engage each person in the team around the standards and how they apply to this part of the site visit. It’s not just about the case that we’re auditing, it’s really about how you develop the team culture to get everybody behind a process improvement that came from this adverse event.”

Process improvementsSite reviewers identify patient care challenges across a spectrum of clinical topic areas and offer suggestions for improvements in administrative processes related to equipment needs, scheduling and job sharing, and time management.

“One program was able to arrange one-stop shop-ping for its patients so that they can get their CEA [carcinoembryonic antigen], their CAT [computerized axial tomography] scan, and their MRI [magnetic res-onance imaging] in one day,” said Dr. Farkas, noting that such strengths are institution-specific and may be difficult to achieve at every site.

Dr. Margulies offered another example of a process improvement, one that a site reviewer to his institu-tion sought to replicate at his center. “The use of whole blood is new in trauma. We developed a mobile refrig-erator so that the blood that is sent out to trauma is

kept at a specified temperature, rather than in a cooler where the blood warms up and is basically wasted if it is not used,” Dr. Margulies said.

Dr. Hopewood said a process improvement his insti-tution is adopting—based on what he encountered as a site reviewer—involves decreasing emergency room (ER) visits and unexpected admission for chemotherapy patients. “Some programs preemptively call patients early in the morning to ascertain how they are feel-ing. Certain chemotherapy regimens result in potential diarrhea or neutropenia, and targeting those patient populations and leaving room for empty appointments later in the day can reduce visits to the ER, resulting in better quality of care,” Dr. Hopewood said.

Dr. LaMasters said process improvements often entail understanding why the standard was created and realizing the difference between “the letter of the law and the spirt of the law.”

“The letter of the law might state that you have to have equipment that is weight-based appropriate for our patients, but the spirit of the law means under-standing that you can’t have only one chair in your waiting room that is appropriate for a person of size because often family members may also be of size,” explained Dr. LaMasters. “Understanding that the con-cept of this standard is to help the entire institution recognize and be sensitive to patients of size and to be prepared to care for those patients wherever they occur in the institution—even though I’m specifically reviewing the sites where bariatric surgery patients will go,” she said.

Aligning ACS Quality ProgramsTo unify ACS quality programs, the College launched a project in July 2017 to enhance both the site reviewer and the client experience. Although each program was originated with the similar aim of improving surgical care, the models to achieve that goal varied by specialty.

The ACS alignment team identified three goals to unify ACS Quality Programs, including the development


Dr. Hopewood


of a shared information technology platform, similar site visit and performance reports, and a common standards framework and template, including both the formatting and branding of the standards manuals. This updated standards framework com-prises nine standard domains:

• Institutional administrative commitment

• Program scope and governance

• Facilities and equipment resources

• Personnel and services resources

• Patient care: Expectations and protocols

• Data surveillance and systems

• Quality improvement

• Education: Professional and community outreach

• Research

In 2019, the MBSAQIP was the first program to translate its standards into the new framework, successfully meeting one of three goals the ACS established to unify these programs. Other programs migrating to the new standards format this year include:

• GSV: July 2019

• CoC: October 2019

• NAPRC: May 2020

• Trauma: 2021 (Q1)

• CSV: 2021 (Q1)

• NAPBC: late 2021


REFERENCES1. Hoyt DB, Ko C (eds). Optimal Resources for

Surgical Quality and Safety. Chicago, IL: American College of Surgeons; 2017.

2. DiRusso S, Holly C, Kamath R, et al. Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma. 2001;51(2):294-299.

3. Azagury D, Morton JM. Bariatric surgery outcomes in U.S. accredited vs non-accredited centers: A systematic review. J Am Coll Surg. 2016;223(3):469-477.

4. Knutson AC, McNamara EJ, McKeller DP, Kaufman CS, Winchester DP. The role of the American College of Surgeons’ cancer program accreditation in influencing oncologic outcomes. J Surg Oncol. 2014;110(5):611-615.

5. American College of Surgeons. Quality Programs. National Accreditation Program for Rectal Cancer. Become an NAPRC site reviewer. Available at: facs.org/quality-programs/cancer/naprc/site-reviewer. Accessed March 17, 2020.

6. American College of Surgeons. Quality Programs. Commission on Cancer. Become a site visit reviewer. Available at: facs.org/quality-programs/cancer/coc/become-site-reviewer. Accessed March 17, 2020.

7. American College of Surgeons. Quality Programs. National Accreditation Program for Breast Centers. Become a site reviewer. Available at: facs.org/quality-programs/napbc/become-reviewer. Accessed March 17, 2020.


Dr. Barnhart

REFERENCES, CONTINUED


In March 2019, the ACS Quality Portal (QPort) was com-pleted, successfully meeting another goal in the alignment process. The MBSAQIP was the first to migrate to QPort, and other quality programs will be migrating to the portal in the near future.

Alignment efforts are intended to provide consistent, high-quality experiences to all our hospitals participating in ACS Quality Programs. By providing a consistent framework for the standards manuals, portal, and reports for all ACS verifica-tion programs, the ACS aims to bring QI and leadership teams at participating hospitals together to work toward surgical quality within their institutions. The objective is to provide a road map of strengths and opportunities for improvement.

ACS Quality Programs in the futureWith more than 105 years of experience in QI, the ACS con-tinues to define the standards necessary to provide optimal patient care across all surgical specialties. The College’s ongo-ing commitment to this goal continues with the development of a new standards-based program—a verification program based on the Optimal Resources for Surgical Quality and Safety, with pilot visits occurring over the last year.14,15

Site visits are an essential component of achieving qual-ity in all phases of surgical care. Standardizing the College’s approach to verification and accreditation processes for both established and new Quality Programs will likely enhance the effectiveness of site reviews.

“Participation in accreditation programs does not guar-antee high-quality care,” note the authors of the Red Book, “but it does demonstrate a commitment to such aims.”1 The authors assert that “clearly defined roles and responsibili-ties, coupled with appropriate resources and support” can lead to improved patient outcomes, shorter lengths of stay, and a reduction in costs. ♦


8. American College of Surgeons. Quality Programs. Verification, Review, and Consultation Program. VRC site reviewer criteria and application. Available at: facs.org/quality-programs/trauma/tqp/center-programs/vrc/reviewer. Accessed March 17, 2020.

9. American College of Surgeons. Quality Programs. Verification, Review, and Consultation Program. The VRC consultation process. Available at: facs.org/quality-programs/trauma/tqp/center-programs/vrc/process. Accessed March 17, 2020.

10. American College of Surgeons. Quality Programs. Children’s Surgery. Children’s Surgery Verification. Available at: facs.org/quality-programs/childrens-surgery/childrens-surgery-verification. Accessed March 17, 2020.

11. American College of Surgeons. Quality Programs. Commission on Cancer. Apply for accreditation. Available at: facs.org/quality-programs/cancer/coc/apply. Accessed March 17, 2020.

12. Bost SJ, Ball JN, Sanddal ND, et al. ACS COT leads study to develop comparative data on trauma care organization. Bull Am Coll Surg. 2020;105(4):43-48. Available at: bulletin.facs.org/2020/04/acs-cot-participates-in-study-to-develop-comparative-data-on-trauma-care-organization/. Accessed June 19, 2020.

13. American College of Surgeons. Quality Programs. Commission on Cancer. Site visit preparation. Pre-Review Questionnaire. Available at: facs.org/quality-programs/cancer/coc/accreditation/site-visit-prep. Accessed March 17, 2020.

14. Hoyt DB. Executive Director’s annual report. Bull Am Coll Surg. 2019;104(12):37-53. Available at: bulletin.facs.org/2019/12/2019-executive-directors-annual-report/. Accessed April 1, 2020.

15. Puls MW, Hughes TG, Sarap MD, Caropreso PR, Nakayama DK, Welsh DJ. New ACS-led verification program aims to improve care for rural surgical patients. Bull Am Coll Surg. 2020;105(4):24-28.

The Surgical Metrics Project:

What was achieved, and where is it headed?

| 25JUL 2020 BULLETIN American College of Surgeons

THE SURGICAL METRICS PROJECT

by Carla Pugh, MD, PhD, FACS; Cassidi Goll; Anna Witt;

Hossien Mohamadipanah, PhD; and Brett Wise



Clinical Congress 2019 provided the opportu-nity for surgeons to participate in The Surgical Metrics Project. A total of 255 attendees visited

The Surgical Metrics Project booth to explore the use of wearable technologies as a means of measur-ing surgical decision making and surgical technique. Spearheading the effort is Carla M. Pugh, MD, PhD, FACS, coauthor of this article and professor of surgery, and her research team at the Technology Enabled Clinical Improvement (T.E.C.I.) Center, Stanford University, CA. The initial goal of The Surgical Met-rics Project is to enable information exchange and facilitate data sharing. It is imperative that surgeons lead the discussion about how their data should be managed and applied.

The Surgical Metrics Project exhibit contained 10 surgical simulation stations where participants were equipped with wearable technologies and asked to “run the bowel” and perform an open repair of any small bowel enterotomies identified in a segment of porcine intestines.

Participation in The Surgical Metrics Project Upon entering The Surgical Metrics Project exhibit, participants completed a one-page demographic survey. A summary of the survey results are shown in Figure 1, page 27.

After providing their demographic information, participants were fitted with a wearable electroenceph-alography (EEG) sensor to record and measure brain activity (see Figures 2a–2c, page 28). The sensors were attached to their foreheads, at which point participants were led to the cognitive testing area to undergo a base-line assessment of their cognitive skills.

Participants were then outfitted with magnetic motion-tracking sensors on their hands and an audio recorder on their lab coat. Once participants were fully instrumented with the wearable technologies (see Figure 2d, page 28), they stepped into one of the

THE SURGICAL METRICS PROJECT RESEARCH ADVISORY BOARD MEMBERS• Peter Angelos, MD, PhD, FACS

• Megan Applewhite, MD, FACS

• Jo Buyske, MD, FACS

• E. Patchen Dellinger, MD, FACS

• David Hoyt, MD, FACS

• Carlos Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

• Steven Stain, MD, FACS

• Patricia Turner, MD, FACS

COMMITTEE ON SURGICAL SKILLS TRAINING FOR PRACTICING SURGEONS • Barbara Bass, MD, FACS, FRCS(Hon),

FRCSI(Hon), FCOSECSA(Hon)

• Ajit Sachdeva, MD, FACS, FRCSC, FSACME

10 simulated surgical environments equipped with two video cameras, a stopwatch, one surgical assis-tant, and all of the surgical tools necessary to operate on their “patient.”

The research team used a template and surgi-cal tools to pre-injure the porcine tissue in the lab such that each surgeon was presented with the same case. Surgeons had varying completion times and approaches to the procedure. The team was able to capture all of these preferences and individual

decisions using magnetic motion-tracking sensors, audio recorders, video cameras, and EEG sensors.

Upon completion of the simulated surgical pro-cedure, researchers documented the surgeon’s procedure time and performed a leak test to deter-mine the quality of the repair (see Figure 2e, page 28).

The standardized operative surgical task and wearable technologies allowed the team to collect baseline data to better understand how surgeons’



FIGURE 1. SURVEY RESPONDENT DEMOGRAPHICS (N = 255)


The Surgical Metrics Project exhibit featured 10 surgical simulation stations



Above and right: Participant engaging in the baseline cognitive assessment

with the EEG on his forehead

Four wearable technologies were used to capture video, audio, motion, and EEG data from participants

After each participant indicated they had completed the procedure (or their allotted time of 15 minutes ran out), researchers clamped one end of the bowel and inserted

a motorized pump into the other end to perfuse liquid through the bowel to determine the integrity of the repair

FIGURE 2. THE SURGICAL METRICS PROJECT IN ACTION

2a

2b

2a

2d

2c

2e



ADDITIONAL INFORMATION

Additional information and videos about The Surgical Metrics Project are available at the following links:

• Surgeons test new wearable tech that helps measure operating skills: CBS SF Bay Area KPIX: https://sanfrancisco.cbslocal.com/2019/11/14/surgeons-test-new-wearable-tech-that-helps-measure-operating-skills/

• Stanford Medicine: The metrics of surgery: https://youtu.be/GUQzBW7WfTc

decision making, technical skill, and communication strat-egies contribute to procedural outcomes.

Reactions to The Surgical Metrics ProjectThe Clinical Congress News, the daily paper published during the conference, queried participants for their ini-tial reactions to The Surgical Metrics Project. “It’s really important to get baseline data in terms of where surgeons in practice are—in both their cognitive and technical abili-ties,” said Sabha Ganai, MD, PhD, FACS, Springfield, IL.

Arthur Berg, DO, Hackensack, NJ, said, “This is an interesting way to see and quantify variations of sur-geon techniques in terms of different movements and different decisions. It’s really great that they’re actu-ally using objective data—EEG monitoring—to see the different variations in technique, and it will be cool to see the differences between beginners and more highly trained, experienced surgeons.”

“This can help us to understand what the differences are between novices and experienced surgeons. Once we understand the differences, we’ll be able to get novice surgeons looking more like experienced surgeons in a shorter period of time. The value is getting lots of people to do it, so having it here at Clinical Congress is a great chance to get real data that will yield real results,” said David M. Notrica, MD, FACS, FAAP, Phoenix, AZ.

In addition to the anecdotes shared with the Clinical Congress News, several participants engaged in The Surgi-cal Metrics Project conversation on Twitter. A tweet by Andrew S. Wright, MD, FACS, Seattle, WA, described

Tweet by Andrew S. Wright, MD, FACS, Seattle, WA, describing his experience with The Surgical Metrics Project As The Surgical Metrics Project database grows,

Stanford researchers anticipate that they will gain a clearer understanding of the variance in surgical

decision making and technical approaches



FIGURE 3. ATTITUDES REGARDING DATA AND ASSESSMENT (N = 255)

his experience with The Surgical Metrics Project and encouraged others to participate (see photo, page 29).

Paving the way for a new frontier of data-driven metrics to advance quality, The Surgical Metrics Project aims to include all members of the surgical community in the conversation regarding data use and data sharing. As part of The Surgical Metrics Proj-ect data collection, Dr. Pugh and her research team had the opportunity to gauge participants’ attitudes regarding data and assessment. For the responses, see Figure 3, this page.

Looking forward Ongoing data analysis is now taking place and with guidance from The Surgical Metrics Project Advi-sory Board (see sidebar, page 26), Dr. Pugh and her research team will determine how to distribute feed-back to participants. The overall goal is to develop an anonymous database of video, motion, and audio data to facilitate surgical planning, training, and review.

“The Surgical Metrics Project is the foundation of assessing surgical technique,” according to American College of Surgeons Executive Director David B. Hoyt, MD, FACS. “Once validated it can define how we might measure skills acquisition, obtain mastery, and even demonstrate deterioration of skills over time.”

The College is proud to announce the continuation of its strategic partnership with the T.E.C.I. Center and plans to continue offering The Surgical Metrics Project at Clinical Congress. ♦

Authors’ noteThe T.E.C.I. Center is a research group directed by Dr. Pugh that aims to transform human health and welfare through advances in data science and personalized, data-driven performance metrics for health care providers. More infor-mation about the T.E.C.I. Center is available at http://med.stanford.edu/tecicenter.html.


EARLY SURGEONS IN ST. AUGUSTINE

Surgeons appointed by Spanish royalty contributed to development of oldest U.S. city:

St. Augustine, FL

by John D. Ehrhardt, Jr., MD,

and J. Patrick O’Leary, MD, FACS

Editor’s note: The American College of Surgeons History and Archives Committee (formerly the Surgical History Group) hosts an annual poster session at Clinical Congress. The following article is based on the second-place winner of the poster competition at Clinical Congress 2019 in San Francisco, CA. An article based on the first-place poster was published in the April issue of the Bulletin.

Surgeons played an active role during 16th century conquistador explorations of Flor-ida and the later development of a Spanish

colony at St. Augustine, settled in 1565 and recog-nized today as the oldest continuously occupied European-established settlement in the continental U.S. However, limited access to health care was a significant barrier to cultivating the colony. Surgeons, both free and imprisoned, faced adversity and treated early settlers and soldiers using scarce supplies. As the colony grew, surgeons became community leaders, often enjoying royally appointed positions and open lines of communication with the Spanish crown.

Surgeons during conquistador expeditionsJuan Ponce de León (see Figure 1, page 33) is regarded as the first documented conquistador to explore the Florida coast in anticipation of establishing a

Spanish colony. His first Florida voyage landed along the northeast peninsular coast near modern-day St. Augustine in 1513. That expedition explored Flor-ida’s east coast, the Florida Keys, the Dry Tortugas, and parts of southwest Florida until a tropical squall sent their ships back to Puerto Rico.1 The entourage returned to Florida’s Gulf Coast in 1521, the region where foul weather had abruptly halted their first voyage.2 During that mission, Ponce de León unwit-tingly became the first documented surgical patient in the continental U.S.2

As soldiers unloaded supplies onto a remote island near what is now Fort Myers, they were ambushed by Calusa natives, a then-dominant tribe in Southwest Florida. Ponce de León suffered a penetrating arrow shot in a vulnerable area of the groin caught between two plates of armor. His mariners bolstered a respectable defense against Calusa archers and carried their commander to safety. The ship surgeon removed the arrow and controlled hemorrhage, but Ponce de León soon developed shock. Although unnamed in expedi-tion documents, historians believe Gaspar López de Villalobos, a personal physician to Ponce de León on previous voyages, performed the procedure.3

Ponce de León’s condition worsened, and he ordered the fleet to retreat to Cuba. At the time, Havana was the nearest Spanish settlement where they could access medical supplies and possibly locate another surgeon. Ponce de León ultimately died from shock three days after arriving in Havana. Hemorrhagic shock is a possible cause of death, but he survived the initial procedure and retreat to Cuba.

Some historians have suggested his gradual dete-rioration may have been caused by a poison Calusa natives routinely applied to their arrow tips.4 They derived a toxic substance from the sap of the Manchi-neel tree, indigenous to the subtropical Everglades and the Caribbean.5 Cardiovascular, pulmonary, and neurologic sequelae from the toxin may have


HIGHLIGHTS• Identifies surgeons’ roles during 16th century

conquistador expeditions to Florida

• Summarizes how surgeon leaders were integrated into the colonial community of St. Augustine, FL

• Describes how Spanish, French, and English surgeons practiced at the Spanish Royal Hospital in St. Augustine


influenced his clinical course.6 It also is possible that Ponce de León developed bacteremia and died from septic shock, an all-too-common scenario more than 400 years before the discovery of antibiotics.

Ponce de León’s death in 1522 highlighted the challenges of New World conquest. Trauma, infectious disease, and a limited surgical workforce in the New World all plagued missions aimed at establishing a Florida colony. The remote peninsula remained wild, elusive, and unsettled for another 40 years, during which five more Spanish conquistadors attempted to settle in Florida. Hernando de Soto led the largest expedition from 1538 to 1542. The f leet landed near Tampa Bay and explored the Gulf Coast and southeast U.S. Many surgeons who arrived with the f leet likely disbanded along the harsh trek, setting up camp with native tribes, a common practice among those disaffected by conquistador brutality.

Surgeons are mentioned only a couple of times in more than 1,000 pages of narrative documents from the de Soto expedition;7 nonetheless, these few pas-sages are telling. Soldiers disliked one ship surgeon who had falsely advertised his medical and surgi-cal expertise; he later unravelled under pressure as a clinically incompetent imposter. The narrative elaborated: “There was not in the whole army more than one doctor, and he was not so skillful and dili-gent as was needed; on the contrary, he was stupid and practically useless.”8 The clinician described was little more than a Good Samaritan who had an interest in medicine, and may have spent some time lending a hand to an empiric practitioner. Spanish regulations on medical and surgical practice, though

part of established law on the Iberian Peninsula, held little weight in the untamed frontier of Florida.9

De Soto narratives later described another scene in which a Spanish settler distrusted the expedition surgeon. The patient doubted the surgeon’s ability, noting his lack of dexterity and haphazard treat-ment for a penetrating knee injury. Displeased by the clinical services rendered, the patient remarked that he would never seek the surgeon’s expertise again, even if on his deathbed. Angry with the accu-sations, the unnamed surgeon replied that he would refuse treatment if the patient returned, even under life-threatening circumstances.8 It remains unclear whether both mentions of surgeons referenced the same person. These isolated journal entries likely were dramatized to some extent but provide insight into daily struggles conquistadors faced on a Florida expedition.

Sixty years after Columbus’s first voyage in 1492, health care delivery in the New World still had its challenges across the Caribbean, especially outside of royal colonies like Santo Domingo, Dominican Republic; San Juan, Puerto Rico; and Havana. First-hand accounts of mass trauma, endemic disease, starvation, and lackluster medical care trickled back to the Spanish crown. In 1561, King Philip II decided that settling Florida was no longer worthwhile and suspended all plans for future conquistador expeditions.10

Without Spanish occupation, other European imperials began to express interest in colonizing the Florida peninsula. In June 1564, French f leets made remarkable progress along the unsettled northeast-ern coast of Florida under the leadership of René

Juan Ponce de León, Florida conquistador and first documented surgical

patient for an operation to remove a lodged

arrow from his groin (public domain image)

FIGURE 1.



Laudonnière. His voyage led a group of French Protestants known as Huguenots to construct and populate a fort near modern-day Jacksonville. They christened the settlement as Fort Caroline, making the first fortified European settlement in the main-land U.S. a French colony.11

French surgeons in Florida An unnamed surgeon at Fort Caroline contributed to French efforts to settle Florida. He integrated with native Timucua shamans and encouraged the transfer of medical knowledge and technique (see Figure 2, this page). One notable product of this exchange was the European acquisition of the medicinal sassafras plant. After the surgeon at Fort Caroline sent samples back to France, sassa-fras became popularized across Europe as a wonder drug. Spanish physician Nicolás Monardes’ 1565 monograph Historia Medicinal de las Cosas que se Traen de Nuestras Indias Occidentales (Medical Study of the Products Imported from our West Indian Posses-sions)—the first comprehensive European book

about New World medicine—featured a 20-page discussion on sassafras. One excerpt explained that the French showed the Spanish its medicinal prop-erties and acknowledged the French for treating ill Spanish colonists (see Figure 3, page 35).12 Given the imperial rivalry between the Spanish and French, it was remarkable for a Spanish physician to credit the French with exchanging New World medical wisdom during this period. A separate letter in 1565 from a Fort Caroline settler confirmed that it was the surgeon who facilitated the sassafras exchange.13

Spanish forces led by Admiral Menéndez de Avilés massacred the French at Fort Caroline in August 1565. They spared some women, children, and the surgeon, who conveyed local medical knowledge as recognized by Monardes’s 1565 text. French sur-geons, in more ways than one, proved their worth over the next 50 years in St. Augustine. Spanish ship surgeons passed through St. Augustine, but their presence was often transient and short-lived. No salary or benefits package was large enough to keep a Spanish physician stationed in the rural, dirt-road, tidal marshland of St. Augustine. Spaniards

Timucua tribe treating sick patients near Fort Caroline. Art by French Huguenot settler Jacques le Moyne de Morgues (Library of Congress)

FIGURE 2.



addressed their physician shortage in part by cap-turing French ship surgeons and holding them prisoners.

A severe storm in the winter of 1576 blew a French ship, Le Prince, ashore near Santa Elena, a Spanish post in South Carolina. Natives killed most of the crew and enslaved Frenchmen who remained. A total of 40 prisoners from the shipwreck lived and worked for the local tribe. In August 1579, Florida Gov. Pedro Menéndez Marqués issued a command that an army raid their village. Spanish forces kid-napped the native chieftain’s mother, wife, and sister, later releasing them in exchange for 16 French prisoners. Spanish authorities charged the French

with piracy in Florida waters and proceeded to exe-cute most of them. Governor Menéndez Marqués commanded they spare only a handful of French prisoners—one surgeon and three boys who could interpret native languages.14

The French surgeon was Jean de Le Compte (iden-tified in Spanish letters as Juan de LeConte). Spanish authorities soon realized Le Compte possessed med-ical knowledge and sent him to St. Augustine. Upon his arrival in late 1579, Le Compte continued his prison sentence for a grueling seven years, in which he met the medical needs of Spanish and Timucua throughout the community. His good deeds led to a promotion to chief surgeon at the military fort

FIGURE 3.

Folio from an English translation of Nicolás Monardes’ 1565 monograph, regarding French acquisition of medicinal plants at Fort Caroline, Joyfull newes out of the new found world: wherein are declared the rare and singular vertues of divers and sundrie herbs, trees, oyles, plants & stones, with their applications as well to the use of phisicke, as chirurgery...Also the portrature of the

sayde herbes, very aptly described (Courtesy of the Florida State University Libraries, Special Collections and Archives)



in 1586, a position that came with a modest salary. Because St. Augustine began as a military town, most of his patients were soldiers at the fort. Over the course of his tenure as their surgeon leader, the colony grew and expanded his clinical responsibili-ties to a larger breadth of patients.15

Le Compte was the only permanent medical figure in Florida for more than two decades. After 23 years of service, he declared that he was “old and tired and cannot support himself.”16 He requested a return trip to Europe if the royal authorities were unwilling to negotiate for higher pay. Spanish authorities declined his highball request for a tenfold salary increase. Flor-ida Gov. Gonzalo Méndez de Canço urged him to draft a formal address to the King of Spain regarding his salary and benefits as the only resident physician of the colony. As a testament of his faith and reliance upon his colony’s only permanent surgeon, Governor Méndez de Canço affixed a letter of recommenda-tion to the surgeon’s appeal for a higher salary. The monarch acknowledged the appeal and returned an offer for two-and-a-half times Le Compte’s origi-nal salary.16

Le Compte’s service in St. Augustine was para-doxical. The Spanish were not French allies, but they needed to recruit a physician to their new colony. It speaks volumes that Spanish authorities needed to capture a surgeon and hold him as prisoner to keep a resident physician in St. Augustine. He ran his clinical practice with the support of assistant surgeons and apothecaries who were less skilled.

In an August 1583 letter, Governor Menéndez Marqués wrote to the Spanish crown, mentioning Le Compte as the Frenchman who is “a surgeon” and noting the lack of Spaniards of equal skill.17 Not only was their medical competence question-able, but they arrived and departed with each new breeze that brought ships through the mouth of the Matanzas River. The king wanted French pris-oners like Le Compte sent to Spain, presumably

for trial, but Governor Menéndez Marqués refused to relinquish Florida’s only surgeon. He believed that if Le Compte left St. Augustine, “he would be very much missed, and so I determined this time to leave him here.”17

Three unnamed French surgeons were dis-cussed in letters during the latter half of the 16th century. The St. Augustine community relied on their training to meet the town’s health care needs as well as the demands of Spanish medical regula-tions, calling for a surgeon to be stationed at each Spanish military fort. On one later occasion in 1668, conf lict between Gov. Francisco de la Guerra y de Vega and French surgeon Pedro Pique ultimately led to a pirate raid on St. Augustine. Pique f led on a ship sailing toward Havana that English pirates captured. Florida medical historian William Straight later wrote about the incident,16 in which the cap-tured surgeon reportedly led the pirates back to St. Augustine and helped them gain entrance to the Matanzas River Inlet with confidential port code signals, thus facilitating a British raid on the Spanish town. Eighty civilians were killed, and the wood-frame hospital was burned to the ground.

Surgeons at the growing Florida colonyClinical practice represented only one aspect of sur-geon life in colonial Florida. Surgeons stationed in St. Augustine served primarily as general practitio-ners, but there were scattered reports of surgical procedures throughout the f irst Spanish period (1565–1763). Most surgical procedures on civilians were undocumented or only mentioned brief ly on bills and receipts. Le Compte’s service at St. Augus-tine showed that he often reduced and immobilized fractures of the upper and lower limbs in addition to treating skull fractures. He also handled pen-etrating trauma from arrows, swords, and musket balls with some regularity.



FIGURE 4.

