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AdvocacyUpdate from the Statehouse

Ohio Chapter S-PAC Needs You! General SurgeryInside the General Surgeon Shortage Crisis Is Practicing Medicine Worth It? Chapter NewsCancer Liaison Report

November Council Meeting Reports Resident Research Forum Pulse Throughout OhioDistrict Council Reports

Dr. And Mrs. Reiling Recipients of Distinguished Philanthropist Award

Where Do You Practice? – Gary Williams, MD, FACS From the College Plus Much More...

W i n t e r 2 0 0 9

Inside the General Surgeon Shortage CrisisOhio State University surgeons predict a shortageof 1,300 surgeons by 2010

AdvocacyUpdate from the Statehouse . . . . . . . . . . . . . . . . . . . . . 4

Ohio Chapter S-PAC Needs You! . . . . . . . . . . . . . . . . . 6

S-PAC Contribution Form . . . . . . . . . . . . . . . . . . . . . . 7

General SurgeryInside the General Surgeon Shortage Crisis . . . . . . . . . 8

Is Practicing Medicine Worth It? . . . . . . . . . . . . . . . . 12

Chapter NewsOhio Chapter Past Presidents . . . . . . . . . . . . . . . . . . . 14

Cancer Liaison Report . . . . . . . . . . . . . . . . . . . . . . . . . 15

November Council Meeting Committee Reports . . . . 17

Resident Research ForumPotential Hepatoprotective Role for CXC Chemokine Receptor-1 after Liver Ischemia/Reperfusion in Mice . . . . . . . . . . . . . . 20

Impact of Resident Surgeon on Margin afterBreast Conservative Surgery . . . . . . . . . . . . . . . . . . . . 20

Significance of Atypical or Multiple Sentinel Lymph Node Drainage Basins in Patients with Melanoma . . . . . . . . . . . . . . . . . . . . . . . 21

Pulse Throughout OhioDistrict Councilor Reports . . . . . . . . . . . . . . . . . . . . . 22

Dr . and Mrs . Reiling Recipients of Distinguished Philanthropist Award . . . . . . . . . . . . . . 24

Where Do You Practice? . . . . . . . . . . . . . . . . . . . . . . . 24

From the CollegeCall Issued for Nominations for the ACS Board of Regents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

David B . Hoyt, MD, FACS, to Become ACS Executive . . . . . . . . . . . . . . . . . . . . . . . . 26

Table of Contents

Ohio Chapter, American College of Surgeons Executive Committee

Michael D. Sarap, MD, FACSSoutheastern Ohio Physicians [email protected]

Joseph J. Sferra, MD, FACSToledo Surgical Specialists [email protected]

Steven M. Steinberg, MD, FACSThe Ohio State [email protected]

Linda M. Barney, MD, FACSWright State University Dept of [email protected] Past President

Christopher R. McHenry, MD, FACSMetroHealth Medical [email protected] President

District Councilors

Brent Michael Alan Bogard, MD, FACSCleveland [email protected]

Victoria L. Van Fossen, MD, FACSDalton & Van Fossen Surgeons [email protected]

Michael Bielefeld, MD, FACSSurgical Specialist of Bowling Green [email protected]

Peter F. Klein, MD, [email protected]

David M. Hasl, MD, FACSLancaster Surgical [email protected]

J. Allen McElroy, MD, FACSSurgical Associates of [email protected]

Akpofure Peter Ekeh, MBBS, MPH, FACSMiami Valley [email protected]

Cari A Ogg, MD, FACSCincinnati General Surgeons [email protected]

ACS Board of Governors: Ohio Members

Linda M. Barney, MD, FACSWright State University Dept of [email protected]

Alice Ann Dachowski, MD, FACSHolzer [email protected]

David N. Linz, MD, FACSCanton General Surgery [email protected]

Michael E. Stark, MD, FACSSurgical Partners [email protected]

Ohio Chapter Committees

Advocacy & Health Policy

Michael E. Stark, MD, FACSSurgical Partners [email protected]

James I. Merlino, MD, FACSSurgeon Cleveland Clinic [email protected]

Assn of Women Surgeons Representative

Nancy L. Gantt, MD, FACSSt Elizabeth Health [email protected]

Awards & Bylaws

Gary B. Williams, MD, FACSSumma Health [email protected]

William C. Sternfeld, MD, FACSToledo [email protected]

CAC Representative

James I. Merlino, MD, FACSCleveland Clinic [email protected]

Commission on Cancer

Daniel P. McKellar, MD, FACSCommission on [email protected]

Valeriy Moysaenko, MD, FACSLegis [email protected]

Communications

Scott Michael Wilhelm, MD, FACSUniversity Hospital [email protected]

Community Hospital

Mary Carey MacDonald, MD, FACSSamaritan Professional [email protected]

Michael D. Sarap, MD, FACSSoutheastern Ohio Physicians [email protected]

Delegate to OSMA

William C. Sternfeld, MD, FACSToledo [email protected]

Development

Linda M. Barney, MD, FACSWright State University Dept of [email protected]

Mark A. Malangoni, MD, FACSMetroHealth Medical [email protected]

Medical Education/Program

Steven M. Steinberg, MD, FACSThe Ohio State [email protected]

Bruce Jeffrey Averbook, MD, FACSMetroHealth Medical [email protected]

Membership

Christopher A. Grove, MD, FACSUpper Valley Professional [email protected]

Juan A. Crestanello, MD, FACSThe Ohio State [email protected]

Nominating

Christopher R. McHenry, MD, FACSMetroHealth Medical [email protected]

Resident Essay Contest

Randy J. Woods, MD, FACSWright State [email protected]

Walter Cha, MD, [email protected]

Resident/Young Surgeons Education

Peter F. Klein, MD, [email protected]

Jeffrey Alan Blatnik, MDUniveristy Hospitals Case Medical [email protected]

Mario Castillo-Sang, MDUniversity of Toledo Medical [email protected]

Ohio Committee on Trauma

Charles J. Yowler, MD, FACSMetroHealth Medical [email protected]

Jonathan M. Saxe, MD, FACSWright State [email protected]

Executive Office

Brad L. Feldman, MPA, CAE, [email protected] Director Pulse is the official publication of the Ohio Chapter, American College of Surgeons. It is published two times a year in Columbus, Ohio as a benefit of membership and circulated free of charge to Ohio Chapter members.

Information appearing in this publication is obtained from sources we believe to be reliable. The information may not be a complete statement of all available data and is guaranteed as such. Conclusions are based solely on editorial judgment and analysis of technical factors and surgical/medical industry information sources. Pulse is copyrighted and portions may be reprinted with the permission of the Ohio Chapter. Pulse is not responsible for the contents of its advertisements and advises all members to investigate claims before making any purchases.

Permission requests to reproduce written material should be sent to:Ohio Chapter, ACSP.O. Box 1715Columbus, OH 43216-1715(877) 677-3227

© Copyright 2009, Ohio Chapter, ACS. All rights reserved.

OhiO Chapter, ameriCan COllege Of SurgeOnS

www.ohiofacs.org

WiNTeR 2009 3

President’s Message

The Ohio Chapter has remained very active in the six months since the Annual Meeting was

held in Cleveland . We continue to receive favorable comments about the meeting from attendees, vendors and the speakers . Congratulations to Past President McHenry, members of the Program Committee, Ohio Chapter Executive Director Brad Feldman, and the Ohio ACS staff for putting together a great event . A recap of the meeting and activities appeared in the Summer 2009 edition of Pulse .

The Chapter has continued to be involved with advocacy efforts throughout the year both at a state and national level . In conjunction with our advocacy advisors we have communicated directly and through letters of support (and nonsupport) with state legislators in regards to numerous bills and issues . I have been involved in small roundtable discussions with Senator Sherrod Brown and Representative Zack Space during the legislative recess to give input on the impending healthcare legislation . It is imperative that each of us continues to have direct input to our legislators about the importance of including Medicare physician payment reform and tort reform in any new national healthcare plan .

The Chapter has made minor changes in the structure of certain committees that should help improve efficiency and communication between related committees . We have confirmed chairpersons and vice-chairpersons for each committee . Every chapter member that was involved in committee work prior to the change remains in a position to make a contribution to the chapter with the new arrangement .

We continue to prepare for the next Annual Meeting in Columbus . We have arranged for the ACS Columbus area Committee on Applicants to perform interviews with potential new members during the meeting . The ACS office in Chicago granted us an extension on the time frame to submit the interview information to allow for them to be carried out during the Annual Meeting . We have a commitment from OSU College of Medicine and their Department of Surgery to hold the Zollinger Lecture at our venue as part of our meeting . Dr . Chris Ellison has arranged for Dr . Steven Stain, Chair of Surgery at Albany Medical Center to be the speaker . The Central Ohio Trauma System (COTS) may also utilize our event to coordinate their first annual trauma paper and poster symposium . I look forward to working with the Program Committee in the coming weeks to build on the success of last year’s impressive roster of expert speakers .

Brad and I were asked to give a brief presentation at the National ACS meeting in Chicago at the Chapter Showcase . We reported on our recent collaborative efforts with local hospitals/universities, the American Cancer Society, Ohio Women in Surgery, and vendors that have invigorated our state chapter and made the recent meeting a success . I also was asked to participate in the medical student program at the ACS . I gave my view of practice in a rural private community setting . The Ohio Chapter held a reception in Chicago for ACS attendees from the Buckeye State . The gathering was financially supported by Cook Medical and was very well attended by new and established chapter members .

