ACS Surgery News

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.