Letters from the Second Spanish Period (1784–1821) related to surgeons in St. Augustine (East Florida Papers, Library of Congress)

Most detailed evidence for the scope of clinical sur-gery came through letters with Spanish authorities, in which surgeons at the royal hospital in St. Augustine reported their expert opinion to the crown on con-ditions of Spanish statesmen. Natives shot military leader Don Francisco Ponce de León during an upris-ing in 1705. Musket balls shattered his humerus and the standard of care warranted an amputation for the comminuted fracture. He died of hemorrhagic shock during the procedure, making it unclear whether traumatic axillobrachial arterial injury or uncon-trolled surgical bleeding led to his death. In 1727, chief surgeon Juan Frisonou documented that his patient, Gov. Antonio de Benavides, developed an abscess that required an operation. Frisonou located the painful pocket of pus between his buttocks, near the lower level of the coccyx, and commented that it impaired the governor’s ability to urinate and empty his bowels. Frustrated by the lack of surgical instru-mentation in St. Augustine, Frisonou recommended transporting the governor to Cuba. In Havana, chief physician and surgeon Carlos Del Ray drained the governor’s 7 cm perirectal abscess.16

On rare occasions, surgeons attracted negative attention to St. Augustine. As the colony grew, the problem became not the supply of surgeons but the need for well-trained surgeons who practiced responsibly. One chief garrison surgeon, Carlos Robson, was embroiled in a scandal during the 1680s. In a letter to royal authorities, colonial Gov. Juan Márquez Cabrera wrote, “Not only is he not a physician or a qualified surgeon, but also he is deprived of consciousness most of the time by being drunk.”18 Years later, concerns arose about another surgeon, and the governor wrote, “Although we have a great need for a physician, if there is not a competent one to be found, we will manage with the surgeon of the garrison who, were he not so taken by rum, is not bad, but everybody refrains from calling him.”16 Royal officials responded to the negligence by calling on the Hospitalliers de San Juan de Dios, a Catholic fraternal order devoted to providing health care in underserved areas that still exists today.19 Florida officials requested that three men come from Havana to staff the St. Augustine hospital, creating tension among local priests in



REFERENCES 1. Kelley J. Juan Ponce de León’s discovery of Florida:

Herrera’s narrative revisited. Revista De Historia De América. 1991;111(1):31-65.

2. Synder C. Don Juan Ponce de León and the first operation in Florida. J Fla Med Assoc. 1965;52(7):488-493.

3. Picaza JA. European medicine in America before Florida’s discovery: The fleet physician. J Fla Med Assoc. 1990;77(11):971-975.

4. Grunwald M. The Swamp: The Everglades, Florida, and the Politics of Paradise. New York, NY: Simon & Schuster; 2006: 24-39.

5. Cheney R. Geographic and taxonomic distribution of American plant arrow poisons. Am J Bot. 1931;18(2):136-145.

6. Duke JA. Duke’s Handbook of Medicinal Plants of Latin America. Boca Raton, FL: CRC Press; 2008: 548-553.

7. Clayton L, Moore E, Knight V, et al. The de Soto Chronicles (Vols. 1–2). Tuscaloosa, FL: University of Alabama Press; 1995.

8. Irving T. The Conquest of Florida by Hernando de Soto. New York, NY: George P. Putnam & Sons; 1869: 279, 300.

9. Lanning JT, TePaske JJ. The Royal Protomedicato: The Regulation of the Medical Professions in the Spanish Empire. Durham, NC: Duke University Press; 1985.

10. Bolton HE. The Spanish Borderlands. New Haven: Yale University Press; 1921:134.

11. Laudonnière R. A Notable History Containing Four Voyages Made by Certain French Captains unto Florida. Martin Basanier (ed). Larchmont, NY: Henry Stevens, Son & Stiles; 1964.

12. Monardes N. Joyfull Newes Out of the Newfounde Worlde, Englished by John Frampton. London: B. Norton; 1596: 46-64.

13. Covington JW. La Floride: 1565. Fla Hist Q. 1963;41(3):274-281.14. Carvajal AM. Chief Pilot Antonio Martínez Carvajal of Florida

to the Crown, Havana. Microfilm. November 3, 1579. Archivo General de Indias, William Straight Collection, Florida International University, Reel 54: 3. Accessed September 28, 2019.

15. Webster M. Medical men and medical events in early St. Augustine. J Fla Med Assoc. 1965;52(7):494-497.

16. Straight WM. Medicine in St. Augustine during the Spanish period. J Fla Med Assoc. 1968;55(8):731-741.

St. Augustine who held privileges at the hospi-tal as medico-friars. They protested the arrival of medical support from Cuba, but the crown ultimately overrode their petition and wrote an order for new hospital administrators.

The surgeon’s role in colonial Florida soci-ety has been best captured by the East Florida Papers,20 a vast repository of colonial documents from the Second Spanish Period (1784–1821) com-piled by the U.S. Library of Congress. Surgeons exchanged more than 100 letters with other surgeons, colonial Florida governors, and the Spanish crown. This correspondence speaks vol-umes, especially when considering the position of surgeons in Europe, who had less social status than physicians, training as apprentices and practicing their craft without a formal medical education.21 Another noteworthy characteristic was communication between French, Spanish, British, and American surgeons, many of whom practiced at the same St. Augustine Royal Hospi-tal at one time or another. As a dominant Spanish colony, they communicated almost uniformly in Español Castellano—the King’s Spanish—despite their multinational heritage as a collective group.

The East Florida Papers, portions of which are still undergoing English translation and tran-scription, add clarity to Florida medical history and paint surgeons’ lives on a more personal level (see Figure 4, page 37). These documents show surgeons appointed and vetted by the Span-ish monarchy, demonstrating the formality and permanence intended by granting privileges to practice at the Royal Hospital. Even into the early 19th century, royally appointed surgeons were required to petition the crown if they intended to resign from their position.22 They most com-monly requested transfer to Havana, at that time a bustling port with more resources than St. Augustine. As government employees, they




17. Marques PM. Governor Pedro Menéndez Marqués of Florida to the Crown, St. Augustine. Microfilm. August 1, 1583. Archivo General de Indias, William Straight Collection, Florida International University, Reel 54: 3. Accessed September 28, 2019.

18. Cabera JM. Governor Juan Márquez Cabrera of Florida to the Crown, St. Augustine. Microfilm. April 30, 1685. The Stetson Collection, Reel 86: 1. Accessed September 28, 2019.

19. McMahon BN. The Story of the Hospitallers of St. John of God. Westminster, MD: Newman Press; 1958.

20. The East Florida Papers. U.S. Library of Congress Manuscript Division. Microfilm. Available at: https://lccn.loc.gov/mm80019398. Accessed March 12, 2020.

21. Risse GB. Medicine in New Spain. In: Medicine in the New World, New Spain, New France, New England (Numbers RL, ed). University of Tennessee Press; 1987:12-63.

22. Coppinger J. Jose Coppinger to Jose Cienfuegos, Florida. Microfilm. September 1, 1816. The East Florida Papers. Accessed September 28, 2019.

23. Detailed proceedings concerning disposition of Minorcan Agueda Villalonga living in St. Augustine with leprosy, St. Augustine. Microfilm. July 19, 1791. The East Florida Papers, Miami-Dade Public Library. Reel 173: 6. Accessed September 28, 2019.

24. Governor of Florida to Josef Taso, St. Augustine. Microfilm. April 27, 1788. The East Florida Papers, Miami-Dade Public Library. Reel 45: 1. Accessed September 28, 2019.

25. Cienfugos J. Jose Cienfuegos to Governor of Florida, Havana. Microfilm. July 31, 1818. The East Florida Papers, Miami-Dade Public Library. Reel 6: 1. Accessed September 28, 2019.

REFERENCES, CONTINUEDperiodically wrote local governors to ask for house repairs.

Surgeons testified in court for their clinical expertise and as respected leaders in the commu-nity. One documented hearing in 1791 focused on banishing a patient with leprosy from St. Augus-tine.23 Other ill patients periodically were sent to Havana, in anticipation that the sea breezes and higher elevation in Cuba would offer cleaner air, believed to be more suitable for recovery. Other letters described surgeons who were called on horseback to remote parts of Florida and coastal Georgia where they operated in the f ield.24 Although surgeons were respected as a whole, some documents commented on the arrest and imprisonment of individual surgeons, one of whom needed to be extradited from “America” in 1818,25 likely because he f led across the border to Georgia, then part of the newly formed U.S.

A ltogether, the h istory of surgery in St. Augustine is rich and contrasts with exist-ing papers that focus on medical developments in the British colonies, including Jamestown and Plymouth in 1607 and 1620, respectively. The roy-ally appointed surgeons of St. Augustine made significant contributions to the establishment of clinical practice in the New World, and their impact is more than a footnote in this nation’s medical history. ♦



2019 ACS Governors Survey:Surgeons wanted: Workforce challenges in health care

Recent literature reveals a growing need for more infor-mation on, and awareness of, the surgeon workforce shortage. For example, the Bulletin published an arti-

cle by Mark W. Puls, MD, FACS, a general surgeon and an ACS Governor in Alpena, MI, on the increasing shortage of surgeons in rural settings, a trend that has been attributed to an aging workforce and other factors. This shortage has left many rural U.S. counties without any surgeons, even though more than half of the counties have a local hospital.

Another study by E. Christopher Ellison, MD, FACS, chief, division of general surgery and the Robert M. Zollinger Pro-fessor, The Ohio State University, Columbus, and colleagues showed that although the number of general surgery resident positions and graduating surgical residents has been rising in the U.S. for more than 10 years, these increases have been insufficient to maintain the ideal number of surgeons for the population.

Several surgical specialties also face workforce challenges. A 2019 Association of American Medical Colleges (AAMC) report predicted a U.S. surgeon shortage of 23,000 surgeons in 2032. (Note: At press time, the AAMC has just released a report estimating that the surgeon shortage could be as high as 28,700 by 2033.) The AAMC projects that clinical demand

by

David J. Welsh, MD, FACS;

Hiba Abdel Aziz, MBBCH, FACS;

Juan C. Paramo, MD, FACS;

John Kirby, MD, FACS;

Dhiresh Rohan Jeyarajah, MD, FACS;

David W. Butsch, MD, FACS;

Christopher DuCoin, MD, MPH, FACS;

Joann Lohr, MD, FACS;

and

Shilpa Shree Murthy, MD, MPH

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and inter-national members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College lead-ership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate.

One of the survey’s topics was surgeon workforce. This article outlines the Governors’ feedback on this issue.


2019 ACS GOVERNORS SURVEY

will continue to outpace the supply of surgeons with a projected total shortfall of 46,900−121,900 by 2032. This projected shortfall range is based on a model that accounts for population projections, demand and supply projections, estimates of physician specialty choice, recently revised federal health professional shortage area designations for primary care and mental health, and lower projections of future insur-ance coverage expansion. A shortage of physicians in surgical specialties is estimated to be between 14,300 and 23,400.

In 2016, the U.S. Department of Health and Human Services issued a report on national and regional pro-jections of supply and demand for surgical specialty practitioners from 2013 to 2025. The study projected that a shortage of surgical specialists would rise to 24,330 by 2025, with wide geographic variation: 1,750 in the Northeast, 7,040 in the Midwest, 10,210 in the South, and 5,330 in the West.

Practice settings and geographyBecause surgeon workforce needs can differ based on practice settings and geographic location, a closer look at the practice settings of the survey’s respondents was warranted: 75 percent were in full-time academic practice or hospital employment (see Figure 1, page 42), and only 24 percent of respondents practice in settings with a population of less than 250,000 (see Figure 2, page 42). In addition, 74 percent of ACS Governors indicated they worked in groups of five or more surgeons. This finding is important in light of an article by Jonathan Ford Hughes that examined physician shortages by U.S. regions. He predicted greater shortages in the South and Midwest, as well as higher shortages in rural settings—geographic areas and practice types less commonly represented in the Governors’ sample.

Research findings on physician shortages may vary depending on the specialty and the location under analysis. For example, surgeons in academia or hos-pital employment may be less affected than surgeons

in rural settings. Rural general surgeons continue to face an increasing workload demand, but with a median age in the late 50s, they also are aging out of practice.

Specialty variationsMost Governors (65 percent) indicated they did not perceive workforce shortages in their geographic area. Although 55 percent indicated that their specialty was experiencing no shortages, further analysis revealed that while obstetrician-gynecologist Governors did not see shortages in their respective geographical areas, they did recognize overall specialty shortages. Governors from other specialties reported similar observations, with more global shortages in the fol-lowing specialties: vascular (60 percent), wound care (58 percent), cardiothoracic (57 percent), colorectal (52 percent), and pediatric surgery (50 percent).

Quality of careThe survey also sought to determine if workforce shortages led to treatment delays and reduced quality of care. Most Governors (75 percent) indicated they did not perceive significant delays in the delivery of patient care, and 74 percent noted they had not seen a nega-tive effect on the quality of care rendered because of a perceived shortage of surgeons. Although 34 percent of international Governors indicated they experienced shortages of surgeons in their geographic area and spe-cialty, this shortage was reported to be the cause of less than 20 percent of the significant delays in elective surgical procedures and adversely affected the quality of care in less than 20 percent of the cases.

RecruitmentMost Governors (78 percent) said it takes at least six months to replace a partner or add a new surgeon to their practice (see Figure 3, page 42), but variances were




FIGURE 1. Type of surgical practice

FIGURE 2. Population of practice location

FIGURE 3. Estimated time to replace and/or add a surgeon



FIGURE 4. Is locum tenens used for unfilled positions?

FIGURE 5. Where workforce needs and deficiencies, such as rural surgery shortages, are discussed

FIGURE 6. How important is it for the College to continue addressing surgical workforce issues?



BIBLIOGRAPHYAmerican Medical Association. U.S. Physician Shortage

H-200.954. Available at: https://policysearch.ama-assn.org/policyfinder/detail/workforce%20shortages?uri=%2FAMADoc%2FHOD.xml-0-1344.xml. Accessed February 20, 2020.

Association of American Medical Colleges. 2019 update: The complexities of physician supply and demand: Projections from 2017 to 2032. Available at: https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Accessed February 20, 2020.

Bailey P. Surgical workforce shortages in rural areas. Available at: www.mdedge.com/surgery/article/109133/practice-management/surgical-workforce-shortages-rural-areas. Accessed February 18, 2020.

Darves B. Physician shortage spikes demand in several specialties, 2017. Available at: www.nejmcareercenter.org/article/physician-shortage-spikes-demand-in-several-specialties-/. Accessed February 18, 2020.

Ellison EC, Pawlik TM, Way DP, Satiani B, Williams TE. Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. Surgery. 2018;164(4):726-732. Available at: www.ncbi.nlm.nih.gov/pubmed/30098811. Accessed February 20, 2020.

G4 Alliance. The surgical workforce shortage—A global crisis. Available at: https://static1.squarespace.com/static/5435b2b9e4b0e1fd29fa9d26/t/5a67ac0a652dea5f53dd05ca/1516743691252/Surgery+Workforce+-+G4+Briefing_Final1-1.pdf. Accessed February 20, 2020.

Haskins J. Desperately seeking surgeons. Available at: www.aamc.org/news-insights/desperately-seeking-surgeons. Accessed February 20, 2020.

Hughes JF. Physician shortage: Which U.S. regions affected the most? MDLinx.com. July 17, 2019. Available at: www.mdlinx.com/internal-medicine/article/3888. Accessed March 10, 2020.

seen among practice settings. Many solo private prac-tice surgeons (47 percent) indicated they needed more than a year to add a partner. More than six months was needed for new surgeon recruitment for a variety of practice settings: private practice multispecialty (67 per-cent), hospital employment (65 percent), government (60 percent), and military service (60 percent). Governors in solo private practice (57 percent) needed more than six months to recruit another surgeon. Forty percent of private practice single-specialty groups with more than five members indicated they needed more than a year for recruitment. Interestingly, 33 percent of Gover-nors in government practices were able to successfully recruit in less than six months.

Overall, Governors in private practice multispecialty groups with primary care and surgical care settings were the most successful: 25 percent fulfilled positions in less than six months, 50 percent within six months to a year, and 25 percent needed more than a year to recruit. Inter-nationally, 40 percent of Governors were able to replace surgeons in fewer than six months, but one-third needed more than a year. Interestingly, only 11 percent of all Governors used locum tenens for unfilled positions (see Figure 4, page 43).

Addressing workforce needs Most Governors (73 percent) said they believe ACS chapter and specialty society meetings provide the best platform for addressing workforce needs and deficien-cies (see Figure 5, page 43). Discussions about workforce needs also occurred at residency programs (55 percent) and local medical schools (43 percent). Most Governors did not appear to seek out the ACS as a national orga-nization for solutions to surgeon practice recruitment or more global workforce issues, suggesting an oppor-tunity for ACS action.

Despite most Governors not recognizing a work-force shortage in their practice geographic area, 94 percent (see Figure 6, page 43) believed it was an important issue for the ACS to continue address-ing in the future, especially by creating more




Kenning TJ. Neurosurgical workforce shortage: The effect of subspecialization and a case for shortening residency training. Available at: https://aansneurosurgeon.org/departments/neurosurgical-workforce-shortage-effect-subspecialization-cast-shortening-residency-training/. Accessed February 18, 2020.

Lynge DC, Larson EH, Thompson MJ, et al. A longitudinal analysis of the general surgery workforce in the United States, 1981–2005. Arch Surg. 2008;143(4):345–350. Available at: https://jamanetwork.com/journals/jamasurgery/fullarticle/599060. Accessed February 20, 2020.

Ohio State University Wexner Medical Center. Study suggests part-time solution to surgeon shortage. Available at: https://wexnermedical.osu.edu/mediaroom/pressreleaselisting/study-suggests-part-time-solution-to-surgeon-shortage. Accessed February 20, 2020.

Palikuca P. A surgeon shortage is mounting, recent report finds. Available at: https://thedo.osteopathic.org/2019/05/a-surgeon-shortage-is-mounting-recent-report-finds/. Accessed February 18, 2020.

Puls MW. Dispatches from rural surgeons: Shortage of rural surgeons: How bad is it? Bull Am Coll Surg. 2018;103(4):52-55. Available at: bulletin.facs.org/2018/04/shortage-of-rural-surgeons-how-bad-is-it/. Accessed February 18, 2020.

Rapaport L. General surgeon shortage growing in U.S. Available at: www.reuters.com/article/us-health-shortages-surgeons/general-surgeon-shortage-growing-in-u-s-idUSKCN1L920O. Accessed February 18, 2020.

Thompson MJ, Lynge DC, Larson EH, et al. Characterizing the general surgery workforce in rural America. Arch Surg. 2005;140(1):74-79. Available at: https://jamanetwork.com/journals/jamasurgery/fullarticle/508241. Accessed February 18, 2020.

U.S. Department of Health and Human Services Health Resources and Services Administration. Bureau of Health Workforce National Center for Health Workforce Analysis. National and regional projections of supply and demand for surgical specialty practitioners: 2013–2025. Available at: https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/surgical-specialty-report.pdf. Accessed February 20, 2020.

BIBLIOGRAPHY, CONTINUEDsurgical residency programs and training positions (60 percent).

Governor recommendationsAlthough most Governors report that they have yet to personally experience a workforce hardship that impedes access or the provision of quality care in their practice area, they do recognize that a more global problem exists and encourage the College to keep this issue a high priority. Many Governors (142) offered recommendations on how the ACS could better address surgical workforce issues. For example, inter-national Governors suggested enhancing collaboration between the international chapters and the ACS, as well as among international surgeon groups. Interna-tional Governors also asked for additional statistics and resources to better understand surgeon workforce needs through both dedicated meetings and presenta-tions at the Clinical Congress.

Within the U.S., rural communities seem to be experiencing the greatest surgeon workforce chal-lenges. Many Governors called for additional funding for rural surgery and targeted rural residency training positions and programs. Governors also recommended increasing advocacy focused on federal legislative efforts, such as the Ensuring Access to General Surgery Act (H.R. 1841) and Keep Physicians Serving Patients Act of 2019 (H.R. 3302). The College supports both bills. Additional outreach to state and local government leaders, ACS chapters, medical schools, and residency programs is encouraged as well.

The surgeon workforce shortfall is a multifac-eted issue that requires both national and regional, practice-specific solutions. An additional in-depth study and analysis of surgeon workforce shortages is warranted to better understand its complexities and refine long-term solutions. Governors strongly encourage the College to continue focusing on sur-geon workforce concerns to ensure access to optimal surgical care for all patients and the future success of the profession. ♦




2019 ACS Governors Survey:ACS Governors: Bidirectional communication ambassadors

by

David W. Butsch, MD, FACS;

David J. Welsh, MD, FACS;

Hiba Abdel Aziz, MBBCH, FACS;

Juan C. Paramo, MD, FACS;

John Kirby, MD, FACS;

Dhiresh Rohan Jeyarajah, MD, FACS;

Christopher DuCoin, MD, MPH, FACS;

Shilpa Shree Murthy, MD, MPH;

Julian A. Smith, MB BS, FACS;

and

Joann Lohr, MD, FACS

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and inter-national members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College lead-ership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate.

One of the survey’s topics was ACS communication and repre-sentation efforts. This article outlines the Governors’ feedback on this issue.


Members of the ACS B/G serve as an official, direct com-munications link between the Board of Regents and the Fellows. Governors have the responsibility to com-

municate across all strata of the College in the following ways:

• Provide bidirectional communication between the B/G and constituents

• Provide reports to their chapter or specialty society

• Welcome Initiates/Fellows from the ACS chapter or surgical specialty society that the Governor represents into the College

• Promote ACS Fellowship in state and specialty societies

The ability to effectively communicate and promptly respond to members on everyday concerns and urgent issues is critical to the ACS’ continued growth and evolution. The con-tinued relevancy of the College depends on how appropriately it addresses and represents the views of its members. To better understand the effectiveness of the College’s communication efforts, Governors responded to survey questions regarding



preferred communication methods, the effectiveness of addressing membership concerns, and how repre-sentative the College is on key issues. The survey also explored whether improvements to communication initiatives were necessary.

Bringing concerns forwardWhile serving as a Governor, respondents indicated how often a Fellow brought a specific concern to them to either address directly or bring forward to ACS leadership (see Figure 1, this page). Only 8 per-cent of all domestic Governors had a concern brought to them monthly, whereas 31 percent had a concern brought to them once a quarter, 30 percent only once a year, and 30 percent have not received a concern to address. (The percentages in this article are rounded figures.) International Governors reported a simi-lar experience, with 11 percent indicating monthly, 27 percent quarterly, and 27 percent once-a-year requests for advice or concerns. Interestingly, 30 per-cent of all Governors had never received a concern to address; International Governors tracked similarly with 34 percent.

Over a 12-month period, most Governors reported they had received more than two concerns (47 percent) or three to five concerns (42 percent). Only 11 per-cent of Governors indicated they received six or more concerns. In contrast, most international Governors (59 percent) reported three to five concerns, 10 per-cent reported more than 10 concerns, and 31 percent reported more than two concerns.

For those Governors who never had a concern brought to their attention, 70 percent attributed this,

at least in part, to a lack of clarity by Fellows regarding the process for addressing concerns. Lack of interest by Fellows accounted for 54 percent, and for 15 per-cent, there were no needs that members felt had to be brought forward as a concern because the issue was already being addressed (see Figure 2, page 48). Similarly, international Governors cited lack of inter-est as the leading factor at 66 percent, followed by lack of knowledge among Fellows on how to address concerns at 40 percent.

Several Governors noted that they did not know what the ACS could do or its level of effectiveness in addressing any forwarded concerns. These results reveal an opportunity to better educate Governors on how to solicit and address the concerns of their constituents, an opportunity to inform Fellows about how and when to contact Governors when an issue arises, and information on how issues are considered and handled when brought to the ACS leadership.

Resolving concernsGovernors who were contacted by Fellows with concerns primarily resolved their issues by con-tacting their local chapter (57 percent), contacting their respective specialty societies (32 percent), and a minority (28 percent) contacted the College’s Chicago, IL, and/or Washington, DC, offices (see Figure 3, page 48). For international Governors, a similar pattern was revealed, with 66 percent resolving their issues via their local chapter, 28 percent contacting the Chi-cago and/or Washington, DC, offices, and 17 percent contacting their respective specialty societies.

FIGURE 1. During your time as a Governor, how often did Fellows bring specific concerns to you that they would like the ACS to address?

FIGURE 2. What factors do you believe contribute to the lack of concerns from Fellows? Select all that apply.

FIGURE 3. How have you advanced any specific concerns that you and/or a constituent wanted the ACS to address? Select all that apply.



Most Governors (69 percent) who advanced a con-cern ranked their efforts as extremely or moderately effective. Only 26 percent ranked their efforts as slightly effective and 5 percent believed the process was inef-fective. Several Governors who found the process to be ineffective noted that in many cases the concern was already being addressed by the College and, therefore, they chose not to advance it further.

Communication methodsThe survey also queried respondents on the commu-nication methods they have used to contact the ACS regarding a specific issue. Most Governors (85 percent) used e-mail, 67 percent communicated in person, and 46 percent used the phone (see Figure 4, page 49).

EffectivenessWhen evaluating the effectiveness of the communica-tion method used in contacting the ACS, 71 percent believed e-mail was very or moderately effective, 56 percent believed in-person contact was very or moderately effective, and 44 percent found phone calls to be very or moderately effective (see Table 1, page 49).

Regarding instances when urgent feedback on topical issues is needed, the survey also queried respondents on their communication preferences. Most Governors (80 percent) ranked e-mail as their preferred choice, followed by text messaging (46 per-cent), and 44 percent ranked the ACS Communities as their third choice (see Table 2, page 50). International Governors similarly ranked e-mail as their top choice



(91 percent), followed by text messaging (52 percent), and ACS Communities (36 percent).

Preferred communication methods did not vary by age group. Across all ages, most Governors wanted the flexibility to communicate via a variety of meth-ods. This preferred flexibility is aligned with the College’s ability to tailor messages to different audi-ences via multiple communication channels.

Responding to Fellows’ concernsGovernors also were queried on the way the ACS typically responds to Fellows’ concerns. Although most Governors (69 percent) found the College to be approachable and appreciative of concerns raised by Fellows, 25 percent believed the ACS response was bureaucratic and procedural, and 6 percent found the College to be distant and nonrepresentative. Interna-tional Governors reported a similar experience, with 73 percent indicating the ACS was approachable and representative, 20 percent saying the ACS was bureau-cratic and procedural, and 7 percent viewing the College as distant and nonrepresentative. Acknowledging a Fel-low’s concern and providing feedback and/or a response

in a timely fashion by the respective Governor remains a challenge, according to the survey findings.

Conclusions and improvementsCommunication preferences are rapidly changing. It is critical that the College keep abreast of new technol-ogy and preferences among its membership, especially as they may differ by age, practice type, and specialty. Although the survey revealed that most Governors are satisfied with how the ACS communicates and responds to urgent issues, the College must continue to disseminate information via a variety of communica-tion channels to accommodate all member preferences. It also is important that the College ensure all members are aware of the variety of communication vehicles the College uses to disseminate information.

There is clearly an opportunity for better engage-ment with the ACS. For example, members can seek assistance from ACS through the following channels:

• Contact a Governor

• Contact a member of the Board of Regents

TABLE 1. How effective was your communication method?

Very effective

Moderately effective

Slightly effective

Not at all effective N/A Total

Phone 26.09% 17.75% 4.35% 1.45% 50.36% 276

E-mail 42.39 28.26 11.59 1.81 15.94 276

In-person 37.32 18.84 8.70 2.54 32.61 276

FIGURE 4. In general, what communication methods have you used to contact the ACS about an issue?


• Contact a College Official

• Contact the ACS via phone: 800-621-4111 or 312-202-5000; fax: 312-202-5001 (general) or 312-202-5007 (Member Services); or e-mail: [email protected] (general) or [email protected] (Member Services)

• Post a message in an ACS Community

• Use the Find a Surgeon tool on facs.org to connect with other members

Informing members of all the available channels for com-municating and raising concerns with the ACS will remain a key focus of the B/G Communications Pillar today and in the future.

Governors also will be key to educating Fellows on how to bring concerns forward. Annually, all Fellows receive a “You Have a Voice” e-mail/letter in January or February that lists the contact information for their respective chapter Gover-nors and the chair of their specialty-specific Advisory Council. This important document will need to be expanded with additional information on how to bring forward concerns to the ACS, as well as the key role Governors play in champion-ing Fellows’ concerns.

Effective communication is essential to the success of any organization. The survey results reveal that although strong and effective communication exists between the Col-lege administrative leadership, the Board of Regents, the B/G, and the Fellows, the College must continue to adapt to the communication preferences of its membership, adopting new technology as needed. A focus on the importance of effec-tive communication and actively working to improve and expand the available opportunities for outreach, dialogue, and feedback will support and empower members. Future ACS communication efforts must continue to fulfill the five C’s of effective communication: clarity, consistency, creativ-ity, content, and connections. ♦

TABLE 2. When urgent feedback on topical issues is needed, how would you prefer the ACS contact you?