As the newly elected president of the Chapter, I have contacted surgeons in both large and small practices in Ohio to offer the services of the Ohio Chapter to their practice and to listen to issues that they may have . I have visited or contacted surgeons in Zanesville, Marietta, Martins Ferry, Lancaster, Cincinnati, and Columbus . I have interacted with many others while teaching ATLS courses in Columbus . Physicians at my hospital in Cambridge invited Dr . Gordon Gee, president of The Ohio State University, to our institution to have a frank discussion about the importance of small community hospitals and their role in providing healthcare to Ohioans . We discussed the very real issues of financial viability of small hospitals and our difficulty in attracting specialists in the present economic climate . I would very much appreciate the opportunity to visit surgical training programs in the state and to interact with residents to give them some exposure to the Chapter and, more importantly, to suggest the possibility of some of these surgeons staying in general surgery and practicing in smaller communities .

Michael D . Sarap, MD, FACS

OhiO Chapter, ameriCan COllege Of SurgeOnS

www.ohiofacs.org

WiNTeR 20094

After a contentious budget debate wrapped up in mid-July, state legislators – and the state – needed a break! Over the summer, legislators spent nearly eight weeks in their home districts . Legislative session and committee hearings resumed the week of September 15 and are continuing through the end of the year . The most significant topic to be discussed during this time is a proposal to fill a new budget gap created when the proposal to allow video lottery terminals (VLTs) at Ohio’s seven racetracks fell through . House Bill 318, legislation to delay the final phase of an income tax reduction, has passed the House and is being debated in the Senate as budget filler anticipated to generate close to the amount of revenue lost in the failed attempt to allow VLTs in Ohio . Ohio Chapter will be closely monitoring this activity as the Senate considers additional cuts to the state budget in order to avoid a tax increase in balancing the budget .

Also, the Ohio Legislature has been criticized recently for lack of legislative activity; state lawmakers have passed just nine bills this year . Some may consider this inactivity a positive, not a negative!

Shannon Jones Seated as New State Senator

Hearts have been heavy around Capital Square since the untimely passing of Sen . Robert Schuler (R – Cincinnati) . Sen . Schuler passed away earlier this summer leaving a vacancy for the important 7th District Senate seat that encompasses part of Hamilton County and all of Warren County . With several strong personalities vying for the appointment, the Senate Republican

caucus chose Rep . Shannon Jones (R – Springboro) to fill the seat .

Jones was chosen over, amongst others, her former House colleagues; former representatives Tom Brinkman and Michelle Schneider . Because the 7th Senate District seat was up for grabs in 2010 (due to the term limitation of the former Sen . Schuler), it is possible that Brinkman, Schneider and others will run against Jones in the primary next year . If that happens, Sen . President Bill Harris (R – Ashland) has stated unequivocally that the caucus will be 100% behind Sen . Jones .

Senator Jones is active in health care and insurance issues and has been a good friend to physicians in her time in the Ohio House . We look forward to working with her as a state senator .

Meanwhile, House Republicans appointed Rep . Peter Strautberg (R-Anderson Township) to fill the Jones vacancy in the 67th House District .

Bills of Interest to Ohio ChapterOhio Chapter continued to

monitor and participate in policy discussions on a number of key healthcare proposals, including:

HB 56 (Miller)/ SB 64 (Coughlin) – Colorectal cancer screening insurance mandate

This bill has not had recent activity . Insurance mandates are a tough sell to the Ohio General Assembly . Insurance and the small business community have worked hard to slow down consideration of a number of insurance reforms, including mandated coverage for diabetes education and supplies and the diagnosis and treatment of autism .

HB 93 (Skindell) – Bicycle helmet requirement for children

Legislation requiring children under the age of 18 to wear a bicycle helmet has been considered by the Ohio General Assembly for a number of years . This General Assembly, legislators are considering a bill introduced by Representative Mike Skindell . Like previous versions, this bill also establishes a special fund for fines ($25 for violations) that would be used to purchase helmets for low-income families . The bill is pending in Public Safety and Homeland Security Committee and has had three hearings .

HB 122 (Boyd)/ SB 98 (Patton) – Physician designation bill

The Academy of Medicine of Cleveland and Northern Ohio and the Ohio State Medical Association are working to advance this legislation that would establish standards for physician rating systems established by health insurance companies . The bill would prohibit such systems from being based solely on cost measures . HB 122 was voted out of House Health Committee in October; SB 98 has had one hearing in the Senate .

HB 185 (Book/DeGeeter) – Prohibiting unilateral contract changes

The Ohio State Medical Association is working with bill sponsors Rep . Todd Book (D-McDermott) and Rep . Timothy DeGeeter (D-Parma) to clarify an important provision from House Bill 125 from the 127th General Assembly intended to level the playing field in the relationship between providers and insurance companies by

Update from the Statehouse By Tracy Intihar, Ohio Chapter Legislate Agent

Advocacy

(continued on page 5)

WiNTeR 2009 5

prohibiting an insurance company from making one-sided contract changes . Insurance companies have found a loophole in the law so this language simply and clearly states that a material amendment to a health care contract does not become part of the contract unless agreed upon by both parties . The bill passed out of the full House at the end of October and is pending in the Senate .

HB 206 – APN Prescriptive Authority for Schedule II Drugs

House Bill 206 is a bill designed to grant advanced practice nurses prescriptive authority for Schedule II drugs . The bill passed out of House Health Committee on October 6, 2009 . It has not yet been scheduled for a full House vote .

HB 267 – Official Prescription Drug Program, Introduced in House

Rep . Clayton Luckie (D-Dayton) recently introduced HB 267, a bill that creates a new prescription drug program in Ohio . The bill creates a monitoring program in the State Board of Pharmacy to detect prescription fraud and abuse . Prescribers would be required to purchase tamperproof prescription pads from the Board of Pharmacy . The Board would create a unique identification number for each prescription .

This identification number would be used to track inappropriate and illegal use of prescription drugs, especially narcotics . When analyses of official prescription data indicate that a physician’s patient is obtaining controlled substances from multiple sources, the Board would notify the provider . To pay for the program, the bill proposes that prescribers be required to use the Board’s prescription pads and pay a $250 annual fee . Rep . Luckie has stated that his goal with the proposed law is to create a program that cuts down on fraud and abuse of prescription drugs . This program is modeled after a New York program that is reported to have saved millions of dollars in prescription abuse . Unlike the Ohio proposal, the New York program is free to prescribers .

Ohio Chapter’s immediate concerns include the following:• Do providers really

need government-run prescription program?

• The details on how this program will really work seem foggy

• This proposes a significant fee to be paid by the prescriber to participate

The bill was introduced in August 2009 and has received one hearing in the House Health Committee .

Ohio Chapter staff and legislative consultants from the Capitol Consulting Group will be working closely on this bill to ensure that surgeons’ interests are heard .

SB 86 (Buehrer) – Physician qualified immunity for emergency and disaster care

This bill will provide a new limited liability for physicians in disaster and emergency situations . In sponsor testimony, Senator Steve Buehrer (R-Delta) said that the bill would provide protections to specialists who provide on-call support to emergency room physicians . Senator Buehrer went on to say that the bill would not exclude a malpractice lawsuit, but would create a higher “willful and wanton” standard for pursuing it . Legislators and interested parties are debating how this standard compares to other legal standards . In particular, Senator Bill Seitz, the chairman of the committee hearing the bill, has suggested using “reckless disregard” as the standard . The bill has had a number of hearings in Senate committee . OCACS submitted a letter of support for the bill .

Update from the Statehouse (continued)

Advocacy

WiNTeR 20096

Advocacy

In order to advance the goals of the profession through political involvement, the Ohio Chapter has a Political Action Committee (PAC) .

Having a strong PAC fund assists the Ohio Chapter in forming relationships with legislators who are in-tune with the problems and needs of our profession and patients . Engaging in the political game will help the Ohio Chapter “fight fire with fire” and enable our association to support the key legislators who sustain our profession .

On behalf of the Ohio Chapter, thank you to all members who contributed to S-PAC in 2009:

Alice Dachowski, MD, FACS

Michael Stark, MD, FACS

Michael Sarap, MD, FACS

Michael Bielefeld, MD, FACS

Mark Malangoni, MD, FACS

Christopher Grove, MD, FACS

Cari Ogg, MD, FACS

William Sternfeld, MD, FACS

Steven Steinberg, MD, FACS

Charles Yowler, MD, FACS

Randy Woods, MD, FACS

Linda Barney, MD, FACS

Nancy Gantt, MD, FACS

Valeriy Moysaenko, MD, FACS

Joseph Sferra, MD, FACS

Brad Feldman, MPA, CAE, IOM

Christopher McHenry, MD, FACS

Gary Williams, MD, FACS

Again, we thank these individuals for their support and contribution to S-PAC . Together, we will fight the legislative battles for the Ohio surgical profession . For more information on the Ohio Chapter legislative agenda or how you can participate, contact the Ohio Chapter Executive Office at (877) 677-3227 or email ocacs@ohiofacs .org .

Ohio Chapter S-PAC Needs You!