First choice

Second choice

Third choice

Fourth choice Score*

ACS Communities 3.62% 31.88% 43.84% 20.65% 2.18

E-mail 80.07 15.94 2.90 1.09 3.75

Social media 1.81 6.16 29.71 62.32 1.47

Text 14.49 46.01 23.55 15.94 2.59

*A higher score is preferable.


BIBLIOGRAPHYBelonwu V. 20 ways to communicate effectively

with your team. Small Business Trends. April 30, 2020. Available at: https://smallbiztrends.com/2013/11/20-ways-to-communicate-effectively-in-the-workplace.html#comments. Accessed March 17, 2020.

Keates C. The five C’s of effective communication. Forbes. September 2018. Available at: www.forbes.com/sites/forbescoachescouncil/2018/09/10/the-five-cs-of-effective-communication/#60d62d2f20c8. Accessed March 16, 2020.

Makoul G. Essential elements of communication in medical encounters. Acad Med. 2001;76(4):390-393.

Richards L. How effective communication will help an organization. Houston Chronicle. March 2019. Available at: https://smallbusiness.chron.com/effective-communication-organization-1400.html. Accessed March 17, 2020.

Robinson L, Segal J, Smith M. Effective communication. HelpGuideOrg International. Available at: www.helpguide.org/articles/relationships-communication/effective-communication.htm. Accessed March 16, 2020.

Skills You Need. What is communication? Available at: https://skillsyouneed.com/ips/what-is-communication.html. Accessed March 17, 2020.

Touro University Worldwide. Five ways to define good communication. Available at: www.tuw.edu/program-resources/good-communication/. Accessed March 16, 2020.

2019 ACS-COSECSA Women Scholarsdescribe how they and their patientsbenefit from the scholarships:

Part I

Editor’s note: The following is the first of two articles pro-filing the 2019 American College of Surgeons-College of Surgeons of East, Central and Southern Africa Women Schol-ars. Part II will be published in the October issue of the Bulletin.

Sub-Saharan Africa suffers from a severe short-age of surgeons. The data indicate that there are only 0.5 surgeons for every 100,000 people,

and though women comprise more than 50 percent of the population, they represent only 7 percent of the surgical workforce.*

To address this challenge, the American College of Surgeons (ACS) and the College of Surgeons of East, Central and Southern Africa (COSECSA) developed a scholarship program to support women in their final year of surgical residency to help them complete their training and to encourage other women in medicine to consider surgery as a profession. This scholarship is financially supported jointly by the ACS Foundation and the Association of Women Surgeons. Each schol-arship is worth $2,500 and is administered through COSECSA. Since its inception in 2017, 30 scholarships have been awarded.

COSECSA is the leading surgical organiza-tion in the sub-Saharan region and is dedicated to improving surgical education standards and strengthening overall quality of surgical care. To become COSECSA Fellows, candidates must suc-cessfully pass both a written and a clinical exam. Candidates who successfully complete the written exam are invited to the clinical exam, which usually takes place in December during the annual general COSECSA meeting. The ACS-COSECSA Women Scholars Program provides women residents with the opportunity to sit for the final oral examination.

Process for selecting scholarsOnce the trainees successfully complete the written exam, they become eligible for the scholarship. Subse-quently, members of the COSECSA Examination and Credentialing Committee and Operation Giving Back (OGB) Educational Subcommittee finalize the selec-tion. In December 2019, several ACS Fellows traveled to Kampala, Uganda, for the 20th Annual General Meeting and Graduation Ceremony of COSECSA. At the meeting, ACS Fellows assisted in administering the clinical examinations on site and participated in the annual meeting. ACS-COSECSA Women Schol-ars had the opportunity to connect and interact

*O’Flynn E, Andrew J, Hutch A, et al. The specialist surgeon workforce in East, Central and Southern Africa: A situation analysis. World J Surg. 2016;40(11):2620-2627.


2019 ACS-COSECSA WOMEN SCHOLARS

by Natalie Bell

and Girma Tefera, MD, FACS

with ACS Fellows, including Past-First Vice-Presi-dent Hilary Sanfey, MD, BCh, FACS; Sherry Wren, MD, FACS, member, ACS Committee on Global Engagement through OGB; ACS Past-President Patricia Numann, MD, FACS; Sharon Stein, MD, FACS, member, ACS Women in Surgery Commit-tee (WiSC); Past-ACS Governor Kristin Long, MD, FACS; Celeste Hollands, MD, FACS, member, WiSC; and Girma Tefera, MD, FACS, Medical Director, ACS OGB, and coauthor of this article.

According to Abebe Bekele, MD, FCS, FACS, chair, examinations and credentials committee, COSECSA, the program has contributed to an abun-dance of opportunities for women in the region. “The scholarship is instrumental in supporting women scholars to sit for their fellowship exami-nation and, most recently, allows our young women to register for training under COSECSA. This undoubtedly contributes to increasing the surgical workforce in the region, and to the progress women surgeons have made in the field,” Dr. Bekele said.

In this article, we introduce six of our 12 women scholars from 2019. The other six will be featured in the October issue of the Bulletin. If you are inter-ested in financially supporting the scholarships, visit the ACS Foundation web page ( facs.org/donate) and designate your support toward OGB, program

designation: ACS-COSECSA Women Scholars Program.

Dr. Kibansha faithfully pursues career in urologyMatumaini Hope Kibansha, MD, received her bachelor’s degree in medicine and surgery from Makerere University Medical School, Kampala, in 2009. She then joined a district general hospital in southwestern Uganda, where she initially practiced as a medical officer for two years, later becoming the head of the same hospital. In 2014, Dr. Kiban-sha received her master’s degree in surgery from her alma mater, and in 2019, completed her master of science in urology from Kilimanjaro Christian Medical College, Moshi, Tanzania. Dr. Kiban-sha completed her fellowship in urology through COSECSA. Dr. Kibansha’s career interest is in recon-structive urology. She is a Rotarian, enjoys nature walks, loves dancing, and takes pleasure in mentor-ing young physicians.

“It was a great favor from God to be a beneficiary of the ACS-COSECSA Women’s Scholarship. This [opportunity] came at a time when I was financially unstable since I had just completed my training in urology. I didn’t have to feel the [financial] pain



The 2019 ACS-COSECSA Women Scholars and members of the ACS at a post-exam celebratory dinner, where

they networked and shared experiences

because of this award. I am forever grateful, and may God strengthen our society,” Dr. Kibansha said.

Inspired by parents’ experiences, Dr. Yimam pursues MIS oncology Hanan Alebachew Yimam, MD, completed her under-graduate studies in 2013 at the University of Gondar College of Medicine and Health Sciences School of Medicine, Ethiopia. She then went on to com-plete her postgraduate training in general surgery at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, in 2019 and recently began working at St. Paul’s.

Dr. Yimam was inspired to help others who need medical care after witnessing her mother’s experi-ence with Ethiopian surgeons during her battle with breast cancer, as well as her father’s experience with Ethiopian surgeons during treatment for renal cell carcinoma. Dr. Yimam intends to study minimally invasive surgery (MIS) in the future.

Dr. Yimam said she would have been unable to cover the fee and expenses of Fellowship in COSECSA without the scholarship. “The scholarship helped me on so many levels. It inspired me and female resi-dents and colleagues around me. It gave me courage always to do more as a human being for the nation, for the world,” she said. “Thank you for giving me this opportunity.”

Dr. Shinondo overcomes challenges in pediatric surgeryPatricia Shinondo, MD, is a pediatric surgeon who com-pleted her undergraduate training in 2009 at the Kuban State Medical University, Krasnodar, Russia, where she quickly learned to adapt to challenging circumstances

as a woman student far from home. This experience helped Dr. Shinondo during her surgical training in the male-dominated field of pediatric surgery at the University of Zambia, leading to her graduation as the first Zambian woman pediatric surgeon in 2019. Dr. Shinondo is pursuing a fellowship with COSECSA and has a keen interest in research, surgical education, and global surgery. She is part of the global pediat-ric surgery community seeking to improve access to children’s surgical care and to provide safe surgery for children in low- and middle-income countries.

“The ACS-COSECSA Women Scholars Program scholarship was not only the financial ticket and means to get me through the pediatric surgical fel-lowship and examination, but also an opportunity for continued surgical and professional development thanks to the ACS five-year membership and the COSECSA annual fellowship fee coverage,” Dr. Shi-nondo said. “Being the first female Zambian pediatric surgeon, I inevitably have to continue proving myself against my male peers, but with this award I can stay abreast of current surgical trends and practice and be a step ahead.”

Dr. Munanzvi pays it forwardKudzayi Sarah Munanzvi, MD, is an aspiring pediat-ric surgeon who completed her undergraduate degree in 2017 at the University of Zimbabwe College of Health Sciences, and practices at Harare Central Chil-dren’s Hospital, Zimbabwe. Dr. Munanzvi has been involved in establishing a short course in pediatric surgery for junior physicians, and in developing a new protocol for the management of patients with gastroschisis. She also is proud to have provided medi-cal services for sex workers at the Centre for Sexual Health and HIV/AIDS (human immunodeficiency

Dr. Kibansha Dr. Yimam Dr. Shinondo



virus/acquired immunodeficiency syndrome) Research Zimbabwe.

Dr. Munanzvi is passionate about surgical educa-tion and laparoscopy and aspires to merge these two disciplines and share them with upcoming surgeons. Having been mentored by the eminent pediatric sur-geon Bothwell Mbuwayesango, MD, Dr. Munanzvi has not only gleaned meticulous surgical skills, but also adopted Dr. Mbuwayesango’s mantra that surgeons can improve patient outcomes by learning how to do simple things well.

“The ACS-COSECSA Women Scholars Program has provided a platform for me to interact with emi-nent women surgeons—pioneers in their fields who are willing to give me a ‘hand up.’ Spending time with these women and getting to learn from them has been a phenomenal opportunity,” Dr. Munanzvi said. “With-out the financial assistance from this program, I would not be where I am today. I am grateful to have been awarded the opportunity to benefit from the program.”

Dr. Odhiambo looks forward to expanding professional networkClara A. Odhiambo, MD, is a general surgeon and endoscopist at St. Francis Hospital Nsambya, a COSECSA-accredited hospital in Kampala, Uganda. Dr. Odhiambo also is an honorary lecturer for the Mother Kevin Postgraduate Medical School, St. Fran-cis Hospital Nsambya. She attained her undergraduate degree from Gulu University in northern Uganda and completed her postgraduate studies in 2017 at Uganda Martyrs’ University Nkozi. Dr. Odhiambo is a proud member of COSECSA.

Apart from surgery, she is a dedicated wife and mother of two beautiful daughters. She enjoys sing-ing and cooking for her family.

“I am excited and honored,” Dr. Odhiambo said. “I look forward to numerous networks on the path to surgical excellence.”

Dr. Ahmed strives to improve the surgical communityMarta S. Ahmed, MD, is assistant professor of general surgery, Debre Berhan University, Ethiopia. She com-pleted her undergraduate degree in 2014 at Mekelle University School of Medicine, Tigray, Ethiopia, and then pursued general surgery training at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. Dr. Ahmed’s parents inspired her to develop an interest in medicine, which led to her lifelong dream of becoming a surgeon. She intends to continue prac-ticing surgery, while encouraging women to join the profession and engage in surgical innovation and research.

“This scholarship was very important to me for many reasons. First, it provided me the opportunity to take the COSECSA Fellowship of the College of Surgeons general surgery examination by covering all the expenses of travel, accommodations, and the examination fee. Now because of this scholarship, I am a Fellow of COSECSA. Second, this scholarship gave me the chance to join the ACS as an Associate Fellow, as well as obtain membership with COSECSA, which helps me to get additional benefits,” Dr. Ahmed said. “I am so grateful for being one of the awardees of this scholarship because this journey would not have been possible without the dedicated support I received from the scholarship. I would like to thank the ACS and I look forward to working with the ACS and COSECSA to help my community in the surgical practice.” ♦

Dr. Odhiambo Dr. AhmedDr. Munanzvi



For more than 100 years, the American College of Surgeons (ACS) has led national and interna-tional initiatives to improve quality in hospitals,

specifically in the fields of trauma, cancer, and surgi-cal care. The ACS was the forebear of what is now The Joint Commission and continues to develop quality standards for cancer, trauma, metabolic and bariatric, and geriatric patient care.

The ACS soon will launch a standards program to ensure surgical care facilities are in compliance with the guidelines outlined in Optimal Resources for Surgi-cal Quality and Safety (also known as the Red Book) and for rural hospitals, as noted in an article in the April issue of the Bulletin.* The execution of these pro-grams and their impact on surgical patients often is underappreciated. The following case history features a nonsurgical department quality review and its effect on a rural surgical patient.

A patient in rural North Dakota was diagnosed with diffuse helicobacter (H.) pylori-negative gastric

mucosa-associated lymphoid tissue (MALT) lymphoma after diagnostic upper endoscopy in a critical access hospital (CAH). Three weeks after initial treatment decisions were made, an internal quality review—performed by the referring tertiary center’s pathology department—uncovered a discrepancy that drastically altered this patient’s clinical outcome.

Case historyIn a town of approximately 1,000 people, an 81-year-old male presented to the local monthly general surgery clinic with complaints of a one-year history of vague epigastric pain and sore throat without weight loss, appetite change, fever, or chills. He was otherwise in good physical health, working full time in his weld-ing shop, which involved lifting up to 80 pounds and pushing objects greater than 130 pounds.

According to his surgical and medical history, the patient had been treated for colon cancer requiring surgical resection and chemoradiation therapy, pros-tate cancer requiring prostatectomy, and bradycardia requiring placement of a cardiac pacemaker. His only medications were benazepril, hydrochlorothiazide, aspirin, omeprazole, and multivitamins. He quit smok-ing more than 50 years ago and consumed one or two alcoholic beverages a week. He had a sister who had Lynch syndrome with colon and uterine cancer.

Following the initial surgery consultation, the patient underwent a diagnostic upper endoscopy at the CAH, which demonstrated diffuse gross flattening of the gastric mucosa with hyperemia without ulceration within the body of the stomach. Distal to this abnor-mality was a pale, flattened area without ulceration, less than 1 cm in size. Multiple biopsies were taken of these areas, in addition to a sample for H. pylori eval-uation. Specimens were reviewed by the consulting

HIGHLIGHTS• Describes a case history in which a nonsurgical

department quality review led to a better outcome

• Identifies cancer care challenges for providing timely diagnosis and treatment

• Discusses the importance of continuity of care and effective communication strategies for rural cancer patients

*Puls MW, Hughes TG, Sarap M, Caropreso P, Nakayama DK, Welsh DJ. New ACS-led verification program aims to improve care for rural sur-gical patients. Bull Am Coll Surg. 2020;105(4):24-28. Available at: https://bulletin.facs.org/2020/04/new-acs-led-verification-program-aims-to-improve-care-for-rural-surgical-patients/. Accessed June 22, 2020.

A call into the distance:How quality review can change a rural cancer patient’s outcome

by Mary O. Aaland, MD, FACS, and Karen W. Luk, MD


QUALITY REVIEW FOR CANCER PATIENTS

pathology department at the regional medical center 65 miles away. The pathology report returned as mucosal involvement of extranodal marginal zone lymphoma of MALT lymphoma; H. pylori was negative.

Two weeks after the endoscopy, medical oncol-ogy staff at the regional medical center referred and evaluated the patient for the H. pylori-negative MALT lymphoma. However, the following week, the patholo-gist updated the surgeon on the patient’s biopsy results in accordance with the pathology department’s internal quality review, a process performed once a month in which a randomly selected group of specimens are re-examined for accuracy and consistency. According to the updated evaluation, the patient not only had MALT lymphoma, but also may have had adenocarcinoma.

More information was needed to officially make the diagnosis. Thus, a second endoscopist performed another upper endoscopy at the regional center. The original lesions were again encountered, biopsied, and found positive for adenocarcinoma. The specimens were sent to the region’s largest academic center for additional review, which confirmed the presence of a small focus of poorly differentiated adenocarcinoma. The patient was then referred to the same academic center for the remainder of his work-up and treatment.

Staging computed tomography (CT) and positron emission tomography (PET)/CT imaging, repeat endoscopy with endoscopic ultrasound, and diagnos-tic laparoscopy with peritoneal washings identified no signs of metastatic disease, and the patient ultimately underwent definitive resection by total gastrectomy four months after his original endoscopic evalua-tion. Final diagnosis based on his surgical pathology was multifocal involvement of MALT lymphoma with 1.8 x 1.5 x 0.5 cm of invasive poorly differenti-ated intramucosal adenocarcinoma with signet cell component. All lymph nodes were negative, making the final stage pT1a, pN0. The diagnosis, determined preoperatively, was consistent with a gastric collision tumor; a rare pathology more often seen incidentally within surgically resected specimens.† The patient’s

postoperative course and recovery were uneventful. Today, the patient continues to work in his welding shop.

Challenges in cancer careOptimal care for any cancer patient demands timely diagnosis and treatment. The diagnostic process involves a series of professionals—from the surgeon performing the procedure and obtaining the appropri-ate biopsy, to the procedure room team organizing and identifying each specimen, to the lab technicians pre-paring the tissue samples, to the pathologist making the final interpretation. Each member of the team is directly responsible for the patient and can contribute to diagnostic progress or delay.

Once patients are diagnosed with a malignancy and referred to a tertiary care center, they become part of multidisciplinary tumor board conferences and are assigned care coordinators to manage appoint-ments and therapy schedules. Unfortunately, this level of organization does not exist for patients during the diagnostic period, and ownership of the patient’s care is less well-defined, especially in rural America. This case demonstrates challenges within the diagnostic phase that influence cancer care for patients in rural communities.

The first challenge is maintenance of quality in diagnostic techniques for accurate disease identifica-tion. A critical component of the diagnosis in this case was the second review of the initial biopsy as part of the pathology department’s routine quality review process. Had it not been for this quality review, this patient would have received inappropriate treatment and later developed advanced disease.

The second challenge is communication. Equally important to the pathologist’s addendum was the direct phone call from the pathologist to the patient’s care team at the community hospital, including the initial endoscopist who promptly redirected the patient’s care. Efficient and effective communication is fundamental to convey changes in diagnosis and treatment. To suc-cessfully contact rural providers, it also is important to consider the communication method.

†Schizas D, Katsaros I, Michalinos A, et al. Collision tumors of the gas-trointestinal tract: A systematic review of the literature. Anticancer Res. 2018;38(11):6047-6057.

The first challenge is maintenance of quality in diagnostic techniques for accurate disease identification.... The second challenge is communication.



Challenges in rural health careThe electronic health record (EHR) has become a convenient way for providers to exchange patient infor-mation with each other, but it can be an unreliable communication modality for some regions because of a lack of integration between referring and referral sys-tems. This patient’s case involved three different EHRs, which is typical for individuals whose care begins at a CAH and ends hundreds of miles away at a tertiary academic center. Therefore, information that may be updated within the tertiary center may not be updated at the other institutions where a rural patient seeks care.

The surgeons and clinicians caring for rural patients also may practice in multiple facilities, transitioning days to weeks between separate computer communi-cation systems. For this reason, message receipt and response times can be prolonged. For these providers, no e-mail, secure chat, or instant message can replace the more traditional provider-to-provider phone call to relay time-sensitive information. When it comes to keeping in touch with patients—an equally important task—a phone call might be the only way to reach indi-viduals without reliable Internet access. Although many potential barriers to adequate communication can be found in rural health care, in this case, the barriers were avoided because the pathologist placed a simple phone call to personally discuss new concerns with the initial endoscopist, resulting in little to no delay for an accurate cancer diagnosis.

A third factor that influences prediagnosis care in rural centers is continuity. In tertiary medical centers, the pre- and postdiagnosis phases are well guided within a confined network of specialists and through multidisciplinary meetings, but for rural America, the diagnosis of surgical disease may be more disjointed. Rural hospitals often are supported by providers with limited surgical background. Locum tenens are common in these hospitals, not only among the phy-sicians, but also for nursing and other ancillary staff. Diagnostic procedures are offered on a limited basis, and imaging and pathology require interpretation at a remote facility.

To mitigate some of this fragmentation, the Uni-versity of North Dakota, Grand Forks, established

a rural surgery support program in July 2014 to promote quality surgical care for vulnerable com-munities that previously lacked access to consistent surgical care. Part of the program’s commitment was to employ a single surgeon in the same commu-nities to facilitate familiarity and continuity through regular general surgery call schedules, as well as 24-hour/seven-days-a-week direct phone availabil-ity. This surgeon serves as an immediate surgical resource for the local primary care providers regard-ing patients such as this 81-year-old patient, whose outcome was dependent on timely direct commu-nication; this patient’s case was a success in part because of this program.

No single program is applicable for all health care systems. Each quality improvement program should be tailored to its respective community. This case demonstrates the need to consider the needs of rural communities where the diagnostic evaluation begins. The referral and referring centers must connect at all phases of care—patient consultation, preoperative, intraoperative, postoperative, and after discharge—otherwise, quality surgical care will be lost.

The right provider at the right timeNo physician is further from direct contact with the patient than the pathologist, yet his or her findings direct treatment plans every day. At the same time, the pathologist’s information is only meaningful when it is communicated in a timely manner to the other members of the patient’s care team. In this case, a pathology quality improvement program prevented the pathologist from making an incomplete diagnosis, but the pathologist’s phone call to the right provider at the right time was the primary reason the patient is alive and cancer-free today. This patient’s success validates the need for multidisciplinary quality review, communication, and continuity between tertiary and rural centers. The emphasis of these principles through programs such as the Red Book and the Col-lege’s new rural verification programs will facilitate recognition of community-specific needs to improve the health and safety of patients nationwide. ♦



STATE LEGISLATIVE WRAP-UP

Surprise billing, trauma, and cancer top state legislative agendas in 2020

THIS

PAG

E: N

AGEL

PH

OTO

GRAP

HY/

SHU

TTER

STO

CK.C

OM

by Christopher Johnson, MPP

Editor’s note: The information in this article was current before the coronavirus disease 2019 (COVID-19) pandemic led to state legislature shutdowns. For the latest informa-tion on state legislative activity, read the weekly Bulletin Brief and Bulletin Advocacy Brief, which is published every other week.

More than half of the state legislatures have picked up where they left off in 2019, carry-ing over priority legislative issues into 2020,

whereas those states that do not carry over legis-lation (a term for bills that span two years) from the previous year have quickly introduced their own legislative solutions to the major issues facing surgeons and patients. These bills concern issues such as out-of-network surprise billing, STOP THE BLEED®, trauma prevention and readiness, nonphysician scope of practice, and cancer prevention and screening. The state legislatures of Montana, Nevada, North Dakota, and Texas comprise the small group that does not meet in 2020. The American College of Surgeons (ACS) is tracking more than 1,400 bills in the 46 states in session in 2020. The following is a summary of the advocacy efforts and legislation that the ACS is tracking.

Out-of-network surprise billingState legislation to address out-of-network surprise medical bills continues to be a priority issue before state legislatures. At press time, 30 states had intro-duced at least one bill that would create a new law or amend existing state law to address out-of-network surprise billing. Legislation in Georgia, Indiana, and Virginia had advanced out of their legislature’s cham-bers, sending bills to the governor, whereas bills in Hawaii, Kentucky, and Nebraska had passed out of the originating chamber.

The Georgia Senate passed S.B. 359 on February 24, 2020, while the House passed H.B. 888 on March 3, 2020. The bills would take patients out of the middle of pricing issues, leaving negotiations on cost of care between the physician and insurer for emergency care and nonemergency care provided by an out-of-network physician at an in-network facility. For payment, the bill would treat out-of-network physicians providing emergency services the same as in-network physicians with regard to the patient’s health insurance plan, while an out-of-network physician providing services in an in-network facility would be reimbursed the greater of the following: the median in-network rate of all insurers for the same or similar service, the most recent amount paid to the physician for the same


STATE LEGISLATIVE ACTIVITY

THIS

PAG

E: N

AGEL

PH

OTO

GRAP

HY/

SHU

TTER

STO

CK.C

OM

out-of-network services, or an amount determined by the insurer. The bill provides an arbitration process for physicians who do not agree with the amount paid by the insurer. Additionally, the bill exempts patients that agree to see an out-of-network physician from the surprise billing prohibition.

The Georgia Society of the ACS (GSACS) has been working as part of a coalition with other physician groups to advocate on behalf of surgeons to negotiate more favorable language in a final bill. The GSACS has actively engaged on the issue of out-of-network surprise bills in the legislature the past few sessions. The Georgia governor and legislative leadership have publicly stated that passing legislation to address the issue is a key priority for 2020.

The Indiana legislature passed a version of H.B. 1004 that came out of a conference committee when the House rejected amendments made to the bill passed by the Senate. The approved version of the bill is now headed to Governor Eric Holcomb (R), which would set reimbursement for care by an out-of-network physician at the in-network price unless the patient has consented in writing to paying a higher charge amount based on a good-faith estimate. The bill stipu-lates that a patient seeing a physician that is contracted with their health insurance provider also can request a good-faith estimate of charges. The bills do not pro-vide physicians with additional ACS-supported avenues for negotiation with insurers, such as an independent dispute resolution process.

Two distinct legislative proposals moved through the Virginia House and Senate, culminating in the pas-sage of H.B. 1251 and S.B. 172, respectively. H.B. 1251 was originally the preferred bill of the Medical Society of Virginia (MSV). That support faded when H.B. 1251 was amended with insurance-friendly language that would reimburse out-of-network physicians who pro-vide emergency services or services at in-network facilities for the “market-based value” of the service. Market value is based on the weighted average of the

amount paid to a physician from Medicare and the unweighted average amount paid by a commercial insurer. Under H.B. 1251, physicians may dispute the reimbursement to the Virginia State Corporation Com-mission’s Bureau of Insurance. The MSV ultimately preferred S.B. 172, which prohibits balance billing, applies to both emergency care and care provided at in-network facilities by out-of-network physicians, sets the initial payment at usual and customary commercial payment rate, and includes a baseball-style arbitration system (both sides present their final amount and an arbitrator chooses one) to dispute the payment.

However, due to a last-minute deal between the House and Senate, both versions of the bills were amended in favor of legislation that was based on the legislation passed by the state of Washington in 2019. That agreed bill headed to Governor Northam (D) for his signature includes a ban on balance billing, the establishment of commercially reasonable payments based on the median average of in-network and out-of-network paid claims, as well as the median average of billed charges, and inclusion of arbitration.

Other notable state legislative efforts to address out-of-network surprise billing are as follows:

• Hawaii (S.B. 2423 and H.B. 1881) would prohibit a non-participating physician from billing a patient, managed care plan, or other payor an amount more than what they are allowed to bill Medicare.

• Idaho (H.B. 506) would limit payment rates to out-of-network physicians for emergency or nonemergency care to the allowed amount; in nonemergency situ-ations, out-of-network physicians may bill a higher amount when the patient agrees in writing to pay out of pocket for uncovered costs from the out-of-network physician.

• Nebraska (L.B. 997) states that it is permissible for physicians to bill for charges if the charges are based



on the higher of the health carrier’s contracted rate or 125 percent of Medicare and would establish a media-tion process.

• Kentucky (S.B. 150) would establish a database of billed charges for use to determine “usual and customary” rates and includes an independent dispute resolution process.

• Maine (L.D. 2105) would enable uninsured patients and individuals covered by a self-insured plan to initiate an independent dispute resolution process to challenge physicians’ bills and to resolve disputes between physi-cians and insurers for billed charges.

• Arizona (S.B. 1602) already has a law partially address-ing out-of-network surprise bills that would repeal the arbitration option; however, it would set up a database to determine usual and customary rates at the 80th percen-tile of all charges for a given service in a geographic area.

Scope of practice expansionNonphysician health care practitioners continue their efforts to expand their legal scope of practice to include procedures beyond their education and training and to gain independent practice authority by removing supervision and collaboration require-ments. Consequently, the ACS continues to advocate for state legislation to maintain high standards for education and training of all health care practitioners to perform surgical procedures and to support other physician specialties that have concerns about legis-lative encroachment. To date this year, the ACS has sent letters to legislators in Missouri, South Dakota, and West Virginia opposing legislation to grant independent practice to certified registered nurse anesthetists (CRNAs). Despite opposition, the bill in South Dakota passed and was signed by the gov-ernor. Bills on CRNA scope have been introduced in

Indiana, Mississippi, Missouri, South Dakota, Vir-ginia, and West Virginia. The College sent a letter to the Idaho Board of Nursing opposing a board state-ment recommending that CRNAs call themselves nurse anesthesiologists.

The College sent a letter to Idaho legislators opposing legislation that would expand the scope of practice for optometrists to include certain surgical procedures, such as laser surgery. Other optometrist scope bills have been introduced in Mississippi, Nebraska, and Wyoming.

The ACS has been supporting the Florida Chap-ter’s efforts to oppose legislation, H.B. 607 and S.B. 1676, which would create a new specialized practice license for autonomous practice advance practice registered nurse (APRNs) and autonomous physician assistants (PAs) to practice without phy-sician supervision as well as APRN-Independent Practioners. The Florida Speaker of the House Jose Oliva (R) has publicly stated that passing legisla-tion to author independent practice for APRNs and PAs is one of his legislative priorities for the year. An amended version of H.B. 607 that only granted independent practice to APRNs passed out of the legislature and was quickly signed by Governor DeSantis (R) on March 11.

Trauma legislation The College continues to advocate for the safety of individuals and access to care in the event of a trau-matic injury, working with the ACS Committee on Trauma (COT) and state chapters on issues related to state trauma systems, advancing the STOP THE BLEED campaign, and supporting laws that would result in a reduction of injuries.

Trauma systems and funding Kansas Gov. Laura Kelly (D) included a recommen-dation in her fiscal year 2021 budget proposal to

IVAN

VIE

ITO

TRAV

ELER

1116

POW

ERO

FFO

REVE

R

CS F

OTO



provide funding directly from the state general fund to the Kansas Trauma Program to avoid a revenue shortfall, as well as increase funding to the Divi-sion of Public Health to support the trauma system.

A bill in New Jersey, A.B. 2050, would deny a certificate of need to a health care facility seeking to designate itself as a trauma center if the facility is within 15 miles of an existing trauma center. In addition, the Commissioner of Health could not issue a request for certificate of need without the favorable approval of the New Jersey State Trauma System Advisory Committee.

STOP THE BLEEDSTOP THE BLEED legislation continues to gain support among state lawmakers, who are reaching out to the ACS for model legislation and for sup-port of their own STOP THE BLEED legislation. Bills to advance STOP THE BLEED training and access to bleeding control kits are under consid-eration in 12 states: California, Florida, Illinois, Iowa, Massachusetts, Michigan, Missouri, North Carolina, New York, Pennsylvania, Tennessee, and Washington. The Iowa legislation, H.F. 2169, was amended to add STOP THE BLEED training to Iowa secondary school health education programs. The Iowa Chapter of the ACS and State COT sent letters of support for legislation that advanced out of the House Committee on Education February 18. The Tennessee House passed H.B. 1587 on February 27 to require STOP THE BLEED train-ing for school personnel and permit the installation of bleeding control kits.

A bill in Washington, S.B. 6157, that would require STOP THE BLEED training for school personnel and make available bleeding control kits in school buildings passed out of the Senate Committee on Early Learning and K–12 Educa-tion January 31 but was subsequently moved to the Rules Committee.

Violence preventionThe Connecticut Chapter of the ACS submit-ted testimony at a public hearing March 16 on H.B. 5448, which would expand the state risk pro-tection order law. Under the expansion, family members and physicians could apply for a protec-tive order requiring individuals to surrender their firearms, as well as prohibit them from purchasing new firearms during the extent of the order.

The Washington state legislature passed S.B. 6288 to “establish the Washington office of firearm safety and violence prevention to provide statewide leadership, coordination, and techni-cal assistance to promote effective state and local efforts to reduce preventable injuries and deaths from firearm violence.”

Motorcycle helmetsThe Connecticut Chapter of the ACS submit-ted testimony at a February 28 public hearing on S.B. 148, which would require all individuals younger than 21 years old to wear a helmet while operating a motorcycle.

The Missouri COT testif ied against S.B. 590, which would roll back the state’s universal motor-cycle helmet law to require only riders younger than 18 years old to wear a helmet or all riders operating the vehicle with a learner’s permit. How-ever, the bill would prohibit law enforcement from stopping riders solely on the basis of not wearing a helmet.

Bills in Maryland, Massachusetts, Nebraska, New York, Vermont, Washington, and West Vir-ginia would eliminate requirements for adults to wear a helmet. Bills in Hawaii, Iowa, New Hamp-shire, and Oklahoma would require adults to wear a helmet. New York has legislation to study the effi-cacy of wearing a helmet while riding a motorcycle, and West Virginia has a bill to allow out-of-state residents to ride without a helmet.


GJGK

PH

OTO

GRAP

HY/

SHU

TTER

STO

CK.C

OM

JAM

ES K

IRK

IKIS

PH

OTO

GRAP

HY/

SHU

TTER

STO

CK.C

OM


Vehicle passenger safetyThe New York Chapter of the ACS has actively sup-ported S. 4336/A. 6163, which would require all passengers ages 16 and older to wear a seat belt when riding in the rear seat of a vehicle. The chapter issued a memorandum of support for the legislation in addi-tion to activating a grassroots call to action. The New York Assembly passed the bill February 12 followed by the Senate passing the bill on March 3. The legislation is in the State Assembly pending final action before heading to Gov. Andrew Cuomo (D). The Connecti-cut Chapter of the ACS is part of an AAA (formerly the American Automobile Association)-led coalition to support legislation, S.B. 151.

Cancer-related legislationThe ACS Commission on Cancer and other stake-holder organizations continue to monitor and engage on cancer-related state legislation, such as raising the age for the purchase of tobacco and vapor products to age 21 from 18 years old; expanding health insurance coverage expansion for breast, cervical, colorectal, and prostate cancer; and protecting minors from the harmful effects of tanning beds, as well as permit-ting students to use sunscreen products at school and school events.

Tobacco 21 and vaporThe federal government passed and enacted legisla-tion to raise the age to purchase tobacco products nationally to age 21 from 18 years old, but the groundswell of support for enacting state legislation to follow suit, referred to as Tobacco 21, remains strong in 2020. States that had not passed their own laws raising the age before passage of the federal law are still advancing legislation to address issues specific to state regulations on the sale of tobacco products, such as retail licensing and identification, as well as aligning state law with the federal law

for funding from the Substance Abuse and Mental Health Services Administration.

At press time, 27 states were considering Tobacco 21 legislation: Alabama, Alaska, Arizona, Colo-rado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Mis-sissippi, Missouri, Nebraska, New Hampshire, New Mexico, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Washington, West Virginia, Wisconsin, and Wyoming. The bill in Wyoming was signed by Governor Gordon (R) while the Indiana legislature sent their bill to Governor Holcomb (R) for his signature. Tobacco 21 bills in Kentucky, New Hampshire, and Wis-consin also had passed out of at least one legislative chamber.

In addition to raising the age for the purchase of tobacco products, state legislators have emphasized including electronic cigarette and vapor products as part of the Tobacco 21 bills and have introduced leg-islation to curb vapor product use, such as banning f lavored nicotine products. The New York Chapter of the ACS is supporting a proposal in Governor Cuomo’s budget to ban the sale of f lavored nico-tine products. In 2019, the New York State Supreme Court struck down an executive order from Gover-nor Cuomo to achieve the same result. The states of Massachusetts and New Jersey have enacted bans, whereas Arizona, Colorado, Connecticut, Florida, Hawaii, Kentucky, Maryland, Michigan, Missouri, Nebraska, Oklahoma, Oregon, South Dakota, Vermont, Virginia, and Washington State have introduced bills to regulate the ingredients in electronic cigarette vapor products in addition to a ban on the use of nontobacco flavors.

Skin protectionThe College continues to support legislative efforts to protect children and minors from dangerous exposure to ultraviolet light through the passage

G N

AGEL

BEN

KRU

T

STEP

HEN

EM

LUN

D

ZRF

PHO

TO




of laws allowing primary, middle, and secondary school students to possess and use sunscreen prod-ucts on school premises and at school-sponsored events, as well as establishing minimum age require-ments to use tanning beds. Three states have active bills related to sunscreen in schools: Massachusetts, Rhode Island, and Virginia. The Virginia Senate passed S.B. 44 January 14.

Legislation in 14 states restricts a minor under the age of 18 from using a tanning bed: Arizona, Iowa, Michigan, Mississippi, Missouri, Nebraska, New Jersey, New York, Ohio, Oklahoma, Penn-sylvania, South Carolina, Utah, and Virginia. The Utah House passed H.B. 34 February 20, and the Virginia House passed H.B. 38 February 7, moving both bills to their state’s respective Senates. Bills in Iowa, H.F. 283; Oklahoma, H.B. 3506; and Penn-sylvania, S.B. 909, do not align with the College’s position in that they provide too many exemptions, such as allowing a parental waiver for a minor under 18 years old age to use a tanning bed.

Bariatric surgery coverageThe Connecticut Chapter of the ACS is continuing its efforts to enact legislation to expand essential health care insurance benefits to include coverage for bar-iatric surgery. The Connecticut Chapter submitted testimony in support of S.B. 204 for a February 26 Joint Committee on Insurance and Real Estate hear-ing. The legislation is similar to a 2019 bill that the Connecticut Chapter also supported.

COVID-19States have issued coronavirus disease 2019 (COVID-19)-related Executive Orders regarding dental, medical, and surgical procedures. For more infor-mation on state-level legislation, visit www.facs.org/covid-19/legislative-regulatory/executive-orders.

Get engaged Engagement of ACS Fellows is critical in ensuring that surgeons continue to be leaders in patient safety and health care quality. Fellows are encouraged to support ACS advocacy efforts by participating in state chapter meetings and lobby days, building rela-tionships with elected officials (critical to effective grassroots advocacy), speaking about public policy issues with colleagues, responding to grassroots Action Alerts from the College, and attending the annual ACS Leadership & Advocacy Summit.

The ACS State Affairs team is available to answer questions and provide background information regarding state issues and policy programs. Numer-ous state advocacy resources are available on the College’s website at facs.org/advocacy/state, and Fel-lows may contact us any time at [email protected] or at 202-337-2701. ♦


The ongoing coronavirus disease 2019 (COVID-19) crisis has uncovered numerous deficiencies in the health care system and its capability to respond to a global pandemic.

Although as of press time the spread of the disease appears to have slowed in select countries, parts of the U.S. continue to experience growth in the number of cases. The influx of crit-ically ill patients had overwhelmed the capacity of an already taxed health care system in many regions, and providers had rap-idly exhausted critical supplies needed to protect themselves and provide optimal care for their patients. Notably, critical short-ages in essential personal protective equipment (PPE), along with a previous reliance on foreign supply chains, had left health care personnel, as well as patients, in a particularly vulnerable state. As a result, providers were understandably frustrated and often resorted to bringing their own supplies, as well as cleaning and reusing items normally recommended for single use.1

This critical shortage, however, spurred innovation and brought forth novel approaches to overcoming the supply gaps. Of these, additive manufacturing and three-dimensional (3-D) printing emerged as promising solutions to this and future medi-cal supply dilemmas.

How it worksThe techniques associated with 3-D printing use a multitude of materials to create on-demand, user-defined objects that can be produced on site and are rapidly adaptable to the current needs.

HIGHLIGHTS• Describes 3-D-printing

products, including ventilator parts, respirator masks, face shields, and nasopharyngeal swabs, that can close the gaps in equipment shortages

• Identifies early adopters of this technology

• Summarizes areas for further investigation, including the evaluation of the safety and efficacy of these solutions

Example of 3-D printed

respirator mask


Filling the gap:Using 3-D printing to overcome critical equipment shortages during the COVID-19 crisis

by Daniel T. Lammers, MD; Matthew J. Eckert, MD, FACS; and Jason R. Bingham, MD

3-D PRINTING FOR CRITCAL EQUIPMENT SHORTAGES

Additive manufacturing techniques have been used in the medical field for years; however, they have been confined largely to anatomic modeling, custom-fit sur-gical implants, and tissue engineering.

In response to the COVID-19 pandemic, numer-ous grassroots movements surfaced to help combat the ongoing logistical shortages facing the health care community. To date, items such as ventilator parts, respirator masks, face shields, and nasopharyngeal swabs have all been designed by numerous multidis-ciplinary members of the 3-D-printing community, ranging from physicians and engineers to high school students. 3-D printing offers the ability to create cus-tomized, reusable parts that can be produced at a rate that is scalable to fill supply gaps in resource-stressed health care systems.

Early adoption of these techniques has not been widely accepted in the medical community. Concerns surrounding the safety, performance, and efficacy of 3-D-printed PPE, medical devices, and equipment have been raised because of the untested nature of these products.

Despite these concerns, numerous Italian hospitals incorporated these techniques to create 3-D-printed mechanical ventilator valves following the depletion of their supply and cite their use as a critical component of patient care during the peak of their crisis.2 Although the demand for mechanical ventilators continues to rise in the U.S., the use of these 3-D-printed mechani-cal ventilator parts has not been reported.

Nevertheless, some U.S. hospitals have turned to 3-D printing to address the critical shortages of naso-pharyngeal swabs for patient testing, as well as PPE for both health care personnel and patients. North-well Health, the largest health care system in New York State, recently announced it was able to produce thousands of nasopharyngeal swabs per day using 3-D printing to help avoid supply shortages as widespread testing is implemented.3

In March, physicians at Billings Clinic, MT, announced production of 3-D-printed personal

respirator masks, which led to significant demand for a 3-D-printed reusable personal mask.4 The “Montana Mask” has the capability to change filter materials based on supply availability and situational risk pro-file. Numerous private and academic entities have also recently described similar successes, ranging from small- to large-scale production of 3-D-printed face shields for health care workers. One example of institutional production of 3-D face shields is the Uni-versity of California-San Francisco clinical technologies program.5

Pros and consHesitancy and skepticism regarding these new manu-facturing techniques, however, continue to surround the multiple PPE prototypes recently developed, resulting in mixed feelings within the health care com-munity. With recent Centers for Disease Control and Prevention (CDC) recommendations supporting the nationwide use of masks in public places, at press time the critical shortage of PPE was projected to worsen. Researchers at the National Institutes of Health (NIH), Veterans Affairs, and Food and Drug Administra-tion (FDA) recognized these issues and implemented programs, such as the NIH 3D Print Exchange—an open-sourced, online file-sharing community dedi-cated to the safe development of 3-D-printed medical devices, to help overcome the critical supply defi-ciencies.6 The Joint Commission issued a statement authorizing the use of PPE brought from home, but consensus statements from the U.S. medical associa-tions supporting the use of 3-D-printed materials are lacking.7

Despite being an exciting and promising solution for the critical supply shortage the health care system is facing, the rapid creation of 3-D-printed materials remains an ongoing source of debate. Proponents argue that Internet-based, open-source file-sharing net-works, along with the global armamentarium of 3-D printers, act as a major strength and force multiplier



for this movement, contending that decentralization improves overall access to these resources.

Opponents and skeptics fear that the lack of a centralized repository places end users at risk of using potentially inferior products. Many questions regarding the safety of the materials used in these approaches, as well as their efficacy, have yet to be answered within the scientific community. Many of these designs have yet to meet or be subjected to the rigorous quality assurance testing processes that define industry standards. Programs such as the NIH 3D Print Exchange should help to address these con-cerns; however, objective data within the literature surrounding these products is sparse. Recognizing these concerns, supporters of this movement argue that 3-D-printed products should not replace standard equipment, but rather serve as an alternative option should the need arise.

COVID-19 reveals deficiencies The ongoing COVID-19 crisis has uncovered a multitude of limita-tions within our health care system. At press time, social distancing efforts suggested promising confinement of disease spread, but these efforts had fallen short in terms of addressing the needs of the thousands of afflicted patients and the health care personnel striving to care for them. Prospective planning and the develop-ment of novel solutions need to be actively pursued to ensure the U.S. health care system is designed to proactively respond to such enormous challenges now and in the future.

As technology-based fields continue to become more prominent components of our society, adaptations of their state-of-the-art processes, specifically additive manufacturing and 3-D printing, within the health care system may prove to be the missing link in overcoming the logistical and supply gap shortages. Nonetheless, the concerns regarding the safety and efficacy of these innova-tive solutions is valid and more research should be rapidly sought before widespread adoption can be recommended. ♦

Editor’s noteThe views addressed in this article represent the opinions of the authors and do not reflect the views of the U.S. Army, the Department of Defense, or the U.S. government.

REFERENCES1. Thielking M. Frustrated and afraid about

protective gear shortages, health workers are scouring for masks on their own. Stat News. March 18, 2020. Available at: www.statnews.com/2020/03/18/ppe-shortages-health-workers-afraid-scouring/. Accessed April 4, 2020.

2. Feldman A. Meet the Italian engineers 3-D printing respirator parts for free to help keep coronavirus patients alive. Forbes. March 19, 2020. Available at: www.forbes.com/sites/amyfeldman/2020/03/19/talking-with-the-italian-engineers-who-3d-printed-respirator-parts-for-hospitals-with-coronavirus-patients-for-free/#5bdb5b1778f1. Accessed April 3, 2020.

3. Carroll L. New York’s Northwell Health begins 3-D printing nasal swabs for coronavirus testing. Reuters. March 31, 2020. Available at: www.reuters.com/article/us-health-coronavirus-usa-swabs/new-yorks-northwell-health-begins-3d-printing-nasal-swabs-for-coronavirus-testing-idUSKBN21I2Y2. Accessed April 3, 2020.

4. Make the Masks. The Montana Mask. Available at: www.makethemasks.com/. Accessed April 3, 2020.

5. University of California-San Francisco. Face Shield Project. Available at: www.library.ucsf.edu/news/ucsf-3d-printed-face-shield-project/. Accessed April 3, 2020.

6. National Institutes of Health. COVID-19 supply chain response. National Institutes of Health 3D Print Exchange. Available at: https://3dprint.nih.gov/collections/covid-19-response. Accessed April 1, 2020.

7. The Joint Commission. Statement on Use of Face Masks Brought From Home. March 31, 2020. Available at: www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/infection-prevention-and-hai/covid19/public_statement_on_masks_from_home.pdf. Accessed April 4, 2020.



S tarting this past winter, the coronavirus disease 2019 (COVID-19) pandemic has swept across the world, with the U.S. reporting the highest number of cases globally. New

York, NY, and surrounding areas experienced a disproportion-ately higher number of cases, with their death toll at more than 24,000 at press time, owning 8 percent of the entire world’s car-nage. Nassau County specifically had seen nearly 40,000 cases, a rate of nearly 1,861 cases per 100,000 people, one of the highest in the greater New York region.1

Our 450-bed community hospital—Mount Sinai–South Nassau—is located in the heart of that suburban county and thus within the regional epicenter of this deadly virus. Our institution transformed from a primarily suburban center to a global COVID-19 hotbed. We augmented our staff with physi-cians from across the country, admitted thousands of cases (2,300 as of the publication of this article), and upgraded our critical

by Justin Gauthier, MD

HIGHLIGHTS• Describes the experiences

of a chief surgical resident treating COVID-19 patients

• Summarizes the trend of COVID-19 leading to AKI

• Outlines one community hospital’s investigation of increased pneumothorax rates and COVID-19

Photo: The author outside his hospital, taking a break from treating COVID-19

patients (photo by Jason D’Cruz, surgery intern, Mount Sinai-South Nassau)


COMMUNITY HOSPITAL BATTLES COVID-19

Community hospital’s losing battle with COVID-19:

A surgery resident’s account

care unit to five times its pre-COVID-19 capacity. Although we optimistically focused on the more than 60 patients successfully extubated and the nearly 1,000 COVID-19-recovered discharges, sadly we also have lost more than 400 lives to this horrific pandemic.

As I approached the end of my final year of train-ing, I had envisioned this period as a time to prepare for private practice and study for boards. Instead, as the chief surgical resident at a facility in the heart of this war, I was on the front lines battling its unpre-dictable sequelae. Our training program was halted, roles were changed, and positions were reassigned, as we were all enlisted to this army of physicians. As residents, we found ourselves powerlessly fight-ing an invisible enemy and witnessing scenes of fatality that are unlikely to leave our nightmares anytime soon. The following describes some of our experiences.

Acute kidney injury and failed hemodialysisOur institution recently submitted for publication an article identifying the trend between COVID-19 and the onset of acute kidney injury (AKI). We found that AKI developed in 81 percent (n = 142) of intubated patients, with a greater percentage of patients devel-oping AKI in the expired group when compared with the group of living patients (92 percent versus 72 per-cent). We further calculated the odds ratio for death after the diagnosis of AKI as 4.5 and thus concluded that intubation was a harbinger to AKI, as well as to eventual expiration.

Our study shows that intubated COVID-19 patients are at risk of developing AKI and that their chance of survival diminishes significantly after its onset. In an attempt to counteract this deleterious sequelae, nephrologists have been recommending hemodial-ysis (HD). These specialists have extrapolated that

by using HD, we could filter the cytokine and other immune factors from the blood, thereby preventing the virus’ deadly effects. Historically, HD has been the most widely used tool in our armamentarium for correcting rising creatinine levels.2

HD, however, is a very expensive, physically taxing, and time-consuming process for patients.3 It requires the placement of a temporary dialysis cathe-ter, which is an invasive procedure that leads to many potential complications (infection being the most pertinent, pneumothorax being the most detrimen-tal).4 Placement of these dual-lumen catheters has become the responsibility of surgical residents, as, historically, vascular surgeons have been tasked with inserting large-bore central venous devices. Until the COVID-19 pandemic, our team placed roughly one HD catheter per week. Since the onset of this kidney-killing virus, our team places an average of three to five urgent HD catheters per day.

Though not yet exclusively studied, anecdotal evi-dence has shown that HD has no significant positive effect on the COVID-19 patient’s clinical course or AKI progression. This statement is not to fault the nephrologists nor the intensivists; it is just all we know.

Though peritoneal dialysis (PD) has started to be used instead, the shift occurred more out of neces-sity (limited hemodialysis machines) than improved efficacy. PD also is unstudied in COVID-19-related AKI. Some have theorized it is more cogent to employ continuous renal replacement therapy in the man-agement of COVID-19-induced AKI,5 but no reports on the efficacy of this approach have been published at press time. Highly educated medical profession-als are relying on what they have previously seen to work in medicine, rather than any evidence base, because the facts pertaining to this evasive enemy are not yet available.

As residents, we found ourselves powerlessly fighting an invisible enemy and witnessing scenes of fatality that are unlikely to leave our nightmares anytime soon.



Pneumothorax, pneumomediastinum, and plenty of pigtailsIn the first five weeks since the outbreak of this deadly virus, I placed more pigtail catheters in hypoxic patients than in my previous five years of surgical training. Now, when our thoracic surgery service is called for urgent placement, after a large pneu-mothorax is noted on a recent chest X ray, the story sounds rehearsed: “COVID-positive, PEEP [positive end-expiratory pressure] above 10 cm H2O and PaO2 less than 50 mm Hg.” On further examination, respi-ratory rates are universally in the 30s, presumably in an attempt to blow off the severe hypercapnia, typi-cally above 50 mm Hg. As the textbook teaches, the 14Fr Wayne pigtail catheters are placed in the second intercostal space, midclavicular line, without even contacting our attendings.

This drastically increased rate of pneumotho-rax has again led our institution to investigate the causative connection with the COVID-19 virus. A formal study is under way, but preliminary results show nearly half of the intubated COVID-19 patients required pigtails for clinically significant pneumo-thorax. Furthermore, our thoracic surgeons were consulted, and have been subsequently following with serial chest X rays in an overwhelming major-ity of the 80-patient critical care units. In specific cases, we were occasionally required to place surgical chest tubes (30–34Fr in the traditional 5th intercostal space, midaxillary line) and even twice resorted to venting skin incisions to relieve extensive, clinically diminutive, subcutaneous emphysema.

We first postulated that this procedure was a response to the high levels of PEEP the critical intensivists were using to adequately oxygenate the patients’ COVID-19-infected lungs. After several multidisciplinary meetings, the team universally low-ered the PEEP levels, capping them at 10 cm H2O.

Despite this effort, we found very little change in the pneumothorax rate. We thus reconsidered its etiology as potentially secondary to the fragility of patients’ lungs. Treated similarly to patients with acute respiratory distress syndrome, the brittle lung parenchyma of COVID-19 is failing with only the smallest amount of positive pressure, even with noninvasive methods. Our surgical team, again, performed the most appropriate intervention to treat the patients’ symptoms, seemingly without altering the clinical course.

Many silver bullets, no cure…yetUniversity Hospitals Birmingham, U.K., published a research briefing in April that highlighted all the active COVID-19 trials internationally.6 The brief-ing, though primitive, was intriguing—ivermectin removed the in-vitro viral load in 48 hours; siltux-imab and other immunotherapies touted significantly reduced c-reactive protein levels, but some patients actually worsened; angiotensin-converting enzyme inhibitors were reducing mortality and intensive care unit admission rates with an odds ratio of 0.29. These studies, like many regarding COVID-19, have small sample sizes but stimulate significant hope that a cure will emerge.

Our hospital, like most affected around the world, are attempting most of these potential ther-apies. COVID-19-positive patients are universally receiving ritonavir, tocilizumab, full-dose lovenox, intravenous famotidine, and even the controversial hydroxychloroquine. We also initiated a protocol trial for convalescent plasma exchange. Some col-leagues claimed that this therapy was the new silver bullet and would be the long-awaited cure. Recov-ered COVID-19 victims eagerly donated their plasma which, containing IgG and IgM antibodies, would

A formal study is under way, but preliminary results show nearly half of the intubated COVID-19 patients required pigtails for clinically significant pneumothorax.



potentially cure well-selected patients. However, without ran-domized control trials, it is impossible to prove the efficacy of these treatments compared with a placebo. Overall, what I can state anecdotally, and based on lengthy discussions with my colleagues, is that no therapy yet initiated in our hospital has had any obvious meaningful effect on our patients’ prognoses.

It is with great reluctance that we take on this next revolution-ary endeavor. In Israel, a minute group of qualified COVID-19 patients were given pluripotent stem cells with incredible results. The theory is that these placenta-derived mesenchymal cells, because of their unique limitless capabilities, can mitigate the tissue-damaging effects of the virus, particularly in the pulmo-nary and renal systems. Though inclusive of only a small subset of qualified patients, and therefore, again, a minimally powered study, the results appear very promising. After anxiously awaiting its transatlantic arrival, we gave these 15 intramuscular injec-tions to several specifically selected patients in our critical care unit. The improvement in chest X rays and arterial blood gases have been astounding; in only three days, it looked as if we had tested a different patient. Though we are hesitant to declare vic-tory, with much larger trials to be conducted, this therapy does give hope for the positive outcome of this battle.

Throughout this pandemic, our program’s surgical residents have successfully placed hundreds of HD catheters and pigtails, administered every potentially curative therapy mentioned, and yet our mortality rate in the critical care unit has remained dauntingly high. Again, specialty-trained physicians are treat-ing the symptoms of COVID-19, but apparently not affecting its prognosis. We have spent hundreds of thousands of dollars, countless numbers of hours, and irreplaceable years of our lives training to fight illness. On a scale unlike ever before, all this education, all this research, all this dedication to our trade, is simply not enough. When these patients become critically ill, regardless of our best lifesaving measures, this deadly virus has consistently proven victorious. Though a vaccine, or even our novel stem cell study, may prove to be a successful remedy, the toll this pandemic has taken on health care professionals is one that will not soon be forgotten. ♦

REFERENCES1. Statista. COVID-19 death rates by age

group in New York City 2020. Available at: www.statista.com/statistics/1109867/coronavirus-death-rates-by-age-new-york-city/. Accessed May 1, 2020.

2. Friedrich JO, Wald R, Bagshaw SM, Burns K, Adhikari N. Hemofiltration compared to hemodialysis for acute kidney injury: Systematic review and meta-analysis. Crit Care. 2012;16(4):R146.

3. Loubeau PR, Loubeau JM, Jantzen R. The economics of kidney transplantation versus hemodialysis. Prog Transplant. 2001;11(4):291‐297.

4. Bevc S, Pecovnik-Balon B, Ekart R, Hojs R. Non-insertion-related complications of central venous catheterization—temporary vascular access for hemodialysis. Ren Fail. 2007;29(1):91-95.

5. Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367(26):2505-2514.

6. University of Birmingham. COVID-19 research briefing. Available at: www.birmingham.ac.uk/university/colleges/mds/Coronavirus/COVID-19-research-briefing.aspx. Accessed May 1, 2020.