Have you been Checking your e-News?

e-News is an email communication sent to members once per month around the 15th regarding surgical news, Ohio Chapter updates, volunteer opportunities, continuing education, and much more. if we do not have your current email address on file, please contact us at [email protected] so you can startreceiving e-News.

in the past, members have expressed concerns that they were not receiving e-News, yet were signed up for it. if you experience this problem, make sure that [email protected] is not getting flagged as spam by your email service provider. ensure Ohio Chapter e-News reaches your inbox, and add [email protected] to your address book.

WiNTeR 20098

“Who will fix our hearts, your hip, and deliver our grandchildren?”

According to three Ohio surgeons, perhaps no one will .

While conducting research on an estimated 500,000-doctor shortage for a book released in 2005 entitled Consumer Driven Healthcare, Dr . Thomas E . Williams, wondered how this shortage — expected to be realized by 2015 — would affect the profession he called his own .

Dr . Williams, a clinical associate professor emeritus of surgery in the Division of Cardiothoracic Surgery at The Ohio State University Medical Center, has co-authored another study that is predicting a shortage of 1,300 general surgeons by the year 2010 and as much as 6,000 by year 2050 . This surgeon deficiency would have devastating consequences for those in need of medical care .

In their recently-released book, Dr . Williams and co-authors Dr . Bhagwan Satiani and Dr . E . Christopher Ellison discuss the many corollary effects this surgeon shortage will yield . Their book, The Coming Surgeon Shortage: Why They Are Disappearing and What That Means for Our Health, predicts that an increase in emergency room wait times could be the least of our worries .

Small Practices Will be Overmatched

Perhaps facing the biggest burden in this general surgeon shortage will be private practices . Many practices are already having trouble competing and keeping up with the salaries and benefits that hospital-based practices offer . If the demand for surgical procedures rises and the supply decreases, the small private

practice groups are going to have a harder time competing and recruiting for the same person coming out of residency than hospitals employing surgeons or a group where 10 to 15 surgeons have shared overhead .

Over-WaitGeneral surgeons bear the brunt

of taking surgical emergencies out of emergency rooms and make timely and critical decisions on whether or not to operate on injured patients . As the general surgeon shortage worsens, emergency room wait times will inevitably rise . Waiting times for elective surgeries will increase as well .

While waiting for surgical care has obvious implications such as prolonged periods of pain and suffering, the most devastating consequences ultimately result from the effects of untreated injuries and disease progression . When every second counts, the ability to count on prompt medical attention is paramount to staying healthy and, more importantly, staying alive . This surgeon shortage is more than a healthcare provider issue; it’s a healthcare recipient issue .

Rural Areas Will Feel the Greatest Impact

While the surgeon shortage will have far-reaching implications, the geographic regions most likely to be affected are rural areas — cities with populations under 100,000 people . In the book authors’ home state of Ohio, smaller cities like Findlay, Portsmouth, and Marietta are facing several key issues keeping surgeons away .

Among them are that many people prefer to live in larger cities where there is access to many different goods and services that the smaller

areas cannot provide . According to Satiani, a professor of clinical surgery at The Ohio State University Medical Center, “The spouses of doctors don’t want to be located in areas where they don’t have access to cities and all the things that go with them .”

A big challenge is the increase in two-income families . If a surgeon were working in a rural area, then the spouse would need to find a job in that same area . The problem is that there are more opportunities in the big cities, thus making the likelihood of a surgeon moving to a smaller city even less .

Being a Surgeon Isn’t What It Used to Be

In the past, not many professions required as much education and training as surgeons, but this was balanced out by better pay relative to those other professions . Today, there are numerous other occupations that are almost equitable in the amount of necessary education and training that offer comparable or better pay .

The primary concern amongst surgeons is reimbursements . Recent studies show that more than half of current surgeons believe that Medicaid reimbursement is less than their cost of providing care . “You can’t run a practice without reimbursements, because practice expenses include malpractice insurance and salaries . Since 1981, reimbursements have decreased 50 percent, and with regard to the consumer price index, it’s almost 80 percent,” said Dr . Williams .

As the required training and average workload for surgeons increases and the reimbursements decrease, it leaves little financial incentive for surgeons to remain in the profession . “This has

Inside the General Surgeon Shortage Crisis Ohio State University surgeons predict a shortage of 1,300 surgeons by 2010By Antonio Ciaccia

General Surgery


WiNTeR 2009 9

aggravated the problem in several surgical specialties and in general surgery, because from an economic perspective, it’s not a field that is as attractive to go into today as was 10 to 15 years ago,” said Dr . Ellison .

According to Dr . Williams, “There are three times as many law school applications and three times as many first-year places in American law schools as there are first-year places in the medical schools . If you graduate from law school and are employed by a prestigious law firm in New York City, you can make $160,000 as a 26-year-old . We can’t do that in medicine .”

Lifestyle IssuesOne of the greatest challenges of

being a surgeon is the wear and tear it can have on everyday life . Surgeons — especially those in general surgery — face the encroachment of their jobs into their personal lives on a regular basis . Today, trainees are faced with lifestyle choices that they have to make . If they work in a hospital-based practice, there’s more control of hours . However, for those surgeons in small community hospitals where they may be the only general surgeon on staff, they can be on call 24 hours a day, seven days a week .

Contrary to what may be assumed as a shortage of interest in entering the surgical profession, there are no vacant training spots for surgery in the United States . The desire to be a surgeon still exists according to the book authors . “I think that once they get into surgery, people are turning to more controllable specialties like plastic surgery, surgical oncology, and transplant surgery versus general surgery, which is more intense in terms of demand and a reduced lifestyle, because

you can’t control the emergency surgeries,” said Dr . Ellison .

The Surgical Cap and its Effect on the Shortage

In 1997, the American Medical Association, the American Osteopathic Association, and several other similar groups, anticipating a surplus of doctors and surgeons, prevailed on Congress to limit and cap all the medical and surgical residencies at around 105,000 . Complications arose as time progressed due to the fact that there were no provisions to keep pace with America’s dramatically increasing population and its underestimated surgical needs . In 1997, America had a population of less than 280 million people . With America’s population now comprised of more than 300 million people, Dr . Williams and his book’s co-authors believe that the decision to cap residencies should now be reevaluated .

More Operations, More Problems?Not only has the U .S . population

increased while the amount of physicians has essentially remained stagnant, people are having more surgeries than they used to .

Dr . Williams reported that according to studies, surgical workloads are expected to increase 20 to 40 percent by 2020 . With more surgical procedures available and frequency rates of surgeries per person on the rise, more surgeons are needed to make up the difference . In the midst of the current cap on residencies, that won’t happen .

The Threat of Malpractice SuitsMalpractice has become a focal

point in the medical community in recent years . Many believe that the threat of malpractice suits may be

keeping bright minds away from the profession, instead focusing on careers with less risk associated with the job . There are not many known surveys that ask college students why they would or would not want to become a surgeon, so it is difficult to determine the effect that the threat of malpractice suits may have on potential medical students .

“While it may be difficult to determine the effect malpractice has on prospective medical students, I do think it affects the other end — early retirement,” said Dr . Ellison .

A negative result of the high level of malpractice suits and high insurance premiums is that it eventually drives people away from the surgical practice . In states like Ohio, surgeons face several factors that impact their practice . Medical liability premiums and electronic medical records are expensive . It is difficult and taxing to maintain a practice . There is increased scrutiny of practices by patients and lawyers . These are all reasons that surgeons are leaving the profession early .

Dr . Ellison added, “Dr . Satiani, Dr . Williams, and I all know people that left their practice in their young 50s and said ‘I’m not doing this anymore .’

They’ve got 20 years of functional practice left, and they hang it up .”

And It Gets WorseIn a 2008 survey conducted by

the Physicians’ Foundation, 270,000 physicians were polled to examine the causes behind the doctors’ dissatisfaction, the state of their practices, and the future of care . More than 150,000 physicians — 49 percent of those polled — said that over the next three years they plan to reduce the number of patients

Inside the General Surgeon Shortage Crisis Ohio State University surgeons predict a shortage of 1,300 surgeons by 2010(continued)

General Surgery


WiNTeR 200910

they see or stop practicing entirely . Perhaps most alarming is that 60 percent of those polled said that they would not recommend medicine as a career to young people .

“Nearly half of the surgeons currently practicing are cutting back services in one way or another . And when you consider the aging population, you’ve got 35 percent of all physicians over the age of 55 . What if, of that group, half starts to cut back and retire? Then all of our projections are even worse . Our projections are very conservative . We haven’t taken into account the early retirements and people just getting fed up,” said Dr . Satiani .

Does the Entire System Need Reconstructive Surgery?

With all of the problems that are symptomatic of the general surgeon shortage, it could be assumed that the entire system is inherently flawed . Should medical students depend on the government for paid training, or could a solution arise from the private sector? Is reform necessary to lower the number of malpractice suits and thus lower insurance premiums? Does there need to be an overall change in philosophy that medical establishments are places of business and not community giving centers that can be under-reimbursed by entities like Medicare and Medicaid? Do medical students need the lengthy amounts of undergraduate education currently required by the country’s collegiate institutions?

Dr . Satiani believes it takes a change in basic thinking . The government funds a majority of graduate medical education . “If the government controls the purse, they pretty much own the system . If they pay for the majority of funding for

graduate medical education, then that’s who controls it basically . They don’t tell you how many people should go into this specialty and how many should go into that specialty — they were thinking about it though . But if you cap the number of physicians, then you have the final say . My thought is if there’s no further money in the government — which I frankly doubt — why don’t we just do partnerships with the private sector? Then we could figure out a way to find some return on that money and try to fund more physicians . That would be the logical thing to do .”