FOR YOUR PATIENTS

ACS quality and safety case studies:

Virtual acute care for older patients reduces hospital length of stay

by Melanie Morris, MD; Lauren Wood, MPH; Emily Simmons, MSN, RN, CNL, FGNLA; Shari Biswal, MSN, RN, PCCN, CNL; David James, DNP, RN-BC, CCNS, LSSGB;

Jasmine Vickers, MPH, CHES; John Russell, MBA, CPA; Katrina Booth, MD; and Kellie Flood, MD

The U.S. surgical patient population is aging, with 38 percent of operations

performed on older adults. Traditionally, postoperative patients have received care in a surgical ward. Nurses and other members of the multidisciplinary health care team are trained to provide postoperative care to surgical patients but may not receive special training to prevent or manage preexisting geriatric syndromes, such as cognitive impairment, delirium, and functional decline. Furthermore, even if trained, these health care professionals must work in microsystems that support the delivery of evidence-based geriatric care processes to achieve quality outcomes.

The University of Alabama at Birmingham (UAB) recognized an opportunity to redesign geriatric care delivery at the microsystem level (a surgical ward), with the goal of providing care that is safe, timely, effective, efficient, equitable, and patient-centered for an older surgical patient population. For this initial project implementation, the

focus was on reducing delirium, improving patient mobility, decreasing hospital length of stay (LOS), and improving rates of discharge to home.

Putting the quality improvement (QI) activity in place UAB Hospital is a large public health care and tertiary referral center with approximately 1,200 beds. More than 36,000 operations are performed annually at the facility. It is the only Level I trauma center in Alabama. The hospital is continually full, with a 95–98 percent occupancy most days. We have embarked on a throughput initiative to decrease LOS to create more bed availability to serve more patients in the large catchment area.

UAB Hospital has an acute care for elders (ACE) unit designed to care for older adults admitted to the hospitalist service. Health care personnel in the unit have daily team meetings guided by a geriatric physician or nurse practitioner. The UAB ACE unit has demonstrated that this model increases the delivery of evidence-

based geriatric care processes with subsequent reductions in cost and 30-day readmissions.1 This model was used to design the Virtual ACE intervention with the goal of delivering the core ACE care processes to surgical patients admitted to a surgical ward without the daily presence of a geriatric provider (physician or nurse practitioner).

Based on well-established, improved outcomes from the ACE unit care and the growing geriatric surgery literature, including best practice guidelines for optimal perioperative management of geriatric surgical patients,2 the team recognized the need to disseminate ACE-like care (Virtual ACE) to surgical patients admitted to surgical wards.

To prepare the hospital system for this care delivery redesign, a core team of geriatricians, geriatric nurse practitioners, and geriatric-trained nurses used the Institute of Healthcare Improvement model for improvement with iterative Plan, Do, Study, Act (PDSA) cycles to implement standardized geriatric screens into the electronic


FOR YOUR PATIENTS

health record (EHR) for use by nurses on our ACE and other pilot units. More specifically, patients were screened for cognitive impairment, functional impairment, and mobility. Each PDSA cycle worked to ensure the new screens fit into the nursing workflow. The geriatric team also joined a collaborative with Aurora Health System, headquartered in Milwaukee, WI, and embedded the ACE Tracker report into the hospital EHR. The ACE Tracker is an electronic report that displays the results of geriatric assessments, including screens for function and delirium; process and outcome metrics, such as LOS; use of tethers, such as Foleys, restraints, and oxygen; and administration of medications for all patients on a specific unit.3

With this infrastructure in place, the geriatric team then engaged stakeholders from other interprofessional disciplines (rehabilitation therapists, pharmacists, dietitians, care coordinators, social workers, nurses, nurse practitioners, and physicians) and family caregivers in an iterative process to inform and pilot test the development of the Virtual ACE intervention care processes, workflows, and nurse-driven care algorithms. These care pathways targeted four geriatric domains: function/mobility, pain management, delirium prevention and management, and

interprofessional team approach for care transitions planning. Finally, the developed and vetted care algorithms for each of these domains were packaged into the Virtual ACE intervention.

Next, implementing the Virtual ACE intervention was pilot tested on orthopaedic4 and then trauma surgery units to learn and refine the implementation process, which resulted in a revised implementation strategy that was then brought to the gastrointestinal (GI) surgery units.

Stakeholder engagement meetings with members of the GI surgery unit began in January 2016. These initial meetings centered on attaining guidance, feedback, interest, and support from the surgical medical director, followed by engaging frontline staff and leadership of the unit interprofessional health care team members. Members of the unit interprofessional team also served as the liaisons for their disciplines throughout the education and implementation phases of Virtual ACE. We framed the Virtual ACE care processes as a model of care for all vulnerable patients—making geriatric care just routine care. In addition, Virtual ACE is designed to align with hospital and health care professional priorities, including reduced LOS, less use of restraints, early mobility, and so on. Buy-in was immediate.

Description of the QI activity After securing key stakeholder support in individual meetings, a Virtual ACE kick-off meeting took place in March 2016, with the entire unit-based interprofessional team leadership in attendance. One role of this team was to review and provide feedback and advice on the roles and responsibilities of each discipline and key components and goals of Virtual ACE, and help develop the project educational plan for the leadership and frontline staff.

The Virtual ACE intervention implementation included interprofessional team training and up to six months of intensive coaching, followed by three to six months of surveillance and retraining/coaching as needed to ensure the new care processes are hardwired into the teams’ approach. Team training was delivered to groups of the varied disciplines, further enforcing the role of working as a team to address geriatric syndromes. The core curriculum included cases and data designed to create a sense of urgency for change, followed by knowledge and skills required to implement the care processes and algorithms for the targeted geriatric syndromes.

Three nurse-driven care algorithms included in the intervention target were as follows:

For this initial project implementation, the focus was on reducing delirium, improving patient mobility, decreasing hospital LOS, and improving rates of discharge to home.


FOR YOUR PATIENTS

• Nonpharmacological pain management.

• Early safe mobility.

• Delirium prevention and management, including avoidance of potentially inappropriate medications for older adults (Beers Criteria medications). These pathways include geriatric screens for function (Katz Index of basic activities of daily living), mobility ( Johns Hopkins Highest Level Mobility Scale), cognition (Six Item Screen), and delirium (Nursing Delirium Screening Scale).5-9

Based on screen results, the care algorithms include steps to guide nurses and other disciplines toward preventing and addressing any identified risk factors or existing syndromes. For example, the early safe mobility algorithm includes setting goals for patient mobility, optimizing pain management, verifying mobility orders, and educating patients and families about the benefits of mobilization while in the hospital. The ACE Tracker report provided the most up-to-date results of these screens and other care processes for the interprofessional team, especially nurse leaders of the unit, to coordinate the daily plan of care.

The Virtual ACE curriculum was delivered in three one-hour sessions April 10 to May 15, 2016.

Trainees included all staff from the core disciplines on these two GI surgical units (nurses, patient care technicians, unit secretaries, rehabilitation therapists, pharmacists, dietitians, chaplains, care coordinators/managers, and social workers). Virtual ACE training for physicians was delivered in two one-hour didactic sessions in April and May 2016. The education was provided by the core Virtual ACE team. One goal was to equip and empower the team to provide evidence-based geriatric care as much as possible without daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service for the most complex or vulnerable patients.

Following the training, the units received support from the Virtual ACE coach. The coach is a master’s prepared nurse who has training in geriatrics and QI, is a member of the core geriatric team, and has responsibilities for the day-to-day management of the Virtual ACE initiative. Coaching sessions included rounds with staff and one-on-one consultation on using the ACE Tracker report to identify at-risk patients and activate the clinical algorithms to prevent and manage geriatric syndromes. The Virtual ACE coach also worked with unit leadership to remove barriers to implementing the Virtual ACE model, such as hardwiring the process for

obtaining gait belts and items for a delirium prevention toolbox. In June 2017, these GI surgical units implemented the final unit-based change in structure to further enhance use of the ACE Tracker and geriatric interprofessional team care, conducting daily interprofessional team rounds every weekday morning. These transition of care rounds were implemented across all medical-surgical units at UAB Hospital in 2016–2017 and serve as the foundational structure for interprofessional team coordination of Virtual ACE care. The GI surgical units’ staff receive booster coaching in use of these daily team meetings to identify patient care issues, especially those related to pain, mobility, and delirium in geriatric patients.

Resources used and skills neededThe time and effort to develop and implement the Virtual ACE intervention was part of the routine leadership and QI responsibilities of the core geriatric team charged with operationalizing multiple hospital-based geriatric programs, including Virtual ACE. This core team includes a 0.3 full-time equivalent (FTE) geriatrician and three FTE geriatric-trained clinical nurse leaders, with approximately 0.5 FTE nurse time dedicated to Virtual ACE teaching and

One goal was to equip and empower the team to provide evidence-based geriatric care as much as possible without daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service for the most complex or vulnerable patients.


FOR YOUR PATIENTS

coaching. Additional project-specific costs included staff time for the education sessions, food provided during training, and supplies. The hospital provided funding for all these costs.

ResultsThe primary outcome measure for this case study is hospital and postoperative LOS, and the balancing measure was 30-day readmissions. To determine these outcome measures, we examined institutional American College of Surgeons National Surgical Quality Improvement Program data for patients ages 70 and older who underwent colectomy, proctectomy, esophagectomy, hepatectomy, or pancreatectomy from January 1, 2013, to October 23, 2018, and stratified the information into standard care or Virtual ACE care. Demographics, hospital LOS, postoperative LOS, and readmission rates were recorded and compared. Binomial regression models were performed for LOS. The overall cohort included 676 patients—318 standard care and 358 Virtual ACE care, with a 3 percent overall mortality rate. The two cohorts were similar in age (74.9 versus 75.1 years, p = 0.83), gender (57 percent versus 56 percent male, p = 0.79), and comorbidities. More patients had independent functional status in the standard care cohort (99 percent versus 97 percent, p = 0.015).

Overall hospital LOS (median seven days [5–10 interquartile range [IQR] versus five days [3–8 IQR] p < 0.001) and postoperative LOS (median seven days [5–10 IQR] versus four days [3–7 IQR]) were significantly shorter in patients admitted post-Virtual ACE intervention. Readmission rates were similar (11 percent versus 12 percent, p = 0.1), signaling that reducing LOS did not adversely affect 30-day readmissions. The LOS model showed that Virtual ACE care decreased both hospital LOS (incident rate ratio [IRR] 0.74 [0.66–0.83], p < 0.0001) and postoperative LOS (IRR 0.69 [0.61–0.71], p < 0.0001).

Barriers encountered during Virtual ACE implementation included the challenge of finding ideal times to train health care providers from all disciplines on two busy acute care units. Another initial challenge was resupplying tools in a timely manner. This latter challenge has led to new and sustainable processes for securing these items through hospital central supply. These units, as is typical for hospital units, continue to undergo staff turnover, prompting the need to develop a process for introducing new staff to Virtual ACE initiatives, as well as providing at least annual booster training for existing staff. Both processes are now in place.

A limitation to the case study, which is common to

pragmatic QI studies, is the challenge in accounting for all possible confounding variables from other hospital or unit interventions that also may have affected LOS. Of note, enhanced recovery after surgery (ERAS) is known to reduce LOS, and the GI surgical service implemented ERAS for colorectal surgery patients in 2015, prior to launch of the Virtual ACE intervention. Whereas Virtual ACE also includes care processes addressing mobility, it supports and complements ERAS with training, screening, and care algorithms that address the unique vulnerability of older adults.

The Virtual ACE initiative approximate costs related to training staff and supplies were $6,000.

To estimate potential cost savings for reduction in LOS, we used our cost accounting system to identify patients from fiscal year 2018 who were 70 years of age or older and underwent a GI operation, yielding a sample of 221 patient encounters. The average direct cost for the last full day of each patient’s hospitalization was $1,053. So, each hospital day of shortened hospital stay saves $1,053.

Tips for othersWe have learned several lessons that we have used in each iterative PDSA cycle. They are as follows:

Allow frontline staff to participate in developing the plan to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.


FOR YOUR PATIENTS

• Stakeholder engagement from the beginning and throughout is critical for success.

Ȗ Speak the language that is important to your institutional leaders. Although delirium reduction is a key quality outcome for patients, it also leads to significant reductions in LOS, which is a strategic priority for our senior leaders. So, communicating the benefits of Virtual ACE with a focus on LOS impact is important to hospital leadership stakeholders.

Ȗ Speak the language that is important to your frontline care providers. The challenge of managing delirious patients is a chief concern of frontline nurses. Thus, communicating the benefits of Virtual ACE on delirium reduction is important to achieve buy-in from this group of stakeholders.

Ȗ Allow frontline staff to participate in developing the plan to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.

• Sustainment

Ȗ Provide frequent measures of progress, celebrate successes, and actively partner to overcome barriers to keep stakeholders and staff engaged.

Ȗ Manage-up the unit leaders and staff to their supervisors and senior leaders so they are the recipients of system-wide recognition they deserve for leading change.

Ȗ Create a process to onboard new staff and provide booster training at least annually and as needed regarding the Virtual ACE care processes.

Ȗ Create a unit-based accountable care team structure and culture, including providing process and outcome measures in accessible data reports or dashboards, so the unit-based interprofessional team leaders transition from dependency on the Virtual ACE coach to truly owning and driving the ongoing improvements. This transition moves the team from buy-in to ownership. ♦

REFERENCES1. Flood KL, MacLennan PA, McGrew D, Green

D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981-987.

2. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Surgical Patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947.

3. Malone ML, Vollbrecht M, Stephenson J, Burke L, Pagel P, Goodwin JS. Acute care for elders (ACE) tracker and e-geriatrician: Methods to disseminate ACE concepts to hospitals with no geriatricians on staff. J Am Geriatr Soc. 2010;58(1):161-167.

4. Booth KA, Simmons EE, Viles AF, et al. Improving geriatric care processes on two medical-surgical acute care units: A pilot study. J Healthcare Qual. 2019;41(1):23-31.

5. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.

6. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychological function. JAMA. 1963;185:914-919.

7. Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medical patients: A quality-improvement project. J Hosp Med. 2016;11(5):314-317.

8. Carpenter CR, DesPain B, Keeling TN, Shah M, Rothenberger M. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med. 2011;57(6):653-661.

9. Gaudreau JD, Gagnon P, Harel F, Tremblay A, Roy MA. Fast, systematic, and continuous delirium assessment in hospitalized patients: The nursing delirium screening scale. J Pain Symptom Manage. 2005;29(4):368-375.

Provide frequent measures of progress, celebrate successes, and actively partner to overcome barriers to keep stakeholders and staff engaged.


FOR YOUR PATIENTS

by Clancy J. Clark, MD; J. Bart Rose, MD; Judy C. Boughey, MD, FACS; and Flavio G. Rocha, MD, FACS

ACS Clinical Research Program:

Ga-68 imaging changes clinical management of GI and pancreatic neuroendocrine tumors

Standard management of gastrointestinal and pancreatic neuroendocrine

tumors (GEP-NETs) is surgical resection. However, identifying the primary tumor and burden of disease can be problematic, leading to challenges in surgical planning, optimal chemotherapy selection, and surveillance. Since the Food and Drug Administration approved gallium 68 dotatate (Ga-68) positron emission tomography (PET) on June 1, 2016, clinical management of GEP-NETs has rapidly evolved, and this new imaging modality has opened the field to new surveillance schema, as well as targeted interventions, such as lutetium 177 dotatate (Lutathera).

GEP-NETs are rare tumors of the pancreas and the tubular gastrointestinal (GI) tract (stomach, duodenum, small bowel, pancreas, appendix, colon, and rectum). These tumors can secrete bioactive substances (functional tumors), leading to constellations of clinical syndromes. Overall, incidence of GEP-NETs

increased from approximately one per 100,000 persons in 1973, to seven per 100,000 in 2012.1 In 2017, the World Health Organization (WHO) recategorized neuroendocrine neoplasms into low proliferative index neuroendocrine tumors and high proliferative index neuroendocrine carcinomas deemphasizing anatomic location.2 Proliferative indices are determined by Ki-67 levels (a nuclear protein associated with cellular division) with a high-grade (G3) tumor defined as more than 20 percent staining positive (see Table 1, page 77). While some anatomic locations can be associated with improved outcomes, high Ki-67 percentages found in poorly differentiated and undifferentiated neuroendocrine carcinomas can predict worse overall survival.3

Well-differentiated GEP-NETs typically overexpress somatostatin receptors, specifically somatostatin receptor subtype 2. In both functional and nonfunctional GEP-NETs, somatostatin analogs (such

as octreotide, lanreotide, and pasireotide) can inhibit tumor growth and improve progression-free survival as demonstrated in the PROMID (Placebo-Controlled, Double-Blind, Prospective, Randomized Study on the Effect of Octreotide LAR in the Control of Tumor Growth in Patients with Metastatic Neuroendocrine Midgut Tumors) and CLARINET (Placebo-Controlled Study of Lanreotide Antiproliferative Response in Patients with Enteropancreatic Neuroendocrine Tumors) trials.4-6

Progress to dateTaking advantage of somatostatin receptor overexpression, GEP-NETs can be localized using somatostatin receptor-targeted imaging modalities.7 Imaging of somatostatin receptors in a tumor was first described in 1984 and more specifically for NETs in 1993.7,8 Gamma radiation-based octreotide scan, which has been in use for more than 20 years, uses an indium 111 isotope with known poor image


FOR YOUR PATIENTS

quality, has a high radiation dose requirement, and requires prolonged scintigraphy for imaging (typically more than one day). Radiolabeled meta-iodobenzylguanidine (MIBG) with iodide 123 or 131 also has been used for neuroendocrine cancers but similarly struggles with spatial resolution.

Ga-68 PET combined with computed tomography (CT) or magnetic resonance imaging substantially improves spatial differentiation and detection of NETs with sensitivity ranging from 80 percent to 100 percent and specificity ranging from 82 percent to 90 percent. The patient experience is much better than in previous studies because imaging takes two hours rather than two days. Ga-68 imaging has a significantly improved detection rate for primary tumor compared with octreotide scan. Importantly, studies have demonstrated that Ga-68 imaging provides additional information resulting in change in clinical management for more than 70 percent of patients.3 Improved

GEP-NET imaging can assist with locating the primary tumor, preoperative planning, quantification of disease burden, and surveillance monitoring. For example, in a 51-year-old man who presented with shock from upper GI bleeding from presumed peptic ulcer disease, gastroduodenal artery coils placed by interventional radiology obscured visualization of a duodenal NET on CT but was readily visible on Ga-68 PET/CT (see Figure 1, page 78).

Reflecting improvements in image quality, guidelines by the National Comprehensive Cancer Network and the North American Neuroendocrine Tumor Society have now recommended Ga-68 imaging over somatostatin receptor scintigraphy (octreotide scan) for the detection and surveillance of GEP-NETs.9-11

Ongoing studyWhile Ga-68 PET has become the standard imaging study for evaluation of GEP-NETs,

multiple studies are ongoing to define its optimal role in clinical practice. Retrospective studies have suggested that Ga-68 imaging altered diagnosis and management in up to one-third of NET patients and 50 percent of those referred for surgical resection. Most changes in surgical management were found in small bowel NETs (6/7) and consisted of additional lesions that precluded curative therapy in four patients. In 77 patients with known metastatic disease, additional sites of metastases were seen in 37 and consisted of distant lymph nodes (18), bone (15), and liver (9). Occult primary tumors were seen in 3/13 (28 percent) of patients who presented with M1 (metastatic spread) disease.12

Based on a recent review of clinicaltrials.gov, 51 studies are evaluating Ga-68 PET with 23 recruiting participants, 7 closed to enrollment, and 12 sponsored by the National Institutes of Health. We eagerly look forward to the results of these studies, particularly as a means of clearly

a Pancreatic NENs further subdivided into well-differentiated G3 NETs and poorly differentiated G3 NECsb Differentiated into small and large cell

New category: mixed NEN/non-NEN (MiNEN) hyperplastic and preneoplastic lesionsNET = Neuroendocrine neoplasm tumorNEC = Neuroendocrine carcinoma NEN =Neuroendocrine neoplasm (includes NETs and NECs)HPF = High power field

TABLE 1.WHO CLASSIFICATION 2017 FOR GASTROENTEROPANCREATIC NEOPLASMS

Grade Description Ki-67, % Mitotic index (HPF)

G1 Well-differentiated NET < 2 < 2/10

G2 Well-differentiated NET 3–20 2–20/10

G3a Poorly differentiated NECb > 20 > 20/10


FOR YOUR PATIENTS

FIGURE 1.CORONAL Ga-68

VS. CORONAL CT IMAGING

A. Coronal Ga-68 PET/CT

demonstrated high standardized uptake value associated with

the primary duodenal NET not visible in normal CT

B. Coronal CT image demonstrating artifact created by gastroduodenal artery coils

placed during acute GI bleeding thought to be secondary

to peptic ulcer disease

identifying which patients would benefit most from liver-directed therapy, cytotoxic systemic chemotherapy, or other novel targeted treatment options, including Lutathera. In the Neuroendocrine Tumor Therapy (NETTER-1) phase 3 trial, the peptide receptor radionucleotide therapy Lutathera resulted in an improved 20-month progression-free survival of 65.2 percent over the 10.8 percent demonstrated in the octreotide long-acting repeatable group.13 Additionally, targeted molecules for imaging and treatment for non-somatostatin expressing GEP-NETs are still lacking and critically needed in these patients with a traditionally more aggressive disease. ♦

REFERENCES1. Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and

survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol. 2017;3(10):1335-1342.

2. Lloyd R, Osamura R, Klöppelm G, Rosai J, eds. WHO Classification of Tumours of Endocrine Organs, 4th edition. World Health Organization, Geneva; 2017.

3. Wang R, Zheng-Pywell R, Chen HA, Bibb JA, Chen H, Rose JB. Management of gastrointestinal neuroendocrine tumors. Clin Med Insights Endocrinol Diabetes. October 24, 2019 [Epub ahead of print].

4. Caplin ME, Pavel M, Cwikła JB, et al. Lanreotide in metastatic enteropancreatic neuroendocrine tumors. N Engl J Med. 2014;371(3):224-233.

5. Rinke A, Wittenberg M, Schade-Brittinger C, et al. Placebo-Controlled, Double-Blind, Prospective, Randomized Study on the Effect of Octreotide LAR in the Control of Tumor Growth in Patients with Metastatic Neuroendocrine Midgut Tumors (PROMID): Results of long-term survival. Neuroendocrinology. 2017;104(1):26-32.

6. Rinke A, Müller H-H, Schade-Brittinger C, et al. Placebo-Controlled, Double-Blind, Prospective, Randomized Study on the Effect of Octreotide LAR in the Control of Tumor Growth in Patients with Metastatic Neuroendocrine Midgut Tumors: A report from the PROMID study group. J Clin Oncol. 2009;27(28):4656-4663.

7. Krenning EP, Kwekkeboom DJ, Bakker WH, et al. Somatostatin receptor scintigraphy with [111In-DTPA-D-Phe1]- and [123I-Tyr3]-octreotide: The Rotterdam experience with more than 1000 patients. Eur J Nucl Med. 1993;20(8):716-731.

8. Reubi JC, Landolt AM. High density of somatostatin receptors in pituitary tumors from acromegalic patients. J Clin Endocrinol Metab. 1984;59(6):1148-1151.

9. Shah MH, Burns J, Zuccarino-Catania G. Neuroendocrine and adrenal tumors. NCCN Guidelines Version 1.2019. Available at: www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf. June 2019. Accessed March 3, 2020.

10. Strosberg JR, Halfdanarson TR, Bellizzi AM, et al. The North American Neuroendocrine Tumor Society consensus guidelines for surveillance and medical management of midgut neuroendocrine tumors. Pancreas. 2017;46(6):707-714.

11. Howe JR, Merchant NB, Conrad C, et al. The North American Neuroendocrine Tumor Society consensus paper on the surgical management of pancreatic neuroendocrine tumors. Vol 49. 2020. Available at: https://nanets.net/images/guidelines/NANETS_2020_Surgical_Management_of_PNETS.pdf. Accessed June 8, 2020.

12. Crown A, Rocha FG, Raghu P, et al. Impact of initial imaging with gallium-68 dotatate PET/CT on diagnosis and management of patients with neuroendocrine tumors. J Surg Oncol. 2020;121(3):480-485.

13. Strosberg J, El-Haddad G, Wolin E, et al. Phase 3 trial of 177 Lu-Dotatate for midgut neuroendocrine tumors. N Engl J Med. 2017;376(2):125-135.


FOR YOUR PATIENTS

Level 1 evidence often is lacking secondary to ongoing trials, new

treatment paradigms, or lack of feasibility. For example, small, retrospective, single institutional series suggested no benefit to completion lymph node dissection with sentinel node metastases for melanoma.1 A large surveillance, epidemiology, and end results (SEER) tumor registry study also demonstrated no survival advantage.1 These data guided clinical practice before publication of the Multicenter Selective Lymphadenectomy Trial (MSLT)-II prospective randomized trial that confirmed the nonrandomized studies. For Merkel cell cancer, a rare neuroendocrine tumor of the skin, a randomized trial regarding sentinel node biopsy is infeasible. However, SEER registry data comparing sentinel lymph node biopsy and nodal observation demonstrated a prognostic and therapeutic advantage to sentinel node biopsy.2

Evolving treatment paradigms for localized pancreatic cancerEffective multiagent chemotherapy has revolutionized the treatment of metastatic and localized pancreatic cancer. FOLFIRINOX and nab-paclitaxel/gemcitabine improve survival for patients with metastatic pancreatic cancer.3 As a result, the use of neoadjuvant and adjuvant multiagent chemotherapy for localized pancreatic cancer has increased. Prospective randomized data and retrospective studies demonstrate profound improvement in survival for resected localized pancreatic cancer with the addition of multiagent chemotherapy, 45–60-month median survival.4-6

Multiple clinical trials are investigating the timing and content of adjuvant therapy for localized pancreatic cancer. However, there is a dearth of Level 1 data to guide therapeutic paradigms. Small and large database studies can bridge these knowledge gaps. In this column, localized pancreatic

cancer is divided into four subgroups: locally advanced, borderline resectable, high-risk, and imminently resectable.

Locally advanced pancreatic cancerEffective chemotherapy has improved survival and resectability for locally advanced pancreatic cancer. With traditional neoadjuvant chemoradiation, such patients are rarely converted to resectable. Multiple centers have reported outcomes with neoadjuvant therapy for locally advanced pancreatic cancer and note increased conversion rates with multiagent chemotherapy. Investigators at the Medical College of Wisconsin, Milwaukee, reported outcomes in 108 consecutive patients with locally advanced pancreas cancer treated in 2009−2017.7

The most common definition for locally advanced pancreatic cancer is greater than 180° encasement of the superior mesenteric artery


by Timothy L. Fitzgerald, MD, FACS

NCDB cancer bytes:

Neoadjuvant and perioperative chemotherapy for localized pancreatic cancer:Leveraging small and large databases in the absence of Level 1 evidence

FOR YOUR PATIENTS

(SMA), celiac, hepatic artery, or unreconstructable occlusion of the portal vein. The group from Wisconsin further subdivides these patients into Type A and Type B.7 Evans Type A has more than 180° involvement of the SMA/hepatic artery but less than 270, greater than 180° involvement of the celiac not involving the aorta. Evans Type B patients have more extensive vascular involvement. Most patients received FOLFIRINOX or nab-paclitaxel/gemcitabine, with radiation. A total of 50 percent of patients went to the operating room, and successful outcomes were reported in 42 percent, 62 percent for Type A, and 24 percent for Type B. Median overall survival after resection was approximately 40 months.

The Mayo Clinic, Rochester, MN, reported outcomes for 123 patients receiving total neoadjuvant therapy from 2010 to 2017.4 The neoadjuvant regimen was most often FOLFIRINOX or nab-paclitaxel/gemcitabine, followed by radiation therapy. Chemotherapy regimens were changed for nonresponders. Only 37 percent had locally advanced disease; the remainder were borderline resectable. The investigators reported significant downstaging, even with little radiographic response. Three factors were associated with survival: more than six cycles of chemotherapy, decreased

carbohydrate antigen (CA)-19-9, and pathologic response. Survival was not associated with anatomic classification or change in chemotherapy. Overall survival was almost 60 months.