According to Dr . Ellison, “I think the financing has been flawed, but I don’t think the entire system is flawed . You may question whether you need three years of medical school or four . There’s a question of whether that fourth year is really valuable or not, but the medical schools are dependant upon the tuition the fourth year to help offset the expenses of the first, second, and third years . I don’t think they would give up that fourth year very easily . So then you ask the next question, ‘well, can there be maybe just two years of undergraduate and then go into medical school?’ But the problem is that you need a certain level of maturity when you begin your residency, and it’s been observed that people that do six years of training sometimes don’t have the maturity level that it takes to handle difficult patients in the emergency department or the operating room . That extra two years makes a big difference . I think the financing of medical education is in serious trouble, and it’s flawed because there’s just not enough government financing for it to be effective .”

The RepairThe problems are clear . Surgeons

are feeling strapped by a lack of reimbursements and the high costs associated with operating a practice . The demands on their personal lives are too significant . The cap on surgical residencies is preventing many medical students from responding to the growing demand for surgeries . The solutions, while not as clear-cut, are a great starting point to remedy this crisis . Dr . Williams and his book’s co-authors have several recommendations .

The first would be to start a campaign to encourage undergraduate students in colleges to become medical students . There is a great need to increase the number of students interested in medicine in general, because shortages will affect all areas . Secondly, within medical schools, all surgical specialties have to engage students early in their careers so that students have an idea that all surgical disciplines are valuable and that they can still have a reasonable lifestyle depending on how their practice is organized . The third and most critical component of fixing this predicament is increasing the number of medical students graduating in the United States . With residency positions capped according to the Balanced Budget Act of 1997, the number of training physicians supplemented and paid for by the government cannot be increased to meet current demands . The last recommendation is figuring out a way to reduce the cost of medical education so trainees don’t start their careers with debts of more than hundreds of thousands of dollars .

“Part of the solution is going to be that third-party payers are going


General Surgery


WiNTeR 2009 11

to need to recognize that the value of surgical work is going to have to be increased substantially,” said Dr . Ellison . “Surgeons will be in such demand that they will be able to pick and choose who they take care of . They can’t take care of everybody . And they may pick and choose on economic basis . I’m not saying that’s the right thing to do, but they could do that . They could refuse to take Medicaid or Medicare, and just take private insured patients . Most physicians would not do that, but that could be natural fallout .

“I think that the other thing that may be an unintended consequence is people living in the United States going to other countries to get their medical care . We’re already seeing that with joint replacements .

You have people going to India to get a hip replacement, because it’s much less expensive . Secondly, the insurance companies may drive that effort, because they could pay the hospital and the physician in India to do it . They could give the patient a little cash to help them fly over there and get back, and it’s still going to cost them less . I think that that’s going to be an unintended consequence . When that happens, who is going to take care of the complications when the patient comes back and has an infected hip? The most expensive part of a joint replacement is if you get an infection . I think there are going to be all kinds of unintended consequences for this problem . I think that Dr . Satiani’s idea of a partnership between third-party

payers, government, and hospitals is probably where the answer lies .”

Dr . Satiani added, “I think we need to sit down a serious commission to look at this . We’ve had commissions before, but unfortunately they’ve been dead wrong over many years . We don’t have a crystal ball . I’m not saying it’s their fault . I’m just saying that circumstances change, and we just have to be ready to adapt . The way I see it, if the government doesn’t have any more dollars, then partner with the private sector to figure out what incentives we can give them . There are many ways to be creative to get funding for medical education . We can do it .”


General Surgery

WiNTeR 200912

Every physician will encounter days during which he or she wonders if the complications and sacrifices of a career in medicine are truly worth it . It may be onerous medical school debt, the latest Center for Medicare & Medicaid Services announcement about further decrease in reimbursement, Congress imposing another “Stark IV” regulation, threat of a lawsuit, increased liability and disability insurance premiums, or appealing an insurance company’s repeated denial of office procedures . Or it may be the sacrifice of seeing your family less .

You see your friends from school and college coming home at a reasonable hour in the evening . Going to a physician’s lounge or a physician meeting used to be a positive social experience . Not anymore . You end up going for one reason or another only to regret it . Too much negativity . Through this, one theme endures – you, the physician, want to practice medicine, and know that the reason for pursuing medicine is still relevant . To relieve suffering, find cures, and help people to lead healthier and happier lives . You ask yourself, “Am I making a difference? Do my patients really appreciate what I am doing?” Several events have made me doubt myself throughout the years:

• My first letter from a plaintiff attorney regarding a patient I had helped recover from a disastrous complication due to incompetent care rendered by another physician .

• The first and only malpractice case of my career .

• The first patient death from an elective procedure under my care .

• A patient’s family threatening me with a lawsuit in the hospital corridor over my refusal to operate on his family member based on lack of an indication .

I started keeping a ‘thank you’ file in a desk drawer in my office when I first started my practice thirty years ago . The file grew thick over time . Most times I was too busy to really read what patients or their families had written . Then, I would go back to it periodically whenever I started to question my decision to go to medical school or envy other people around me . There are many, many cards and letters in my ‘thank you’ file . The most touching comments came via handwritten letters from patients and their families .

• The family of a 90-plus year old on whose leg I, after much self-examination, agreed to do a bypass in order to save her limb so she could continue to live on her farm by herself .

• The daughter in the Emergency Room who twisted my arm to operate on her 80 year old blind mother who was in extremis from a ruptured abdominal aortic aneurysm . Her mother never turned a hair and went home alive, alert, and back to her daughter and her grandchildren .

• The son of an Italian woman who had convinced her I was of Italian heritage (based upon my last name), who wrote to tell me after his mother’s death how she continued to thank the Italian doctor who had saved her from a stroke with carotid surgery .

There are many more letters which bring tears to my eyes years later . They kept me in the game

and helped me put the negative events in perspective . One such letter from a patient’s daughter is one I have read several times over my career . Her father was presented with a symptomatic expanding abdominal aortic aneurysm but was also found to have bilateral femoral and popliteal aneurysms and later developed a thoracic aneurysm . I had to operate on him several times to repair all his aneurysms . Some years later I had to use both his arm veins to salvage his limb in a long and difficult procedure . He finally moved to Holland . Her letter arrived after I had seen him for the last time .

“Dear Dr . Satiani,

Over the years, you have saved my dad’s life many times . I don’t know if we have ever really thanked you and let you know how much you’ve done for our whole family . After one long surgery, you came out with a glass of milk and said, ‘He made me miss my lunch!’ That was the first laugh and sign of relief we had in almost 7 hours . Not only have you saved a man’s life and legs but you gave 5 daughters, and so far, 12 grandchildren more time to love and know a wonderful ‘Pop’ and ‘Opa!’

You also gave him the chance to go back to his home in Holland and get to know his family again . I know this is just all part of your job, but I believe you are a good man especially when it comes to family . You operated on my Dad right before you were leaving for your own father’s open heart surgery . I am sure your father is very proud of you, as I am thankful there are good doctors like you to keep good fathers like mine around! My dad raised me by himself since I was 12 years old . And I am sure he would’ve been a lot healthier if he had not .

Thank you .”

Is Practicing Medicine Worth It? By Bhagwan Satiani, MD, FACS, MBA, FACHE

General Surgery


WiNTeR 2009 13

My advice is for all physicians to save all communications from patients and their families . You are going to need them . The letters and cards offer tremendous consolation during times when you are second

guessing your choice of medicine as a profession . Keep the letters in a file in a desk drawer at work and the thoughts in those letters close to your heart . You will need them to maintain optimism and help you re-commit to

the reason you chose medicine . You might even be rewarded . I recently tore open a card from almost twenty years ago and a $50 bill fell out!

So to answer the question: Yes, it is worth it .

Is Practicing Medicine Worth It? (continued)

General Surgery

WiNTeR 2009 14

Chapter News OhiO Chapter, aCS paSt preSidentS

Edwin Ellison, MD. . . . . . . . . . . . . . . . 1957Robert T. Allison, MD . . . . . . . . . . . . . 1958Byron G. Shaffer, MD . . . . . . . . . . . . . 1959Jack W. Cole, MD . . . . . . . . . . . . . . . . 1960Berton M. Hogle, MD . . . . . . . . . . . . . . 1961Franklin L. Shively, Jr, MD, FACS . . . . . 1962Stanley O. Hoerr, MD . . . . . . . . . . . . . . 1963Tom E. Lewis, MD, FACS . . . . . . . . . . . 1964Walter A. Hoyt, Jr, MD, FACS . . . . . . . . 1965Warren Wendell Green, MD . . . . . . . . . 1966Stephen Ondash, MD . . . . . . . . . . . . . 1967Richard Zollinger, MD . . . . . . . . . . . . . 1968Tom Morgan, MD. . . . . . . . . . . . . . . . . 1969C. William Loughry, MD . . . . . . . . . . . 1970Miles Flickenger, MD. . . . . . . . . . . . . . 1971Mary M. Martin, MD, FACS . . . . . . . . . 1972Charles Lovingood, MD . . . . . . . . . . . . 1973P.J. Robechek, MD . . . . . . . . . . . . . . . . 1974Byers Shaw, MD . . . . . . . . . . . . . . . . . 1975William J. Flynn, MD . . . . . . . . . . . . . . 1976Tom Kelly, MD . . . . . . . . . . . . . . . . . . . 1977Robert P. Hummel, MD, FACS . . . . . . . 1978Robert E. Hermann, MD, FACS . . . . . . 1979Roland A. Gandy, Jr, MD, FACS . . . . . . 1980Robert K. Finley, Jr, MD, FACS . . . . . . . 1981Larry C. Carey, MD . . . . . . . . . . . . . . . 1982Robert M. Zollinger, Jr, MD, FACS . . . . 1983William V. Sharp, MD . . . . . . . . .1983-1984Sterling W. Obenour, MD, FACS . . . . . . 1984Rex K. Whiteman, MD . . . . . . . . .1985-1986Richard B. Reiling, MD, FACS . . . . . . . 1987John Peter Minton, MD, FACS, PhD . . . 1988Richard B. Fratianne, MD, FACS . . . . . 1989Lawrence H. Linder, MD, FACS . . . . . . 1990Sidney F. Miller, MD, FACS . . . . . . . . . . 1991Josef E. Fischer, MD . . . . . . . . . . . . . . 1992Juan R. LaCerda, MD . . . . . . . . . . . . . 1993Dennis Ross Irons, MD, FACS . . . . . . . 1994Jeffrey L. Ponsky, MD, FACS . . . . . . . . 1995Ezra Steiger, MD, FACS . . . . . . . . . . . . 1996Michael A. Flynn, MD, FACS . . . . . . . . 1997G. William Parker, MD, FACS . . . . . . . . 1998Mark A. Malangoni, MD, FACS . . . . . . 1999Margaret M. Dunn, MD, FACS . . . . . . . 2000Michael S. Nussbaum, MD, FACS . . . . 2001Joseph P. Crowe, Jr, MD, FACS . . . . . . . 2002Robert E. Falcone, MD, FACS . . . . . . . 2003E. Christopher Ellison, MD, FACS . . . . 2004Michael E. Stark, MD, FACS . . . . . . . . 2005Gary B. Williams, MD, FACS . . . . . . . . 2006William C. Sternfeld, MD, FACS . . . . . 2007Linda M. Barney, MD, FACS . . . . . . . . . 2008Christopher R. McHenry, MD, FACS . . . 2009

The next issue of Pulse is in need of your article or news item relevant to the Ohio Chapter members. if you have a story relevant to surgery in Ohio, but no time to write it, contact the executive Office and we’ll do the follow-up. Keep in mind that this issue of Pulse will be printed and mailed to every Ohio Chapter member. This is your opportunity to be heard!

Contact the Ohio Chapter, ACS executive Office by email [email protected] or by telephone at (877) 677-3227.

Submit an Article for the Next edition of Pulse – Deadline is May 1

Attention members! in late 2008, we took Pulse to the next level.in an effort to keep members informed about the

important issues facing the medical profession, Ohio Chapter launched Pulse NOW!, which features all the news you need to know in a clear, concise, two-to-three-page fax bulletin. each edition of Pulse NOW! is released on a monthly basis and is packed with the latest Ohio Chapter news and hot legislative updates.To clarify, the regular version of Pulse isn’t going

anywhere. You will still receive two issues per calendar year. Pulse NOW! will serve only to supplement the regular editions of Pulse, giving you a double dose of news and information from the Ohio Chapter.Please ensure that the executive Office has your correct

fax number to be sure you don’t miss out on this valuable member resource. Please call us at (877) 677-3227 or email us at [email protected] to let us know if you need to update your contact information.

i Want My Pulse NOW!

WiNTeR 2009 15

As the co-chairs of Ohio’s Cancer Liaison Physicians, we have been involved with the Ohio Partners for Cancer Control . This organization fosters collaboration among organizations and individuals that are interested in reducing the cancer burden on Ohio’s citizens . Several years ago, this organization formulated a statewide cancer control plan for Ohio . The member organizations are all well known to you, such as the American Cancer Society, Ohio Cancer Registrars Association, Ohio Department of Health, American College of Surgeons Commission on Cancer and many others of equal or greater stature . Questions about the effectiveness of an organization always arise . This is necessary and appropriate . Every organization should assess if it is making a measureable difference . As chairman of the Treatment and Care Taskforce of the Ohio Partners for Cancer Control, Dr . Moysaenko has been asked to improve the quality of care in Ohio . This monumental task is actually something that all of you accomplish through your individual contributions . Those of you who are Cancer Liaison Physicians help your Commission on Cancer accredited cancer programs improve the quality of care by monitoring the CP3Rv2; those of you practicing in Commission on Cancer accredited cancer programs improve the

quality of care by embracing and implementing Commission on Cancer quality initiatives; those of you who submit information to the cancer registry documenting your clinical cancer stage and compliance to evidence-based treatment guidelines improve the quality of registry data . The registrars contribute heroically by compiling the data in a precise, complete and timely manner so that it accurately reflects all the clinical work . The data acquisition is a difficult task because cancer care is fragmented throughout the various inpatient and outpatient facilities .

Has all this work measurably improved the quality and documentation of the quality of care in Ohio? We believe it has . Allow us to show you a glimpse of what the CP3Rv2 provides about the improvement of the quality and documentation of the quality of care in Commission on Cancer accredited cancer programs in Ohio . First, we must comment that Ohio has about 93 CoC accredited cancer programs . These programs are scattered throughout the state and provide over 80% of the cancer care in Ohio . The CP3Rv2 contains secure information about some of the National Quality Forum Indicators for breast, colon and rectal cancer treatment within your CoC accredited cancer programs . It also contains aggregate data for the state of Ohio . One of the indicators for colon cancer is “Adjuvant chemotherapy is considered or administered within 120 days of diagnosis for patients under the age of 80 with AJCC Stage III colon cancer .” In 2004 the statewide data indicated compliance with this measure in 88 .1% of AJCC Stage III colon cancer

cases . Prior to 2004, the compliance rate was somewhat lower . In 2006 the compliance rate with this measure was 90 .4% . This is a measureable improvement in the quality and the documentation of the quality of colon cancer care . A second measure of quality for colon cancer management is the recovery/evaluation of lymph nodes in colon cancer . The measure reads as follows “At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer .” In 2004 for all CoC accredited Ohio cancer programs the rate was 55 .7% . In 2006 for all CoC accredited Ohio cancer programs the rate was 70 .9% . Another measureable improvement!

We would encourage all of you to look at the CP3Rv2 data available in your secure cancer program database and revel! Log in to CoC Datalinks to review your cancer program’s performance over the range of National Quality Forum care measures at www .facs .org/cancer . Have your password available or ask your cancer registrar to help you enter the database .

Thank you for helping us improve the quality of cancer care in Ohio!

Cancer Liaison Report Ohio Partners for Cancer ControlBy Val Moysaenko, MD, FACS, & Dan McKellar, MD, FACS

Advocacy

WiNTeR 2009 17

The following are excerpts from some of the written committee reports provided at the November, 2009 Ohio Chapter Council Meeting held in Columbus . Read

on to find out what some of the volunteer committee have been and are currently working on . If you are interested in serving on a committee of the Ohio Chapter, contact the

Executive Office at (877) 677-3227 or ocacs@ohiofacs .org and we will put you in touch with the committee chair .

The OCACS, in conjunction with Covidien and the AWS, sponsored a “Career Development Seminar for Women in Surgery” at the Ohio Chapter, ACS Annual Meeting on May 9, 2009 . The program was geared to both surgical residents and young attending surgeons . Topics presented included career choices, becoming a member of

the profession, and finding wellness and balance in your life . While attendance was light, the response of the attendees to the program was overwhelmingly positive . The opportunity for networking with female surgeons from across the state was also invaluable . Several attendees voiced an interest in attending similar programs in the

future, and in assisting with marketing to increase attendance . The AWS is encouraging its members to become active in their state ACS chapters, and, based on the success of programs such as ours, work with companies such as Covidien to develop programs for women surgeons .

November Council Meeting Committee Reports

Association of Women Surgeons Liaison ReportSubmitted by Nancy L. Gantt, MD, FACS

Chapter News

The Board of Governors Annual Business Meeting occurred on October 11, 2009 .

With regards to fiscal affairs, the College remains in a good financial position despite the economic downturn and an increased dues deficit . ACS decreased its overhead from 30% to 26 .2% . There will be no dues increase for the American College of Surgeons for 2010 . The last dues increase for general membership was in 2003 . For the ACS, the revenue producing programs include the Commission on Cancer, NSQIP, ATLS, JACS, and the Clinical Congress . The dues/revenue deficit has gone up from $34 in 2007 to predicted $215 in 2010 . The program costs/member are about $633/member . Costs per member by Division are up especially in the Advocacy and Health Policy Division . The 20F Street NW Project has cost approx . $114 million .

According to the study published in September 2009 issue of Annals of Surgery, among surgeons surveyed,

there was an 8% suicidal ideation rate .

The Board of Governors Committees will be including a RAS member to serve on the standing committees . The RAS has initiated a Research Fellowship Data Bank, promoted a Resident Volunteerism Award, and sponsored Resident Essay contests .