Borderline resectableIn the absence of Level 1 data, neoadjuvant multiagent chemotherapy has become the standard of care for borderline resectable pancreatic cancer.3 The Alliance for Clinical Trials in Oncology defines borderline resectable as more than 180-degree involvement of the superior mesenteric vein (SMV)/portal vein that is reconstructable, the involvement of the SMA/celiac axis of more than 180 degrees, or short segment hepatic artery involvement. The Japanese Society of Pancreatic Surgery reported outcomes in 884 patients with borderline resectable pancreatic cancer treated in 2011−2013, the largest series to date. In this manuscript, upfront surgery is compared with neoadjuvant chemotherapy +/- radiation. In the upfront surgery group, 93 percent of the patients were resected versus 75 percent in the neoadjuvant group. Despite the lower resection rates, neoadjuvant therapy was associated with improved survival, 25.7 versus 19.0 months, and increased R0 resection rates.8

The role of radiotherapy for borderline resectable pancreatic cancer is unclear. Results from a prospective randomized trial by the Alliance comparing neoadjuvant FOLFIRINOX with/without radiation are pending. Unfortunately, much of the retrospective data regarding neoadjuvant radiation therapy combines locally advanced and borderline resectable.

Our group, using National Cancer Database (NCDB) data, investigated the role of radiation therapy in addition to multiagent chemotherapy for locally advanced and borderline resectable disease. The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons (ACS) and the American Cancer Society. The reader should be mindful that the data used in the study are derived from a deidentified NCDB file. The ACS and the CoC have not verified and are not responsible for the analytic or statistical methodology employed or the conclusions drawn from these data.

A total of 2,703 patients diagnosed in 2006−2014 were included in the study. Radiation therapy was associated with increased complete pathological response rates, R0 resection rates, and downstaging with no improvement in survival. The Japanese Society of Pancreatic Surgery also failed to demonstrate improved

Effective multiagent chemotherapy has revolutionized the treatment of metastatic and localized pancreatic cancer. FOLFIRINOX and nab-paclitaxel/gemcitabine improve survival for patients with metastatic pancreatic cancer.


FOR YOUR PATIENTS

survival with neoadjuvant radiation in borderline resectable patients.8 Conversely, a multi-institutional French study noted improved survival with radiation therapy after neoadjuvant chemotherapy.6

High-risk pancreatic cancerMany patients are high risk, even when not locally advanced or borderline resectable. NCDB data can classify patients into high and low risk for mortality.9 This study included 25,897 patients diagnosed in 2004−2013 with stage I, II, or III pancreatic cancer. Factors associated with mortality include size (</> 2 cm), grade, lymph node metastasis, adjuvant therapy, and surgical margins.

For example, a patient younger than 65 years of age with a small, low-grade tumor, who undergoes an R0 pancreatic resection and is treated with adjuvant therapy, has an expected five-year survival of 51 percent. In contrast, a 70-year-old patient with a larger, high-grade tumor resected with positive margins treated with adjuvant therapy has an expected five-year survival rate of 5 percent. Unfortunately, many of these factors are unknown preoperatively. The National Comprehensive Cancer Network (NCCN) defines preoperative high-risk features as high CA-19-9, lymph node disease, pain, and weight

loss.10 The American Society of Clinical Oncology (ASCO) guideline also includes reversible medical conditions and large size.5 In the absence of clear-cut data, expert opinion from both ASCO and NCCN recommends consideration of neoadjuvant therapy for high-risk patients.

Imminently resectableSurgeons should be mindful that at least 20 to 30 percent of patients treated with neoadjuvant therapy will never undergo surgical resection. The recently published PRODIGE 24/CCTG PA.6 trial is a prospective randomized trial comparing postoperative FOLFIRINOX to gemcitabine in 493 patients enrolled in 2012−2016.11 The survival in the FOLFIRINOX group was 54.4 months versus 35.0 with gemcitabine. Given the excellent outcomes with upfront resection with postoperative multiagent chemotherapy and high dropout rates, the question remains, which patients should undergo upfront surgery?

Although the cancer care community has achieved broad consensus regarding neoadjuvant therapy for advanced tumors, questions remain about how to manage patients who fit into none of these categories. To answer this question, our group examined 13,412 NCDB patients with T1 and T2 tumors diagnosed in 2006−2014.13

Four groups were defined: chemotherapy-only, surgery-only, neoadjuvant, and postoperative adjuvant. Chemotherapy-only patients have the worst survival rate, followed by surgery-only. Outcomes are improved with the addition of adjuvant therapy.

Neoadjuvant and postoperative adjuvant chemotherapy had similar survival rates. Only one-quarter of patients who start with curative intent chemotherapy underwent resection. A series from the University of Pittsburgh, PA, reported similar findings.12 In this series, 552 patients with resected pancreatic adenocarcinoma treated in 2008−2015 were included, and the authors noted improved survival with at least six cycles of perioperative chemotherapy. Similar to our findings, the authors noted no effect on survival if therapy was delivered preoperatively, perioperatively, or postoperatively. One could define a group of patients as imminently resectable if they do not have high-risk features and can be resected with an anticipated negative margin. In this group, upfront resection should be considered.

ConclusionAlthough prospective randomized trials remain the gold standard, large and small data sets can inform clinical

Although prospective randomized trials remain the gold standard, large and small data sets can inform clinical practice.


FOR YOUR PATIENTS

practice. Large national registries such as the NCDB can be leveraged to answer important clinical questions. When using such databases, it is important that investigators understand the limitations of the data, study clinically meaningful hypothesis-driven questions, apply appropriate controls, and account for imbalance in study arms with appropriate techniques such as propensity matching.

In the rapidly evolving clinical paradigms for localized pancreatic cancer, a combination of Level 1 data and database studies inform management. Clearly, multiagent chemotherapy has improved survival for localized pancreatic cancer. For locally advanced pancreatic cancers, neoadjuvant treatment should be given. By dividing patients into Evans Type A and B, we can better educate patients about the likelihood of a successful operation. In this setting, with a high risk of R1 resection, it is reasonable to consider the addition of radiation therapy to preoperative multiagent chemotherapy. For patients with borderline resectable tumors four months of neoadjuvant therapy, ideally FOLFIRINOX, and selective use of radiation therapy should be considered. High-risk disease can be defined as the abutment/involvement of major vasculature structures, high cancer antigen 19-9, pain, weight loss, reversible medical comorbidities, and tumor size greater than 2 cm. In such patients, neoadjuvant or perioperative multiagent chemotherapy should be considered. In a select group of patients with imminently resectable tumors, upfront surgery with postoperative adjuvant FOLFIRINOX could be considered. ♦

REFERENCES1. Kachare SD, Brinkley J, Wong JH, Vohra NA, Zervos EE,

Fitzgerald TL. The influence of sentinel lymph node biopsy on survival for intermediate-thickness melanoma. Ann Surg Oncol. 2014;21(11):3377-3385.

2. Kachare SD, Wong JH, Vohra NA, Zervos EE, Fitzgerald TL. Sentinel lymph node biopsy is associated with improved survival in Merkel cell carcinoma. Ann Surg Oncol. 2014;21(5):1624-1630.

3. Vidri RJ, Vogt AO, Macgillivray DC, Bristol IJ, Fitzgerald TL. Better defining the role of total neoadjuvant radiation: Changing paradigms in locally advanced pancreatic cancer. Ann Surg Oncol. 2019;26(11):3701-3708.

4. Truty MJ, Kendrick ML, Nagorney DM, et al. Factors predicting response, perioperative outcomes, and survival following total neoadjuvant therapy for borderline/locally advanced pancreatic cancer. Ann Surg. April 5, 2019 [Epub ahead of print].

5. Khorana AA, McKernin SE, Katz MHG. Potentially curable pancreatic adenocarcinoma: ASCO clinical practice guideline update summary. J Onc Practice. 2019;15(8):454-457.

6. Pietrasz D, Turrini O, Vendrely V, et al. How does chemoradiotherapy following induction FOLFIRINOX improve the results in resected borderline or locally advanced pancreatic adenocarcinoma? An AGEO-FRENCH Multicentric Cohort. Ann Surg Oncol. 2019;26(1):109-117.

7. Chatzizacharias NA, Tsai S, Griffin M, et al. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery. 2018;163(5):1053-1062.

8. Nagakawa Y, Sahara Y, Hosokawa Y, et al. Clinical impact of neoadjuvant chemotherapy and chemoradiotherapy in borderline resectable pancreatic cancer: Analysis of 884 patients at facilities specializing in pancreatic surgery. Ann Surg Oncol. 2019;26(6):1629-1636.

9. Fitzgerald TL, Hunter L, Mosquera C, et al. A simple matrix to predict treatment success and long-term survival among patients undergoing pancreatectomy. HPB (Oxford). 2019;21(2):204-211.

10. Tempero MA. NCCN guidelines updates: Pancreatic cancer. J Natl Compr Can Netw. 2019;17(5.5):603-605.

11. Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med. 2018;379(25):2395-2406.

12. Epelboym I, Zenati MS, Hamad A, et al. Analysis of perioperative chemotherapy in resected pancreatic cancer: Identifying the number and sequence of chemotherapy cycles needed to optimize survival. Ann Surg Oncol. 2017;24(9):2744-2751.

13. Vidri RJ, Olsen WT, DE Clark DE, Fitzgerald TL. No advantage of neoadjuvant therapy for clearly resectable pancreatic cancer. Ann Surg Onc. 2019;26(2):S33-S33.

In the rapidly evolving clinical paradigms for localized pancreatic cancer, a combination of Level 1 data and database studies inform management.


FOR YOUR PATIENTS

A look at The Joint Commission:

Recommendations pour in as surgeons navigate COVID-19 pandemic

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


FOR YOUR PRACTICE

When the number of confirmed cases of coronavirus disease

2019 (COVID-19) began rising across the U.S. in March, regulators and administrators called for hospitals, surgeons, and other providers to take several measures to combat the disease and its spread, including delaying or postponing elective surgical and procedural cases. As the immediate threats waned, public health authorities called on the public and the health care community to respond in other ways.

Immediate response to the crisisThe Centers for Disease Control and Prevention (CDC) recommendations to health care organizations included delaying both inpatient and outpatient nonemergent surgical and procedural cases, as well as prioritizing urgent and emergency visits and procedures to keep staff and patients safe, preserve personal protective equipment (PPE)

resources and other supplies, and ensure that hospitals could keep up with the anticipated demands in capacity.1

The U.S. Surgeon General also recommended canceling all nonemergent operations. Then, on March 13, the American College of Surgeons (ACS) released recommendations for hospitals and surgeons on delaying or postponing nonemergent procedures, followed by “COVID-19: Guidance for triage of non-emergent surgical procedures” on March 17, 2020.2-3

As the number of COVID-19 cases began to level off, hospitals and surgeons sought to provide opportunities to patients who needed nonemergency operations. In response, the ACS issued “Local resumption of elective surgery guidance” April 17.4

My take on the ACS recommendations is that we all must rise to the local challenges this pandemic poses and preserve the “three S’s” (space, staff, and stuff ) to serve the anticipated needs

My take on the ACS recommendations is that we all must rise to the local challenges this pandemic poses and preserve the “three S’s” (space, staff, and stuff) to serve the anticipated needs of our patients.

People wearing cloth face coverings or face masks over their mouths and noses to contain their respiratory secretions helps to reduce the dispersion of droplets from an infected individual.


of our patients. I also believe that the principle of having the medical need for a given procedure determined by the surgeon is paramount to protect the patients at large and surgeon-patient trust. And although the logistical feasibility is determined by administrative personnel, the principle that the surgeon determines the need puts the health care professional at the center of the decision-making process. This is good for medicine and for patients.

At a time when surgical procedures were postponed and nonemergent visits to the clinic also were being rescheduled, many surgeons turned their attention to the service they could provide in the intensive care unit (ICU), demonstrating their leadership and commitment to patient care.

Staying safe in a post-pandemic worldAs surgical professionals returned to the operating room and clinic, concerns about the risk of transmitting COVID-19 virus continued to surface. To help alleviate these concerns,

hospitals and ambulatory surgery centers (ASCs) around the country began requiring that everyone who entered the facility—including staff, patients, and visitors—wear a mask. As surgeons resume nonemergent procedures, this policy will be critical in curbing the spread of COVID-19 to patients and staff.

The CDC added this advice to their late-April infection prevention and control recommendations related to COVID-19, and The Joint Commission supports this policy. The CDC guidance—“Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings”—states that health care facilities should “implement source control for everyone entering a healthcare facility (e.g., health care personnel, patients, visitors), regardless of symptoms.” This process is critical to address asymptomatic and presymptomatic transmission of COVID-19.5

People wearing cloth face coverings or face masks over their mouths and noses to contain their respiratory

secretions helps to reduce the dispersion of droplets from an infected individual.1 Face coverings will decrease the possibility that anyone with unrecognized COVID-19 infection will expose others to the disease.1 However, for source control to be effective, everyone in the hospital or ASC must wear a mask while inside to prevent droplet and—to a lesser extent—aerosol spread of COVID-19 and other respiratory viruses.2

The Joint Commission has issued a statement that universal masking within health care settings is a vital tool to protect staff and patients from being infected by asymptomatic and presymptomatic individuals and should be implemented anywhere coronavirus is occurring. Even one case of community spread means that the facilities and staff are at risk because asymptomatic and presymptomatic patients may come in for care and inadvertently infect staff.

The Joint Commission’s statement also summarizes key steps for implementing the CDC’s recommendation, as follows.5

FOR YOUR PRACTICE

If there are actual or anticipated shortages of face masks, they should be prioritized for health care personnel and for patients with symptoms of COVID-19.


For patients and visitors

• All patients and visitors should be instructed to wear a cloth mask when entering any health care building.

• If they arrive without a cloth mask, one should be provided.

• If there is a sufficient supply of medical-grade face masks, one may be provided instead of a cloth mask.

• Patients may remove the cloth face covering while in their own rooms, but they should put the face covering back on when leaving their room or when others who are not wearing a mask enter the room.

• If available, hospitals and ASCs should consider switching patients who have tested positive for COVID-19 or who have respiratory symptoms—such as a cough or sneeze—to a medical-grade face mask.

Per the CDC recommendations, face masks and cloth face coverings should not be placed on the following:

• Infants and toddlers younger than age two

• Anyone who has trouble breathing

• Anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance

For health care personnel

• Facility staff should wear at least a cloth mask when leaving their home

• When providing direct patient care to any patient, health care personnel should don a medical-grade, official PPE face mask or respirator, depending on the care provided. According to the CDC, “Cloth face coverings are not considered PPE because their capability to protect health care personnel...is unknown.”

• Health care personnel who provide support services but do not provide direct patient care should also wear a face mask. However, to conserve supplies, the face mask may be cloth. Outbreaks of COVID-19 have occurred among health care personnel who provide support services.

• Masks may be removed when social distancing of at least six feet

is possible (such as after entering a private office). To ensure staff can remove their masks for meals and breaks, scheduling and location for meals and breaks should ensure that at least a six-foot distance can be maintained between staff.

• It is important for hospitals and ASCs to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the face mask is touched, adjusted, or removed, hand hygiene should be performed.

The CDC guidance recommends that “as part of source control efforts, [health care personnel] should wear a facemask at all times while they are in the health care facility.”4 If there are actual or anticipated shortages of face masks, they should be prioritized for health care personnel and for patients with symptoms of COVID-19. Health care personnel may wear cloth face coverings when not engaged in direct patient care.5

“To avoid risking self-contamination, [health care personnel] should consider continuing to wear their respirator or facemask (extended

FOR YOUR PRACTICE

REFERENCES1. Centers for Disease Control and Prevention.

Resources for clinics and healthcare facilities. March 16, 2020. Available at: www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html. Accessed May 31, 2020.

2. American College of Surgeons. COVID-19: Recommendations for management of elective surgical procedures. March 13, 2020. Available at: facs.org/about-acs/covid-19/information-for-surgeons/elective-surgery. Accessed May 31, 2020.

3. American College of Surgeons. COVID-19: Guidance for triage of non-emergent surgical procedures. March 17, 2020. Available at: facs.org/about-acs/covid-19/information-for-surgeons/triage. Accessed May 31, 2020.

4. American College of Surgeons. Local resumption of elective surgery guidance. April 17, 2020. Available at: facs.org/covid-19/clinical-guidance/resuming-elective-surgery. Accessed May 31, 2020.

5. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings. Available at: www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed May 31, 2020.

6. The Joint Commission. Statement on Universal Masking of Staff, Patients, and Visitors in Health Care Settings. Available at: www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf. Accessed May 31, 2020.


FOR YOUR PRACTICE

use) instead of intermittently switching back to their cloth face covering,” the guidance recommends. “Of note, N95s with an exhaust valve might not provide source control. [Health care personnel] should remove their respirator or facemask and put on their cloth face covering when leaving the facility at the end of their shift. They should also be instructed that if they must touch or adjust their facemask or cloth face covering, they should perform hand hygiene immediately before and after.”5

The Joint Commission encourages health care facilities to remind patients and visitors that they should be wearing a face mask when they arrive for care. Hospitals and ASCs also can provide links to CDC resources, such as how patients can make their own masks with commonly available materials.6

To assist with rapid implementation of the CDC recommendations, The Joint Commission developed the following resources:6

• Signage that can be posted at entrances in black and white and in color

• An infographic on the do’s and don’ts for wearing face masks during the COVID-19 pandemic that can be used to educate staff and patients

These resources—as well as the full statement on universal masking—can be found at www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf. ♦

DisclaimerThe thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the ACS.

Resources and the full statement on universal masking can be found at www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf.

Specialty societies provide surgeons in training with opportunities to expand their knowledge and

clinical expertise through their training. Residency programs have a long checklist of knowledge and skills training they must provide to their trainees, yet somewhere along the way, the enrichment related to networking and career building gets lost. The Resident and Associate Society of the American College of Surgeons (RAS-ACS) is a specialty organization for residents and recent graduates that connects them to people and projects specifically for young surgeons. These opportunities help residents develop professionally as they progress through their training and early years in practice.

The RAS-ACS assists residents who want to attain skills pertaining to advocacy, health policy, leadership, global health, and career planning. It allows for networking and camaraderie, both of which are essential for professional development. This camaraderie fosters a kinship among residents whose common goal of surgical excellence attracts them to this profession. The challenge lies in attracting residents in the surgical specialties, such as residents in obstetrics and gynecology, otolaryngology−head and neck

PENNSYLVANIA OB-GYN RESIDENCY PROGRAMS AND REPRESENTATIVES

Abington Memorial Hospital, Abington

Dr. Perrin DowningDr. Tanvi Joshi

Allegheny Health, Pittsburgh

Dr. Mary Sims

Crozer-Chester Medical Center, Upland

Brett Smith-Hams

Albert Einstein Medical Center, Philadelphia

Dr. Katelyn Brendel

Geisinger Medical Center, Danville

Dr. Luke KingDr. Julia Middleton

Jefferson University Hospital, Philadelphia

Dr. Nimali Weerasooriya

Lankenau Medical Center (Main Line Health), Wynnewood

Dr. Sumin Park

Lehigh Valley Health Network, Allentown

Dr. Jose Lazaro

Penn State Medical Center, Hershey

Dr. Alexa Swailes

Pennsylvania Hospital, Philadelphia

Dr. Jordann Mishael-Duncan

Reading Hospital (Tower Health), West Reading

Dr. Sonia Bhandari Randhawa

St. Luke’s University Hospital– Bethlehem

Dr. Julia Ritchie

Temple University Hospital, Philadelphia

Dr. Miriam AioubDr. Olga Mutter

University of Pennsylvania, Philadelphia

Dr. Leigh Ann Humphries

University of Pittsburgh Magee Women’s Hospital, Pittsburgh

Dr. Alison Zeccola


by Sonia Bhandari Randhawa, MD, and Enrique Hernandez, MD, FACS, FACOG

FOR YOUR PROFESSION

From residency to retirement:

ACS offers opportunities for increased specialty resident participation in the College

surgery, urology, and so on. These residents likely find their own specialty organizations provide much of the support they need, but they also would benefit from the extensive resources offered by the College.

Obstetricians-gynecologists (OB-GYNs) have been an integral part of the ACS since its founding more than 105 years ago. In fact, the College’s founder, Franklin H. Martin, MD, FACS, chose the name Surgery, Gynecology & Obstetrics (now known as the Journal of the American College of Surgeons) for the organization’s clinical publication. OB-GYN residents are an important part of the ACS legacy and should be encouraged to be active participants in the largest and preeminent surgical association in the world.

Expanding involvement of OB-GYN residents in RASThe ACS Advisory Council for Obstetrics and Gynecology noted the void in OB-GYN resident involvement in RAS, and despite multiple efforts in the past, was unable to increase membership. At the 2019 Leadership & Advocacy Summit, the OB-GYN advisory council proposed a systematic effort to increase OB-GYN residents’ interest in

ACS. In the past, the program directors had been contacted through mail with little to no response. This year, the Resident Liaison on the advisory council and co-author of this article, Sonia Bhandari Randhawa, MD, paired with ACS Regent Enrique Hernandez, MD, FACS, FACOG, a member of the advisory council and a coauthor of this article, in an effort to significantly increase OB-GYN resident involvement in the ACS.

The goal was to form a Pennsylvania OB-GYN Resident Committee under the ACS to help residents learn about and take advantage of the resources that the ACS has to offer, including leadership, advocacy, and surgical skills training, as well as networking opportunities. The authors started by reaching out to each of the 16 Pennsylvania residency program directors and coordinators, asking each program to nominate a resident to the committee. The purpose of the request was to give the program directors a chance to select a resident who was most interested in the surgical aspects of OB-GYN and, in turn, will carry their ACS membership throughout their career. Some programs were eager early on, whereas others needed to be contacted directly by an ACS

Regent who knows the leaders of the programs. Our persistence eventually led to 15 of the 16 programs expressing interest in the project and nominating one to two residents per program.

Once we had representatives from most OB-GYN residency programs across the state, we hosted a welcome dinner for the selected residents where they learned about the ACS and the resources it has to offer them and about the goals of our committee. We had a significant turnout at the dinner and positive responses from the residents nominated to become ACS members.

We asked these residents to take back to their programs what they learned about the College and to encourage their fellow residents to join the organization; to select a junior resident in their program who would continue in this role after the initial group graduated; and to participate in a statewide service project for residents to lead a sanitary supply drive for a women’s shelter in their community.

We are looking forward to this group of residents becoming actively involved in the RAS-ACS and in the Pennsylvania ACS chapters’ (Keystone, Metropolitan, Northwestern, and Southwestern) activities. ♦

The RAS-ACS is a specialty organization for residents and recent graduates that connects them to people and projects specifically for young surgeons.


FOR YOUR PROFESSION

From the Archives:

German influences on U.S. surgery and the founding of the ACS

by David E. Clark, MD, FACS

Franklin Martin, MD, FACS, Founder of the American College of Surgeons

When the American College of Surgeons (ACS) was founded in

1913, the German-speaking countries of Europe were the preeminent leaders in biomedical science. Abraham Flexner, MD, and other U.S. physicians admired the principles of German medical education, including national standards for students and universities, academic freedom, the expectation of postgraduate training, and an adventurous tradition in which “the student wanders from place to place, seeking new teachers.”1 World War I would have a devastating impact on Germany’s reputation following the war, but we should acknowledge its inf luences on the genesis of our College.

During the latter 19th century, more than 15,000 U.S. physicians traveled to Germany, Austria, and Switzerland for postgraduate education.2 Visiting physicians and scholars praised German dedication to research, innovation, and teaching, but disliked how European professors treated patients as social inferiors.2

Conversely, German surgeons who visited the U.S. during the early 20th century were impressed by the practical skills, excellent nurses, private philanthropy, and respect for patients they found.2

Meanwhile, millions of people dissatisfied with life in central Europe were migrating to the U.S. Among these European immigrants were dozens of German-educated surgeons, including Christian Fenger, MD, and Carl Beck, MD, in Chicago, IL, who further inf luenced Americans unable to afford a European tour. Many of these immigrants remained members of the German Surgical Society (also known as DGCH), which William S. Halsted, MD, FACS; Roswell Park, MD, FACS; and John B. Murphy, MD, FACS, also joined.

Admission to the American Surgical Association (ASA), founded by German-American Samuel Gross, MD, in 1880, was limited to 125 members. In 1903, younger American academic surgeons founded the Society for Clinical Surgery (SCS), whose even smaller membership included ACS founders and

leaders Dr. Murphy; George Crile, MD, FACS; Harvey Cushing, MD, FACS; Charles Mayo, MD, FACS; J.M.T. Finney, MD, FACS, the first President of the ACS; and A.J. Ochsner, MD, FACS, all of whom had studied in Germany. Following the German “wanderlust” tradition, members of the SCS traveled from place to place to observe surgical centers at home and abroad.3

In 1904, Dr. Halsted described his residency program at the Johns Hopkins Hospital, Baltimore, MD, as designed “to adopt as closely as feasible the German plan.”4 He also criticized the exclusive surgical societies in America and advocated for a broad-based organization like the DGCH, which “admits to its fellowship any reputable surgeon of any country of the world, and its halls at each Congress are filled and overf lowing.”4 Dr. Park had made a similar recommendation in his role as ASA President in 1901.5

In 1905, ACS founder Franklin H. Martin, MD, FACS, established Surgery, Gynecology & Obstetrics (SG&O, now the


FOR YOUR PROFESSION

Journal of the American College of Surgeons), with Swiss-American Nicholas Senn, MD, FACS, as Editor-in-Chief. During its first decade, more than 40 percent of the literature cited in SG&O was in German. After the SCS proposed a translated abstract publication like the Zentralblatt für Chirurgie,3 Dr. Martin expanded SG&O to include the International Abstract of Surgery. Dr. Martin explicitly intended the initial Clinical Congresses as a way to make the SCS model more widely available.

Within a few years, the Clinical Congresses were “filled and overf lowing” and evolved into the ACS. Other than Dr. Martin, most of the initial ACS Regents and Presidents were SCS and ASA members. The new organization adopted the name and some traditions of the British Royal Colleges, ties that would be strengthened by wartime alliance, but in 1913, it owed at least as much to Germany as to Great Britain. ♦

REFERENCES1. Flexner A. The German side of

medical education. Atlantic Monthly. 1913;112:654-662.

2. Bonner TN. American Doctors and German Universities. Lincoln, NB: University of Nebraska Press; 1963.

3. Cushing H. The Society of Clinical Surgery in retrospect. Ann Surg. 1969;169(1):1-9.

4. Halsted WS. The training of the surgeon. Bull Johns Hopkins Hosp. 1904;15:267-275.

5. Sparkman RS, Shires GT, eds. Minutes of the American Surgical Association. Dallas TX: Taylor Publishing Co; 1972.

Dr. Halsted Dr. Martin Dr. Murphy

Dr. SennDr. ParkDr. Ochsner

Dr. FinneyDr. CushingDr. Crile

Dr. Mayo

NAT

ION

AL C

ANCE

R IN

STIT

UTE

Photos courtesy of the American College of Surgeons Archives, except where indicated


FOR YOUR PROFESSION

The ISCR expands scope to include emergency general surgery

J A N U A R Y 2 0 2 0 | V O L U M E 1 0 5 N U M B E R 1 | A M E R I C A N C O L L E G E O F S U R G E O N S

BulletinF E B R U A R Y 2 0 2 0 | V O L U M E 1 0 5 N U M B E R 2 | A M E R I C A N C O L L E G E O F S U R G E O N S

Bulletin

Recapturing the joy of surgery

Olga M. Jonasson, MD, Lecture:

M A R C H 2 0 2 0 | V O L U M E 1 0 5 N U M B E R 3 | A M E R I C A N C O L L E G E O F S U R G E O N S

Robert N. McClelland, MD, FACS, founder of SRGS

BulletinA P R I L 2 0 2 0 | V O L U M E 1 0 5 N U M B E R 4 | A M E R I C A N C O L L E G E O F S U R G E O N S

Death of Dr. Isaac Burrell inspired black hospital movement

Read Bulletin: ACS COVID-19 Updates at facs.org/about-acs/covid-19/newsletter

Bulletin


This year has been one of unprecedented change in most of our lifetimes as a result of the coronavirus disease 2019 (COVID-19) pandemic and the outcry against systemic racism. The monthly Bulletin of the American College of Surgeons (ACS) went on pause for three months so we could devote resources to publishing Bulletin: ACS COVID-19 Updates as the pandemic spread rapidly across the nation. After 15 issues of the newsletter and as the curve began to f latten in early hotspots, we switched to a weekly format focused not only on COVID-19-related developments, but also other

ACS business and activities in a weekly newsletter called Bulletin Brief, which you should receive every Tuesday and replaces ACS NewsScope. The new Bulletin Advocacy Brief e-newsletter will be released every other Thursday.