The Board of Governors Joint Session with the Board of Regents focused exclusively on revising the draft of the College’s 2009 State on Health Care Reform (HCR) . There was much lively and focused discussion . Four main points are supported in the Statement: 1) Quality and Safety, 2) Patient Access to Surgical Care, 3) Medical Liability Reform, and 4) Reduction in Health Care costs . The final draft is now available on the ACS website .

Christian Shalgian from the ACS Washington DC office reviewed in detail the College’s position on the current bills in Congress . The Board of Governors annual survey for 2009

revealed these as the top five issues: 1) HCR, 2) Reimbursement, 3) Liability, 4) Workforce, and 5) GME .

There is now a new subgroup of the Health Policy and Advocacy Group called the Health Policy and Advisory Council, composed on interested Governors and Fellows . It will have three taskforces focusing on regional variations of care, payment methods, and workforce issues .

With regard to the Committee on Socioeconomic Issues on which Dr . Linz sits, we are developing statements regarding guidelines regarding: 1) the surgeons and interaction with technology industry, and 2) the need for independence during surgical training . Dr . Clifford Yo gave an update on ACS NSQIP and noted the positive results of the study published in Annals of Surgery in September, 2009 . The college is promoting NSQUIP as part of its Health Care Reform Initiative .

CMS released its final 2010 Medicare Physician Fee Schedule .

ACS Board of Governors ReportSubmitted by Alice Dachowski, MD, FACS, David N. Linz, MD, FACS, & Linda M. Barney, MD, FACS

WiNTeR 200918

November Council Meeting Committee Reports (continued)

Chapter News

The committee has several goals to work towards for the upcoming year . We will continue our recruitment efforts focusing on residents and will identify a speaker and activity for the Annual Meeting . We will continue to identify and send members to American College of Surgeons Leadership Meeting in Washington, DC .

Resident participation in the last Annual Meeting was robust, with programs in Cincinnati and Cleveland presenting research papers . Participation from residents from Toledo and Columbus was also noted .

It will be our goal to increase the participating number of residents both presenting and attending in the meeting . For this purpose

we will start contacting program coordinators in Ohio . We would also like to increase participation of other subspecialties such as urology in the field of oncology .

Young Surgeons/Resident CommitteeSubmitted by Peter F. Klein, MD, FACS, & Mario Castillo-Sang, MD

I sit on the Ohio State Medical Association’s Focused Task Force on Legislative Activities where these bills are discussed . I had the pleasure and honor of moderating a session at the recent ACS Clinical Congress on State Advocacy and believe it was well received .

We are planning an Advocacy Day at the Ohio State House in 2010, most likely in March or April . Our new contact person for our state advocacy is Alexis Walters .

We are tracking both bills at the state and national levels . See our Update from the Statehouse for more details on these pieces of legislation .

Advocacy and Health Policy CommitteeSubmitted by Michael E. Stark, MD, FACS

WiNTeR 2009 19

Chapter News

November Council Meeting Committee Reports (continued)

The following tasks have been completed since May 2009 on behalf of Ohio’s Cancer Liaison Physicians .

• Publication and distribution via email of quarterly newsletters describing CoC initiatives, new compliance requirements for cancer program standards, American Cancer Society initiatives, state cancer control activities and show casing the work of individual cancer liaison physicians .

V . Moysaenko:

• Installed as secretary of Ohio Division ACS .

• Regularly attended and participated in quarterly ACS Ohio Division Finance and board meetings .

• Actively participated in ACS Quality of Life Taskforce .

• Provided input to ACS National regarding the Health Initiatives Program .

• Actively participated in ACS clinical trials taskforce .

• Participated regularly in Ohio Partners for Cancer Control consortium as executive committee member . Working to develop an infrastructure and funding sources .

• Participated regularly in Ohio Colorectal Cancer Control consortium as executive committee member and have provided articles for presentation .

• Participated in the Medical Advisory Board of the Ohio Department of Health providing input on the evaluation of a cancer “hotspot” and on ovarian cancer .

• Presentation on the Collaborative Action Plan to ACS staff May, 2009, Columbus, Ohio .

• Presentation on Cancer Program Standard 4 .3 to Cleveland Registrars, August, 2009, Cleveland, Ohio .

• Collaborating with the Center for Health Affairs to publish a brief on cancer quality initiatives .

• Participated in the CoC Cancer Liaison Physician Summit, August 25,2009, Chicago, Il, refining the role of the cancer liaison physician .

• Member of the Registry Operations Work Group . Currently revising cancer program registry standards for the Commission on Cancer .

• Contacted five CoC indentified facilities exploring their interest in CoC accreditation .

• Cancer Program Surveyor for the Commission on Cancer .

• Submitted an article to ACoS, Ohio Chapter for publication in the Pulse, demonstrating the effectiveness of CoC accreditation in helping cancer programs comply with quality of care standards, thereby elevating the standard of cancer care for the entire state .

• Cancer Liaison Physician Outreach Program: John Alduino and I have been visiting newly appointed CLPs welcoming them to the fellowship of cancer liaison physicians, providing resources and offering them our help in fulfilling their roles . This project also includes facilitating an effective relationship between the CoC approved cancer program and the ACS Ohio Division . See included article for details .

Congratulations to Dr . Dan McKellar who received the Outstanding Achievement Award by the American College of Surgeons Commission on Cancer for his accomplishments as State Chair of Cancer Liaison Physicians in Ohio .

Commission on Cancer ReportSubmitted by Val Moysaenko, MD, FACS, & Dan McKellar, MD, FACS

WiNTeR 200920

Planned as part of the Ohio Chapter Annual Meeting, residents in Ohio surgery and surgery specialty programs enter the Annual Resident Research Forum and Poster

Session . Below are the abstracts submitted by the 2009 second place winners . (The first place winners were included in the Summer 2009 edition of Pulse .) The 2010 Call for

Abstracts is now open and the Ohio Chapter is accepting submissions . Complete details can be found online at www .ohiofacs .org . The deadline is February 26, 2010 .

Annual Resident Research Forum WinnersResident Research Forum

BASIC SCIENCE – SECOND PLACE

Potential Hepatoprotective Role For CXC Chemokine Receptor-1 After Liver Ischemia/Reperfusion in Mice

Callisia N. Clarke, Amit Tevar, Michael J. Edwards, Alex B. Lentsch, The University of Cincinnati, Department of Surgery, Cincinnati, Ohio

Background: Hepatic ischemia/reperfusion (I/R) injury is a major complication of trauma surgery, liver resection, and transplantation . CXC chemokines and their receptors, CXCR1 and CXCR2, have been implicated as key mediators of the inflammatory cascade following hepatic I/R . In addition, we have recently shown that signaling through CXCR2 is detrimental to liver recovery and regeneration after hepatic I/R . However, the role of CXCR1 signaling is unknown . The purpose

of this study was to investigate the function of CXCR1 after liver I/R .

Methods: Male wild-type (Balb/c) and CXCR2-/- mice underwent partial hepatic ischemia for 90 minutes and were reperfused for up to 96 hours . Sham operations used the same protocol without vascular occlusion . Blood and liver samples were collected for analysis . Serum ALT levels were used as a marker of hepatocellular injury, and myeloperoxidase (MPO) content used as a measure of neutrophil infiltration . Western Blot and immunohistochemistry was used to analyze CXCR1 expression . PCNA labeling was used as a marker of proliferation . Repertaxin, a competitive inhibitor of CXCR1 and CXCR2, was used to block ligand signaling through CXCR1 in CXCR2-/- mice .

Results: In both wild-type and CXCR2-/- mice, CXCR1 expression

was found to increase in the liver after 24 hours of reperfusion and was maximal after 96 hours of reperfusion . This expression appeared to be hepatocyte-specific by Western blot and immunohistochemistry . When CXCR1 signaling was inhibited by administering repertaxin in CXCR2-/- mice at the time of reperfusion, there was no difference in hepatocellular injury or inflammation when compared to control-treated mice . However, when repertaxin was administered 24 hours post-reperfusion there was a significant increase in hepatocellular injury and a delayed in recovery compared to control-treated mice . There was no difference in hepatocyte proliferation between control- and repertaxin-treated mice .

Conclusion: Our data suggest that CXCR1 has divergent effects from CXCR2 and may have hepatoprotective effects during liver recovery and regeneration after I/R .

CLINICAL SCIENCE – SECOND PLACE

Impact of Resident Surgeon on Margin after Breast Conservative Surgery

Osama Hamed, George Kerlakian, Amy Engel, Janet Lang, Richard Welling, Department of Surgery, Good Samaritan Hospital, Cincinnati Ohio

Purpose: Margin involvement after breast conservative surgery is associated with increased risk of local recurrence . Re-excision procedures have resulted in an

increased incidence of subsequent breast deformity, more stress on the patient, and delay in the delivery of adjuvant therapy, and increase in overall cost of treatment . However, the effect of having a resident surgeon as the primary operator with direct general surgery faculty supervision on the surgical margin of resection has yet to be studied .

Methods: A retrospective analysis, with data obtained from the tumor registry, was conducted on 2,006 women that underwent breast conservative surgery from 2002-2007 .

Data were collected on multiple variables including primary operating surgeon, surgical margins on final pathology, age, family history, previous incisional biopsy, cancer stage, lymph node involvement, re-excision, and final histology .

Results: Of the 2,006 women that underwent breast conservative surgery, 1,297 women (65%) were operated on by a breast surgeon as the primary operator without residents and 699 women (35%) were operated on by a resident surgeon, under direct faculty general


WiNTeR 2009 21

surgeon supervision . A total of 166 patients (8 .3%) had a positive surgical margin after breast conservative surgery, which included 102 patients operated on by breast surgeons and 64 patients operated on by resident surgeons with faculty general surgeon supervision . There was no statistical significant difference in the incidence of positive surgical

margin between breast surgeons (8 .0%) and resident surgeons (9 .2%) (p =0 .34) . Positive margin after breast conservative surgery was significantly associated with positive family history (p=0 .01), T1 lesion (p<0 .001), previous incisional biopsy (p=0 .03), and infiltrating ductal carcinoma histology (p<0 .001) .

Conclusion: Resident surgeons appropriately supervised did not increase the incidence of positive margin after breast conservative surgery .

ONCOLOGY – HOLZER CLINIC AWARD (SECOND PLACE)

Significance of Atypical or Multiple Sentinel Lymph Node Drainage Basins in Patients with Melanoma

Harvey Chim, Melanie Lynch, Julian A. Kim, Division of Surgical Oncology, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio

Background: The purpose of this study was to identify the proportion of patients undergoing sentinel lymph node biopsy for melanoma who had atypical or multiple drainage basins and determine the clinical significance of removal of these nodes based upon final histology .

Methods: A retrospective analysis was performed on a cohort of patients (n=94) with primary or recurrent melanoma who were evaluated

in a multidisciplinary melanoma clinic from May 2006 to May 2008 . Multivariate statistical analysis was performed in order to identify variables associated with a positive sentinel lymph node biopsy .

Results: Mean age of patients was 56 .9 years . Mean Breslow thickness of melanomas excised was 2 .3 + 2 .9mm, and there were no significant differences in mean Breslow thickness associated with location . Lymphatic drainage to atypical lymph nodal basins including periscapular, epitrochlear, popliteal and pectoral were identified in 8 patients (9%) . Patients with atypical nodal drainage sites demonstrated a high rate of sentinel node positivity (4/8, 50%) compared to patients with typical nodal sites (26/86, 30 .2%) . Patients with multiple nodal drainage basins also had a high rate of sentinel node

positivity (7/13, 53 .8%), compared to patients with a single nodal basin (23/81, 28 .4%) . Variables associated with metastatic disease identified in the sentinel lymph node by logistic regression included Breslow’s thickness of the primary melanoma and drainage to multiple lymph node basins (p < 0 .05) .

Conclusions: Atypical and multiple lymph node drainage sites were associated with a significant frequency of sentinel node positivity . Accepting the limitations of this retrospective analysis, the presence of atypical or multiple lymph node drainage basins should not be overlooked as the false negative rate of the procedure may be adversely affected .

Annual Resident Research Forum WinnersResident Research Forum

WiNTeR 200922

Below, please find a summary of the district activity as reported at the Ohio Chapter Council Meeting held in November 2009 .

District Councilor ReportsPulse Throughout Ohio

Most hospitals in the area are experiencing financial struggles and there has been a significant increase in charity care being provided . Many hospitals have laid off clinical personnel and closed specialty units that have been in the red . Several hospitals have developed specialty units in areas

that experience better reimbursement – oncology and orthopaedics . The University of Toledo and Promedica are discussing new partnerships that may offer new opportunities for resident training . Changes in insurance options have resulted in more open access to patients . For surgeons, insurance negotiations and

reimbursement have not improved . There continues to be difficulty in recruiting new surgeons to the area and emergency department coverage is becoming more of a problem in some subspecialties and general surgery as well .

This summer more than 200 physicians and administrative leaders from Summa Health System gathered to learn more about national healthcare reform and its impact on the system .

SHS financial performance remains strong and is ahead of budget . Some adjustments were made such as delaying construction of the Crystal Clinic Orthopedic Center, hiring restrictions and elimination of merit increases for employees . Summa remains Summit County’s largest employer with 10,000 employees .

Summa Western Reserve Hospital is the region’s first physician owned full-service community hospital . This for-profit joint venture between physician group Western Reserve

Partners and Summa Health System currently utilizes the former Cuyahoga Falls Hospital . The new facility is expected to be completed in 2012 and will be located in northern Summit County off of State Route 8 . This will serve both northern Summit and southern Cuyahoga counties . The Crystal Clinic Orthopedic Hospital will open on Summa’s main campus in 2011, have 94 inpatient beds, 12 state of the art operating rooms, and a biomedical research institution .

University Hospital is building a new healthcare campus that includes a hospital and medical office building at Chagrin Highlands in Beachwood . It is scheduled to open in 2011 and will cost $230 million . Since 2006,

University Hospitals has expanded its ambulatory center to Twinsburg, Mayfield, Hudson, Mantua, and Sharon Townships . UH Concord in Lake County opened in July 2009 and UH Medina Health Center will open in early 2010 . Also a UH Cancer Hospital housing all of Ireland Cancer Centers inpatient and outpatient services will open in May, 2011 . This 120-bed cancer hospital will be at the main campus and cost $229 million .

AGMC Heart and Vascular Center continues to expand and offer state of the art electrophysiology procedures . AGMC and Akron Children’s Hospital opened a new 24-hour full service emergency department at AGMC Wellness Center in Bath .

Northwest Ohio DistrictSubmitted by Peter F. Klein, MD, FACS

Northeast Ohio DistrictSubmitted by V. Van Fossen, MD, FACS

WiNTeR 2009 23

Save the Dates2010 and 2011 Annual Meetings - Don’t Miss Them!

Each spring, the Ohio Chapter of the American College of Surgeons hosts their Annual Meeting to promote the learning and development of statewide doctors, fellows, and residents in surgery programs . This two-day event has grown over the years into an interactive experience for all learning levels to promote various fields of surgery including plastics, cardiac, wounds, orthopedic, and vascular to gain knowledge and insight about procedures that are happening around the state . With the variety of doctors that join the speaking panel each year, participants are guaranteed to

leave the Annual Meeting with insight and tools to use in their everyday work .Along with the in-depth learning sessions that all

participants will benefit from, students enrolled in residency programs in Ohio are invited to submit their research to the Poster Abstract Contest sponsored by the Ohio Chapter of American College of Surgeons . This contest allows members of the Ohio Chapter to see cutting edge research that is taking place in the schools, but also promotes relationships between members and residents that can last for years to come .

While attending the Annual Meeting, be sure to stop and see the resident posters … you may find your next bright idea there!Since the medical profession is always looking towards

the future, we at the Ohio Chapter of American College of Surgeons are doing the same for your annual meetings . Be sure to mark your calendars for the 2010 and 2011 Annual Meeting dates to hear what meeting attendees constantly call “great speakers .”

Pulse Throughout Ohio

Healthcare in Cincinnati is changing dramatically . The Catholic Healthcare Partners (CHP) continues to work diligently to transition the Jewish Hospital into their systems . The Health Alliance is reorganizing in response to the change . Once the Jewish Foundation selected CHP as their suitor, Fort Hamilton hospital also made the decision to withdraw from the Health Alliance . With these changes, there has been a community interaction and concern for the continued healthcare in Cincinnati .

Along with other changes in the Health Alliance, the West Chester Medical Center opened in May . The facility is up and running with emergency room, ICU, and operating rooms . The growing pains are being ironed out as the hospital awaits its fate .

Trihealth system has had no major changes . Bethesda North Campus continues to grow with a new breast center and state of the art ICU . The Mary Jo Cropper Family Center

for Breast Care opened in August at full capacity and the center is working on ACS accreditation to become a Center of Excellence .

Hospitals in the Greater Dayton area have continued to trim jobs in light of the current economic situation . The ongoing shifts in the region’s “payer mix”, with dwindling numbers of individuals covered by third party health insurers and an increased uninsured population, has been cited for these job lost .

Kettering Health Network and Greene Memorial Hospital plan to build a 35-acre medical campus in Beavercreek that would include a freestanding emergency center and research and education operations . The proposed development, expected to cost between $75 million and $100 million, will be built over the next five years . Meanwhile, both Kettering Medical Center and Miami Valley Hospital are completing large additions to their facilities .

As the healthcare reform debate rages on, a recent forum in the Dayton area brought hospital administrators, medical school representatives and area local businesses together to discuss the issues . There was a general consensus that some form of change that was needed, and discussions focused on of consequences for local businesses if the sweeping reforms should pass .

The Dayton Heart and Vascular Hospital closed its doors finally in August of this year . They have been acquired by Good Samaritan Hospital Dayton for $55 million . The heart hospital has moved its entire operations to the new $31 million four-floor addition to Good Samaritan . In addition to the open heart procedures, and endovascular procedures are performed by both cardiologist and vascular surgeons .

Southwest Ohio DistrictSubmitted by Cari A Ogg, MD, & A. Peter Ekeh, MD, FACS

District Councilor Reports (continued)

WiNTeR 200924

“Where Do You Practice” is a new series for Pulse . This series highlights where our Ohio surgeons practice, in what type of setting, and why they made the

decisions they did . We would like to thank Dr . Gary Williams for being our first highlighted surgeon .

Tell us briefly about you:I am 63 years old and have been

married for 40 years . I was born and raised in Akron and am a graduate of Akron Public Schools, the University of Akron, and The Ohio State University College of Medicine . I was trained at Akron

City Hospital and am currently chief of the Division of General Surgery-Summa Health System . I have served as a councilor, president of Ohio Chapter ACS, and ACS Governor .