With this issue of the magazine, we resume a more regular publication schedule for the traditional Bulletin. One more issue of the Bulletin will be published this year in October. The Bulletin will resume monthly publication in January 2020.

Throughout all the upheaval and uncertainty, we hope that the Bulletin in its various forms has continued to serve as a

trusted and valued resource for all members of the College. As always, please provide any comments or suggestions on how we can best serve you at [email protected].

Thank you for your continued efforts “to serve all with skill and fidelity” and for your continued support of the Bulletin. ♦

NEWS

Letter from the Editor

by Diane Schneidman, Editor-in-Chief


NEWS

The American College of Surgeons (ACS) Cancer Programs is proud to announce the launch of the Cancer Surgery Standards Program (CSSP). Led by Chair Matthew H.G. Katz, MD, FACS, and Vice-Chair Kelly K. Hunt, MD, FACS, the CSSP seeks to improve the quality of surgical care provided to persons with cancer through the development of technical standards and quality measures; the creation and dissemination of electronic tools to support implementation and adherence to these standards; and the education of surgeons, trainees, and staff.

The ACS has been committed to setting standards for more than 100 years and sponsors a multitude of initiatives focused on improving the quality of care. Surgical clinical research trials, including many conducted by the ACS through the American College of Surgeons Oncology Group, have generated data that demonstrate that the specific methods by which certain technical aspects of surgery are conducted have a direct impact on patient outcomes. In some cases, the results from these trials led to the widespread adoption of standardized surgical approaches and evidence-based best practices.

Background and origins of CSSPThe CSSP has its origin in the Cancer Care Standards Development Committee of the ACS Clinical Research Program (ACS CRP), which was established to evaluate the level of evidence that exists to support the development of standardized surgical approaches and to develop standards based on this evidence. The committee also was tasked with improving the quality of surgical data captured during the conduct of clinical trials. The collaboration between the ACS and the Alliance for Clinical Trials in Oncology, created in 2012 by Heidi Nelson, MD, FACS, past-Program Director of the ACS CRP, current Medical Director of ACS Cancer Programs, and co-author of this article, has produced two volumes of Operative Standards for Cancer Surgery, each of which describes evidence-based standards for the technical conduct of oncologic surgery. Two additional volumes currently are in production. These technical standards are now being implemented into surgical practice through collaboration with other ACS Cancer Programs.

Announcing the new Cancer Surgery Standards Program

by Matthew H.G. Katz, MD, FACS; Kelly K. Hunt, MD, FACS; Heidi Nelson, MD, FACS; and Amanda Francescatti, MS

Current volumes I, II, and III of Operative Standards for Cancer Surgery


NEWS

For nearly 100 years, the Commission on Cancer (CoC) has set standards to ensure patients received the best care possible through accreditation of cancer practices. Over the last decade, the CoC standards have shifted from facilities and equipment to processes, and now toward outcomes-based standards. In 2020, the CoC included six of the operative standards—two for breast cancer surgery, two for colorectal cancer surgery, and one each for lung cancer surgery and melanoma surgery—in the Optimal Resources for Cancer Care (2020 Standards). The evidence from the Operative Standards for Cancer Surgery manuals formed the basis for the six CoC operative standards, and adherence to these standards will be required for maintenance of CoC accreditation. Download the 2020 Standards at facs.org/2020standards.

Goals of the programThe CSSP builds upon this history with a view toward standardizing operative documentation such that it

accurately reflects oncologically critical standard components. Increased collaboration across surgical teams using the common language of these standardized operative reports is an important goal for this new program.

In order to facilitate implementation of the operative standards in CoC-accredited sites, to improve the quality of surgical documentation, and to educate surgeons and surgical trainees, the CSSP is developing synoptic operative reporting templates and point-of-care electronic documentation tools. Furthermore, the program will create cancer surgery protocols to provide guidance on the collection of essential data elements for cancer surgery. Educational content will be created and disseminated to assist with implementation of these standards and tools at each accredited center.

Disease site-specific workgroups within the CSSP include a diverse group of experts in the surgical oncology community and representatives from the ACS Young Fellows

Association, the Resident and Associate Society of the ACS, and surgical societies such as the American Society of Colon and Rectal Surgeons, the American Society of Breast Surgeons, and the Society of Surgical Oncology. Additionally, the CSSP will benefit from broad representation from, and coordination between, the other ACS Cancer Programs, including the CoC, ACS CRP, National Accreditation Program for Breast Centers, National Accreditation Program for Rectal Cancer, and American Joint Committee on Cancer.

Leaders of the ACS Cancer Programs have been gratified to have the approval of David B. Hoyt, MD, FACS, ACS Executive Director, and the Board of Regents to launch the CSSP. We look forward to providing our members with tools and resources to help improve the quality of surgical care for all persons with cancer. ♦

The CSSP builds upon this history with a view toward standardizing operative documentation such that it accurately ref lects oncologically critical standard components.

1953 CoC Manual for Cancer Programs

Howard M. Snyder III, MD, FACS, a pioneer in pediatric urology and a former American College of Surgeons (ACS) Regent and Governor, passed away June 4 at age 76 from complications of Parkinson’s disease and the coronavirus disease 2019 (COVID-19). Prior to his retirement in 2015, Dr. Snyder was a pediatric urologist in the division of urology at Children’s Hospital of Philadelphia (CHOP), PA, and professor of surgery in urology, Perelman School of Medicine at the University of Pennsylvania. His contributions to the field shaped modern understanding and treatment of many urologic conditions in young patients.

Service to patients and countryDr. Snyder earned his undergraduate degree from Princeton University, NJ; received his medical education at Harvard Medical School, Boston, MA; and then spent a year in the U.K. learning from experts in pediatric urology. He returned to the U.S. in 1980 and began to practice at CHOP at the recommendation of C. Everett

Koop, MD, FACS, then-surgeon-in-chief of the hospital and future Surgeon General of the U.S., and John W. Duckett, MD, FACS, a renowned urologist. He remained there until his retirement in 2015.

In addition to his practice in Philadelphia, Dr. Snyder was proud to follow in his grandfather’s and father’s footsteps by serving in the U.S. armed forces. Dr. Snyder served for more than 20 years in the U.S. Army Medical Corps and was deployed to active duty in 2003 in Operation Iraqi Freedom. He also served as a professor of surgery at the Uniformed Services University of the Health Sciences, Bethesda, MD.

Innovator and leader in pediatric urologyDr. Snyder’s research and innovation in pediatric urology led to advancements in diverse areas of care, including posterior, prune belly syndrome, ureteroceles, hypospadias, cryptorchidism, management of neuropathic bladder, andrology, and pediatric urologic oncology.

Many of his treatments remain the standard of care to this day.

Dr. Snyder was actively involved as a member and leader of many medical societies. An ACS Fellow since 1984, he served as a Governor (2002–2008) and a Regent (2007–2016), chaired the Advisory Council for Urology (2003–2007), and served on several committees. Dr. Snyder also was a member and leader of the American Association of Genitourinary Surgeons; the American Surgical Association; the American Board of Urology, on which he served as a member and examiner; among others. In 2013, he received the American Urological Association’s Urology Medal for contributions to pediatric urology.

Comments from friends and colleagues at the ACSDr. Snyder’s undeniable skill as a surgeon and compassionate demeanor found him many friends among his surgical colleagues.

Marshall Z. Schwartz, MD, FACS, FRCSEng(Hon), Past-Vice-Chair, ACS Board of Regents,

ACS remembers Howard M. Snyder III, MD, FACS, trailblazer in pediatric urology


NEWS

Dr. Snyder

said, “How do you summarize a 47-year wonderful friendship with someone who was so giving of himself ? Howard was a multidimensional person who loved to learn and teach. We first met in 1973, when we were general surgery residents rotating to Boston Children’s Hospital, MA. Our close friendship developed even though we pursued different surgical fields within the pediatric age group—Howard in pediatric urology (he became an international icon) and me in pediatric general surgery. Ironically, in 1996 we ended up in Philadelphia together living less than one mile apart. Howard was already established in Philadelphia, and he and his wife Mimi took us under their wings and exposed us to the arts, local and regional surgical associations, and so on. He had many diverse interests including art, music, old pocket watch collecting, and gourmet cooking, to name a few. We were both excited when we became Regents of the College. We shared a common passion as Regents, which was to improve the visibility of the College

within our federal government. We wanted to emphasize the College’s mission of quality surgical care and patient safety and the accomplishments of the College in fulfilling these goals. I will miss him dearly.”

“Howard and I shared an apartment when we were residents at the Brigham [Boston] in the early 1970s,” said Lenworth M. Jacobs, Jr., MD, MPH, FACS, ACS Regent. “It was a pleasure to learn from his wise counsel and thoughtful comments about pretty nearly any subject. We all had a wonderful time with friends from across the entire spectrum. He also was always open to helping others and to lending a hand to those who needed it. He was an excellent surgeon and was superbly trained. He really made a positive impression on the world. I will miss him terribly. Rest in peace.”

James K. Elsey, MD, FACS, ACS Regent, described Dr. Snyder as “a brilliant man, a superb surgeon, and an ACS servant, but, most importantly, he was a warm, caring, compassionate man and my friend. I’ll never forget one night, shortly after

I was elected to the Board of Regents, he called me at my home. He wanted to introduce himself as a seasoned member of the Board. He offered to be my mentor in the room to help me get a good start and navigate the complexities of the job. I have never forgotten that act of kindness. What I came to find out during the several years of working with him was that this was his way with everyone, and his avuncular nature permeated all the actions of his life. I will miss him, and I am sure he is getting his just reward.” ♦

Dr. Snyder’s research and innovation in pediatric urology led to advancements in diverse areas of care, including posterior, prune belly syndrome, ureteroceles, hypospadias, cryptorchidism, management of neuropathic bladder, andrology, and pediatric urologic oncology. Many of his treatments remain the standard of care to this day.


NEWS

NEWS

ACS mourns the passing of Francis Robicsek, MD, PhD, FACS, a dedicated humanitarian surgeon

Francis Robicsek, MD, PhD, FACS, a cardiothoracic surgeon from Charlotte, NC, whose innovations in surgery and consummate humanitarianism brought profound health improvements around world, passed away peacefully April 3. He was 94 years old. Dr. Robicsek’s commitment to his patients, domestic and international, made a lasting impact and was recognized by the American College of Surgeons (ACS) in 2017 with the ACS/Pfizer Surgical Humanitarian Award.

Early dedication to domestic patient careBorn and educated in Hungary, Dr. Robicsek came to the U.S. to escape the Hungarian revolution in the 1950s, after becoming the chief of the University of Budapest department of cardiac surgery at just 29 years old. He began practicing at Charlotte Memorial Hospital, NC, now the Carolinas Medical Center,

where he worked alongside Paul Sanger, MD, and Fred Taylor, MD, to perform Charlotte’s first open-heart operations, and coordinated with an engineer to construct the heart-lung machine needed to keep a patient’s heart beating during surgery. In 1986, Dr. Robicsek and Harry Daugherty, MD, performed the city’s first heart transplant. Dr. Robicsek continued to perform surgery at Carolinas Medical Center until his retirement from active practice in 1998, but he continued teaching and mentoring well after that.

Dr. Robicsek’s passion for humanitarian aid was apparent from his early days in the U.S. He chose to operate on African-American patients who, in the segregation era, were denied treatment at the former Charlotte Memorial Hospital. Dr. Robicsek worked around this limitation by admitting black patients to a tuberculosis hospital nearby and performing operations there. He went on to

found one of the first integrated patient practices in the area.

In 1959, Dr. Robicsek cofounded Heineman Medical Outreach, Inc., a one-time research organization in Charlotte, NC. As president of the organization for nearly 50 years, Dr. Robicsek guided its evolution to a local and humanitarian aid program in partnership with the Carolinas HealthCare System.

A lifetime of international humanitarianismThe breadth of Dr. Robicsek’s humanitarian spirit became clear through his work on the global stage. Dr. Robicsek began his international humanitarian work in the early 1960s in Honduras, treating surgical tuberculosis patients and then expanding his surgical services to other countries, providing direct surgical care to patients in Belize, Guatemala, Nicaragua, and Eastern Europe. His


Dr. Robicsek

NEWS

contributions to cardiothoracic surgery in Central America are particularly noteworthy. Dr. Robicsek performed the first open-heart operations in Honduras and Guatemala and initiated and assisted the first open-heart surgery by a native surgeon in Belize.

In the 1970s, he arranged to have patients from Guatemala f lown into Charlotte for operations, and he accepted Guatemalan surgeons for training fellowships. His ties with the Guatemalan government and health care system eventually led to the founding of Unidad de Cirugía Cardiovascular de Guatemala—or UNICAR—the Guatemalan Heart Institute, where more than 700 heart operations are performed annually. These and other operations in Central America are made possible in part by the more than $1.5 million in new and refurbished hospital supplies that Dr. Robicsek arranged to have delivered to

the region each year. UNICAR now serves patients from neighboring countries, as well.

The facilities of Carolinas Medical Center were provided for the training and education of Guatemalan surgeons, technicians, and nurses who specialized in different areas related to cardiovascular surgery. For many years, he maintained a guest house at the hospital for these health care workers to train at no cost. Dr. Robicsek’s efforts also led to the establishment of burn units, mammography, echocardiogram networks, catheter labs, and more across Central America. Since 2010, when Heineman and the Carolinas HealthCare System established the International Medical Outreach Program, these humanitarian efforts have continued to grow.

Dr. Robicsek was recognized with high honors from the Guatemalan government for his efforts, including the highest Guatemalan award,

La Orden del Quetzal, in the rank of Grand Commander, by the President of the Republic during the founding of the Cardiovascular Surgery Unit of Guatemala in 1976.

For his dedicated patient care in Charlotte and lifelong commitment to providing cardiothoracic surgery and health services in Guatemala and around the world, Dr. Robicsek will be remembered as a surgeon and person of rare caliber. ♦


Dr. Robicsek (left) at the bedside of a young patient who

underwent open-heart surgery at

UNICAR.

ACS issues call to action on racism as a public health crisis:

An ethical imperative

In light of the disproportionate effects of the coronavirus disease 2019 (COVID-19) on African-American and other minority communities, as well as the continued police violence against black people in the U.S., the American College of Surgeons (ACS) in early June issued a call to action declaring racism as a public health crisis.

“At a time when people are desperately seeking a vaccine to allow them to shed their ‘protective face masks’ and return to a semblance of normalcy, unfortunately, African Americans continue to confront, all too frequently, mistreatment or brutality by some law enforcement officers, which has given rise to more than an aspirational slogan, but rather an urgent cry: ‘Black Lives Matter,’” the call to action reads. The compounding effects of systemic racism that led to the recent killing of Ahmaud Arbery, Breonna Taylor, and George

Floyd sparked nationwide protests that demanded justice against the deep racial inequities in the U.S.

According to the ACS Board of Regents and the Committee on Ethics, which developed the comments, “These unprecedented crises call for enlightened and innovative leadership, inspired intervention, and compassionate service from all members of the ACS.” Specifically, the College calls upon its members to work toward eliminating health care disparities, identifying the structural racism that leads to a greater prevalence of chronic illness, and recognizing that racial injustice exacerbates existing health care disparities. College leadership said, “Correcting these injustices now, by denouncing racism and its deleterious effects on the health of Black and Brown people, is among the most important missions of the ACS.”

Read the full call to action at facs.org/about-acs/responses/racism-as-a-public-health-crisis. ♦

These unprecedented crises call for enlightened and innovative leadership, inspired intervention, and compassionate service from all members of the ACS.


NEWS

Owen H. Wangensteen, MD, FACS, who chaired the department of surgery, University of Minnesota, Minneapolis, for several decades and established the American College of Surgeons (ACS) Surgical Forum—now the Owen H. Wangensteen, MD, FACS, Scientific Forum—presented annually at Clinical Congress, remains a surgeon of great renown. Another highly esteemed surgeon and a champion of bariatric and metabolic surgery who trained under Dr. Wangensteen, Henry Buchwald, MD, PhD, FACS, has recently published a recollection of the heady days at the University of Minnesota and the important contributions Dr. Wangensteen and his attendings and residents have made to surgical care.

Surgical Renaissance in the Heartland: A Memoir of the Wangensteen Era chronicles Dr. Buchwald’s personal journey from Nazi-occupied Austria to New York, NY, and ultimately to Minneapolis and his professional career at the University of Minnesota—both forever changed under the guidance and tutelage of Dr. Wangensteen and the surgeons he recruited. Dr. Buchwald chronicles the culture of innovation that Dr. Wangensteen cultivated and how it led the scientific and clinical discoveries associated with the latter half of the 20th century.

Dr. Buchwald is professor of surgery and biomedical engineering and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery Emeritus, University of Minnesota. He is the recipient of the 2019 ACS Jacobson Innovation in Surgery Award, presented by the College in recognition of his pioneering work and innovative research in metabolic and bariatric surgery.

Surgical innovationAmong his own innovations, Dr. Wangensteen proved that simple gaseous bowel distention, primarily from swallowed air, was the responsible


Memoir recounts “golden age” of surgical innovation Dr. Wangensteen led at University of Minnesota

NEWS

PRAISE FOR SURGICAL RENAISSANCE IN THE HEARTLAND

“The significance and origin of the values behind the Wangensteen legacy are brought to life in Surgical Renaissance in the Heartland. This is a must read for everyone involved in surgery and will help us remember the origin of our wonderful profession.”

—David B. Hoyt, MD, FACS, ACS Executive Director

“Who would have guessed that a Minnesota farm boy would found one of the greatest research surgical centers in the world? In this remarkable book, Henry Buchwald, one of today’s great surgeon-leaders, reveals not only how it happened, but also how we can and must learn from that experience.”

—Walter J. Pories, MD, FACS, director, Metabolic Surgery Research Group, East Carolina University, Greenville, NC

“Initially as surgery resident, then as a faculty member, and subsequently as one of the giants in his field, Henry Buchwald has expertly captured this vibrant atmosphere of medical discovery. His very personal and beautifully written account of this unique period is well worth the read.”

—Marshall Z. Schwartz, MD, FACS, Past-Vice-Chair, ACS Board of Regents

agent for intestinal obstruction. Dr. Buchwald writes, “Most important, he invented nasogastric and nasointestinal suction, later referred to as ‘Wangensteen suction,’ performed by the ‘Wangensteen tube.’” This device evacuated intestinal gas and f luid, relieving the abdominal distention of a bowel obstruction, allowing patients to recover spontaneously or be adequately prepared free of sepsis for interventional surgery. “This innovation alone saved millions of lives” and “reduced the mortality of acute intestinal obstruction to below 3 percent” down from 40 percent in the 1930s, according to Dr. Buchwald.

The son of Midwestern farmers, Dr. Wangensteen transformed surgical education for aspiring surgical investigators, establishing a surgical residency with a mandatory seven-plus years—five years of clinical training, supplemented by two or more

Dr. Wangensteen circa 1935 Dr. Wangensteen circa 1961


NEWS

Among his other accomplishments, Dr. Wangensteen founded the journal Surgery in 1937; established the Society of University Surgeons in 1939; and originated the ACS Surgical Forum in 1940.

years in a basic science research laboratory coincident with the return to the classroom for a PhD in surgery and, whenever possible, an advanced degree in a basic science. By the end of his more than three-decade tenure as department of surgery chair in 1967, the graduates of his program included 38 department heads, 31 division heads, 72 program directors, and 110 full professors.

Among his other accomplishments, Dr. Wangensteen founded the journal Surgery in 1937; established the Society of University Surgeons in 1939; and, as noted previously, originated the ACS Surgical Forum in 1940.

University of Minnesota and advances in surgeryMuch of the memoir focuses on three of Dr. Wangensteen’s most influential mentees and their impact on Dr. Buchwald’s professional development. These individuals included C. Walton Lillehei, MD, FACS, known as the father of open-heart surgery; Richard C. Lillehei, MD, FACS, a transplant surgeon; and, most significantly for Dr. Buchwald, Richard L. Varco, MD, FACS.

Dr. Varco was known as “the surgeon who other surgeons at Minnesota

consulted on how to develop, ref lect upon, and improve their concepts,” according to Dr. Buchwald. In many ways, Dr. Varco was the progenitor of Dr. Buchwald’s specialty. In 1953, Dr. Varco performed the first intestinal bypass operation to incite massive weight loss.

Dr. Buchwald describes Dr. Varco as an “insightful and complex technical marvel,” as well as a scholar, innovator, innovative thinker, teacher, and curmudgeon. While Dr. Buchwald was pursuing his research interests in cholesterol control to prevent cardiothoracic and vascular disease, Dr. Varco was developing the jejunoileal bypass operation for morbid obesity, taking more than 90 percent of the small intestine out of contact with food to reduce caloric consumption. Dr. Varco repeatedly asked Dr. Buchwald to start performing the procedure, but Dr. Buchwald refused. He wanted his name to be associated with his work in lipid and atherosclerosis management—not bariatric surgery. Furthermore, Dr. Buchwald had developed the partial ileal bypass for cholesterol control and was gaining recognition for that procedure.

At one point, Dr. Varco developed a condition that made

it impossible for him to operate. He pleaded with Dr. Buchwald in 1966 to perform a jejunoileal bypass. Dr. Buchwald initially hesitated because of his focus on perfecting partial ileal bypass and his other research interests. Seeing a friend and mentor in need, Dr. Buchwald reluctantly yielded, and since 1966 his name has been associated with bariatric surgery.

“However, I have no regrets,” Dr. Buchwald writes. “Indeed, as I became more and more acquainted with the problem of morbid obesity and the unfortunate individuals suffering from this disease, the more grateful I was to Richard for forcing me to become involved, and very rapidly I became dedicated to the discipline.”

Dr. Buchwald also recounts his longstanding friendship with Ward O. Griffen, MD, FACS, past-chair, department of surgery, University of Kentucky, Lexington, and a leader of the ACS; both the Lillehei brothers; Jack Bloch, MD, FACS; and John P. Delaney, MD, PhD—all residents who trained under Dr. Wangensteen.

Surgical Renaissance in the Heartland: A Memoir of the Wangensteen Era is published by the University of Minnesota Press, Minneapolis. ♦


NEWS


NEWS

The Board of Directors of the American College of Surgeons Professional Association (ACSPA) and the Board of Regents (B/R) of the American College of Surgeons (ACS) met February 6–8, 2020, at the College’s headquarters in Chicago, IL. The following is a summary of key activities discussed. The information provided was current as of the date of the meeting.

ACSPAIn 2019, the ACS Political Action Committee, ACSPA-SurgeonsPAC, supported more than 120 candidates, political campaign committees, and other PACs. Nearly $400,000 was raised for key congressional champions. Commensurate with congressional party ratios, 50 percent of the amount given went to Republican and 50 percent to Democratic campaigns.

ACSIn addition to reviewing reports from the ACS division directors, the B/R approved the following policy statement:

• Statement on Suicide Prevention

The B/R also accepted resignations from 12 Fellows and changed the status from Active or Senior to Retired for 74 Fellows.

The Regents also approved the formation of the Ontario Chapter in Canada.

Division of EducationThe Committee on Ethics, housed in the Division of Education, held several programs at Clinical Congress 2019 in San Francisco, CA, including the John J. Conley Ethics and Philosophy Lecture, What We Talk About When We Talk About Surgery, by Gretchen M. Schwarze, MD, FACS. Additional events included the 2019 Ethics Colloquium, The Ethics of Extraordinary Care; a Panel Session, Should Surgeons Care for their Family Members?; a Meet-the-Expert session, Dealing with Death and Dying: How to Conduct Goals of Care Discussions, Provide Quality Care to Dying Patients, and Cope After a Difficult Death; and a Postgraduate Course, Ethical Issues in Geriatric Surgical Care. Plans are under way to develop programs for Clinical Congress 2020.

Division of Integrated CommunicationsIn 2019, the Division of Integrated Communications developed and supported initiatives to enhance the College’s external reputation, increase engagement among members, boost awareness of and interest in industry-leading programs, and drive awareness of

cutting-edge science. The position of Director of the Division of Integrated Communications was filled when Cori McKeever Ashford officially joined the College in December 2019.

STOP THE BLEED®

In October 2019, bleedingcontrol.org became StoptheBleed.org as the next step in raising the public profile of this internationally renowned public safety program. StoptheBleed.org is the College’s first entirely public-facing website. The content reflects a new approach to informing, educating, and empowering the general public to learn more about the STOP THE BLEED program. Since its launch and through January 20, StoptheBleed.org page views were up 46 percent and sessions were up 55 percent compared to bleedingcontrol.org. New social media handles were launched alongside the new STOP THE BLEED website to help spread information about the program. Twitter (@StopTheBleedACS) and Facebook accounts provide STOP THE BLEED-related updates and showcase the efforts of school and community groups that are training the public in their areas.

Clinical Congress 2019Eleven studies from the Clinical Congress Educational Forum were promoted through press releases. These studies, selected for the impact and

Report on ACSPA/ACS activities, February 2020

by Ronald J. Weigel, MD, PhD, FACS


NEWS

newsworthiness of their findings, addressed topics including the recurrence of traumatic injuries in children, the impact of surgeon shift length on patient outcomes, the ability of artificial intelligence to triage postoperative patients, and use of the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Surgical Risk Calculator to predict quality-of-life outcomes for geriatric surgical patients. Scientific presentations and activities during Clinical Congress 2019 captured 286 media mentions, with an overall potential reach of 466.8 million.

GSVThe College’s Geriatric Surgery Verification (GSV) Program—introduced at the July 2019 ACS Quality and Safety Conference in Washington, DC—captured national media attention this past summer with several news articles on the need for the program and how it will improve outcomes for older surgical patients. Stories were published online and in print by the New York Times, Associated Press, Kaiser Health News, AARP.com, Reuter’s Health, Becker’s Healthcare, and Fierce Healthcare.

ACS THRIVEIn 2019, the College partnered with Harvard Business School (HBS) to create ACS THRIVE (Transforming Health care

Resources to Increase Value and Efficiency), an ambitious new program to measure and improve the value of surgical care. Leveraging the College’s expertise in quality measurement and HBS’ expertise in activity-based cost accounting, the program will help hospitals accurately measure their costs, tie those costs more closely to robust outcome measures, and take steps to improve the value of care. Presentations were created for use on Capitol Hill and at a preconference session with industry thought leaders for the 2019 Quality and Safety Conference. Nearly 100 Capitol Hill staff members attended the briefing, and multiple media interviews were facilitated.

ACS website (facs.org)In a continuing effort to provide a comprehensive resource for those who visit facs.org, multiple content updates and overall improvements were made to the website last year. In 2019, the College’s website logged 11,264,958 page views from nearly 2.1 million visitors in 3.4 million sessions. Overall website traffic was up from 2018, with 11.6 percent more users, 9 percent more sessions, and 5.5 percent more page views. In 2019, returning visitors represented 17 percent of website traffic, and the remaining 83 percent were new visitors. Planning is under way for an updated facs.org in 2020.

NewsScopeIn 2019, ACS launched a new artificial intelligence (AI)-driven version of ACS NewsScope to all members of the College—My ACS NewsScope—which was distributed twice a week and used AI to deliver customized content to each recipient. The AI database collected articles from nearly 80 sources of both clinical and nonclinical information on topics that are relevant to surgeons. Each issue included a “News Brief” on an important ACS program and occasional updates from the ACS Division of Advocacy and Health Policy. In response to the demand for more clinical information, abstracts from the top 50 journals in surgery were added. The traditional ACS NewsScope (now ACS Bulletin Brief ) continues to be disseminated to more than 55,000 recipients.

BulletinA strategic plan was developed in 2019 to help freshen the print and online editions of the Bulletin. The Bulletin implemented content and design changes in both versions, including adding highlights and pull quotes to online feature stories, redoing the headers and table of contents in the print edition, and making other tweaks that improved readers’ experiences. A new navigational structure has been implemented in the online version to match the print version.


NEWS

Clinical Congress Daily HighlightsClinical Congress Daily Highlights supplements the on-site newspaper, Clinical Congress News, and is distributed to all Fellows, including those unable to attend. The 2019 edition included coverage of 40 sessions and more than 27 video interviews with investigators. Stories included Late-Breaking Clinical Trials, liquid biopsy, robotic surgery, machine learning, personalized medicine, resident duty hours, appendicitis, bariatric surgery outcomes, diverticulitis, and others. The newsletter was distributed twice daily over three days, and stories were shared on social media using the #ACSCC19 and #ACSHighlights hashtags. Plans for 2020 included extending the reach of selected stories through a targeted post campaign on LinkedIn.