Name of your practice/group/institution:

I currently practice in Akron, Ohio at Summa Health Systems (Akron City Hospital) .

How long have you practiced in this setting?

I have been in practice for 33 years .

Where and how long did you practice before your current practice/group/institution?

I was in the private practice of General Surgery for the first 30 years . I sold my practice to

Summa Physicians Inc . (SPI) three and one-half years ago .

Description your practice/group/institution:

SPI was started by Summa Health Systems (SHS) approximately four years ago as a vehicle to both recruit and retain certain physicians in the system . I was actually the second non-hospital based physician to join . SPI now consists of approximately 230 physicians . I retained an attorney from Columbus who specialized in medical mergers to assist with my negotiations with the hospital . I also sought out the wise council of Dr . Bob Falcone .

Each practice within SPI has developed its own unique relationship

Where Do You Practice? By Gary Williams, MD, FACS


Richard B . Reiling, MD, FACS, and Mrs . Elizabeth Reiling were presented with the 2009 Distinguished Philanthropist Award at the 21st annual recognition luncheon of the Fellows Leadership Society (FLS) of the American College of Surgeons (ACS) Foundation . The luncheon was held on October 12, during the College’s Clinical Congress .

In addition to their significant personal contributions, Dr . Reiling has worked tirelessly to raise philanthropic support on behalf of the College . His service on the Committee on Development began in 1997 . During his tenure on that committee and now on the ACS Foundation’s Board of Directors, more than $16 million has been raised to advance numerous

programs and initiatives at the College . Dr . Reiling has presented fundraising opportunities to Fellows at countless chapter and surgical society meetings, engaged corporations and organizations with the ACS Foundation, and advanced the spirit of giving among his colleagues and friends .

Dr . Reiling is medical director at the Presbyterian Cancer Center in Charlotte, NC . A Fellow of the College since 1977, he has long been a strong advocate for the College and the ACS Foundation . Including his recent term as second vice-president of the ACS, Dr . Reiling has served as a Governor-at-Large and member of the Governor’s Committee on Ambulatory Surgical Care . He has also served on

numerous College committees, such as the Committee on Development, Nominating Committee of the Fellows, Committee on Ethics, Member Services Liaison Committee, the Commission on Cancer, and as an ACS delegate to the American Medical Association’s House of Delegates . His distinctive service also includes serving as the president of the Ohio Chapter of the College, chair of its Socioeconomic Committee, and editor of the Ohio Chapter newsletter . He also was the recipient of the ACS Distinguished Service Award in 2004 .

Dr. and Mrs. Reiling Recipients of Distinguished Philanthropist Award


WiNTeR 2009 25

The 2010 Nominating Committee of the Board of Governors (NCBG) has the task of selecting two nominees for pending vacancies on the Board of Regents that will need to be filled during the 2010 Clinical Congress . The current members of the Board of Regents who will be considered for reelection are Barrett G . Haik, MD, FACS, and Howard M . Snyder III, MD, FACS .

The following guidelines are used by the NCBG when reviewing the names of candidates for potential nomination to the Board of Regents .

• Loyal members of the College who have demonstrated outstanding integrity and medical statesmanship along with an unquestioned devotion to the highest principles of surgical practice .

• Demonstrated leadership qualities that might be reflected by service

and active participation on ACS committees or in other components of the College .

• Recognition of the importance of representing all who practice surgery .

• Also to be taken into consideration: geography, surgical specialty balance, and academic or community practice .

Call Issued for Nominations for the ACS Board of Regents From the College


with the parent organization . I am paid by the hospital, but my corporation remains intact and my employees receive their salary and benefits from Gary B . Williams, Inc . SPI funds my corporation and I receive an additional salary to administer that business .

Why did you choose to practice in this setting?

I chose to change at a time when reimbursements were declining, malpractice rates were high, the hassle factor of my private practice was escalating, and it seemed that I was spending more time running the business to the distraction of my medical practice . I had not found an acceptable alternative for me until SPI came along . In other words, I was able to continue my practice as it was without many of the previous hassles . I asked that the transition be seamless and it was remarkably close .

What do you see as the benefits of such a practice/group/institution?

The benefits to me are terrific . Other than those already discussed, they include paying my rent, parking for me and my staff, medical malpractice, and funding all office costs including salaries with guaranteed annual raise, health insurance, and retirement benefits . Also included was a guarantee for me to work to the age of 72 with access to all benefits with a minimum of 16 hours per week, as long as I was mentally and physically capable . There was also no restriction that I needed to operate . Essentially this agreement has allowed me to continue to practice surgery without many of the hassles that I had as a private practitioner .

What do you see as any disadvantages of such as practice/group/institution?

The situation is not perfect . My staff has to file monthly

production reports . I have to go through the corporation for new capital expenditures . I need to occasionally remind them of the original agreement, and I need to re-evaluate the contract every two years . But, as it stands, I would do this again in a heartbeat . My advice would include not to rush into any new arrangement, seek good counsel, make sure you know and understand your own needs for both now and in the future as well as you can, and pay for someone to evaluate and negotiate your particular contract . Negotiate from strength .

If you have any questions you would to ask Dr. Williams, he can be reached at:

Gary B . Williams, MD, FACS Summa Health Systems75 Arch St Ste 405 Akron, OH 44304 williamg@summa-health .org

Where Do You Practice? (continued)


WiNTeR 200926

We are pleased to announce that David B . Hoyt, MD, FACS, chairman, department of surgery; executive vice-dean, school of medicine; and John E . Connolly professor of surgery, University of California, Irvine

(UCI) Medical Center, has been named the new Executive Director of the American College of Surgeons (ACS) . The appointment of Dr . Hoyt, who is a former medical director of the College’s Trauma Programs, was approved and announced by the College’s Board of Regents at their October 15 meeting .

On January 1, 2010, Dr . Hoyt will succeed Thomas R . Russell, MD, FACS, who has completed his second term and a full decade of service as executive director of the American College of Surgeons . Dr . Hoyt and Dr . Russell have already begun, and will continue, to work closely together to ensure a smooth transition at this critical time for the College .

A Fellow since 1987, Dr . Hoyt has been active in a number of College activities . He has been involved with the work of the ACS Committee on Trauma (COT) since 1980 and was chair of the COT from 1998-2002 . He is a member of the national faculty for the College’s Advanced Trauma Life Support (ATLS) course

and is a coordinator, instructor, and director of training for ATLS .

Dr . Hoyt was awarded the College’s highest honor, its Distinguished Service Award, in 2007 . He was a member of the ACS Board of Governors’ Committee on Blood-Borne Infection and Environmental Risk, the Program Committee, and the Regents’ Committee on Informatics . He was also actively involved with the San Diego/Imperial County Credentials Committee for 12 years .

Prior to his position at UCI, Dr . Hoyt was The Monroe E . Trout Professor of Surgery and vice-chairman of the department of surgery at the University of California (UC), San Diego; he was also on the staff at the Veterans Administration Medical Center in San Diego and at Thornton Hospital in La Jolla, CA . Dr . Hoyt obtained his medical degree from Case Western Reserve University, Cleveland, OH, in 1976 . He was intern (1976-1977), resident (1977-1979), research fellow (1979-1980), and senior and chief resident (1982-1984) at the UC San Diego School of Medicine . He served as director of the ICU critical care team at UC San Diego Medical Center from 1985 to 2006 and as director of the division of trauma, burns, and critical care at the center from 1989 to 2006 . Dr . Hoyt also served as assistant professor of surgery

(1984-1989), associate professor of surgery (1989-1995), and professor of surgery (1995-2006) at UC San Diego School of Medicine .

Dr . Hoyt has been president of the Pan American Trauma Society, the American Association for the Surgery of Trauma, the Shock Society, and the San Diego Society of General Surgeons .

In addition to being a member of numerous professional medical and surgical societies, Dr . Hoyt holds membership on the editorial boards of the World Journal of Emergency Surgery, Surgery, Journal of the American College of Surgeons, Journal of Trauma, Shock, and Open Access Emergency Medicine . He has continuously received public funding for trauma-related research and has more than 480 publications .

We hope that you will join us in welcoming Dr . Hoyt to his new role with the American College of Surgeons and thanking Dr . Russell for his remarkable ten years as its executive director .

With all best regards,

A . Brent Eastman, MD, FACS Chair Board of Regents American College of Surgeons

LaMar S . McGinnis, Jr, MD, FACS President American College of Surgeons

David B. Hoyt, MD, FACS, to Become ACS Executive

From the College

• In addition, the College encourages consideration of women and other under-represented minorities .

• Finally, individuals who are no longer in active surgical practice should not be nominated for election or reelection to the Board of Regents .

The surgical specialty that should be given priority consideration is:

• General Surgery

Nominations should include a paragraph or two on the potential contributions each candidate can offer in terms of what he or she can do for the members of the

College and their patients . Submit nominations to memberservices@facs .org .

The deadline for submitting nominations is Friday, February 26, 2010 .

For more information, contact psprecksel@facs .org .

Call Issued for Nominations for the ACS Board of Regents (continued)

OHIO CHAPTER, AMERICAN COLLEGE OF SURGEONS

P.O. BOX 1715COLUMBUS OH 43216-1715

PRSRT STDUS POSTAGE

PAIDPEORIA, IL

PERMIT #618

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