JACSIn 2019, the Journal of the American College of Surgeons (JACS) successfully achieved a subscription benchmark of converting 40 percent of College members to an electronic-only format. The January 2020 issue featured 17 selected papers presented at the Clinical Congress 2019 Scientific Forum—an increase from 13 papers published in the 2018 inaugural issue. In the first three quarters of 2019, JACS full-text articles were downloaded approximately 375,000 times across journalacs.org and the

Science Direct and Clinical Key platforms. In the same period, journalacs.org received nearly 799,000 page views.

Social mediaUpward trajectories continue for engagement with the ACS Facebook, Twitter, and LinkedIn sites. By January 13, 2020, 34,639 people had “Liked” the ACS Facebook page, and 36,308 were following ACS. The College has 55,295 Twitter followers, representing a nearly 5 percent growth since October 2019. The College now has 25,801 LinkedIn followers, an 8 percent increase since October 2019.

ACS CommunitiesSince its launch in 2014, ACS Communities continue to be a popular member benefit. The platform has received 4.5 million page views, and 36,749 members of the College have agreed to the site’s terms of use. The 127 ACS Communities have become the go-to place for members of the College to collaborate with their peers. Popular discussion topics last year included gender equity, family members in the hospital, surprise billing legislation, health care access, gender reassignment surgery, and surgeon replacements. Overall, site visitors have posted 102,455 discussion group posts and viewed library items more than 168,000 times. The five most active communities are

General Surgery, Breast Surgery, Colon and Rectal Surgery, Rural Surgery, and Women Surgeons.

Division of Research and Optimal Patient CareThe Division of Research and Optimal Patient Care (DROPC) encompasses the areas of Continuous Quality Improvement (CQI), including ACS research and the accreditation programs.

Quality and Safety ConferenceThe 2020 ACS Quality and Safety Conference (QSC) will focus on the theme, Achieving Surgical Quality: HOW? and will provide attendees with practical and actionable steps to improve surgical quality and safety at their institutions. Sessions will highlight “the how” of achieving surgical quality, applying evidence-based best practices to improve quality, and how principles of value-based surgery can be better understood and ultimately achieved.

Optimal Resources for Surgical Quality and SafetyThe development of adjunctive and integrated resources/standards based on Optimal Resources for Surgical Quality and Safety is near completion. These standards will be used to launch a Surgical Quality Verification Program. Pilot visits began with a group of targeted hospitals in 2018 and have continued into


NEWS

2020 as the verification elements of the program are further refined. The goal is to refine and revise the standards based on the findings from the site visits and to launch the program in 2020.

ACS NSQIPA total of 853 hospitals participate in ACS NSQIP—712 in the adult option. The pediatric option represents 17 percent of overall participation. Another 26 hospitals are in various stages of the onboarding process. At present, 130 hospitals outside of the U.S. participate in ACS NSQIP—approximately 15 percent of all participating hospitals.

MBSAQIPA total of 936 facilities participate in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), and 60 surgeon surveyors are expected to complete 275 site visits in 2020. Between October 2014 and January 2020, 1,573 site visits were completed.

In 2019, MBSAQIP launched its third national collaborative project, Bariatric Surgery Targeting Opioid Prescriptions (BSTOP), focused on opioid reduction in bariatric surgery. The project’s primary objective is to reduce provider prescription of opioids and patient use during the perioperative period in more than 300 participating hospitals. In January 2020, the second

phase of the project started, with hospitals collecting data after implementation of an evidence-based protocol designed to track use of multi-modal pain strategies. Data will be collected until the project concludes in 2021. Preliminary hospital engagement with BSTOP has been positive.

CSV ProgramThe Children’s Surgery Verification (CSV) Quality Improvement Program launched in 2017 with the goal of ensuring that pediatric surgical patients have access to quality care. In all, 141 centers participate in CSV. All 141 centers also participate in ACS NSQIP Pediatric, an increase of 12 sites since January 2019. Approximately 45 of these centers are in the various stages of verification. A total of 21 active sites are fully verified as Level I children’s surgery centers. Approximately 15 site visits are projected for 2020.

GSV Quality Improvement Program The GSV Quality Improvement Program launched in 2019 and is composed of 30 required and two optional patient-centered standards designed to systematically improve surgical care and outcomes for the aging adult population. The program defines the resources required to achieve optimal patient outcomes for older adults receiving surgical care at verified health care facilities. Hospitals

began enrollment at Clinical Congress 2019. An education curriculum is being developed for sites to help them prepare for the verification process.

ISCR ProgramThe Agency for Healthcare Research and Quality Improving Surgical Care and Recovery (ISCR) Program, a collaborative effort between the ACS and the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore, MD, continues to attract hospitals interested in implementing enhanced recovery practices. Approximately 60 percent of enrolled hospitals also participate in ACS NSQIP. The final cohort launched earlier this year with a concentration on emergency general surgery—specifically, appendectomy, cholecystectomy, and laparotomy. Hospitals participating in ISCR receive a ready-to-use pathway, access to educational materials on how to implement the pathway, access to experts in performance improvement and education who will help them troubleshoot problems as they implement new practices, and inclusion in a community of surgeons and clinicians rolling out the same pathway.

Strong for SurgeryStrong for Surgery (S4S), a joint program of the ACS and


NEWS

the University of Washington, Seattle, is a quality initiative aimed at identifying and evaluating evidence-based practices to optimize the health of patients before surgery. The program empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. Released in 2017, S4S has more than 700 participating sites. Newly added topics include chronic disease management, mental health, and substance abuse.

SSRThe Surgeon Specific Registry (SSR) allows surgeons to track their cases, measure outcomes, and comply with changing regulatory requirements. The SSR can be used to meet the requirements of Centers for Medicare & Medicaid Services (CMS) Quality Payment Program Merit-based Incentive Payment System (MIPS), as well as the American Board of Surgery Continuous Certification Program requirements. The SSR has an active user base of approximately 5,600 surgeons, and more than 2 million case records have been entered into the SSR system since its release in 2017.

Cancer ProgramsThe Commission on Cancer (CoC) accredits more than 1,500 U.S. hospitals. In 2019, the CoC scheduled and surveyed 405

facilities and issued accreditation decisions and performance reports. The new 2020 CoC standards have been released and will be implemented this year.

The National Accreditation Program for Breast Cancer (NAPBC) is a multidisciplinary accrediting body that sets standards, conducts surveys, and accredits 674 U.S. and three international centers. In 2019, NAPBC scheduled and surveyed 185 breast care centers and issued accreditation decisions and performance reports.

Launched in 2017, the National Accreditation Program for Rectal Cancer (NAPRC) sets evidence-based standards and conducts surveys. NAPRC has 15 newly accredited centers, with 42 in the pipeline. Sites must be CoC-accredited to join NAPRC to ensure harmony between both programs.

The National Cancer Database (NCDB) has curated more than 39 million cancer records since inception and is the largest database of its kind in the U.S. The NCDB, through its 1,533 CoC-accredited sites, continues to collect roughly 1.5 million cancer cases annually, which represents 72 percent of all newly diagnosed cancer cases in the U.S. In 2019, the NCDB initiated the new Rapid Cancer Reporting System data processing infrastructure and rolled out the Participant User File program.

The American Joint Committee on Cancer (AJCC) is a multidisciplinary team of professionals who are responsible for developing and publishing staging standards. The AJCC recently published the eighth edition AJCC Cancer Staging Manual, complete with 80 chapters and 100 staging systems, which has sold more than 41,000 copies. In 2020, the AJCC is expected to complete Phase 1 of the structured authoring (EasyDITA) implementation.

The ACS Clinical Research Program (CRP) is strategically aligned with the Alliance National Cancer Institute (NCI)-sponsored clinical trials cooperative group and is supported by the Patient-Centered Outcomes Research Institute and NCI to conduct health sciences research and clinical trials. In 2019, the CRP integrated six operative standards into CoC accreditation standards and sponsored the Designing and Running a Prospective Surgical Clinical Trial Didactic Course at Clinical Congress 2019.

Trauma ProgramsLaunched at Clinical Congress 2019, the FTL 100 Fundraising Campaign was established to generate financial support for 100 Future Trauma Leaders (FTL) to coincide with the 100th anniversary of the Committee on Trauma (COT) in 2022. FTL’s mission is to foster the advancement of


NEWS

future leaders in trauma. The FTL aims to recruit, mentor, provide program support, and reimburse travel to various trauma meetings for eight participants annually. The COT is seeking funding from previous donors and targeted individuals, independent corporations, not-for-profit organizations, and individual trauma leader groups, with a target goal of $1 million to support the program and make it self-sustaining.

The 2019 TQIP Annual Scientific Meeting and Training took place November 16–18 in Dallas, TX, and focused on error management and high-functioning teams. The inaugural Advancing Leadership in Trauma Center Management Course was held at TQIP and received positive feedback. TQIP also is piloting a new peer coaching program. This initiative will link high-performing centers, evaluated via TQIP benchmark report results, with centers requesting assistance, and will help to provide a framework to facilitate a peer coaching relationship. TQIP will celebrate its 10th anniversary in Phoenix, AZ, on December 6–8, 2020.

The STOP THE BLEED program’s primary focus is to provide training in the techniques of basic bleeding control and to impress upon the public of the importance of learning the skills in becoming immediate

responders in the event of a bleeding emergency. A redesigned public-facing website debuted in 2019 to better focus on the general populace. The STOP THE BLEED instructor portal launched January 2020 to provide more automation for potential instructors. The STOP THE BLEED State Champions convened for the first time at Clinical Congress 2019 to discuss roles and responsibilities for states to foster growth, provide necessary resources, and grow public interest and training for STOP THE BLEED.

The COT continues to review and revise standards in the Resources for Optimal Care of the Injured Patient and expects to complete all standards revisions in 2020. Next steps will include transitioning the new standards into a new format, updating the pre-review questionnaire, and developing and rolling out training for reviewers and trauma centers.

The COT also is in the process of implementing its inaugural Firearm Injury Prevention Clinical Scholar in Residence Fellowship later this year.

ACS FoundationThe ACS Foundation remains focused on securing and growing financial support for the College’s charitable, educational, and patient-focused initiatives. The development team and the Foundation Board of Directors

are working to increase individual and corporate support. Through December 31, 2019, philanthropic support totaled $578,801.

The Foundation’s portfolio of new projects and programs continues to expand. Philanthropic gifts from Fellows continue to support Operation Giving Back, international scholarship travel awards, fellowship research awards, STOP THE BLEED training materials, and the Support A Student program. Corporate grants provided support for the following:

• 13 Skills Courses at Clinical Congress

• The third annual Residents Surgical Skills Competition featuring eight teams from across the country

• Educational materials to educate patients and medical staff on proper pain management, wound care, and ostomy maintenance ♦


NEWS

“Life is what happens to you while you are busy making other plans.”

—John Lennon

With practice, business, and travel collapsing in mid-March as the coronavirus disease 2019 (COVID-19) unfolded in the U.S., the leadership of the Florida Chapter of the American College of Surgeons (ACS) faced a difficult decision. We could cancel the in-person Chapter Annual Meeting, May 1–3; postpone the meeting until later in 2020; or conduct the meeting virtually. Changing the annual meeting was no small matter: The chapter year ends and begins anew with the annual meeting, and

a positive contribution margin from the annual meeting is essential to fund other chapter activities throughout the year.

Factors that shaped the decision were the resolution of financial repercussions from canceling hotel and venue contracts, bylaws requirements for the annual governance transition, and the necessity of supporting chapter entries into ACS competitions. Importantly, leadership anticipated the need for surgical community in a time of lingering crisis in a way that would support workforce readiness.

On March 20, Florida Gov. Ron DeSantis (R) issued Executive Order 20–72, which

halted elective surgery through May 8 (subsequently changed to May 3) and reinforced the need for surgical readiness. On March 23, the chapter’s Executive Committee decided to go virtual with the annual meeting May 2.

Going virtualThe theme of this year’s program was “Predicting the Surgeon of 2030.” The program was reshaped from 8.25 Continuing Medical Education (CME) hours in-person to three hours virtually (see Table 1, page 95). The Edward M. Copeland III, MD, FACS, Resident Abstract Competition was condensed into two presentations, the

Lessons from a virtual chapter annual meeting

by John H. Armstrong, MD, FACS; Jay Redan, MD, FACS; and Brian Hart, JD

Screenshot of virtual presentation by Dr. Weigelt


NEWS

top-scoring basic and clinical science abstracts, and inclusive of the Florida Commission on Cancer (CoC) Competition. Other high-scoring abstracts were presented on the chapter website as a Resident Research Abstract Showcase (available at f loridafacs.org/2020-abstracts). Medical student poster submissions also were posted as a Medical Student Research Abstract Exhibition.

Presenting speakers were accepting of the necessity of the virtual format, and postponed speakers were gracious in deferring presentations to the future.

The in-person Exhibit Hall for industry sponsors was converted into a Virtual Solutions Center on the chapter website, available at f loridafacs.org/annual. Exhibitors had “space” to demonstrate their products and technology, and some provided videos.

The chapter’s online platform was assessed for compatibility with virtual program expectations and then

tested with two moderator and three full-scale presenter drills. Program f low was adjusted to accommodate the online platform. Because moderator and presenter video challenged system performance, audio accompanied slides in unrecorded presentations.

Costs for the virtual meeting were anticipated to be significantly less than the in-person meeting, yet still required funding through two sources—participant registration and exhibitor fees. Participants paid by category as follows: Fellow/Associate Fellow, $20; Resident, $10; and Medical Student, $5. Registration also helped to solidify participant intention to attend the virtual meeting. Given the novelty of a virtual meeting and general uncertainty, we set a goal of 100 ACS member participants. The meeting was marketed to members of all three Florida Chapters and the College as a whole through e-mails and the ACS Communities. The exhibitor fee for the Virtual Solutions Center was $250.

Virtual becomes realityA total of 118 ACS members registered for the 195-minute meeting; 113 participated in some portion of the program, with an average time of 163 minutes, and 93 remained for the business meeting. Domestic out-of-state participants connected from Georgia, Massachusetts, North Carolina, South Dakota, Texas, and Virginia; there were international participants from Kuwait. The range of ACS member registration for the last three in-person Chapter annual meetings (2017−2019) was 122−138, with an average 130. The Virtual Solutions Center hosted 18 exhibitors.

The program opened with brief leadership remarks and moved quickly to the first of two 30-minute recorded lectures, Surgical CME by 2030, given by John A. Weigelt, DVM, MD, FACS, ACS First Vice-President.

Next was the one-hour Edward M. Copeland III, MD, FACS, Resident Abstract Competition, with a single moderator and

In-person Virtual

8.25 CME hours 3.0 CME hours

Six lectures Two 30-minute prerecorded lectures

Six resident abstract competition presentations Two resident abstract competition presentations

One panel No panel

Three CoC competition presentations Same

Five Spectacular Case presentations Same

15-minute annual business meeting 10-minute annual business meeting

Medical student and resident poster session Website exhibition and showcase

Surgical Jeopardy Deferred; 2019 team resubmitted

Surgical Olympics Deferred; 2019 team resubmitted

18 exhibitors Same

TABLE 1.MOVING FROM AN IN-PERSON TO VIRTUAL MEETING FORMAT— DIFFERENCES


NEWS

five abstracts. Questions were easily sent via chat and Q&A rooms. The Florida CoC Abstract Competition was scored online.

The one-hour Spectacularly Challenging Case Competition followed with five cases. Again, chat and Q&A rooms ensured engagement between participants and presenters. The winning case was determined with a live poll, with results rapidly visible to all participants and the winner announced moments later.

The second recorded lecture, The Past, Present, and Future of Women in Surgery, by V. Suzanne Klimberg, MD, PhD, FACS, followed.

The business meeting concluded the event and included election of officers and councilors, as well as the annual leadership transition. The meeting started and ended on time, with 93 participants still online at the conclusion. Importantly, there was a high level of engagement throughout the meeting with 255 chat comments and questions.

Meeting expenses were $2,300, inclusive of technology, marketing, and competition awards. Registration fees did not cover these expenses, with the difference made up by Virtual Solutions Center fees.

Keys to successful virtual meetingsA virtual format for chapter meetings is a good option for staying connected when in-person meetings are infeasible. For chapters representing a large geographic area and who have interest in connecting with other chapters, the virtual option might substitute for in-person meetings. We identified seven key considerations for success, as follows:

• Establish meeting expectations. The virtual format cannot replicate all of the dimensions of an in-person meeting, including length. Three hours for a meeting is consistent with a baseball game or movie and makes the meeting more accessible. Thoughtful selection of content and presentations promotes meeting coherence. A place to start in program development is determination of the essential meeting requirements, such as chapter resident paper and case presentations for time-sensitive College competitions, and core governance functions with elections and transitions. The meeting can then be built out

with 30-minute lectures on hot topics that add variety and pique interest.1 Opportunities for engagement between presenters and participants should be defined for each session—not all sessions need Q&A.

• Identify the technology platform. Operating characteristics and engagement possibilities vary across platforms. In the emerging remote meeting industry, the tendency is to overpromise and underperform. The technology creates a temporary network with a dependency on the quality of Internet connectivity, including service providers and browsers. Maximum participant load, ease of connection (initial and sustained), audiovisual quality, and simplicity of use should be defined.2 Chat rooms, text Q&A, and polls promote interactivity and real-time feedback.

• Define the budget. Though expenses are significantly lower with virtual compared to in-person meetings, they still exist. Costs for the technology platform may vary by participant number. Setting a reasoned assumption for the number of participants is necessary to determine registration fees,

A virtual format for chapter meetings is a good option for staying connected when in-person meetings are infeasible. For chapters representing a large geographic area and who have interest in connecting with other chapters, the virtual option might substitute for in-person meetings.


NEWS

which should be much lower than for live conferences. Exhibitors are receptive to modest fees for a virtual presence.

• Script the meeting. A virtual meeting requires specific discipline with regard to flow. Participants are less tolerant of glitches and gaps in virtual meetings and, with one click, can leave. Similar to TED talks, virtual meetings should be scripted tightly to stay on time.3 Scripting helps to sustain meeting tempo. Chat rooms make meeting comments visible in real time and capture thoughts that might otherwise have been expressed in hallways and receptions at live meetings. Q&A rooms are efficient, as typed questions generally are more focused than verbal queries and comments.

• Conduct meeting simulations. Virtual meetings do not move seamlessly between multiple moderators and presenters. Practicing with the technology helps organizers to define strengths and limitations and to make adjustments before the actual meeting.4 We discovered audiovisual fidelity issues with open virtual microphones and video, so we restricted open audio

only to moderators and presenters with no video. Group audiovisual restriction is more reliable than individual participant muting (left uncontrolled, the “airwaves” are filled with echoes from the presenters and background noise). We also recognized the increased importance of moderators in controlling flow by keeping speakers on time and guiding discussion between presenters and text questioners. Simulation also instilled confidence in the presenters and moderators using the technology.

• Include website content. Links to the chapter website enhance virtual meetings. Links to a meeting program booklet, virtual poster exhibit, and industry virtual exhibit area extend meeting connection beyond the assigned time.

• Simplify. The meeting experience is shaped by content, technology, and interaction. The virtual environment has its own complexities. Keeping the instructional design of presentations and technology requirements as simple as possible reduces the risk of failures during the meeting.5 ♦

REFERENCES1. Frisch B, Greene C. What it takes to

run a great virtual meeting. Harvard Business Review. Available at: https://hbr.org/2020/03/what-it-takes-to-run-a-great-virtual-meeting. Accessed May 12, 2020.

2. Harvard Business Review. Running Virtual Meetings (HBR 20-Minute Manager Series). Boston, MA: Harvard Business Review Press; 2016.

3. Anderson C. TED Talks: The Official TED Guide to Public Speaking. New York, NY: Houghton Mifflin Harcourt; 2016.

4. Frisch B, Greene C, Prager D. Virtual offsites that work. Harvard Business Review. Available at: https://hbr.org/2020/03/virtual-offsites-that-work. Accessed May 12, 2020.

5. Reynolds G. Presentation Zen: Simple Ideas on Presentation on Design and Delivery. Berkeley, CA: New Riders; 2008.

Screenshot of Virtual Business MeetingScreenshot of overview of the Edward M. Copeland, III, MD, FACS, Resident Abstract Competition. Note the side panel for

free-text of questions and comments by participants.


Chapter news

by Luke Moreau and Brian Frankel

NEWS

DOMESTIC CHAPTERS

The coronavirus disease 2019 (COVID-19) has forced many domestic and international chapters of the American College of Surgeons (ACS) to postpone or cancel annual

meetings and events over the last several months. While a few chapters were able to hold annual meetings and Surgical Jeopardy competitions in the early stages of COVID-19,

chapters have started organizing virtual meetings so members can continue to participate in educational offerings and network with colleagues.

North Texas Chapter: Annual Meeting, February 21–22, Dallas.

Named lectures, scientific sessions, an abstract competition, and Surgical Jeopardy were some of the highlights

from the two-day meeting.

Left: Catherine Ronaghan, MD, FACS, 2019–2020 North Texas Chapter

President (left), presenting the Robert S. Sparkman plaque to invited

speaker O. Wayne Isom, MD, FACS, New York-Presbyterian/Weill Cornell

Medical Center, New York, NY.

Right: Bernhard Mittemeyer, MD, FACS, delivering the Harry

M. Spence Memorial Lecture

Florida Chapter: Florida then Chapter President John H. Armstrong, MD, FACS (right), and then President-Elect Jay A. Redan, MD, FACS, proudly congratulate graduating medical students during the Resident and Associate Society of the American College of Surgeon (RAS-ACS) virtual graduation ceremony. Their message: no matter where you live and learn, make an ACS chapter part of your life. Read more about the Florida Chapter’s virtual meeting on page 108.


NEWS

Maryland Chapter (MD-ACS): Spring Meeting, March 7,

Annapolis. Attendees gathered for a day of medical education

and professional networking that concluded with Surgical

Jeopardy, which the Anne Arundel Medical Center team won.

Left: Immediate Past-President Jonathan E. Efron, MD, FACS

(left), presented with the President’s Plaque by newly installed MD-ACS President

Jose J. Diaz, Jr., MD, FACS

Right: Winner of the MD-ACS 2020 Resident General

Surgery Abstract Competition Mitchell Huang, Johns Hopkins University (right), with Dr. Diaz

Connecticut Chapter: Honoring its long-standing commitment to medical education, the Connecticut Chapter recently awarded scholarships to graduating physicians from medical

schools in Connecticut. The awards were created to stimulate student interest in the surgical disciplines and to recognize outstanding achievement. Awards were presented to Thais Faggion Vinholo, MD, Yale School of Medicine, New Haven; Rebecca Lynn Calafiore,

MD, University of Connecticut School of Medicine, Farmington; and Seija Maniskas, MD, Frank H. Netter MD School of Medicine at Quinnipiac University, New Haven.

Dr. Vinholo Dr. ManiskasDr. Calafiore


NEWS

Germany Chapter: This year’s International Panel of the ACS and the German Society of Surgery, Women in Surgery, was organized by the ACS Germany Chapter and originally planned for the Annual Congress of the German Society of Surgery on April 21 in Berlin. Because of COVID-19, the session was convened as a videoconference with 220 participants.

ACS President Valerie Rusch, MD, FACS, was Honorary Presenter. Pictured in the photo, from left, upper row: John H. Armstrong, MD, FACS, then Florida Chapter President; Dr. Rusch; Astrid Büren, MD; Thomas Schmitz-Rixen, MD, President, the German Society of Surgery; and Ernst Klar, MD, FACS, Germany Chapter Governor. Additional presentations included “FamSurg—A Program for Establishing Family-Friendly Structures in Surgery,” by Kim Honselmann, MD, University of Lübeck; and “The Male’s View,” by Jakob Izbicki, MD, FACS(Hon), University of Hamburg.

INTERNATIONAL CHAPTERS

India Chapter: The India Chapter held a May 8–10 online International Medical Student Congress with more than 800 delegates participating over three days. Interesting cases,

research work, and clinical photo essays were presented, and two workshops were conducted on scientific paper writing and basic surgical skills. The chapter also held a live webinar,

Surgery during COVID Times—Do’s & Don’ts, as well as an online postgraduate master class that included clinical case presentations and demonstrations of clinical examinations.

Keep your ability to guide your patients’ pain management as sharp as your surgical skills. The American College of Surgeons (ACS) Optimizing Perioperative Pain Management course will ensure you have the latest knowledge to do so.

Nuances of patient characteristics demand a sophisticated approach to pain management. Master the complexities of perioperative pain management with the real-life strategies highlighted in this new online program. With eight new e-learning modules, challenging patient scenarios across preoperative, intraoperative, and postoperative periods are used to demonstrate the array of pain management approaches essential for effective surgical care.

Your patients trust you with all aspects of their care, including pain management.

facs.org/optimizingpainmanagementRegister today!

Perioperative pain management remains the domain of surgeons.

AMERICAN COLLEGE OF SURGEONSDIVISION OF EDUCATIONBlended Surgical Education and Training for Life®

Enhance your skills and earn 8 AMA PRA Category 1 Credits™ by taking this course.

2020_ED_Ad_OptimizingPain_Course_Update_Bulletin_7.5x10.25in_v2a_Release.indd 12020_ED_Ad_OptimizingPain_Course_Update_Bulletin_7.5x10.25in_v2a_Release.indd 1 6/16/20 9:11 AM6/16/20 9:11 AM

Calendar of events*

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

APRILTurkey Chapter—Turkish

National Surgery CongressApril 1–5

Antalya, TurkeyContact: Prof. Mahir Ozmen,

[email protected]

120th Annual Congress of the Japan Surgical Society

April 16–18Yokohama, Japan

Contact: Congress Secretariat,[email protected],

jssoc.or.jp/jss120/

Annual Congress of the German Society of Surgery

April 21–24Berlin, Germany

Contact: Dr. Ernst Klar,[email protected]

Indiana ChapterApril 24–25

Noblesville, INContact: Tom Dixon,

[email protected],infacs.org

South Dakota and North Dakota Chapters

April 24–25Sioux Falls, SD

Contact: Terry Marks,[email protected]

Trinidad and Tobago ChapterApril 26

Piarco Trinidad, West IndiesContact: Dr. Lakhan Roop,[email protected]

Puerto Rico ChapterApril 30–May 2

San Juan, PRContact: Aixa Velez-Silva,

[email protected],acspuertoricochapter.org

MAYFlorida Chapter

May 1–2Orlando, FL

Contact: Brian Hart,[email protected],

floridafacs.org

Missouri ChapterMay 2–3

Lake Ozark, MOContact: Denise Boland,

[email protected],moacs.org

West VirginiaMay 7–9

White Sulphur Springs, WVContact: Ashley Wiley,

[email protected]

Northern California ChapterMay 8–9

Berkeley, CAContact: Christina McDevitt,

[email protected],northerncalifornia45011.wildapricot.org

Ohio ChapterMay 8–9

Toledo, OHContact: Emily Maurer,

[email protected],ohiofacs.org

Michigan ChapterMay 13–15

Boyne Falls, MIContact: Carrie Steffen,

[email protected],michiganacs.org

Australia and New Zealand Chapter

May 13South Wharf, VictoriaContact: Monique Whear,

[email protected]

Virginia ChapterMay 15–16

Williamsburg, VAContact: Susan McConnell,[email protected],

virginiaacs.org

Metropolitan Philadelphia Chapter

May 18Philadelphia, PAContact: Robbi Cook,

[email protected],mp-acs.org

FUTURE CLINICAL CONGRESSES

2020October 4–8Chicago, IL

2021October 24–28Washington, DC

2022October 16–20San Diego, CA

Note:

Due to the COVID-19 pandemic, many ACS meetings and courses are being moved online, canceled, or postponed.

For up-to-date information on chapter meetings, visit facs.org/member-services/chapters/meetings or contact Martha Zuniga at [email protected].


MEETINGS CALENDAR

A M E R I C A N CO L L E G E O F S U R G E O N S

Teach.Listen.Lead.Question.Heal.

I am a Fellow.

PROUDLY DISPLAY THAT YOU’RE A FELLOW OF THE AMERICAN COLLEGE OF SURGEONS. Log in and download FACS artwork at facs.org.

2018_MS_PrideCampaign_Walking_BULLETIN_7.5x10.25_v01.indd 1 1/9/2018 8:17:52 AM

facs.org/clincon2020

ACSCLINICAL

CONGRESS 2020

The Best Surgical Education. All in One Place.

OCTOBER 4–7VIRTUAL

in the time of covid-19

Documents